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research paper topic : food oppression and thai street food vendors

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title: The impact of PM2.5 on the human respiratory system

source: JTD
doi: 10.3978/j.issn.2072-1439.2016.01.19
credibility evaluation: Group 1

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Review Article on Pollutional Haze

Background

Recently, with accelerated urban development and modernization, air pollution is worsening and its impact on human health has become a main research topic. Air pollutants include gaseous pollutants and particle matters (PM). The pathogenicity of PM is determined by their size, composition, origin, solubility and their ability to produce reactive oxygen. Studies ( 1) have shown that smog is generally caused by high concentrations of fine particles (particle size less than or equal to 2.5 btm, referred to as PM2.5) or aerosols. It has been found that PMs with an aerodynamic diameter smaller than 10 µm have a greater impact on human health. One group of PM identified, PM2.5, have small diameters, however large surface areas and may therefore be capable of carrying various toxic stuffs, passing through the filtration of nose hair, reaching the end of the respiratory tract with airflow and accumulate there by diffusion, damaging other parts of the body through air exchange in the lungs. What's more, adults exposed to other high levels of ambient air pollution, for example PM10 and coarse particulate, also have shown increased prevalence of respiratory disease.

Recently, a growing number of studies in toxicology, epidemiology and other related fields have demonstrated that respirable particles are closely related to the incidence of human diseases and mortality rate. The "Harvard six Cities Study", published in 1996, revealed that PM2.5 was one of the causative factors of human non-accidental death. In this study, PM2.5 was positively related to daily morality of humans, particularly the elderly (RR =1.5%, 95% CI: 1.1-1.9%) ( 2). The study provides evidence supporting the linear relationship between non-accidental death and PM2.5. Patients with respiratory diseases account for a large proportion of these non-accidental deaths caused by air pollution. Given that PM2.5 causes asthma, respiratory inflammation, jeopardizes lung functions and even promotes cancers, its impact on human respiratory system should not be dismissed ( 3- 5). In this review, we will discuss PM2.5 damage on human respiratory system from epidemiological, experimental and mechanism studies.

Epidemiological evidence of PM2.5 damage on human respiratory system

After twenty years of epidemiological studies, scientists have revealed a significant correlation between fine particle pollutants and respiratory morbidity and mortality ( 6). A report from the last century illustrated that increased PM concentration in the air may directly lead to an elevated morbidity and mortality of a population ( 7, 8). In European Union countries, PM2.5 decreased the average life span by 8.6 months ( 9).

After investigating 29 European countries, Analitis ( 10) found that respiratory mortality increased by 0.58% for every 10 µg/m ³ increase of PM10. It was recently reported that the prevalence rate of respiratory diseases increased by 2.07%, while hospitalization rate raised by 8% accordingly, when the daily PM2.5 increased by 10 µg/m ³ ( 11, 12). This study also reported that elevated air particle pollutants were directly associated with more serious symptoms of respiratory tract diseases, undermined lung function and raised morbidity and mortality of cardiopulmonary diseases. Furthermore, this correlation was more obvious in the elderly, pregnant women, adolescents, infants, patients with a history of cardiopulmonary problems and other susceptible populations ( 13- 15).

Scientists in Canada and the US found that long-term exposure to PM2.5 significantly increased not only the chances of cardiopulmonary problems but also the mortality of lung cancers ( 16, 17). Indeed a study conducted for 7 years (from 2000 to 2007) in the US indicated that the average life span was extended by 0.35 years for every 10 µg/m ³ decrease of PM2.5 ( 18).

From the American Cancer Society, Pope and coworkers ( 19) collected a set of data, based on 500,000 adults living in large cities. They concluded that the overall mortality and mortality of cardiopulmonary diseases as well as lung cancer increased by 4%, 6% and 8%, respectively, for every 10 µg/m ³ PM2.5 increase, after ruling out smoking, diet, drinking, occupation and other risk factors. In addition, a cohort study by the American Cancer Society tracked 1.2 million American adults for 26 years [1982-2008] and found that the mortality of lung cancer increased by 15-27% when PM2.5 air concentrations increased by 10 µg/m ³ ( 20). This risk was even higher among patients with chronic lung diseases. More strikingly, the results of 11 cohort studies in Europe revealed that the population hazard ratio (HR) of lung adenocarcinoma was 1.55 (95% CI: 1.05-2.29), for each increase of PM2.5 by 5 µg/m ³ ( 21). In 2011, after balancing smoking and other interfering factors, a study ( 22) of 63,520 people from 6 regions in 3 states in Japan demonstrated that a higher incidence of respiratory diseases, in particular pneumonia, were closely related to long-term exposure to particles in the air. Yadav et al. ( 23) revealed that the morbidity of asthma, influenza and acute respiratory tract infection increased notably during outbreaks of smog.

Compared with Western countries, research into the hazard of PM2.5 in China began just 10 years ago. It has been reported that PM2.5 mainly occurs in the Beijing-Tianjin-Hebei Economic Zone, the Yangtze River Delta, the Pearl River Delta region, the three northeastern provinces, the Sichuan Basin, and other densely populated areas. It has seriously affected public health both physically and emotionally.

Data from the program ( http://stateair.net/web/mission/1/) which tracks daily PM2.5 concentrations on the grounds of the U.S. Embassy in Beijing in the winter months from 2010 to 2014 showed that daily PM2.5 concentrations exceeded 100 µg/m ³ for more than half of the days and reached as high as 744 µg/m ³, more than 20 times the US Environmental Protection Agency's (EPA) 24-hour standard for PM2.5 of 35 µg/m ³. Surveys in Beijing, Shanghai, Guangzhou and other areas in China ( 24- 29) displayed a strong linear correlation between daily mortality (including non-accidental death) and PM2.5 levels. In addition, the daily mortality significantly increased with increased fine PM concentration. A meta-analysis on the current dose-response relationship of particle exposure and morbidity showed that morbidity increased by 0.38% with each increase of PM10 by 10 µg/m ³ ( 30). Using meta-analysis, Qian et al. ( 31) studied the epidemiological literature published between 1995 and 2003. It was concluded that for every 100 µg/m ³ increase of PM2.5, the morbidity of residents increased by 12.07%. The authors also showed that respiratory outpatient visits increased during smog outbreaks ( 32). Therefore, the impact of particles in the air on the human respiratory system is a worldwide issue of concern.

Experimental evidence of PM2.5 damage on the respiratory system

In animal studies, Phipps ( 33) exposed two groups of mice to either air or cigarette smoke for 5 weeks. After intratracheal injection of streptococcus pneumoniae, bacteria counts in mice lungs after cigarette exposure were 4 times in 24 hours and 35 times in 48 hours higher than the control group, respectively. One study in China found that air pollution could cause damage, lose and dysfunction of rat tracheal cilia, resulting in infection and a declined nonspecific immune defense, and that these mice were then prone to secondary infection ( 34).

In addition, many studies have focused on the impact of PM2.5 on alveolar macrophages. Jalava et al. collected air particles from 6 cities in Europe and cultured them with mice macrophages in vitro for 24 hours. The viability of alveolar macrophages decreased significantly with a PM0.2-2.5 range from 300 pg/mL to 150 g/mL. Furthermore, alveolar macrophages TNF-α expression increased with increased particle concentration ( 35). Renwick et al. carried out intratracheal instillation on rats with fine particles and ultrafine particle suspensions (125 and 500 µg per rat, respectively). A LDH cytotoxicity study indicated that the viability of alveolar macrophages was severely damaged when the fine particle concentration reached 500 µg per rat ( 36). In another study, alveolar macrophages were harvested by instilling PM2.5 suspension (300,750, 2,000, 5,000 µg per rat) into the trachea of Wistar rats. The results indicated that the phagocytize rate and phagocytic index were remarkably lower with increased particle concentrations ( 37). Additional study ( 38) has reported that PM2.5 significantly reduces phagocytosis of alveolar macrophages both in vitro and in vivo.

Mechanism study of PM2.5 and human respiratory system

Recently, the mechanisms of the damaging effects of PM2.5 on the respiratory system have been investigated including:

Injury from free radical peroxidation: earlier studies showed that the free radicals, metal and the organic components of PM2.5 can induce free radical production to oxidize lung cells, which may be the primary cause of body injury (39-42). In 1996, Donaldson and Beswick, etc. reported that the surface itself of environmental particles can produce free radicals. In addition, that the PM2.5 surface was rich in iron, copper, zinc, manganese, and other transition elements, as well as polycyclic aromatic hydrocarbons and lipopolysaccharide, etc. These components can increase free radical production in the lung, consume antioxidant ingredients and cause oxidative stress (39). Many studies (43) have confirmed that the reactive oxygen species (ROS) generated by particles, particularly by water soluble particles, produce hydroxyl radical (* OH) by activating metals. Hydroxyl radicals are the main factor causing oxidative damage of DNA. When damaged DNA is not effectively repaired in time, it can induce teratogenesis carcinogenesis, mutagenesis and other irreversible damages. Mehta et al. (44) found that particles could not only damage DNA and suppress DNA repair, but could also promote the replication of damaged DNA fragments and consequently prompt carcinogenesis;

Imbalanced intracellular calcium homeostasis: calcium is one of the important second messengers that mediates and regulates cell functions both physiologically and pathologically. Abnormally high calcium concentrations activates a series of inflammatory reactions, leading to inflammation and cell damage. PM2.5 induces excessive production of free radicals or ROS and decreases the antioxidant capacity of cells, resulting in the peroxidation of lipids on the cell membrane and the elevation of intracellular Ca²⁺ concentrations. In addition, increased intracellular Ca²⁺ concentrations can further elevate free radical or ROS production (45). Brown et al. (46) showed that it is possible that ROS-mediated regulation of intracellular Ca²⁺ concentrations may be one of the mechanisms of PM2.5-induced cell damages. Xing (47) also indicated that cell apoptosis and necrosis were related to over expression of Ca²⁺ -sensitive receptors;

Inflammatory injury: it has been wildly reported that PM2.5 is related to inflammatory cytokines whereby it stimulates overexpression of a number of transcription factor genes and inflammation-related cytokine genes that cause inflammatory injury. Sigaud et al. (48) found that PM2.5-induced inflammation led to an increase in the number of neutrophils. Gripenbäck et al. (49) reported that exposure to pine dust caused an increase in the number of eosinophils, T cells and mastocytes in bronchoalveolar lavage fluid and in 2003, Gordon (50) showed that PM2.5 and its microenvironment influenced the phenotype and function of two types of alveolar macrophages. The first of these macrophages, known as M1 polarized alveolar macrophage, is primarily induced by Thl-type cytokines (IL-12, IFN-γ) and pathogens in the body and promote inflammation. The second of these macrophages, M2 polarized alveolar macrophage, is closely related to the Th2 type cytokines (IL-4 and IL-13) and the immunomodulatory cytokine (IL-10), which primarily inhibit inflammation. It has been reported that human alveolar macrophages treated with PM2.5 express high levels of M1-associated cytokines (IL-12, IFN-γ) and low levels of M2-associated cytokines (IL-4, IL-10 and IL-13) (51-53). These results indicate that cytokines can both induce neutrophil, T cell and eosinophil migration to the lungs and other tissues, and on their own, migrate to the lung, exhibiting higher cell activities, releasing more inflammatory cytokines and chemokines. The interactions between inflammatory cells and cytokines can damage lung cells synergistically. Consequently, the mechanism of action of PM2.5 in the damage to human health remains one of the primary focuses of many current studies. Several studies have illustrated how one single component of PM2.5 can influence human health, whilst others investigated the details of how an imbalance of key inflammatory cytokines can lead to certain lung diseases. Few studies have, however, investigated the pathogenesis of PM2.5 as a whole. Integration of the fragmented information from previous studies will provide a great deal of knowledge in the understanding of the harm to human health of PM2.5.

Prevention of P M2.5 damage to the respiratory system

Understanding how PM2.5 leads to respiratory diseases will assist in preventing and diagnosing the corresponding health issues and the evolution of more effective methods and technologies for the treatment of PM2.5-induced diseases. China is currently facing severe air pollution in the transition phase of industrialization and urbanization. Less than 1% of the 500 largest cities in China can meet the air quality guidelines recommended by the World Health Organization. Seven of these cities were ranked among the ten most polluted cities in the world ( 54). There has been mounting concern on the part of the government and the population of China generally as to the consequences of such high levels of air pollution, which are so high as to greatly limit visibility. The high levels of pollution was related to the linearity of the health effects ( 55).

Consequently, controlling air pollution is an arduous and long-term task. It is therefore proposed that the following guidelines be in place to address increased PM2.5 concentrations and/or an increase in smog levels:

Remain indoors, close all windows and doors and if going outside, wear a qualified mask and minimize the duration or intensity of outdoor activities;

Sensitive populations (the elderly and those with pre-existing cardiopulmonary problems) should be more cautious of PM2.5 pollution and minimize outdoor PM2.5 exposure;

Patients with chronic cardiopulmonary problems should increase their medication dosage and pay close attention to their health to prevent severity of their symptoms during an increase in smog;

As oxidative stress is one of the main pathogenic mechanisms of PM2.5, taking antioxidant supplements or nutritious food (for example, w-3 fatty acids in fish oil);

Chinese environmental authorities could launch a "smog health index", referring to the Canadian "air quality health index" by Environment Canada (EC). Such an index may instruct members of the public to prepare early and correctly thereby minimizing the health threats of smog.

Acknowledgements

None.

Conflicts of Interest: The authors have no conflicts of interest to declare.

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Cite this article as: Xing YF, Xu YH, Shi MH, Lian YX. The impact of PM2.5 on the human respiratory system. J Thorac Dis 2016;8(1):E69-E74. doi: 10.3978/j.issn.2072-1439.2016.01.19

# data[].attributes.attachment_link.title
The impact of PM2.5 on the human respiratory system

# data[].attributes.attachment_link.description
Review Article on Pollutional Haze Recently, with accelerated urban development and modernization, air pollution is worsening and its impact on human health has become a main research topic. Air pollutants include gaseous pollutants and particle matters (PM). The pathogenicity of PM is determined by their size, composition, origin, solubility and their ability to produce reactive oxygen.

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Title: Women in Informal Employment Globalizing and Organizing
Source: WIEGO
Credibility evaluation: empirical data and field research might contain bias
DOI : none

# data[].attributes.body
title: Street food plan starves poor of choice
source: Bangkok post
source bias: moderate liberal bias
factual reporting: high, contains personal opinions

# data[].attributes.attachment_link.readable_text
Street-food plan starves poor of choice

newspaper section:

Clearing all food vendors from all pavements robs workers of the chance for affordable food. (File photo by Patipat Janthong)

Soon after being hailed as the city with the world's best street food by CNN, and with the Michelin Guide announcing it will visit Thailand this year, City Hall which is known to have a love-hate relationship with street vendors, yesterday decided to keep street food in certain spots in the capital -- to serve tourists, not residents.

While CNN has not named any outstanding street vendors, the Michelin Guide, which will hold a press conference Friday at Phaya Thai Palace, will definitely award a few stars to restaurants in Bangkok. The recognition should certainly benefit local tourism.

Immediately after CNN's announcement last month, Prime Minister Prayut Chan-o-cha called street food part of the uniqueness and charm of Bangkok and asked vendors to follow good hygiene practices, keep pavements clean and cooperate with city officials in maintaining order.

Earlier, City Hall had announced its determination to continue its street clean-up campaign. However it recently rolled back this policy following strong public criticism over its attempt to make the Thong Lor street food scene a thing of the past.

Sirinya Wattanasukchai is an assistant news editor, the Bangkok Post.

In January, Vallop Suwandee, chairman of the advisers to the Bangkok governor, admitted to the Post Today newspaper he did not like street food vendors because "they are the worst of all types of street vendors".

They not only take public space from pedestrians but also make Bangkok pavements dirty, he said.

But yesterday, he changed his mind, insisting that street food in the Khao San and Yaowarat areas will be kept -- mainly to boost tourism. City Hall, however, will impose stricter rules on cleanliness, hygiene and waste management. However, street eateries in other street locations popular among locals, namely Victory Monument, Siam Square and Sukhumvit, are likely to be cleared.

It is clear the Bangkok Metropolitan Administration (BMA) seems more eager to please tourists, who probably visit the capital once in their lifetime, than meet the needs of Bangkok's residents, millions of whom are low-income earners who depend on street food.

While many seem worried this Bangkok "charm" will be wiped from the tourism map, I'm more worried about the disappearance of affordable food choices for average men and women, especially low-income earners.

City Hall has said that vendors can relocate to new locations. But these places are usually managed by the private sector which means they will have to pay high rental fees. The BMA has never explained how low-income earners will survive once street food eateries are swept away.

Two years ago when the BMA tried to ban street food vendors at Ratchayothin intersection, it offered them an alternative location at SCB Park Plaza.

Then came the clean-up campaign against Thong Lor vendors who have long served ordinary Bangkok people and low-income earners there. These vendors were told to move inside buildings in the area.

Does the BMA really think construction workers, who struggle on the minimum wage, can afford to buy lunch in these air-conditioned buildings?

But does "street food" have to be literally defined as such and be sold on pavements or streets? It could exist more easily in the past when Bangkok was not overcrowded with 15 million residents and millions of visitors like it is today. The BMA should redefine the meaning of "street food".

This means carts don't have to be on pavements like in many parts of Bangkok or in the road like in Yaowarat.

Look at how Singapore has managed its hawker centres and food courts which are home to dozens of street food vendors. More remarkably, one vendor won a Michelin star, along with several other top-notch restaurants, when the prestigious guide arrived in the country last year.

It is the BMA's duty to provide subsidised locations where vendors can continue to provide affordable food for those who can't afford expensive meals in air-conditioned shopping malls.

But thinking about it again, should I really be bothered about the disappearance of street vendors?

While the state doesn't seem to try to provide us with places with affordable choices for lunch or dinner like Singapore, it is generous enough to allow hundreds of convenience stores to occupy every corner, almost every 300 metres, where city residents like me can pick anything for breakfast, lunch, afternoon snack or late night dinner.

Sirinya Wattanasukchai

Columnist

Sirinya Wattanasukchai is a columnist for the Bangkok Post.

# data[].attributes.attachment_link.description
Soon after being hailed as the city with the world's best street food by CNN, and with the Michelin Guide announcing it will visit Thailand this year, City Hall which is known to have a love-hate relationship with street vendors, yesterday decided to keep street food in certain spots in the capital -- to serve tourists, not residents.

# data[].attributes.body
title: enjoy thai delicious street food safely
source : samitivej hospital
source bias : views street food as  a negative
factual reporting: high (medical viewpoint)

# data[].attributes.attachment_link.readable_text
HIGHLIGHTS:

Avoid street food vendors in areas with heavy traffic, as consumption of food contaminated with carbon monoxide in large quantities on a regular basis can adversely affect lung functions and the respiratory system. It can cause dizziness, difficulty breathing, nausea and vomiting. Additionally, exhaust fumes contain carbon powder and lead, which are classified as carcinogens.

Choose vendors that serve freshly cooked food over already cooked, ready-to-serve food, which may even be leftover food that has been reheated and served again. Such food carries the risk of contamination from harmful and dangerous bacteria.

Thailand truly is a foodie's paradise, especially when it comes to Thai street food, which has become famous throughout the world. Even CNN, the well-known news agency, has praised Bangkok as the number 1 best city for street food in the world out of 23 cities worldwide. Thailand has kept this position for two consecutive years, beating out cities like Tokyo and Hawaii, which were number 2 and 3 respectively.

Thai people themselves have a long history and close relationship with street food, whether it's a quick on-the-go morning meal of soybean milk, grilled pork, rice porridge, then for lunch with coworkers a plate of rice with pork leg, fried noodles or a wide variety of egg noodles both dry and with soup, and ending the day with a bag of curry or a get-together with friends for some spicy roadside papaya salad or a delicious local dessert, only to return home for the evening to rest and prepare for another new day of delicious foods ahead.

Sometimes, however, roadside eateries can be a matter of concern, particularly because most street food vendors are located on busy sidewalks where crowds of people walk by and cars pass all throughout the day, inevitably contaminating food with germs and dust. In other cases, it's the raw materials themselves that are a concern, since they have not been stored or cleaned properly. Then there's the cooking, where food is sometimes not cooked evenly or thoroughly, or is incorrectly or overly seasoned. So before eating street food, make sure you observe and take proper precautions to ensure that you don't end up having to go to hospital after eating your favorite Thai street food.

Choose Wisely, Both for Taste and Safety

Location: The first thing you must pay attention to is the location. Most street food vendors are located along the footpath for the convenience and easy access of commuters and travelers. These are locations where hungry people will walk by and can easily find something to fill up on. At the same time, however, food found at footpath vendors is at high risk of contamination from dust or smoke from car exhaust pipes. This is particularly true when located in areas of heavy traffic or frequent traffic jams. If you must eat from roadside vendors, you should choose those in well-ventilated areas or those that are far from the footpath itself and not constantly exposed to fumes and smoke from car exhaust pipes.

Cleanliness: You should always take the time to use your eyes to look around. Look a bit deeper at things like cabinets, where materials and ingredients are kept, the dishwashing area, tables, chairs and table condiments. They don't have to be cleaned to the same standard as larger, more expensive restaurants, but rather there should be a level of general cleanliness that can be easily seen and observed.

Freshly Cooked Food: Choose vendors that serve freshly cooked food over already cooked, ready-to-serve food that does not allow you the privilege of knowing how long it has been cooked and sitting out, or even whether it's leftover food from a previous meal that has been reheated and served again. Already cooked food carries the risk of contamination from harmful and dangerous bacteria. Also, be aware that certain foods containing coconut milk can be easily spoiled during hot weather, and that some shops use preservatives in their cooking that can adversely affect the body as well.

Street Food You Should Be Wary Of

1. Fried Foods: This is always a favorite, popular with young children, adults and the elderly alike, as fried foods are easy to eat, delicious and inexpensive. But the deliciousness that comes with the deep frying process can be harmful due to carcinogens and trans fats. Although some shops change their cooking oil frequently, eating greasy and high-fat foods can still cause a number of serious diseases, such as obesity, hyperlipidemia, diabetes and high blood pressure.

2. Grilled or Roasted Pork, Chicken and Seafood: Grilled or roasted food has been cooked using direct contact with the grill. Smoke from the cooker poses a risk of increased carcinogens due to charring and burning. The cleanliness levels of cooking equipment and raw materials pose other risks. This is especially true for seafood, which is often contaminated with formalin in order to extend its freshness and keep it from decaying too quickly. You should also be aware that some meats, as well as dipping sauces, often contain a lot of artificial seasoning to add taste and flavor to the food.

3. Color, Sweetness and Crunchiness of the Food: Whether crunchy snacks, baked goods or preserved foods: to make them more attractive, especially to younger children, colorful foods sometimes contain synthetic coloring which is not intended to be used in food. Additionally, added sweeteners may contain saccharin, while borax may be used to increase crunchiness. If eaten frequently or in large amounts, such additives are harmful to the body.

4. Very Spicy Foods, Various Spicy Salads: These types of food require a lot of seasonings and raw ingredients, particularly fresh vegetables, onions, garlic, peanuts, dried shrimp and dried chili powder, which are often contaminated due to mold. Also, artificial lemon flavors or vinegar that are added to increase the sourness of these salads may cause indigestion and diarrhea.

Unexpected Diseases That Accompany Street Food

Black smoke from the exhaust pipe of a car is caused by incomplete combustion of fuel, which produces carbon monoxide, carbon dioxide, hydrocarbon, nitric oxide and nitrogen oxide as well as other hydrocarbon compounds that are toxic to the environment and human body.

Consumption of food contaminated with carbon monoxide in large quantities on a regular basis can adversely affect lung functions and the respiratory system, causing dizziness, difficulty breathing, nausea and vomiting. Additionally, exhaust fumes also contain carbon powder and lead, which are classified as carcinogens. The World Health Organization (WHO) has set standard levels of lead content in food at no more than 1 microgram of lead per 1 gram of food. Eating foods contaminated with lead over a long period of time can cause brain damage and even death.

Contamination of raw materials and ingredients by germs, bacteria, fungi or mold is another danger that can affect your health. This is because many roadside vendors have very limited space to properly clean raw materials. Containers and utensils must be used repeatedly throughout the day, and ce used in drinks and desserts poses another risk. If you eat food contaminated with bacteria for any of these or other reasons, it can cause food poisoning, cholera or severe diarrhea.

Chemicals, such as preservatives, saccharin, borax and artificial lime derived from synthetic citric acid, are not harmful to the body when consumed in small amounts. When consumed regularly they will accumulate in the body and can eventually be a cause of cancer.

Although street food can be delicious, tasty, convenient and easy on the wallet, if consumed haphazardly and without care and attentiveness, it can negatively affect your health, both now and in the future. Carefully choosing roadside vendors with attention to cleanliness and ingredients is imperative for consumers. Moderate consumption along with regular exercise can provide you with good health and the opportunity to enjoy the delicious street food of Thailand for many years to come.

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Enjoy Thai Delicious Street Food Safely - Samitivej Hospital - Bangkok Thailand

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Thailand truly is a foodie's paradise, especially when it comes to Thai street food, which has become famous throughout the world. Sometimes, roadside eateries can be a matter of concern, if consumed haphazardly and without care and attentiveness, it can negatively affect your health.

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title: Thailand's universal coverage scheme and its impact on health-seeking behavior
source: NCBI
doi: 10.1186/s40064-016-3665-4
Credibility evaluation : Group 1

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Abstract

Background

Thailand's Universal Coverage Scheme (UCS) has improved healthcare access and utilization since its initial introduction in 2002. However, a substantial proportion of beneficiaries has utilized care outside the UCS boundaries. Because low utilization may be an indication of a policy gap between people's health needs and the services available to them, we investigated the patterns of health-seeking behavior and their social/contextual determinants among UCS beneficiaries in the year 2013.

Results

The study findings from the outpatient analysis showed that the use of designated facilities for care was significantly higher in low-income, unemployed, and chronic status groups. The findings from the inpatient analysis showed that the use of designated facilities for care was significantly higher in the low-income, older, and female groups. Particularly, for the low-income group, we found that they (1) had greater health care needs, (2) received a larger number of services from designated facilities, and (3) paid the least for both inpatient and outpatient services.

Conclusions

This pro-poor impact indicated that the UCS could adequately respond to beneficiaries' needs in terms of vertical equity. However, we also found that a considerable proportion of beneficiaries utilized out-of-network services, which implied a lack of universal access to policy services from a horizontal equity point of view. Thus, the policy should continue expanding and diversifying its service benefits to strengthen horizontal equity. Particularly, private sector involvement for those who are employed as well as the increased unmet health needs of those in rural areas may be important policy priorities for that. Lastly, methodological issues such as severity adjustment and a detailed categorization of health-seeking behaviors need to be further considered for a better understanding of the policy impact.

Keywords: Thailand, Universal Coverage Scheme, 30-Baht Scheme, Health-seeking behavior, Out-of-pocket payment

Introduction

Background

Thailand achieved universal health coverage in 2002 through the implementation of the Universal Coverage Scheme (UCS, also known as the 30-Baht Scheme). The UCS, as the main social health insurance program in the country, currently covers approximately 75% (approximately 47 million people) of the entire population, and it accounts for approximately 17% of the country's total health expenditure (Antos 2007; Health Insurance System Research Office [HISRO] 2012).

Before the UCS in 2002, four health insurance programs were implemented, which were (1) the Civil Servant Medical Benefit Scheme (CSMBS), (2) the Social Security Scheme (SSS), (3) the Medical Welfare Scheme (MWS, also known as the Low-Income Card Scheme), and (4) the Voluntary Health Card Scheme (VHCS) (Towse et al. 2004). The CSMBS and SSS were health insurance programs for people in the formal employment sector, while the MWS and VHCS were for those in the informal employment sector.

Specifically, the CSMBS, as a fringe benefit, provided health insurance to government sector employees, their dependents (e.g., parents, spouses, and children), and retirees. The SSS was a compulsory health insurance program for private sector employees, and dependents and retirees were not covered by the scheme. The MWS, as a government subsidy program, was initially introduced for the poor in 1975. Later, its target population was expanded to include the elderly in 1992 and other vulnerable groups (e.g., children under the age of 12) in 1994. Lastly, the VHCS was a voluntary health insurance program for people who were not eligible for the other three programs. Each household could purchase one-year VHCS insurance coverage for 500 Baht (approximately US$15) (Damrongplasit and Melnick 2009).

The four insurance programs were intended to cover the entire population. However, both the MWS and VHCS programs faced operational issues, which caused approximately 30% (approximately 18 million people) to be uninsured by 2001. The MWS suffered from issues of mis-targeting due to difficulties with assessing the incomes of those working in the informal employment sector. A household survey in 2000 indicated that only 35% of all MWS beneficiaries met the MWS eligibility standards (HISRO 2012; NaRanong and NaRanong 2006; Suraratdecha et al. 2005; Tangcharoensathien et al. 2007). The VHCS suffered from issues of adverse selection. Possibly because of its voluntary nature, a study found that the presence of illness was positively associated with the purchase and utilization of the VHCS (Sakunphanit 2006; Supakankunti 2001).

Subsequently, the Thai government established the UCS program in 2002 by integrating the MWS and VHCS programs. Currently, three health insurance programs are implemented for the entire population, which are the CSMBS (9%), the SSS (16%), and the UCS (75%) (HISRO 2012). Table provides the characteristics of the three health insurance programs in brief.

Table 1

Civil Servant Medical Benefit Scheme (CSMBS, 9%): Per capita expenditure in 2010: US$ 367

Target population

Government employees, dependents including parents, spouse and up to two children (age < 20)

Financing source

General tax, noncontributory scheme

Payment method

Fee for service for outpatient services and conventional DRG for inpatient services

Health delivery

Free choice of public providers, no registration required

Benefits package

Slightly higher than SSS and UCS

Social Security Scheme (SSS, 16%): Per capita expenditure in 2010: US$ 71

Target population

Private sector employees, excluding dependents

Financing source

Payroll tax financed, tri-partite contribution 1.5% of salary, equally by employer, employee and government

Payment method

Inclusive capitation for outpatient and inpatient services

Health delivery

Registered public and private competing contractors

Benefits package

Comprehensive: outpatient, inpatient, accident and emergency, high-cost care, with very minimal exclusion list; excludes prevention and health promotion

Universal Coverage Scheme (UCS, 75%): Per capita expenditure in 2010: US$ 79

Target population

The rest of population not covered by SSS and CSMBS

Financing source

General tax

Payment method

Capitation for outpatient services and global budget plus DRG for inpatient services

Health delivery

Registered contractor provider, notably within the district health system

Benefits package

Similar to SSS, including prevention and health promotion for the whole population

The UCS provides a comprehensive benefits package for curative as well as rehabilitation services. Additionally, annual health check-ups and health promotion/disease prevention services are included in the package (Sakunphanit 2006). For health care delivery, the beneficiaries are required to receive health services from a designated facility, a primary care facility, as the gatekeeper to secondary and tertiary care. When the beneficiaries bypass their designated facilities, they are required to pay 100% out-of-pocket (OOP) costs (Limwattananon et al. 2007).

Capitation is the main provider payment method for outpatient services, while a global budget with diagnosis-related groups (DRGs) is the main payment method for inpatient services. The UCS is implemented solely through general tax revenue without contributions from beneficiaries (Antos 2007; HISRO 2012). When the policy was initially implemented in 2002, it required a 30-Baht copayment (approximately US$.90) for both outpatient and inpatient services except among vulnerable groups (i.e., the previous MWS beneficiaries included the poor, the elderly, and children under the age of 12).

Later, in 2006, the 30-Baht copayment requirement was abolished, and most services were free of charge until 2012 (Sakunphanit 2006). In 2012, the requirement was again reinstated with many exemption conditions. To explore the degree of the exemptions, we conducted a preliminary analysis and found that among the beneficiaries who used the UCS services, more than 80% received free services in 2013. Thus, the effects of the reinstated requirement did not appear to be significant.

Significance of the study problem

Previous studies have investigated the impact of the UCS on health care utilization. Those studies consistently found that after the UCS implementation, the overall utilization of designated facilities increased significantly. First, using a trend analysis of health care utilization before and after the UCS, some studies found that the number of outpatient visits and/or inpatient admissions in designated facilities significantly increased after the UCS. Additionally, the increase was significantly higher in low-income groups (HISOR 2012; International Health Policy Program [IHPP] 2007a; Limwattananon et al. 2011; Tangcharoensathien et al. 2007, 2013).

Second, other studies have examined the changes in health-seeking behavior before and after the UCS. For outpatient care, the UCS increased outpatient service utilization in designated facilities, and simultaneously, it decreased informal care utilization such as over-the-counter (OTC) drugs and traditional medicine/healers (Limwattananon et al. 2013). For inpatient care, the UCS increased inpatient service utilization in designated facilities overall, and it shifted the utilization from non-designated facilities to designated facilities (Gruber et al. 2014). Additionally, these patterns occurred significantly more in low-income and older groups.

Furthermore, likely because the UCS increased the utilization of designated facilities that required no or minimal OOP payments and decreased the utilization of out-of-network services that required 100% OOP payments, several studies found that overall OOP health expenditures decreased significantly after the UCS, and this decrease also had an impact on the decreased incidence rate of household catastrophic health expenditures (HISRO 2012; IHPP 2007a; Limwattananon et al. 2007; Somkotra and Lagrada 2009).

Despite the positive effects, other studies have cited the insufficiency of the policy's financing as a potential factor threatening service quality and access. An inadequate infrastructure as well as the brain drain resulting from skilled health workers moving from public to private sectors and rural to urban areas have been documented as issues on the supply side of the public sector (Antos 2007; IHPP 2007b; Sakunphanit 2006; Sakunphanit and Suwanrada 2011). Accordingly, those issues have caused service quality problems of the UCS such as long wait times and limited service access (Kirdruang 2011; Suwannarach et al. 2010).

For such quality problems, the Thai government has tried to encourage private sector involvement and expand benefits coverage. For benefits coverage expansion, the UCS has gradually expanded its benefits coverage from costly services/drugs to traditional Thai services/medicines (NHSO 2014; Rousseau 2014).

However, private sector involvement has been quite low. In 2007, the total numbers of public clinics (or health centers) and hospitals were 9758 and 1020 (156,494 beds), while the total numbers of private clinics and hospitals were 16,800 and 318 (30,564 beds), respectively. Almost all public facilities joined the UCS program, while only 212 private facilities (152 clinics and 60 hospitals) joined the UCS program. Additionally, compared to 2013, the private sector involvement has not noticeably increased. In 2013, a total of 229 private facilities (191 clinics and 38 hospitals) joined the UCS program, and the facilities covered only approximately 5.7% of all UCS beneficiaries (HISRO 2012; National Health Security Office [NHSO] 2014; Sakunphanit and Suwanrada 2011).

Likely for this reason, a substantial proportion of UCS beneficiaries utilizes care outside their designated facilities. A study found that among all UCS beneficiaries, only 40% used the UCS services when they needed care, while the other 60% used services not covered by the UCS, which required 100% OOP payments (Kirdruang 2011). Some people might use informal care (e.g., buying OTC drugs or traditional medicine) due to accessibility problems of the UCS services (e.g., long wait times or transportation). Other people might use non-designated facilities due to acceptability problems of the UCS services (e.g., low quality or dissatisfaction with needed services).

On one hand, low utilization of the UCS services could be considered an appropriate use of health care if we assume that out-of-network services (either informal care or non-designated facilities) are relatively affordable and more accessible. On the other hand, low utilization may also mean that beneficiaries do not want to but are required to use out-of-network services due to individual issues (e.g., time constraints) and system issues (e.g., unavailability of needed services). In that sense, low utilization may be an indication of the policy gap between beneficiaries' health needs and the services available to them. As such, understanding the differential utilization of health services (i.e., health-seeking behavior) and how the behavior is associated with social/contextual factors would be meaningful for current policy evaluations as well as future policy improvement.

In addition, the UCS is operated solely through general tax revenues without insurance contributions. Since all beneficiaries pay taxes, which are partially used for the UCS, its low utilization may also imply an inefficiency of policy financing, making people pay again for health care. As the stated objective of the UCS is to "entitle all Thai citizens to quality health care according to their needs regardless of their socioeconomic status" (HISRO 2012), it is important to understand where and why such policy gaps occur.

Therefore, the purpose of this study was to investigate health-seeking behaviors as well as their social/contextual determinants among UCS beneficiaries. Additionally, the study attempted to answer basic but fundamental questions-(1) who needs health care, (2) what types of health services are utilized, and (3) how much is the average OOP payment according to the type of service.

Methods

Data source and study sample

The study used Health and Welfare Survey (HWS) data from the year 2013. The HWS is a nationwide survey that annually collects data and is administered by the National Statistics Office (NSO) of Thailand. Using multi-stage random sampling, it represents a national cross section of all 76 provinces of Thailand, with approximately equal-sized samples from each province. The data includes comprehensive demographic and socioeconomic information at individual and/or household levels. Additionally, health utilization-related information (e.g., health insurance status and types of health services used) is available in the data.

The purpose of this study was to investigate factors associated with health-seeking behaviors among UCS beneficiaries. Thus, the study first selected the UCS beneficiaries. Then, among the beneficiaries, those who reported experiencing perceived illness during the survey period were selected again, and their health-seeking behaviors were analyzed.

Specifically, the HWS provides a set of questions regarding health-seeking behavior. For outpatient care, two questions were asked of respondents: (1) Have you felt sick during the 1 month prior to the survey date? and (2) If yes, what type of health services did you use? Likewise, for inpatient care, two similar questions were asked of respondents: (1) Have you been hospitalized during the 1 year prior to the survey date? and (2) If yes, what type of hospital did you stay in?

In the study, the beneficiaries who answered "yes" to question (2) were labeled as the "sick group," while those who answered "no" to question (2) were labeled as the "non-sick group." Additionally, the combined group of the sick and non-sick groups was labeled as the "overall group." The sick group was used for the study's main analysis (analysis of health-seeking behavior), while all three groups were used for the study's descriptive analysis. In addition, the study sample was limited to adults over the age of 18 in order to reduce the impact of a potential bias due to juvenile health-seeking behavior, which is influenced by parents (Case and Paxson 2002; Isong et al. 2010). For the juvenile population (UCS beneficiaries under the age of 18), we also conducted the same analyses in the Appendix section.

The 2013 HWS originally included a total of 71,533 individuals and 23,697 households. Among the 71,533 individuals, 56,130 individuals (78.47%) were UCS beneficiaries, of which 40,614 individuals (72.36%) and 15,516 individuals (27.64%) were adults and juveniles, respectively. After data cleaning to eliminate missing and erroneous values, a total of 56,011 individuals (40,521 adults and 15,490 juveniles) was ultimately used as the overall group. In the overall group, the sick group for the outpatient analysis included 13,004 individuals (10,363 adults and 2641 juveniles), while the sick group for the inpatient analysis included 2859 individuals (2315 adults and 544 juveniles).

Variable selection and measurement

The study used Andersen's Healthcare Utilization Model to develop an analytical framework and select the study variables. Andersen's Model classifies health utilization into three different factors, which are predisposing, enabling, and need-for-care factors (Aday and Andersen 1974; Andersen and Davidson 2001; Bradley et al. 2002; Lo and Fulda 2008).

This study included three demographic variables (age, gender, and marital status) as predisposing factors. For enabling factors, four socioeconomic variables (income, employment status, education, and dual coverage) were used as individual-level resources, while the variable region (urban and rural areas) was used as a community-level resource. Lastly, chronic status was used as the need-for-care factor.

For the dependent variable, the study defined health-seeking behavior as an action taken by individuals for the purpose of finding appropriate health care during their experience of perceived illness. Thus, the study used the sick group and classified health-seeking behaviors into four different types, which were (1) no care, (2) informal care, (3) designated facility care, and (4) non-designated facility care. "No care" indicated that the beneficiaries reported experiencing perceived illness but did not use any health services. "Informal care" was defined as the use of any health services not in designated or non-designated facilities. Specifically, the use of OTC drugs or traditional medicines/healers were included in this category. Lastly, "designated facility care" indicated that beneficiaries used health services in facilities designated by the UCS insurance, while "non-designated facility care" indicated that beneficiaries used health services in facilities not designated by the UCS insurance.

This study conducted outpatient and inpatient analyses separately. For the outpatient analysis, the dependent variable included four categories (no care, informal care, designated facility care, and non-designated facility care), while for the inpatient analysis, the dependent variable included two categories (designated facility care and non-designated facility care).

For income, the monthly household income was divided by the square root of the number of household members to obtain a standardized income per single-person household (Foster 2009). Since the income variable was skewed to the right, a log transformation was ultimately used. Age, specifically each individual's age, was treated as a continuous variable, while gender was treated as a binary variable (male and female).

Marital status was measured as a categorical variable with three levels (single, married, and divorced/widowed/separated). Employment status was treated as a binary variable (yes and no). Education was measured as an ordinal variable with three levels (1 = primary school or below, 2 = middle or high school, and 3 = college or above). The study treated dual coverage as a binary variable (yes and no). If beneficiaries had dual insurance (e.g., UCS and private insurance), they were categorized in the yes group.

This study measured region as a binary variable (urban and rural). We defined municipalities as urban areas and non-municipalities as rural areas, according to the definition by the Thai NSO (NSO 2004). Lastly, chronic status was treated as a binary variable (yes and no). The Health and Welfare Survey defines 32 diseases as chronic/congenital diseases. If beneficiaries had any of the defined diseases, they were categorized in the yes group. If not, they were categorized in the no group.

Statistical analysis

This study used binary logistic regression (BLR) and multinomial logistic regression (MLR) analyses. Since the dependent variable (health-seeking behavior) was a categorical variable, both BLR and MLR analyses were performed by setting designated facility care as a reference category. We used odds ratios and their statistical significance to assess the relationship between the dependent variable and the selected variables. If an odds ratio was greater than 1, it indicated a positive relationship. If an odds ratio was less than 1, it indicates a negative relationship (Hosmer and Lemeshow 2000). The statistical significance level was set at 0.05, and all of the analyses were performed using IBM SPSS Statistics Version 20.0 software.

Results

Descriptive statistics

Table presents descriptive statistics from the outpatient analysis. For the overall group (n = 40,521), the average income and age were 9126.30 Baht and 47.44 years, respectively. In the group, 46.26% were male, and 53.74% were female. For educational level, 67.58% had completed primary school or below, 28.12% had completed middle or high school, and 4.30% had completed college or above. For marital status, 17.32, 66.94, and 15.74% were single, married, and divorced/widowed/separated, respectively. For employment status, 73.36% were employed, while 26.64% were not employed. For dual coverage, 4.58% had dual insurance, while 95.42% had only the UCS insurance. For chronic status, 24.67% had at least one of the defined chronic/congenital diseases. Lastly, for region, 51.47% lived in urban areas, while 48.53% lived in rural areas.

In the overall group, approximately 25.57% reported experiencing perceived illness (sick group, n = 10,363). In the sick group, 59.65% received care from a designated facility. Additionally, 18.89 and 10.23% received informal care and care from a non-designated facility, respectively. Furthermore, 11.22% did not use any services even though they reported experiencing perceived illness. For OOP payment, beneficiaries who received care from a non-designated facility paid 777.40 Baht on average (median = 320 Baht). For informal care and designated facility care, beneficiaries paid on average 81.32 Baht (median = 50 Baht) and 55.44 Baht (median = 0 Baht), respectively.

Table also presents additional descriptive statistics for the non-sick group for comparison purposes. We conducted both a t test and Chi square test (not presented in the table) to compare the groups. The results indicated that the sick group included a higher proportion of low-income, older, female, unemployed, and chronically ill individuals. For education, a higher proportion of people had a primary school level of education or below, and a lower proportion had a middle or high school level of education or college level or above in the sick group. For marital status, the sick group included a higher proportion of single and divorced/widowed/separated individuals and a lower proportion of married individuals. Lastly, for region, the sick group had more people living in rural areas.

Table presents descriptive statistics from the inpatient analysis. In the overall group, approximately 5.71% reported experiencing perceived illness (sick group, n = 2315). In the sick group, 91.75% received care from a designated facility, while 8.25% received care from a non-designated facility. For OOP payment and length of stay, beneficiaries who received care from a designated facility paid 185.37 Baht (median = 0 Baht) per day and stayed for 6.27 days (median = 3 days) on average. Meanwhile, beneficiaries who received care from a non-designated facility paid 6614.80 Baht (median = 4285.71 Baht) per day and stayed for 4.41 days (median = 3 days) on average.

Table also provides descriptive statistics for the non-sick group for comparison purposes. The results from both the t test and Chi square test indicated that the sick group included a higher proportion of low-income, older, female, unemployed, dual coverage, and chronically ill individuals. For education, the sick group included a higher proportion of people with a primary school level of education or below and a lower proportion of those with a middle or high school level of education. However, the proportion of individuals with a college level of education or above was not significantly different between the sick and non-sick groups. For marital status, the sick group included a lower proportion of single individuals and a higher proportion of married and divorced/widowed/separated individuals. Lastly, region was not significantly different between the sick and non-sick groups.

Results of health-seeking behavior analysis

Table presents the results from the MLR outpatient analysis. The results of the Pearson's goodness-of-fit test for the MLR model did not present a lack of fit with a p value greater than 0.05. In the model for informal care (vs. designated facility care), a significant relationship was found in six variables (income, age, marital status, employment status, dual coverage, and chronic status). Income was positively related to informal care with an odds ratio equal to 1.195. It indicated that people with higher incomes tended to use informal care, while those with lower incomes tended to use designated facility care. Age was negatively associated with informal care. The odds ratio (0.995) meant that younger adults were more likely to use informal care than older adults.

For marital status, the category of divorced/widowed/separated was positively associated with informal care. It meant that divorced/widowed/separated individuals were more likely to use informal care than single individuals. For employment status, the employed group tended to use informal care, while the unemployed group tended to use designated facility care. For dual coverage, people with dual insurance coverage were more likely to use informal care than those with only UCS insurance. Lastly, chronic status was negatively related to informal care. Beneficiaries without any defined chronic/congenital diseases tended to use informal care, while those with a defined chronic/congenital disease tended to use designated facility care.

In the model for non-designated facility care (vs. designated facility care), a significant relationship was found in six variables (income, gender, educational level, employment status, dual coverage, and chronic status). For income, similar to the results from the informal care model above, beneficiaries with higher incomes were more likely to receive care from a non-designated facility than those with lower incomes. For gender, the odds ratio (1.203) indicated that females were more inclined to receive care from a non-designated facility than males.

For education, the use of a non-designated facility for care was significantly higher in individuals with a college level of education or above than individuals with a primary school level of education or below. However, a significant difference was not found between those with a college level of education or above and those with a middle or high school level of education. For employment status, employed individuals were more inclined to receive care from a non-designated facility than unemployed individuals. For dual coverage and chronic status, people with dual insurance coverage or without any chronic/congenital diseases tended to receive care from a non-designated facility.

Lastly, in the model for no care (vs. designated facility care), four variables (marital status, chronic status, dual coverage, and region) were statistically significant. For marital status, single status was positively related to receiving no care. This meant that single individuals were less likely to use health services from a designated facility than married individuals when experiencing perceived illness. For dual coverage and chronic status, people with dual insurance coverage or without any chronic/congenital diseases were less inclined to use services. For region, people in rural areas were less likely to use services from a designated facility than those in urban areas.

Table presents the results of the BLR inpatient model. The Hosmer-Lemeshow goodness-of-fit test did not show a lack of fit for the model with a p value greater than 0.05. In the BLR model, six variables were statistically significant, which were income, age, gender, education, marital status, and dual coverage. For income and age, the higher income group and older group were more likely to receive care from a non-designated facility than the low-income group and younger group, compared to receiving care from a designated facility. For gender, females were more inclined to receive care from a non-designated facility than males.

Table 5

For education, the higher education group was more likely to receive care from a non-designated facility. Specifically, people with a college level of education or above were more likely to receive care from a non-designated facility than those with a primary school level of education or below and middle or high school levels of education. For marital status, single individuals more often received care from a non-designated facility than the married individuals. Lastly, for dual coverage, the group with dual insurance coverage received significantly more care from a non-designated facility.

Discussion

The study investigated the patterns of health-seeking behavior among UCS beneficiaries in the year 2013. By classifying health-seeking behavior into four categories for the outpatient analysis (no care, informal care, designated facility care, non-designated facility care) and two categories for the inpatient analysis (designated facility care and non-designated facility care), we examined how the behavior was influenced by selected social/contextual factors.

The study findings indicated that the UCS increased the use of designated facilities in vulnerable groups. Specifically, the outpatient analysis showed that receiving care from designated facilities was significantly higher in low-income, unemployed, and chronically ill groups. The inpatient analysis showed that receiving care from designated facilities was significantly higher in low-income, older, and female groups.

This pro-poor impact could be explained using the following equity perspective: vertical and horizontal equity. First, to some degree, the UCS could adequately meet the assumption that vertical equity in access to health services implies that people with greater health care needs must receive more health services than those with fewer needs.

Excessive OOP expenditures have been cited as one of the significant barriers to health access for people, particularly low-income and socially vulnerable groups. When a health system becomes more dependent on OOP expenditures, it can cause catastrophic health expenditures for these people. Accordingly, catastrophic expenditures can drive them back into poverty. Thus, vertical equity is one of the important considerations of health systems operations (OECD 2013; WHO 2013). Since the UCS significantly increased the use of designated facilities for care, which required no or less OOP payments for low-income groups who also had greater health care needs, the policy could have adequately responded to beneficiaries' needs in terms of vertical equity, for which the elimination of financial barriers to access to health services was a major factor.

However, the findings showed that a considerable proportion of beneficiaries used out-of-network services (e.g., approximately 37% of the beneficiaries using outpatient services used either informal care or care from non-designated facilities). In fact, the use of out-of-network services could have been considered an appropriate use of health services if we assumed that people had different preferences and choices. However, the premise of horizontal equity is the universality of access to health services. That is, beneficiaries who have equal health care needs should receive equal treatment, regardless of their socioeconomic situations. This means that the UCS policy must enable all beneficiaries to access their health care benefits under the scheme when needed.

Thus, the evidence of high utilization of out-of-network services could imply a lack of universal access to services provided under the UCS policy. Accessibility issues (e.g., long wait times or transportation) and/or acceptability issues (e.g., low quality or dissatisfaction with needed services) might discourage some groups of beneficiaries (e.g., higher-income groups or employed groups) and prompt them to seek care outside the UCS boundaries. These might be some of the factors hampering universal access and thus horizontal equity.

The stated objective of the UCS is to "entitle all Thai citizens to quality health care according to their needs regardless of their socioeconomic status" (HISRO 2012), which implies that the UCS should not be a selective welfare policy that targets only vulnerable populations but a universal welfare policy that targets everyone. Additionally, considering that the UCS is a tax-based policy, improving its universality should be one of the critical aims for future policy improvement.

In that regard, we aim to discuss possible reasons and policy interventions related to the high utilization of out-of-network services (or low utilization of UCS services) from the perspective of OOP payments and affordability. The study's findings showed that for outpatient care, people who used designated facilities paid 55.44 Baht on average. Those who used informal care and non-designated facilities paid 81.32 and 777.40 Baht on average, respectively. For inpatient care, people who used designated facilities paid 185.37 Baht (per day), while those who used non-designated facilities paid 6614.80 Baht (per day) on average.

For informal care versus designated facility care, the differences in average OOP payments did not seem to be significant. Compared to individual average income (approximately 8400 Baht), the average OOP payment for informal care was less than 1% of the average income, which seemed affordable.

However, between designated facility care versus non-designated facility care, the average OOP payments were significantly different. Specifically, the average OOP payment for outpatient services from non-designated facilities was approximately 10% of the average income, and the average OOP payment for inpatient services from non-designated facilities care was approximately 80% of the average income. Both amounts could hardly be considered affordable for most beneficiaries.

In that sense, private sector involvement would be highly prioritized to address the issue of low utilization. The findings from the outpatient analysis showed that employed individuals depended more on non-designated facilities for care. Since employed individuals may have had less access to designated facilities during the day in general, it was possible that they were compelled to use private facilities after their work hours. As mentioned previously, a total of 229 private facilities (191 clinics and 38 hospitals) joined the UCS program in 2013, which covered only approximately 5.7% of all UCS beneficiaries. Compared to the total number of private facilities (16,800 clinics and 318 hospitals in 2007), 229 private facilities was quite a small number. Along with the previous finding that more than 80% of health services were sought in private clinics (Kirdruang 2011), private sector involvement (particularly private clinic involvement) would be one of the important priorities to address the issue of low utilization.

In addition, affordable costs make the use of informal care more attractive and efficient for those who might have accessibility problems with designated facilities. There may be patients with minor symptoms who desire rapid treatment or medication, and longer wait times or transportation difficulties likely prompt them to opt for informal care. In that sense, private sector involvement as well as benefits coverage expansion to include frequently used medicines may be potential interventions for informal care users.

The higher cost of receiving care from non-designated facilities (particularly inpatient care) likely implies acceptability problems such as low quality or dissatisfaction with needed services at designated facilities. Recipients of care from non-designated facilities may be patients with severe conditions who accordingly need advanced quality services, but these acceptability problems may push them out to non-designated facilities. In that sense, the policy needs to continue improving service quality by expanding and diversifying its benefits according to social needs and consensus. Nevertheless, the actual reasons for these different health-seeking behaviors could be more diverse and significantly differ by social and contextual factors. Because different reasons require different policy interventions, the actual reasons need to be systematically investigated for future policy improvement.

The low utilization of UCS services was found to improve from 2007 to 2013. Specifically, the use of designated facility care increased from 42.78 to 57.54%, the use of informal care decreased from 28.53 to 19.12%, the use of non-designated facility care decreased from 23.35 to 12.90%, and no care increased from 5.34 to 10.44% (Kirdruang 2011). As mentioned previously, we did not notice a significant increase in private sector involvement from 2007 to 2013, thus, this improvement may be partially caused by the expanded benefits coverage of the UCS. Thus, future studies need to examine the impact of the benefits coverage expansion on the use of designated facilities for care. Additionally, other possible confounding factors (e.g., changes in beneficiaries' perceptions of UCS service quality) should be further measured and investigated for a better understanding of this improvement.

In addition, we found that the proportion of people who did not use any health services despite reporting perceived illness increased almost twofold from 5.34% in 2007 to 10.44% in 2013. Furthermore, we noticed some changes in the factors associated with this unmet health need. Specifically, previous findings indicated that in 2007, people in rural areas had significantly higher utilization of designated facilities for care and lower unmet health needs. However, this study found that in 2013, the use of designated facilities for care was not significantly different between rural and urban areas. Additionally, people in rural areas had higher unmet needs (Kirdruang 2011; Limwattananon et al. 2013).

This non-significant relationship of designated facility care utilization between rural and urban areas may have been because either the utilization of UCS services in urban areas relatively increased or the utilization in rural areas relatively decreased. However, the significant increase in unmet needs in rural areas implied the possibility that the utilization of UCS services in rural areas could relatively decrease. Thus, such changes and related factors need to be further explored. This study used a simplistic categorization of region (i.e., urban and rural areas) and did not use a regional distribution of health resources (e.g., the number of health personnel and health facilities by each province or district). We expect that such information would be useful to understand the increased unmet need as well as the regional variation in health-seeking behavior, particularly for people living in remote areas.

Lastly, we would like to mention several limitations in the study. First, the simplistic categorization of health-seeking behavior (e.g., no care, informal care, designated facility care, and non-designated facility care) might not accurately capture the policy impact. Particularly, this study defined both OTC drugs and traditional medicines/healers as the category of informal care. However, certain types of traditional medicines are available in the formal care sector in both designated and non-designated facilities. For instance, some larger designated facilities have their own traditional medicine clinics/departments that operate as independent for-profit units requiring 100% OOP payments.

Additionally, some traditional medicines and doctors are available in licensed traditional medicine clinics, which could be considered non-designated facilities. The HWS data does not specify such information in detail, and therefore, survey respondents could only choose between either herbal/traditional medicine or designated/non-designated facilities. For such issues, the study followed a similar process to previous studies (Kirdruang 2011; Limwattananon et al. 2013).

We initially attempted to use separate categories for OTC drugs and traditional medicines/healers. However, a small sample size (i.e., only 156 beneficiaries used traditional medicines/healers among 13,004 beneficiaries who reported experiencing perceived illness) could not provide a stable estimation in the analysis. Thus, we ultimately combined OTC drugs and traditional medicines/healers and used the combination as the category of informal care in the analysis.

Second, health-seeking behavior varies according to the different severity level of the illness/sickness in general. However, this study was unable to adjust for severity in the analysis because the HWS data, as survey data, provided comprehensive socioeconomic information rather than clinical information. Thus, the policy impact found in this study might have been overestimated or underestimated. If HWS data could be merged with medically related data such as medical claims data or hospital administration data in future studies, it would offer more precise estimations of the policy impact.

Third, the study focused mainly on exploring patterns of health-seeking behavior rather than conducting a cost analysis. A cost-effectiveness or efficiency analysis would be important to evaluate the policy impact from an efficiency point of view. Additionally, health outcome evaluation research would provide additional meaningful insight on the policy impact.

Lastly, the HWS data represented a snapshot of individual health-seeking behavior over only a 1-month period for outpatient care and a 1-year period for inpatient care prior to the survey date, rather than a complete picture between surveys. Thus, a longitudinal analysis to explore changes in health-seeking behavior as well as their social/contextual determinants over time are encouraged to investigate the long-term effects of the policy.

Conclusions

This study investigated patterns of health-seeking behavior and their social/contextual determinants among UCS beneficiaries. The study findings showed that the UCS was adequately responsive to the needs of beneficiaries from a vertical equity perspective. Particularly, for the low-income group, we found that they (1) had more health care needs, (2) received a larger number of services from designated facilities, and (3) paid the least for both inpatient and outpatient services. Nevertheless, the study also found that a substantial proportion of beneficiaries still utilized out-of-network services, which could imply a lack of universal access to policy services from a horizontal equity point of view. Thus, the policy should continue expanding and diversifying its service benefits to strengthen horizontal equity. Particularly, private sector involvement for those who are employed as well as the increased unmet health needs of those in rural areas may be important policy priorities for that. Lastly, methodological issues such as severity adjustment and a detailed categorization of health-seeking behaviors need to be further considered to better understand the policy impact.

Authors' contributions

SCP, as corresponding author, planned the study and carried out the development of the study design, statistical analysis and interpretation, literature review, and manuscript writing. NM participated in the development of the study design and literature review and carried out the data collection and critical revision of the manuscript. TW was involved in the development of the study design and critical revision of the manuscript. All authors read and approved the final manuscript.

Competing interests

The authors declare that they have no competing interests.

Footnotes

¹Thailand's total health expenditure is composed of six different funding sources-(1) UCS (17%), (2) CSMBS (12%), (3) SSS (8%), (4) private insurance (9%), (5) OOP spending (27%), and (6) other public spending (27%). "Other public spending" which is for operating and staffing the system of public health facilities is financed by the Ministry of Public Health (72.5%), local governments (15%), and other ministries (12.5%) (Antos 2007).

²Thailand has its own system of traditional medicine that covers medical practices (e.g., diagnosis and treatment), pharmacy practices (e.g., use of medicinal plants, animals or minerals), midwifery and traditional massage. In the past, traditional Thai medicine had been generally offered by local or non-institutional healers at their homes and religious institutions (Chokevivat and Chuthaputti 2005; Peltzer et al. 2016).

³Over the past decades, the national health development plan (2007-2011) launched an agenda to integrate traditional Thai medicine into the public health care system. In 2008, traditional and alternative medicine accounted for 0.05% of the global UC budget (NHSO 2008). The budget per capita for the use of traditional Thai medicine has increased continuously. The Department of Thai Traditional and Alternative Medicine ( 2011) estimated that 10% of Thai people seeking care in public health facilities received traditional Thai medicine.

⁴Most private clinics belong to medical doctors who work in public facilities, and the doctors operate their own clinics after office hours (Sakunphanit and Suwanrada 2011).

⁵ 1. diabetes; 2. thyroid/goiter; 3. hypertension; 4. heart disease (cardiomegaly/cardiomyopathy/stenosis heart disease/valvular heart disease/coronary artery disease); 5. hyperlipidemias/hypercholesterolemia; 6. stroke; 7. cancer (lung/liver/colon cancer etc.); 8. alcoholism; 9. depression/other mental disorders; 10. dementia; 11. epilepsy/grand mal seizure; 12. cataracts/glaucoma; 13. hearing loss; 14. asthma/emphysema; 15. tuberculosis; 16. allergies; 17. cirrhosis; 18. renal failure/nephrosis; 19. benign prostatic hyperplasia/prostatitis; 20. gallstones; 21. urinary bladder stones (kidney/bladder); 22. gout/rheumatoid; 23. chronic knee pain/osteoarthritis; 24. chronic back pain/chronic neck pain; 25. AIDS; 26. poliomyelitis; 27. leprosy; 28. thalassemia; 29. intellectual disability (Down syndrome); 30. periodontal disease (gingivitis); 31. paresis; and 32. paralysis.

⁶ Unlike this study, Kirdruang's study (2011) used the full sample without dividing those over age 18 and those under age 18; thus, we re-calculated to compare.

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Thailand's universal coverage scheme and its impact on health-seeking behavior

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Thailand's Universal Coverage Scheme (UCS) has improved healthcare access and utilization since its initial introduction in 2002. However, a substantial proportion of beneficiaries has utilized care outside the UCS boundaries. Because low utilization may be an indication of a policy gap between people's health needs and the services available to them, we investigated the patterns of health-seeking behavior and their social/contextual determinants among UCS beneficiaries in the year 2013.

# data[].attributes.body
title: what the street-food ban has really meant for bangkok
source: BK
source bias : slightly liberal
factual reporting:  first hand accounts, and quotes from other major news outlet

# data[].attributes.attachment_link.readable_text
Last year's reports of a government plan to clear Bangkok's major sidewalks completely of their street vendors caught the city unaware, arriving only days after CNN's crowning of the city as "the world's street food capital." The food-loving world-with grilled pork skewers, wok-fried noodles and late-night bowls of rice porridge in mind-met the news with a chorus of dismay. Many criticized the move as a tragedy, a whitewashing of the local culture, and shameful treatment of the city's working class who depend on cheap food to survive.

So when articles surfaced hours later exhorting the world's foodies to relax because street food would remain untouched, they took on the tone of a Trump administration communications official backpedaling over "fake news." Why would anything be announced at all, if nothing was to change? And if nothing had changed, why were vendors already being cleared from certain areas?
It's now one full year since the "ban" came into effect, and the answers to those questions are beginning to surface.

"The only concern from City Hall is that the food remain sanitary"

Vallop Suwandee is chief consultant to the Bangkok Metropolitan Administration (BMA), and for over a year, the long-time civil servant has spearheaded the city's current drive to "clean up" its streets of rogue hawkers. According to Vallop, initial articles announcing a comprehensive clean-up had been "misreported," despite several media outlets directly quoting him outlining a ban on street vendors from the main roads of all 50 Bangkok districts.

The ban only concerned vendors with "temporary" permits, and "a minimum of vendors were affected," he now tells us, adding that he is a fan of street food from around the Thonglor area. "The only concern from City Hall is that the food remains sanitary."

But experts working with vendor groups and academics say that this isn't the whole story. "It is clear that the ban isn't just focusing on a small number of vendors or a particular neighborhood... it is affecting vendors all over the city, from a variety of backgrounds," says Trude Renwick, a U.S.-based scholar working on her PhD dissertation on commercial space in Bangkok.

Bangkok street food first flourished during the '80s and '90s, when the city was under the tenure of former governor Chamlong Srimuang. "The BMA allowed vendors to conduct business on sidewalks in order to lessen the burden on family income," Vallop says. "Pedestrians had no objection because the city of Bangkok was not so crowded."

Today, he says that the clean-up of the streets is simply bowing to the will of the people, who complain that vendors are taking up too much space in a city of an estimated 8.5 million people. The areas most affected are the ones with the most number of complaints-Siam, Sukhumvit, Victory Monument and Saphan Lek.

"Personally, I think Bangkok should look like Singapore"

Vallop also confirms speculation that real estate developers are often behind the anti-street food movement, claiming that the presence of vendors affects their property values. Ultimately, he says he would like to see street food relegated to certain areas, as it is in Kuala Lumpur, Jakarta and Singapore.

"Personally, I think Bangkok should look like Singapore," he says. Unfortunately, Thais make less money (a yearly average of US$5,911 per person according to the World Bank in 2016) than the denizens of Singapore (US$52,963), making access to cheap food more of an imperative.

But Vallop insists that the BMA is looking out for lower-income workers too. The sub-sois of cleared areas such as Thonglor are still open to food vending, and the outer areas of Bangkok remain unaffected. Yaowarat and Khaosan Road continue to be havens for street food-loving tourists. Shoulder-pole hawkers and mobile cart vendors who move from place to place are "welcome" to continue selling, he says. "But please do not come to Bangkok just to set up a food stall after harvest season. "You have to care for the general public and the land value of the shop-house right behind you."

The BMA is also considering an incentive for developers that would allow them to construct higher buildings and increase rental space on the condition that they include a food court in their complexes incorporating street food vendors from the community.

All the BMA would like in return is a little thoughtfulness. Vendors "have to be considerate," says Vallop. "The pavement is for pedestrians. You pay no rent, you pay no sales tax. Please pay back to the community. We need to live together. We need to live in harmony."

Treating the vendors as a nuisance that must be tolerated and managed obscures the genuine good-and money-that they bring to their communities, aid workers say. Sarah Reed of U.K.-based non-profit organization Wiego says the removal of street vendors from areas has actually cut down on foot traffic, adversely affecting the sales of surrounding businesses.

Vendor evictions in Pak Khlong Flower Market, Ramkhamhaeng Market and Sukhumvit resulted in across-the-board sales drops, lessened operating hours and even some closures for surrounding shop-house businesses, Wiego found.

"Before, I thought that this was a problem for the street vendors," one business owner in Ramkhamhaeng told Wiego. "But now I know that the street vendors' problem is my problem too."

Business owners and vendors alike are now finding ways to be heard. In Ari, plans to clear the area were shelved when vendors banded together to form their own advocacy group. Meanwhile, a recent petition to the District Office signed by 30 Sukhumvit businesses is asking that the vendors be permitted to return to Sukhumvit Soi 11.

"The silver lining to this dark cloud is that vendors have gotten organized," says Reed. "There is now a network of vendors that can represent their own needs and interests, and communicate the incredible asset that vending represents to Bangkok's economy."

"Now I know that the street vendors' problem is my problem too"

The cycle of celebrating and discouraging street vending is nothing new to long-time veterans of the street food scene like Sithidet Siripongwatoch of legendary guaythiew kua gai (stir-fried chicken noodle) stall Nai Peng. The Sam Yan neighborhood he has worked in for the past 30 years has changed drastically since he first set up shop at 29, gradually giving way to an ambitious plan to form Thailand's own version of "Silicon Valley." Just a short walk from his bustling, open-air shop-house wreathed in wok smoke, newly-built Chinese-style shop-houses slicked in red paint mimic the buildings of Singapore's Chinatown.

"We don't plan on going anywhere," said Sitidet of his stall, which won Michelin's Bib Gourmand award last year. The closure of the nearby Suan Luang market and recent renovations have cost him up to three years' worth of revenues, he estimates. All the same, "we'll stay until they stop renewing our lease, and then move to the next street over."

What do the vendors on the street have to say?

Lek, Shark fin soup vendor
"I can't afford to rent a shop-house. Prices here can go up to B300,000 [a month] for a space on the main road. I've already started seeing officers coming to regulate and it's terrifying knowing we can't do anything but oblige."

Nok, Pa tong go (fried dough) vendor
"I guess we should consider ourselves lucky that we are only getting regulated but not cleared. Right now, we vendors have to help each other. We have to listen to what they say: stop having stalls that stick out into the road, stop washing dishes on the road."

Jeng, Jui guay
(steamed rice cake) vendor
"If you remove street food everywhere else, there will be a lot more people in Yaowarat and wouldn't that make things even more disorderly? Plus, this is not the only tourist destination in Bangkok. Tourists want to go all over the city. They need street food elsewhere too."

Nui, Somtam vendor
"We're poor. We can hardly afford to rent a home, let alone a shop-house to sell our food. The government needs to care about Thai people and Thai culture, not tourists. Thai people love street food. Somtam is our national food. People rely on it to be accessible everywhere they go."

Sources: Thailand Development Research Institute (TDRI), National News Bureau of Thailand

# data[].attributes.attachment_link.title
What the street-food ban has really meant for Bangkok

# data[].attributes.attachment_link.description
Last year's reports of a government plan to clear Bangkok's major sidewalks completely of their street vendors caught the city unaware, arriving only days after CNN's crowning of the city as "the world's street food capital." The food-loving world-with grilled pork skewers, wok-fried noodles and late-night bowls of rice porridge in mind-met the news with a chorus of dismay.

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title: thai farmers drowning in debt
source: IMMF
source bias: highly liberal
factual reporting: focuses on first hand accounts and analyzes situation  thoroughly and factually

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Thai Farmers Drowning in Debt

By Minh Ly, Baria-Vungtau Newspaper, Vietnam
Thailand is proud of being the world's leading rice exporter, but that does not mean agriculture in Thailand is thriving. Most farmers are heavily in debt and cannot find a way out.

Many Thai farmers borrow from banks to buy fertilisers and pesticides to increase production. Because crop prices remain low, the farmers cannot repay their loans. They become debtors.

"I cannot stop using chemicals, although I want to do it", said Boonsong, a worried farmer in the San Patong area of northern Thailand. "They increase productivity and bring more income for us when crops prices are high. But they also create a disaster-debt. I have to keep spending more money on chemicals."

This farmer, who plants rice and onions for export, said he tried to stop using chemicals for a short time, but his productivity dropped, and consumers did not like his produce.
He held his sore back as he talked. Strain showed on his face.

" How can I earn a lot of money to repay 100,000 baht for fertilisers and pesticides? Boonsong said.

Despite working hard, he added, he still can't earn enough to repay his debts. His income depends on what his produce fetches on the market, but the prices remain low. Meanwhile, chemicals become more and more expensive.

Boonsong explained how he must rotate debts, borrowing from local lenders to pay off outstanding interest to the bank. " I had to use my house and my land as a deposit to borrow money ", he said sorrowfully.

Now his only hope is for crop prices to rise. How long must he wait?

Boonsong's story symbolises agriculture in Thailand. At present, 88 percent of Thailand's 25 million farmers may be in debt.

Solving rural debt isn't easy. Organic farming and self-sufficiency have been touted as one way to liberate farmers. But such methods do little for Thailand's food trade.
Most organic fruits and vegetables do not meet export standards, and exports are vitally important for Thailand.

" We face a big difficulty with marketing," said Ban Doeun, president of an organic farming group in Ban Baa Nord village in Chiang Mai province. " Organic farming is good for human health, but the appearance of the food is not attractive. As a result, many consumers dislike our product. Organic food is also dearer."

Instead of switching to organic crops, Thai farmers may find themselves forced to grow GM (genetically modified) crops.

A growing global population will require the world's farmers to produce more food from the same amount of land. GM crop production, which uses seed technology to make crops more efficient, is seen as one way to do that. But some scientists say GM crops would harm the environment by contributing to a lack of bio-diversity.

Trade liberalisation brought about by the World Trade Organization also may add pressure to grow GM crops. But farmers may be forced to buy expensive seeds from big companies every year to grow GM crops, falling further into debt.

A leading rice trader said farmers created their own problems.

"If farmers could not pay the bank, whey did they borrow so much?" said Vichai Sriprasert, president of Riceland International Ltd., and a board member of Thailand Rice Exporters Association. "They must find a way themselves to pay their debts."

Vichai acknowledged that farmers had borrowed heavily, but saw no benefit from the money. They invested vast sums but had to sell their crops at low prices.

Some critics blame government policy for Thailand's rural debt problem.
Vichai said the government should not interfere in the open market by setting " unrealistic" minimum prices that food processors could not pay.

The rice exporter also would prefer that no pesticides be used, but said he feels most farmers will need them. Using chemicals, however, continues to sink farmers more deeply into debt. And once they are in debt, the banks are reluctant to lend them more money to invest.
Thai farmers cannot find a way out.

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Thai Farmers Drowning in Debt By Minh Ly, Baria-Vungtau Newspaper, Vietnam Thailand is proud of being the world's leading rice exporter, but that does not mean agriculture in Thailand is thriving. Most farmers are heavily in debt and cannot find a way out. Many Thai farmers borrow from banks to buy fertilisers and pesticides to increase production.

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title: A Study of Demand Estimate of Chinese Streetfood made in Thailand in Bangkok Market
source: Bangkok university
credibility evaluation:  empirical data from survey + first hand accounts from tourists and street vendors

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title: lead poisoning and health
source : WHO
source bias: none written from a scientific point of view
factual reporting: high

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Overview

Lead is a naturally occurring toxic metal found in the Earth's crust. Its widespread use has resulted in extensive environmental contamination, human exposure and significant public health problems in many parts of the world.

Important sources of environmental contamination come from mining, smelting, manufacturing and recycling activities and use in a wide range of products. Most global lead consumption is for the manufacture of lead-acid batteries for motor vehicles. Lead is, however, also used in many other products, for example pigments, paints, solder, stained glass, lead crystal glassware, ammunition, ceramic glazes, jewellery, toys, some traditional cosmetics such as kohl and sindoor, and some traditional medicines used in countries such as India, Mexico and Viet Nam. Drinking water delivered through lead pipes or pipes joined with lead solder may contain lead. Much of the lead in global commerce is now obtained from recycling.

Young children are particularly vulnerable to the toxic effects of lead and can suffer profound and permanent adverse health impacts, particularly on the development of the brain and nervous system. Lead also causes long-term harm in adults, including increased risk of high blood pressure, cardiovascular problems and kidney damage. Exposure of pregnant women to high levels of lead can cause miscarriage, stillbirth, premature birth and low birth weight.

Sources and routes of exposure

People can become exposed to lead through occupational and environmental sources. This mainly results from:

inhalation of lead particles generated by burning materials containing lead, for example during smelting, recycling, stripping leaded paint and plastic cables containing lead and using leaded aviation fuel; and

ingestion of lead-contaminated dust, water (from leaded pipes) and food (from lead-glazed or lead-soldered containers) and from hand-to-mouth behaviour.

Young children are particularly vulnerable to lead poisoning because they absorb 4-5 times as much ingested lead as adults from a given source. Moreover, children's innate curiosity and their age-appropriate hand-to-mouth behaviour result in their mouthing and swallowing lead-containing or lead-coated objects, such as contaminated soil or dust and flakes from decaying lead-containing paint. This route of exposure is magnified in children with a psychological disorder called pica (persistent and compulsive cravings to eat non-food items), who may pick away at and eat leaded paint from walls, door frames and furniture. Exposure to lead-contaminated soil and dust resulting from battery recycling and mining has caused mass lead poisoning and multiple deaths in young children in Nigeria, Senegal and other countries.

Once lead enters the body, it is distributed to organs such as the brain, kidneys, liver and bones. The body stores lead in the teeth and bones, where it accumulates over time. Lead stored in bone may be released into the blood during pregnancy, thus exposing the growing fetus Undernourished children are more susceptible to lead because their bodies absorb more lead if other nutrients, such as calcium or iron, are lacking. The very young are at the highest risk, as is the developing nervous system is a particularly vulnerable period

Health effects in children

Lead exposure can have serious consequences for the health of children. At high levels of exposure to lead the brain and central nervous system can be severely damaged causing coma, convulsions and even death. Children who survive severe lead poisoning may be left with permanent intellectual disability and behavioural disorders. At lower levels of exposure that cause no obvious symptoms, lead is now known to produce a spectrum of injury across multiple body systems. In particular, lead can affect children's brain development, resulting in reduced intelligence quotient (IQ), behavioural changes such as reduced attention span and increased antisocial behaviour, and reduced educational attainment. Lead exposure also causes anaemia, hypertension, renal impairment, immunotoxicity and toxicity to the reproductive organs. The neurological and behavioural effects of lead are believed to be irreversible.

There is no known safe blood lead concentration; even blood lead concentrations as low as 3.5 µg/dL may be associated with decreased intelligence in children, behavioural difficulties and learning problems (1).

Burden of disease

The World Health Organization's 2021 update of the Public health impact of chemicals: knowns and unknowns estimates that nearly half of the 2 million lives lost to known chemicals exposure in 2019 were due to exposure to lead. Lead exposure is estimated to account for 21.7 million years lost to disability and death (disability-adjusted life years, or DALYs) worldwide due to long-term effects on health, including 30% of the global burden of idiopathic intellectual disability, 4.6% of the global burden of cardiovascular disease and 3% of the global burden of chronic kidney diseases.

WHO response

WHO has identified lead as one of 10 chemicals of major public health concern needing action by Member States to protect the health of workers, children and women of reproductive age. WHO has made available through its website a range of information on lead, including information for policy-makers, technical guidance, training materials and advocacy materials. WHO has developed guidelines on clinical management of lead exposure and recommends that for an individual with a blood lead concentration ≥ 5 µg/dL, the source(s) of lead exposure should be identified, and appropriate action taken to reduce and terminate exposure.

The successful phasing out of leaded gasoline in most countries, together with other lead control measures, has confirmed significant public health benefits with a significant decline in population-level blood lead concentrations in many countries (2). As of July 2021, leaded fuel for cars and lorries is no longer sold anywhere in the world (3). However, more needs to be done to phase out lead paint; as of March 2023, only 48% of countries have introduced legally binding controls on lead paint.

Since leaded paint is a continuing source of exposure in many countries, WHO has joined with the United Nations Environment Programme to form the Global Alliance to Eliminate Lead Paint which has the aim of encouraging all countries to have legally binding laws to control the use of lead in paint. This goal has received further support in the WHO Chemicals Road map to enhance health sector engagement in the Strategic Approach to International Chemicals Management towards the 2020 goal and beyond (decision WHA70(23)), which includes national action to phase out the use of lead paint.

WHO is currently preparing guidelines on prevention of lead exposure, which will provide policy-makers, public health authorities and health professionals with evidence-based guidance on the measures that they can take to protect the health of children and adults from lead exposure.
References
(1) US CDC Advisory Committee on Childhood Lead Poisoning Prevention. CDC updates blood lead reference value to 3.5µg/dL. Atlanta: US Centres for Disease Control and Prevention; 2021 ( https://www.cdc.gov/nceh/lead/news/cdc-updates-blood-lead-reference-value.html).

(2) End of leaded fuel use a "milestone for multilateralism" press release https://news.un.org/en/story/2021/08/1098792, 2021.

(3) Angrand et al. Relation of blood lead levels and lead in gasoline: an updated systematic review. Environmental Health (2022) 21:138 https://doi.org/10.1186/s12940-022-00936-x.

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Lead is a naturally occurring toxic metal found in the Earth's crust. Its widespread use has resulted in extensive environmental contamination, human exposure and significant public health problems in many parts of the world.

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title: policy issues on street vending: an overview of studies in Thailand, Cambodia and mongolia
source:  ILO
credibility evaluation: Group 1

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Policy Issues on Street Vending: An Overview of Studies in Thailand, Cambodia and Mongolia

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Policy Issues on Street Vending: An Overview of Studies in Thailand, Cambodia and Mongolia

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title: wet market makeover hopes to sway modern hoppers
source: Bangkok Post
source bias: moderate liberal
factual reporting: insights from people from the direct field, history, and factual information

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time for a tune-up: Talat Thetsaban 3, known as 'Talat Yai', has been a centre of social and business activities in Ubon Ratchathani for several decades. It now needs to adjust because competition from more modern, cleaner facilities is luring a new generation away.

Talat Thetsaban 3, known as "Talat Yai", and located in Muang Ubon Ratchathani municipality, is more than a traditional wet market for dwellers of Ubon Ratchathani province.

Called talat sod in local language, a wet market is a quintessential part of Thai life. By contrast with today's well-built modern supermarket, the Thai-style wet market is rudimentary, comprising raised vendor stalls, a roof, basic drainage and few washing basin facilities.

Even though modern trade offers people cleaner and more modern facilities, local people, at least in Ubon Ratchathani province, still flock to shop at local wet markets like Talat Yai.

"For residents of Ubon Ratchathani, a fresh market like Talat Yai and other local community wet markets are more than just places where people go to shop. Going to the market is a form of social interaction in the community," said Nara Huttasin, lecturer at the Faculty of Management Science at Ubon Ratchathani University, and head of a research project that studies business and management models to help traditional Thai-style wet markets move into the future.

The project has chosen Talat Yai, operated by the local municipality and Talat Don Klang, a private-owned medium-size wet market, for its study.

Both talat sod sites are located in Muang Ubon Ratchathani district. The team hopes the outcome of the story will provide a model of good practice for state and private wet markets in the province.

OLD STOMPING GROUND

Located by the Mun River, the provincial central railway station and major roads, Talat Yai has been more than just a market. For local people, it is an old stomping ground.

"During the research, we learned that even local people who moved elsewhere come back to revisit this market every time they return to the province," said Ms Nara.

"Talat Yai," is the oldest market in the province, with records dating back since the reign of King Rama V.

times of yore: Images of Talat Yai from 50 years ago.

Its central location brings in people and creates economic and social activities. Vendors and buyers come to trade, and people come to shop and meet others. Fifty years ago, around the market, three movie theatres were built and when the US Army opened a military base four decades ago, the area around the old wet market became a military enclave.

The market has undergone major changes after two major fires in 1960 and 1970, not to mention renovations.

Ms Nara said the research project is the latest makeover for Talat Yai. Yet this time it involves more than just physical reconstruction.

WET MARKET MAKEOVER

Early this year, the research team started collecting data, holding workshops and holding talks with market operators, vendors and consumers.

The research is funded by Thailand Science Research Innovation (TSRI). The agency has provided grants to 21 universities across the nation, asking these researchers to find innovations that can help develop the well-being of the local community.

This research team said Ms Nara decided to work on an innovation concerning clean food.

"A market is the first spot that we should develop if we want to create food safety and well-being in the community. A market is not just a place where people come to buy and sell foods. It is a focal point in the production chain. It forges connectivity between producers and consumers," she said.

The study started in February this year and will take three years to complete.

Ms Nara said the project will provide answers about a new role and new look for wet markets in modern times.

Nara Huttasin, lecturer

"Wet markets can be like the retail giant Macro, only with walls and air-con removed," said Ms Nara.

She said wet markets need to adjust to avoid disruption.

"Despite fresh markets being a way of life for Thais and still popular with locals, we find that the young generation is starting to shift to modern shops. It is not that the young generation is turning their backs on traditional fresh markets. They want to buy food from a clean market, markets that are not wet and dirty," Ms Nara said.

WET MARKET OF THE FUTURE

The research comes in three phases.

The first phase started in February and will end early next year, and will explore good practices and offer models on making wet markets both cleaner and more convenient, and maintain reasonable prices.

The second phase, expected to start some time next year, will focus on how to turn fresh markets into gastronomy tourism spots and the third will find innovations for market services such as developing environmentally-friendly food packaging from local farm products such as tapioca, or using micro-organisms to treat wastewater.

In terms of the food business, the team is trying to find a way to make local wet markets places for farmers to sell organic products.

"Currently, little organic food and vegetables are sold at wet markets because the market itself is not a place where vendors and organic farmers can sell premium products. So, we need to find a way to make a wet market a place that can promote healthy organic products where both sellers and buyers are happy."

Talat Thetsaban 3 known as "Talat Yai" locating in Muang Ubon Ratchathani Municipality, of Ubon Ratchathani district will get a new facelift to improve service, landscape for making it place for food safety and organic products.

The first phase focuses on getting market operators, sellers and consumers on board to work together. "We learned that vendors want to take part in developing the market. They want to help cleaning the market. Market owners also want to make the market clean and modern, they just do not know how to do it correctly," she said.

The team has brought in experts from eight fields -- food processing, market management, marketing, economics, services, architectural design, product display and service and public hygiene.

Operators and vendors are trained to store fresh meats and vegetables properly. Fresh market executives receive advice on how to design and build fresh markets that are hygienic and environmentally friendly and how to conduct regular food safety sampling. The project also trains vendors in waste management. One activity teaches them to sort organic waste to provide to farmers for making organic fertiliser. The project also brings organic farmers, vendors, consumers and food experts together to discuss developments in organic food.

FUTURE GENERATION

Rattanan Pataratanased, the owner of Talat Don Klang, said the project helps owners of traditional wet markets move into the future. "After joining the project, I learned how to develop the standards and services of our market," said Mr Rattanan.

Joining the research, private owner of Talat Dong Klang invests about 10 million baht to improve landscape and upgrade hygiene infrastructures such as building new washing basin facilities and wastewater treatment plant.

Talat Don Klang is a family business and he is a member of the second generation of the market's management. Mr Rattanan, 43, had to convince his parents and the older generation to invest in the fresh market. So far, the family has spent about 10 million baht making upgrades to the physical space, such as building more washbasins and adjusting roofs and lights to make the market airy and bright.

He said wet markets need to adjust to stay competitive. "Of course, we still have vendors and consumers. But we need to stay ahead of the game and get better because the competition in the market sector is high too," he said. "When people think of good, clean food, they often think about modern shops or superstores. But this project reminds us that any fresh market can sell clean and quality food."

Nutjarin Putthaongraksa, a food vendor in Talat Yai, said vendors are enthusiastic ready to cooperate. She thanked the university for using its knowledge to help the fresh market move into future. She said she wished the university would also help the local administration.

Nimit Sitthitrai, president of the Ubon Ratchathai Provincial Chamber of Commerce said development models and good practices arising from this project will become a prototype for other fresh markets in the province.

Image of Talat Don Klang before getting a face lift. Its former condition reflects typical image of Thai style wet market in Thailand with rudimentary structures.

One of key elements to help Thai style wet market develop is to improve food safety. Health officials help testing food safety to make sure ingredients and food are up to required health standards.

The researchers train vendors to sort wet garbage to make organic fertilisers.

Rattanan Pattaratanased, owner of Talat Don Klang Market, believes Thai style wet market can become more competitive and can reckon with modern trade.

Talat Yai has been existing over century as open market where vendors just bring food to sell. Yet, the first building structure was built in over six decades ago.

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Wet market makeover hopes to sway modern shoppers

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time for a tune-up: Talat Thetsaban 3, known as 'Talat Yai', has been a centre of social and business activities in Ubon Ratchathani for several decades. It now needs to adjust because competition from more modern, cleaner facilities is luring a new generation away.

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title: A foodie's guide to capitalism: understanding the political economy of what we eat
source: published by the NYU press
source bias: liberal
comment: ERIC HOLT-GIMÉNEZ the author has a long history in the fields of agriculture and also economics well known in both fields

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A Foodie's Guide to Capitalism: Understanding the Political Economy of What We Eat

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Capitalism drives our global food system. Everyone who wants to end hunger, who wants to eat good, clean, healthy food, needs to understand capitalism. This boo...

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Title:A recipe for success: How Singapore Hawker Centres Came to Be
Source:  IPS
Crebility evaluation: Group 1

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title: the unbearable whiteness of milk
source:  SSRN
Credibility evaluation: Group 1

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UC Irvine Law Review, Vol. 3, p. 1251, 2013

29 Pages Posted: 27 Jun 2014

Date Written: 2013

Abstract

Food oppression is institutional, systemic, food-related action or policy that physically debilitates a socially marginalized group. This theory attributes racial/socioeconomic health disparities to policies and practices that appear neutral yet disproportionately harm vulnerable individuals, particularly those whose identities lie on multiple axes of oppression, including race, gender, sexual orientation, age, ability, and immigration status. Unbearable Whiteness explores this theory through the specific example of the USDA's dual role of nutrition adviser and entity responsible for the dairy surplus. The USDA's advice in the federal Dietary Guidelines led to a thirty year decline in milk sales. In response, the USDA formed a marketing branch that partners with fast food companies to increase the amount of cheese in their products. This tactic has successfully reduced the surplus and added harmful amounts of saturated fats to the diets of communities who rely primarily on fast food for nutrition in urban centers. These populations consist mainly of low-income African Americans and Latinos. Unbearable Whiteness explores how the joint actions of industry and government may lead to the creation and perpetuation of health disparities and explores legal challenges to the problem.

Keywords: food policy, critical race theory, food justice, health policy

JEL Classification: I18

Freeman, Andrea, The Unbearable Whiteness of Milk: Food Oppression and the USDA (2013). UC Irvine Law Review, Vol. 3, p. 1251, 2013. Available at SSRN: https://ssrn.com/abstract=2338749

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the unbearable whiteness of milk: food oppression and the usda

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The Unbearable Whiteness of Milk: Food Oppression and the USDA

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UC Irvine Law Review, Vol. 3, p. 1251, 2013 29 Pages Posted: 27 Jun 2014 Date Written: 2013 Food oppression is institutional, systemic, food-related action or policy that physically debilitates a socially marginalized group.

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title: food contamination: nationwide tests reveal problems
source: bangkok post
source bias: liberal
factual reporting: statistics + scientific research

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Recent surveys reveal food contamination at fresh markets, roadside stalls as well as places where higher standards of cleanliness would be expected such as supermarkets and department stores.

Food processing and food safety has long been an important field at Thai universities.

Thailand has experienced food safety setbacks in the past in its food export sector ranging from avian flu (article #1 and #2) to contamination of fruit exports to Europe (article #1).

These problems were solved and high standards imposed (See articles #1 (21-11-2008), #1 (19-02-2009)).

Today's article reveals that food safety problems still remain to be solved in food for domestic consumption.

Click button to listen to Food Contamination and rightclick to download

Survey finds harmful bacteria, chemicals rife in popular foods by Sirikul Bunnag

Many popular food items sold in fresh markets, roadside stalls, supermarkets and large department stores have been found to be contaminated with either bacteria or chemicals considered unsafe for consumption.

The findings come from an annual survey conducted by a food safety network made up of Mahidol, Chiang Mai, Khon Kaen, Prince of Songkla universities and the Foundation for Consumers.

Researchers studied food samples between September last year and this year and found the problem to be a major cause for concern.

The overall food safety situation in the country is still worrying despite the government's efforts to improve it over the past decade," said Pornrat Sinchaipanij, a researcher with Mahidol University's Institute of Nutrition.

She pointed out in particular bacterial contamination of school milk.

Up to 25% of pasteurised and 5% of UHT milk samples supplied to schools nationwide had been found to be contaminated with coliform and e-coli bacteria.
The researchers randomly tested food in eight provinces: Bangkok, Samut Songkhram, Phayao, Chiang Mai, Maha Sarakham, Khon Kaen, Songkhla and Satun.

Processed food such as sausages and meatballs contained certain preservatives, which contravenes the Food and Drug Administration's regulation that this kind of food must be free of preservatives

Of the pork and chicken sausage samples tested, 36% and 75% contained benzoic acid. All the meatball samples were found to contain it and all the chicken meatball samples tested positive for benzoic acid and nitrate.

Of all samples of fishballs tested, 75% were found to contain at least one type of preservative.

Accumulation of food preservatives in the body can lead to serious diseases such as cancer, Asst Prof Pornrat said.

The research said the good news from the survey was that none of the tested samples in this food category had borax in them. She attributed this to the government's consistent campaigns to stop the use of this chemical in foods.

In the fruit and vegetables category, 63% of orange samples were found to be contaminated with pesticides. This was followed by long beans (50%), broccoli (44%), cabbages (38%) and Chinese kale (33%).

In the dried food products group, all of the samples of ground dried chillies, 60% of shitake mushrooms, and 64% of dried shrimps contained pesticides, Asst Prof Pornrat said.

In the popular food group, half of the pork samples used in popular Korean grill restaurants tested positive for meat reddening chemicals. All samples of the fermented fish sauce, pla ra, which is a key seasoning ingredient in Northeastern cuisine, were contaminated with bacteria.,

A total of 12% of the noodle samples tested contained fungal aflatoxins exceeding the level considered safe for consumption, she said.

(Source: HEALTH, Survey finds harmful bacteria, chemicals rife in popular foods, 5/10/2010, Sirikul Bunnag, link)
food safety - a scientific discipline that studies the handling, preparation, and storage of food to prevent food from carying illness (See Wikipedia) ความปลอดภัยในเรื่องการอาหารนับแต่กระบวนการการผลิต ขนส่ง การจัดเก็บและจัดจำหน่ายfood processing - the methods and techniques used to make food products from raw food ingredients such as meat and vegetables (See Wikipedia) contamination (noun) - made dirty and dangerous to use or eat after exposure to dirt, germs, chermicals, or radiation การปนเปื้อนเชื้อแบคทีเรีย
reveals - showssurveys - a careful examination of something to determine quality or condition of something (example: a survey of buildings in the city to check for earthquake safety)
fresh market - wet market, an open air food market as commonly found throughout Thailand and Asia (See Wikipedia)
stalls - large tables or small shops with an open front from which goods are sold in a public place แผงขายของ
standard - an acceptable level of quality of achievement มาตรฐาน
setbacks - problems that prevent moving forwards to reach goals, problems that hinder progress
impose - force someone to follow a rule or law consumption - using, eating or drinking something การบริโภค
Avian Flu, bird flu - a danger virus transmitted to humans by birds (See Wikipedia) ไข้หวัดนก

rife - very common or frequent มีอยู่ทั่วไป,แพร่หลาย
contaminated (adjective) - made dirty, polluted or poisonous by the addition of a chemical, waste or infection การปนเปื้อนเชื้อแบคทีเรีย
findings - the results or conclusions of an investigation or research
annual - happening once a year ประจำปี
survey - gathering information about what people think about different subjects (public opinion) by asking large numbers of people questions and counting their answers, and then using statistics, graphs, and tables to present results (See Wikipedia)การสำรวจความเห็น network - a large system of connected parts, organisations, people, etc. เครือข่าย
concern - a worry ความกังวล
major cause for concern - something causes you to worry very much

efforts - people trying to accomplish something, achieve a goal ความพยายาม
improve - to make better ทำให้ดีขึ้น
decade - a period of ten years ทศวรรษ, ระยะเวลา 10 ปี

domestic - inside the country (here: inside Thailand, not exports) pasteurized - heating a food to slow the growth of bacteria in food, the procedure for making milk safe to drink (See Wikipedia)
nationwide - throughout a whole country ทั่วทั้งประเทศ
coliform - a type of bacteria in unclean food and water that can cause health problems (See Wikipedia)
bacteria - the very small living things that cause many sicknesses and diseases in humans (See Wikipedia)
e-coli - a bacteria sometimes found in food that can cause serious food poisoning, often the reason behind food recalls(See Wikipedia)
food recall - when the government requests that some food product be taken off the shelves of stores because it is dangerous to eat
randomly - chosen without any particular pattern (to make sure you get a sample, small but representing the larger group)
randomly tested - searched to see if something was true of the larger group by looking at a smaller group (a "random sample")
sample - a small amount or example of something that shows you what all of it is like Wikipedia)
processed food - food that has been made into a product sold in stores after "food processing"
sausages - a prepared food made from ground meat, animal fat, salt, spices, and herbs packed in a tube-like casing, orignally used as a food preservation technique (See Wikipedia)
preservatives - a chemical added to prevent the food from going bad (rotting, decaying), food preservatives, food additive (See Wikipedia on food additives)
contravene - goes against the law, breaks the law regulation - an official rule that controls the way that things are done in an industry or activity กฎระเบียบ, ระเบียบข้อบังคับ Wikipedia) which can be dangerous if eaten in large quantities (See Wikipedia) Wikipedia on food curing)

accumulation - when something collects or gathers together over time and increases
category - a group of people or things that have similar qualities หมวดหมู่ ประเภท
consistent - doing a task the same way (not changing all the time) อย่างสม่ำเสมอ อย่างเสมอต้นเสมอปลาย
campaigns - a long series of events staged to achieve a goal or to promote something (for example, an "anti-smoking campaign")

pesticides - chemicals that kill insects that can destroy plants
shitake - a mushroom very popular in Asian cooking (See Wikipedia)
grill - to cook something by direct heat, especially under a very hot surface in a cooker ย่าง
random sample - a method in statistics of studying a larger group by only looking at a smaller "randomly" chosen group (See
fermented - changed chemically through the action of living substances, such as yeast or bacteria หมัก
fermented fish sauce - the "pla Ra" used in Thai papaya salad "som tam"
key - important คนสำคัญ
seasoning - things that are added to food to make it taste better, such as spices or even salt and pepper
ingredient - one of the substances that are combined to make something ส่วนผสม
aflatoxins - a type of poisonous fungus or mold (mycotoxin) that can cause cancer (See Wikipedia)
Food and Drug Administration (FDA) - the government agency that regulates food and medicine (they made sure the food and medicine is safe to use) องค์การอาหารและยา
exceeding - passing a limit, going beyond
benzoic acid - a chemical that has been used as a food preservative (See

tested positive - a test to see if something was present (disease in a person, poison or bacteria in food) said that it was present
nitrate - a chemical used to prepare or "cure" food, helps kill bacteria and also produces a special flavour and pink red colour (See

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ข่าวภาษาอังกฤษ

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ข่าวบางกอกโพสต์

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เรียนภาษาอังกฤษ

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Food contamination: Nationwide tests reveal problems

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Recent surveys reveal food contamination at fresh markets, roadside stalls as well as places where higher standards of cleanliness would be expected such as supermarkets and department stores. Food processing and food safety has long been an important field at Thai universities.

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title: characteristics and influential factors of food deserts
Source: USDA
Credibility evaluation: Group 1

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USDA's Economic Research Service previously identified more than 6,500 food desert tracts in the United States based on 2000 Census and 2006 data on locations of supermarkets, supercenters, and large grocery stores. In this report, we examine the socioeconomic and demographic characteristics of these tracts to see how they differ from other census tracts and the extent to which these differences influence food desert status. Relative to all other census tracts, food desert tracts tend to have smaller populations, higher rates of abandoned or vacant homes, and residents who have lower levels of education, lower incomes, and higher unemployment. Census tracts with higher poverty rates are more likely to be food deserts than otherwise similar low-income census tracts in rural and in very dense (highly populated) urban areas. For less dense urban areas, census tracts with higher concentrations of minority populations are more likely to be food deserts, while tracts with substantial decreases in minority populations between 1990 and 2000 were less likely to be identified as food deserts in 2000.

Keywords: Food deserts, food access, low income, census tracts
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Characteristics and Influential Factors of Food Deserts

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USDA's Economic Research Service previously identified more than 6,500 food desert tracts in the United States based on 2000 Census and 2006 data on locations of supermarkets, supercenters, and large grocery stores. In this report, we examine the socioeconomic and demographic characteristics of these tracts to see how they differ from other census tracts and the extent to which these differences influence food desert status.

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Title: bangkok's street food projects
source: FAO
source bias: none
factual reporting: matter of fact tone, clear concise, might be outdated, cites from journals

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Bangkok's street food project
Le projet modèle de vente d'aliments sur la voie publique à Bangkok
Proyecto sobre alimentos callejeros en Bangkok

R. Dawson, S. Liamrangsi and F. Boccas

Richard Dawson is Senior Technical Advisor at the FAO Regional Office for Asia and the Pacific (FAORAP). Suang Liamrangsi is Senior Expert in Public Health at Thailand's Department of Health. Franck Boccas is an FAO Associate Food and Nutrition Officer.

Confronted with the need to control health hazards, street litter, effluent disposal, pollution and obstruction of pedestrian traffic resulting from street food vending, the Bangkok Metropolitan Administration (BMA) authorizes and regulates this activity through the city police and the district Public Health Sections. In the adjacent city of Nonthaburi, the Environmental and Health Division has similar responsibilities.

These local authorities receive technical advice from the national Department of Health (DOH) on aspects of street foods that could affect public health. To guide municipalities, DOH developed a ten-step code of practice for street foods (see Box) which gives recommendations for equipment, handling and storage of foods and general hygiene practices.

With the support of FAO, DOH launched an action-oriented project on street foods in Bangkok and the municipality of Nonthaburi in 1994. This pilot project was intended to improve the safety of the street food areas and the related environment. It was to serve as a model for corrective measures and to attract the interest of decision-makers within BMA. It was hoped that this would lead to further operations in Bangkok and other main cities of Thailand.

To be sustainable, the strategy relied on the resources and energy of the vendors themselves. The project staff gave technical advice, but in order to show that most investments would be made by the vendors if they found the changes to be beneficial, no subsidies were provided to support the improvement of infrastructures. The total budget for the two-year operation, excluding personnel costs and technical assistance by DOH and FAO, was US$25 000.

MODEL STREET FOOD AREAS

Areas in which the code for street foods was to be implemented were identified. It was expected that after implementation of corrective actions the improved areas and the vendors in those areas would become models for other vendors and the public in general.

The involvement and commitment of the Mayor of Nonthaburi, the directors of three district offices of BMA and the staff of DOH were critical for the project's implementation. During the first two months of activities, consultations were held with local authorities to explain the project and to select zones in Bangkok and Nonthaburi.

Four areas in Bangkok - Central, Dusit Zoo, Rachawat and Lad Prao Road - and one in Nonthaburi were selected. The first selection criterion was poor sanitary conditions and a need for improvements to reduce serious health hazards. In addition, the areas were chosen because of the likelihood that sales would increase if sanitary conditions were improved since the areas would be visited by more consumers and tourists. Each of the sites selected had a minimum of 15 vendors, concentrated within a fixed perimeter and operating stationary stalls only. Each area represented one type of street food situation encountered in Bangkok, such as daytime or evening restaurant-like operations or daytime take-away.

THAILAND DEPARTMENT OF HEALTH CODE OF PRACTICE FOR STREET FOODS

Sanitary requirements for street food stalls

1. Vending units should be designed and constructed so that they are strong and easy to clean. They should be kept clean, and food preparation surfaces should be at least at 60 cm above the ground.

2. Foods and drinks should be protected from contamination (microorganisms, toxic chemicals, dirt, etc.). Food displayed for sale should be protected by suitable coverings which can be made of glass, clear plastic or any clean material.

3. Seasonings and ingredients should be of a quality approved by the Food and Drug Administration.

4. Ice for human consumption and drinking-water should be clean and safe. Ice for human consumption should be kept in a clean container and covered. Nothing else should be stored in this container. Handling of ice for human consumption by hands is not permitted. A separate container should be used for the storage of ice used for purposes other than human consumption.

5. Utensils such as bowls, dishes, spoons, forks and chopsticks should be clean, in good condition and made of materials that do not release toxic or hazardous substances into food and drinks. They should be designed for sanitation and kept clean. Utensils with colour decoration on inner surfaces are prohibited.

6. Utensils should be washed in three steps in suitable sinks maintained at least at 60 cm above the ground.

7. Utensils should be kept in a clean place at least at 60 cm above the ground. Bowls, dishes and glasses should be stored in upside-down position. Spoons, forks or chopsticks should be stored with the handles up.

8. Containers and spoons used for seasonings such as vinegar, soy sauce or hot sauce should be made of glass, stainless steel or white porcelain (with no colour decorations), and covers should always be used for protection from contamination.

9. Refuse containers should be of suitable size and designed with a cover. Containers should be emptied and cleaned routinely.

10. Food handlers should be trained specifically on the subjects of personal hygiene and food preparation. They should follow appropriate hygienic food handling practices. The cook should always wear a clean white apron, and hair should be covered.

BENEFITS AND RISKS OF STREET FOODS IN BANGKOK

Street foods make up a significant proportion of the diet of urban residents in Thailand. A study carried out from 1991 to 1993 ¹ found that a wide variety of Thai, Chinese and Indian specialities were available 24 hours a day in Bangkok. Some 213 kinds of street foods including meals, beverages and snacks were sold by approximately 20 000 vendors throughout the city.

Street foods contributed as much as 40 percent of the total energy intake, 39 percent of the total protein intake and 44 percent of the total iron intake for city residents, especially among young people. For children aged four to six years, street foods contributed 88 percent of energy. Street foods provided almost half the energy intake of adults under 40 years of age.

In spite of these benefits, authorities and consumers were concerned about safety issues. The study revealed that the percentage of positive tests for Salmonella spp. in meals ranged from 0 to 10 percent, while the percentage of positive tests for Clostridium perfringens and Staphylococcus aureus ranged from 0 to 33.3 percent and 0 to 30 percent, respectively. It was reported that 22 percent of samples of Som tam (a popular raw papaya salad) had a total plate count of 10 ⁶ to 10 ⁸ CFU/g, 22 percent of samples had coliform bacteria in excess of 1 100 MPN/g and 11 percent of samples had Escherichia coli in excess of 1 100 MPN/g. A greater incidence and higher counts of contaminants were found in beverages. Aflatoxins and lead in excess of permitted levels were also found in foods and drinks.
***
¹ FAO. 1994. Street foods in Bangkok - the nutritional contribution and the contaminants content of street foods, by L.S.R. Hutabarat, An André Mayer Research Fellowship Study. Rome.

Two officers from the BMA district offices were assigned field activities in each area. It was recognized that these personnel would be key to the success of the project and they were chosen for their long experience, good service records, interest and knowledge of the matter. Other crucial components such as career promotions and financial incentives were carefully addressed in the design of the project.

ASSESSING THE SITUATION

A short survey was made to assess the socio-economic situation and sanitary conditions in each area. In addition, general information about each vendor was compiled to allow for an evaluation of the impact of the corrective actions.

Socio-economic factors

Among the vendors enrolled in the project, two-thirds were women over 30 years of age, mostly married. However, in the Rachawat and Central areas, the majority of vendors were men. More than 95 percent of the vendors had completed primary school or more; vendors were literate but had a low level of education.

Not surprisingly, vendors who sold full meals in congested areas (Rachawat, Central and Nonthaburi) earned more than those who sold snacks in less frequented places (Lad Prao Road and Dusit Zoo). In Nonthaburi, Central and Rachawat, the majority of vendors declared earnings of more than 1 000 baht (US$40) per day. The most lucrative area was Central, where eight vendors declared that they earned more than 2 000 baht per day. On Lad Prao Road and in the zoo, most vendors earned less than 1 000 baht per day. The least profitable location was the zoo, where half of the vendors reported earnings of less than 500 baht per day. At the time of the survey, the minimum salary for an employee in Bangkok was 162 baht per day.

Young children obtain a large proportion of energy, protein and dietary fat from street foods

Sanitary conditions

The quality and safety of food in each area was assessed to formulate a plan for corrective actions and to monitor progress towards compliance with the code.

More than 75 percent of the vendors brought water from their homes or nearby areas in plastic containers. In some stalls less than 1 litre of water was used per consumer for cleaning and food preparation purposes, which indicated that cleaning operations were certainly deficient.

On average, coliform bacteria were found in more than 50 percent of the food samples. In some areas, 87 percent of the samples were contaminated. Contamination of vendors' hands and utensils ranged from 18 to 69 percent depending on the area. Where tap water was available, the contamination of utensils was significantly lower.

The disposal of waste water was of particular concern in Dusit Zoo, where the water was emptied directly into the surrounding ponds, causing environmental pollution. In the five other areas, waste water was dumped directly on the road, without any treatment.

Initial inspections of the stalls and food handling practices revealed that no vendors were following the DOH code of practice. Although some vending units were properly designed, they were not kept clean during operation. Foods and drinks were not covered for protection from dust and insects. Some seasonings were not of a quality approved by the Thai Food and Drug Administration. Ice for human consumption was not kept separate from ice for cooling drinks and food products. Eating utensils were sometimes not in good condition, were often washed in buckets set on the floor and were not stored properly. Containers and spoons for seasonings did not conform to specifications. Even those containers that were made of proper materials were not adequately protected from contamination. Garbage bins had no covers or when covered were not equipped with a foot pedal to open the cover. Cooks did not wear aprons or head coverings during operations. Finally, vendors were not properly trained about personal hygiene and food handling.

MOBILIZING THE VENDORS

The mobilization of the vendors was the first action to be carried out. Vendors were summoned by local authorities to attend half-day briefings on the objectives of the project and the code of practice. The district office directors and the Mayor of Nonthaburi chaired the meetings, and field officers and their staff initiated a dialogue with the vendors. The discussions between vendors and authorities led to oral agreements on short-term work plans for the implementation of corrective actions.

These briefings were well attended and provided an opportunity to begin training of the vendors. The DOH officer showed slides, explained the technical justifications for the code and provided guidelines on hygienic food handling practices. Leaflets, aprons and head coverings were distributed at the meetings.

Directly following the briefings, inspections were made to implement the work plans immediately. The mobilization of vendors was achieved through numerous visits and regular inspections made by field officers and their staff as well as the DOH project manager and FAO officers. During these visits the areas were inspected rapidly, vendors were advised on technical matters, and possible corrective actions were discussed on a case-by-case basis. A comparison of the areas demonstrated that a regular presence was required to mobilize vendors.

Water resources are scarce and facilities are inadequate for cleaning

Risk of contamination can easily be reduced through training of vendors

IMPLEMENTING RISK-BASED CORRECTIVE ACTIONS

In assessing the microbiological risks of street food operations in Bangkok and other major cities of Thailand, DOH identified the following major practices to be corrected: the storage and handling of ice for human consumption; the storage and display of food; food handling; and cleaning of utensils. These concerns are reflected in the code of practice.

Storage and handling of ice

In Bangkok, all cold drinks are served with crushed ice in a glass, cup or small plastic bag closed with a rubber band. Therefore, ice represents an important risk which affects many people. Ice is prepared from potable water. However, crushing procedures, transportation and storage at the stall may have an impact on the quality of the ice. When the project began, vendors were storing ice for human consumption in boxes in which dirty soft-drink bottles and unclean plastic bags of food ingredients were kept. Ice boxes were also not kept clean. The ice was widely cross-contaminated even if it had been of satisfactory quality when it reached the stalls.

A great emphasis was placed on correcting these practices to reduce an obvious risk of biological and physical hazard. Since it was recognized that it was impossible to control the handling of ice before it reached the stalls, this strategy was aimed at avoiding additional contamination rather than eliminating all risks. Furthermore, handling practices at the stall had to be corrected before any programme to control the processing and transport operations could be envisioned. The use of different clean containers for ice destined for human consumption and ice for cooling purposes or the separation of ice boxes into two compartments was the technical requirement enforced by the project staff.

Food storage

Precooked ingredients (mostly precooked meat products, meatballs and seafood), spices and raw ingredients (mainly sliced meat, chopped green onions, herbs, sliced raw cucumber, tomatoes, chilies and papaya) for the preparation of noodle or rice dishes and soups were stored at ambient temperature without adequate covering to prevent environmental and insect contamination.

During soup preparation, raw meat, meatballs and noodles were usually immersed in a hot broth for one to two minutes. The soup was then poured into a bowl, and raw ingredients spices and seasonings were added before serving. Fried rice and fried noodles were prepared in a similar way. Precooked poultry was displayed at ambient temperature and served with steamed rice without any reheating. Even when cooking was sufficient to reduce the bacterial load significantly, the addition of raw vegetables, precooked ingredients and spices before serving these dishes was identified as a possible risk of contamination.

The project staff insisted that raw or precooked ingredients, especially those to be eaten raw, be thoroughly cleaned and kept in ice boxes, and that spices and seasonings be kept in closed containers to reduce cross-contamination.

The preparation of Som tam (raw papaya salad) was even more difficult to correct because raw vegetables, chilies, dried shrimps and raw crabs were crushed in a mortar. It was recommended that the quality of ingredients be controlled through washing and storing as described above, that mortars and pestles be properly washed and that the inclusion of raw crabs be avoided.

For the vendors selling curries, soups and composite dishes, the major challenge was to try to keep the food hot and covered in order to prevent bacterial growth and to reduce cross-contamination. Under the existing conditions, it was impossible to maintain the dishes at a proper temperature, i.e. above 60°C. The vendors used a table with a space of 1 to 2 m ² to display five to ten dishes, and they had one or two gas stoves for cooking and heating. Investing in adequate holding equipment was financially impossible. Although not fully satisfactory, the corrective action proposed consisted of increasing the frequency of reheating and covering each dish individually.

Ready-to-eat snacks tended to be deep-fried. In this case the risk was related to the amount of time that they were displayed without protection. The project staff insisted on food covering and proper food handling practices and advocated the use of small packages which the vendors and the consumers found convenient.

Food handling

In large stalls, where specific tasks could be carried out by different individuals, hand washing was recommended especially for cooks. Reorganization of the duties of the different helpers was also advocated to reduce cross-contamination. For example, it was recommended that only one person handle money, and that this person should not touch the food with his or her hands. Having different people handle ready-to-eat food and garbage is another example of an easy risk-management measure.

At first, hand washing was strongly advocated in all situations. However, it was soon apparent that this would be difficult to implement efficiently in stalls where the work force was limited to one or two persons. In these stalls, the vendors had to carry out all tasks. It was impossible to require that they wash their hands every time they touched raw food or unclean surfaces. Instead, they were encouraged to use clean utensils to handle ready-to-eat food.

Cleaning of utensils

The washing of utensils and dishes was another aspect of street food operations that needed to be rectified. Corrective action consisted primarily of requiring that washing be done in three steps (soaping, rinsing and rinsing a second time) in three different sinks held at least 60 cm above the ground, according to Step 6 of the code.

EDUCATING THE PUBLIC

Several steps were taken to support vendors' efforts and to increase public awareness. Large panels and signs were displayed in each of the areas to indicate that the areas were undergoing improvement through joint efforts of municipal authorities, DOH and FAO. Aprons distributed to the vendors were also printed with the logos of DOH and FAO, and various press releases were issued in Thai- and English-language newspapers.

CASE-STUDIES

A short description and a review of the impact of the project activities is given below for three areas.

Central and Lad Prao Road areas

The Central area is located in front of a large shopping mall. Fifteen street food vendors serve common Thai preparations of soups, meals and noodles as well as barbecued snacks to shoppers and mall employees. The 37 vendors on Lad Prao Road sell take-away food on a narrow pavement. Vendors at both sites operate from 10:00 to 20:00.

In the Central and Lad Prao Road areas, corrective actions progressed quickly, thanks to the strong mobilization of the local police and vendors. The implementation of the first nine steps of the code was nearly completed after one year of effort. The improvement of infrastructures, orderliness and cleanliness of both areas was also satisfactory.

Ready-to-eat foods displayed without minimal precautions

In the Central area compliance with Steps 1 to 9 was satisfactory overall, although some adjustments for adequate display of foods and drinks were still needed in two stalls. Vendors financed the installation of additional lights and a removable roof to replace the previous sunshades. Utensil cleaning facilities were improved, and waste water decantation tanks (with grease traps) were installed by the vendors on their own initiative. Garbage bins were provided by BMA, and banners indicating that the area was under improvement were displayed for the information of the public.

Storage of raw and semi-cooked ingredients also improved. For example, showcases were equipped with doors to keep insects out. Separation of ice for human consumption and for cooling purposes was managed regularly by using different ice boxes or arranging two compartments in the same box. Vendors began to keep most of their raw and precooked ingredients in ice boxes and to display only the minimum quantity required for their immediate operation.

In the two largest stalls staff wore clean aprons and head coverings, and owners imposed a rule that their staff wear uniform-colour dress. Although this modification did not directly affect food safety, it demonstrated the increase in motivation and discipline that had occurred. Each of the vendors made visible personal efforts to improve operations and facilities.

After one year, the vendors in the area declared that their daily incomes had increased by 20 percent. This gain demonstrated that consumers reacted positively to the efforts and that improvements could bring benefits to the vendors.

The dynamic on Lad Prao Road was similar. Stalls were progressively equipped with adequate and strong protection devices such as plastic showcases. Cooking equipment was removed from the front of stalls, which eliminated potential physical hazards for passers-by and consumers. The use of individual packages for ready-to-eat snacks began to be standard practice. Although progress was excellent in two stalls, the preparation and storage of food still required general improvement after one year.

Dusit Zoo

Among families, Dusit Zoo is a very popular green spot in Bangkok, especially on weekends. It has one restaurant, two food centres and several snack bars which deliver a wide variety of meals, snacks and beverages for all consumers. Significant progress has been made at the Dusit Zoo Restaurant and in the snack bars. Overall compliance with eight of the ten steps of the code was achieved. Major visible improvements included modifications of food preparation areas, dish cleaning facilities, storage procedures and facilities for raw ingredients and seasonings. However, garbage disposal, storage of utensils, training of vendors in personal hygiene and pest control measures were not satisfactory.

Although more effort was made in the two food centres than in the restaurant, less progress was achieved, primarily because of a different managerial arrangement: the restaurant and snack bars were operated under a contract between the manager and the zoo administration, while the two food centres were run by relatives of the zoo employees on a rotating basis. Each family was given permission to operate a centre for one year. Because the activity of the families was temporary, with no possibility of continuing after the year ended, it was more difficult for the administration to impose sanitary requirements on them than on the manager of the restaurant and snack bars. Their motivation was very low, and it was difficult to persuade them to implement even rudimentary precautions such as the protection of food and drinks from contamination, the use of ingredients and seasonings of a quality approved by the Thai Food and Drug Administration and the proper handling of ice.

The zoo administration closed the food centres during the month of September 1995 to modify the sewage system. During the closure the food centres were cleaned and renovated, which provided better conditions for the application of certain requirements of the code such as those regarding the design of stalls, the design, cleaning and storage of utensils and appropriate waste disposal. A new group of vendors was established, and training in personal hygiene, food preparation and food handling was started on the initiative of DOH. These vendors were authorized to sell for the year ahead and were more cooperative in setting up their operation in conformity with the code. This particular situation is a good illustration that little improvement can be expected if vendors do not have long-term authorization to sell.

LESSONS FOR THE FUTURE

This pilot project has demonstrated that food safety in street food operations can be improved through the implementation of risk-based corrective actions, even if such improvements cannot immediately reduce the risk to the levels that can be attained in fully controlled operations. In food factories, General Principles of Food Hygiene and risk-based management tools such as Hazard Analysis Critical Control Point, Total Quality Management or the International Organization for Standardization's ISO 9000 series can be implemented fully, but this does not appear to be the case with street foods, at least at this time. The elaboration and implementation of corrective actions in street food operations is hampered by the socio-economic situation of the operators, the environment, which cannot be controlled, and the behaviour of consumers, who are often unaware of the risks they face. The inspector cannot ignore these constraints and must identify means of reducing risks where possible without destroying the street food sector, which may be the only source of food available for large clusters of the population and the only source of income for many poor families.

This pilot project emphasized the preparation of foods and their storage and also focused on drinks and ice for human consumption. In the case of Bangkok, imposing separate and clean ice boxes for ice to be used in drinks appeared to be an important and relatively easy-to-implement risk-management measure. Although this strategy could not guarantee safe ice everywhere, it prevented an increase of risk by avoiding mishandling at the stall. Requiring vendors to use seasonings that are approved by the Thai Food and Drug Administration and registered also reduces risk. Checking the integrity of labels on seasoning bottles and banning unlabelled containers can prevent harmful products from being used and is another useful and simple risk-management measure. It was possible to improve the washing of utensils, especially glasses, forks, spoons and chopsticks which all come in direct contact with the mouth and fingers of consumers and can easily carry pathogens from one individual to another. Obviously, such measures have the potential to reduce risk. Last, it is possible to ask operators to modify some of their food handling practices. In particular, they should avoid direct contact of hands with ready-to-eat foods.

Risk managers have two options in designing their policy to control street foods with the view of reducing health risks. The first consists of studying each and every street food process used in the city and trying to identify the points at which control measures can be applied. This is, indeed, the most satisfactory approach to the problem for the researcher. However, when the aim is to propose risk-management tools that can actually be used, it is very likely that the assessment will suggest a limited list of corrective actions, perhaps very similar to those implemented in this pilot project. The second option, which is perhaps more cost effective and less time consuming, is to draw up a list of risk-based corrective actions that have been implemented in other contexts and to verify their validity in the case being addressed so that implementation can begin immediately.

The latter is the approach that was followed in this particular project. A series of risk-based corrective actions, also called "Sanitary requirements for street food stalls", was implemented to reduce the risk in street food operations. Such a list of actions could also be designated as "Code of practice for street foods", "Steps for safer street foods" or "Code of conduct for street food vendors", provided that the text is easy for local authorities to implement. When the list is developed it is extremely important to include other recommendations that may not have a direct impact on food safety but that will stimulate the vendors to improve the general cleanliness and orderliness of their operations. Asking the operators to comply with these requirements is part of the educational process that will lead to risk reduction. It is easy to imagine that vendors who do not make the simple effort to keep their stalls clean and in order will certainly not care about other more complicated and demanding requirements that directly affect food safety. Furthermore, cleanliness and orderliness will attract more consumers and therefore generate additional resources which will encourage the operators to sustain their efforts to improve their operations.

Prospects of expansion

Officers from 16 districts of BMA were invited to a one-day seminar at which technical issues and regulatory and practical aspects of the project were presented. Prospects for expansion were discussed with field officers from the pilot project. Formal negotiations to formulate a plan of action for the gradual establishment of model street food areas in all of the districts of Bangkok have been launched. A project proposal was prepared which may lead to a yearly allocation of funds for each BMA district office for the implementation of the code of practice and the setting up of a street food advisory service within BMA to conduct the activities.

Summary

Street stalls are a convenient, inexpensive and major source of food for the public in Bangkok. These operations are also an important source of income; vendors reported sales of US$20 to $80 per day. However, street foods raise public health concerns. In a study carried out from 1991 to 1993, some of the drinks and foods sampled were found to be contaminated.

National and local authorities in Thailand, with FAO assistance, developed a project to improve the safety of street foods. The project assessed food quality and safety factors such as storage and protection of foods and drinks; use of approved ingredients; cleaning of equipment; food preparation; disposal of garbage; and personal hygiene of food handlers. With this information, Thailand's Department of Health developed a ten-step code of practice for street food operators which is used comprehensively by local authorities.

The vendors, primarily women, were trained and assisted in the means of complying with the code. To motivate vendors to improve their operations, regular inspections by field officers were required.

While the project staff gave technical advice, the strategy relied on the resources and energy of the vendors themselves. Improvements in cleanliness and orderliness attracted consumers, which generated additional resources for vendors and encouraged them to make additional, more difficult changes to reduce health risks. However, the number of feasible corrective actions to improve the safety of street foods is limited by the socio-economic situation of the vendors, the inability to control the environment and the lack of consumer awareness.

Résumé

A Bangkok, les aliments vendus sur la voie publique sont une source commode, bon marché et considérable de nourriture pour les habitants de la ville. Cette activité est aussi une importante source de revenus, d'après les vendeurs, qui font état d'un chiffre d'affaires compris entre 20 et 80 dollars EU par jour. Cependant, la vente d'aliments dans la rue pose un problème de santé publique. Une étude effectuée entre 1991 et 1993 révèle qu'une partie des aliments et des boissons analysés étaient contaminés.

Les autorités thaïlandaises, aux niveaux national et local, ont mis au point, avec l'assistance de la FAO, un projet visant à améliorer l'innocuité des aliments vendus dans la rue. Ce projet a permis d'évaluer la qualité des aliments et les facteurs d'innocuité, notamment le stockage et la protection des aliments et des boissons; l'utilisation d'ingrédients agréés; le nettoyage du matériel; la préparation des aliments; l'évacuation des déchets; et l'hygiène personnelle de tous ceux qui participent à la manipulation des aliments. Muni de ces informations, le Département de la santé thaïlandais a élaboré un code d'usages en 10 parties, à l'intention des vendeurs d'aliments sur la voie publique, qui offre aux collectivités locales un outil complet.

Les vendeurs, en majorité des femmes, ont reçu une formation et une assistance destinées à leur permettre d'appliquer le code. Pour inciter les vendeurs à améliorer leurs méthodes de travail, il est apparu nécessaire de prévoir des inspections effectuées par des agents de terrain.

Le personnel du projet a fourni des conseils techniques, mais la mise en œuvre de la stratégie repose sur les ressources et l'énergie des vendeurs eux-mêmes. L'amélioration de la propreté et de la présentation ont attire les clients, engendrant une augmentation des recettes qui a encouragé les vendeurs à entreprendre des changements supplémentaires et plus difficiles pour réduire les risques sanitaires. Cependant, le nombre de mesures correctives que peuvent prendre les vendeurs pour améliorer l'innocuité des aliments vendus dans la rue est toutefois limité du fait de leur situation socioéconomique, de l'impossibilité de maîtriser l'environnement et de l'absence de prise de conscience chez les consommateurs.

Resumen

Los alimentos callejeros son una fuente cómoda, poco costosa e importante de alimentación para la población de Bangkok. Las operaciones de venta de alimentos en las calles son también una fuente importante de ingresos que reportan a los vendedores entre 20 y 80 dólares EE.UU. al día. Sin embargo, los alimentos callejeros suscitan preocupación en lo que concierne a la salud pública, dada la contaminación de algunos de los alimentos y bebidas de los que se han tomado muestras.

Las autoridades nacionales y locales de Tailandia han desarrollado un proyecto, con asistencia de la FAO, para mejorar la inocuidad de los alimentos callejeros. El proyecto ha evaluado factores relacionados con la calidad e inocuidad de los alimentos, entre ellos el almacenamiento y la protección de alimentos y bebidas, el uso de ingredientes aprobados, la limpieza del equipo, la preparación de los alimentos, la eliminación de los desechos y la higiene personal de los manipuladores de alimentos. Con esta información, el Departamento de Salud de Tailandia estableció un código de prácticas en doce etapas para las personas que manejan alimentos callejeros que las autoridades locales utilizan como referencia.

Los vendedores, principalmente mujeres, recibieron capacitación y asistencia para observar el código. Con el fin de motivar a los vendedores para que mejoraran sus operaciones, fue necesario que funcionarios locales llevaran a cabo inspecciones periódicas.

Aunque el personal del proyecto ofreció asesoramiento técnico, la estrategia se basó en los recursos y energías de los propios vendedores. Las mejoras en la limpieza atrajeron a los consumidores, lo cual generó nuevos recursos para los vendedores y los animó a introducir otros cambios más dificultosos a fin de reducir los riesgos para la salud. Sin embargo, la situación socioeconómica de los vendedores, la incapacidad de controlar el medio ambiente y la insensibilidad de los consumidores limitan el número de medidas correctivas que pueden aplicarse para mejorar la inocuidad de los alimentos callejeros.

# data[].attributes.attachment_link.description
Bangkok's street food project Le projet modèle de vente d'aliments sur la voie publique à Bangkok Proyecto sobre alimentos callejeros en Bangkok R. Dawson, S. Liamrangsi and F. Boccas Richard Dawson is Senior Technical Advisor at the FAO Regional Office for Asia and the Pacific (FAORAP).

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Title: Pathways out of poverty: private firms and economic mobility in developing countries
Source: research gate
source bias: liberal
comment: gives clear concise reasons with backing support

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title: levels and major sources of pm 2.5 and pm 10 in Bangkok metropolitan region
source: science direct
credibility evaluation: group 1

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Abstract

This research was the first long-term attempt to concurrently measure and identify major sources of both PM ₁₀ and PM 2.5 in Bangkok Metropolitan Region (BMR). Ambient PM ₁₀ and PM 2.5 were evaluated at four monitoring stations and analyzed for elemental compositions, water-soluble ions, and total carbon during February 2002-January 2003. Fifteen chemical elements, four water-soluble ions, and total carbon were analyzed to assist major source identification by a receptor model approach, known as chemical mass balance. PM ₁₀ and PM 2.5 were significantly different ( p < 0.05) at all sites and 24 h averages were high at traffic location while two separated residential sites were similar. Seasonal difference of PM ₁₀ and PM 2.5 concentrations was distinct between dry and wet seasons. Major source of PM ₁₀ at the traffic site indicated that automobile emissions and biomass burning-related sources contributed approximately 33% each. Automobiles contributed approximately 39 and 22% of PM ₁₀ mass at two residential sites while biomass burning contributed about 36 and 28%. PM ₁₀ from re-suspended soil and cooking sources accounted for 10 to 15% at a residential site. Major sources of PM 2.5 at traffic site were automobile and biomass burning, contributing approximately 32 and 26%, respectively. Biomass burning was the major source of PM 2.5 mass concentrations at residential sites. Meat cooking also accounted for 31% of PM 2.5 mass at a low impact site. Automobile, biomass burning, and road dust were less significant, contributed 10, 6, and 5%, respectively. Major sources identification at some location had difficulty to achieve performance criteria due to limited source profiles. Improved in characterize other sources profiles will help local authority to better air quality.

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Levels and major sources of PM2.5 and PM10 in Bangkok Metropolitan Region

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This research was the first long-term attempt to concurrently measure and identify major sources of both PM 10 and PM 2.5 in Bangkok Metropolitan Region (BMR). Ambient PM 10 and PM 2.5 were evaluated at four monitoring stations and analyzed for elemental compositions, water-soluble ions, and total carbon during February 2002-January 2003.

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title: a better understanding of thailand's informal sector
source: Bank of Thailand
source bias: liberal
factual reporting: high + statistics + refers to other journals and evidences

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title: 41 percent of sampled fruits, vegetables contaminated
source: bangkok post
source bias: moderate liberal
factual reporting: high

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The Thai Pesticide Alert Network announces the results of its latest survey on contamination of vegetables and fruit at a news conference in in Nonthaburi province on Wednesday. (Photo by Tawatchai Kemgumnerd)

An annual survey of vegetables and fruits found high toxic contamination on 41% of sampled vegetables and fruits, and the problem was bigger at retail stores than wet markets.

The survey by the Thailand Pesticide Alert Network (ThaiPAN) and its partners - local health officials, farmers and residents - collected 286 of popular vegetables and fruits from retail stores and wet markets in Bangkok, Chiang Mai, Khon Kaen, Sa Kaeo, Yasothon, Chanthaburi, Ratchaburi and Songkhla for contamination tests, ThaiPAN coordinator Prokchol Ousap told a news conference in Nonthaburi on Wednesday.

The were sent for standard laboratory tests in the United Kingdom, and high contamination was found in 41% of them, she said.

Vegetables with the highest contamination were Chinese mustard greens, kale, hot , parsley, chilli and cauliflower. Fruits with the highest percentages of harmful contamination were tangerines , rose apples, and grapes.

Unsafe contamination was found in 33.3% of imported fruit and 48.7% of local fruit. Unhealthy contaminants were found in 44% of from retail stores, and 39% of from wet markets , Ms Prokchol said.

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ข่าวภาษาอังกฤษง่าย

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ข่าวบางกอกโพสต์ง่าย

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เรียนภาษาอังกฤษง่าย

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เรียนภาษาง่าย

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41% of sampled fruits, vegetables contaminated

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The Thai Pesticide Alert Network announces the results of its latest survey on contamination of vegetables and fruit at a news conference in in Nonthaburi province on Wednesday. (Photo by Tawatchai Kemgumnerd) An annual survey of vegetables and fruits found high toxic contamination on 41% of sampled vegetables and fruits, and the problem was bigger at retail stores than wet markets.

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title: Street food plan starves poor of choice
source: Bangkok post
source bias: moderate liberal bias
factual reporting: medium

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Street vendor rules in Bangkok 'hurting tourism'

Expert takes aim at pavement evictions

Under the military-appointed Bangkok governor, City Hall has banned most street vendors in many parts of the city including the Yaowaraj (Chinatown) area. (File photo)

City Hall's efforts to regulate the use of pavements is damaging one of Thailand's biggest tourism draws, an expert at Chulalongkorn University's Urban Design and Development Centre (UCDC) has warned.

"The government is trying to make street vendors disappear, despite the global recognition of Thailand's street food scene," said Adisak Guntamuanglee, an expert on urban planning at the UCDC.

The Bangkok Metropolitan Administration (BMA) must find a better policy to manage space, or risk losing its tourism magnet status and hurting the local economy, Mr Adisak said in a seminar entitled "Brainstorming for Practical Rules for Street Vendors" held at Thammasat University.

Mr Adisak floated the idea of a so-called "co-eating space", a concept he said could possibly replace street carts that are seen by some as old-fashioned and unhygienic, while allowing food vendors to remain on pavements.

In several countries, pavements are designed with rest areas that can be used by street vendors, he said.

Adisak Guntamuanglee: 'City Hall can do more than just keep vendors off sidewalks'

"Public spaces, including sidewalks, are not only intended for pedestrians," he said.

Mr Adisak said that certain places, such as the area underneath the BTS Skytrain station in Ari, should be declared off-limits to vendors as they are reserved for ambulances.

However, other areas with pavements that are wide enough to be split and designated as space for street vendors should be redesigned to make them attractive for both Thais and foreigners, he said.

The government will, however, have to invest more in sanitary and waste disposal systems to ensure food hygiene and prevent the vendors' activities from affecting the environment, he said.

"The BMA has the power to manage and address all these issues through better regulations. It can do more than just keep vendors off sidewalks," he said.

It is estimated that there are about 300,000 street vendors in Bangkok alone, 37% of who are food vendors, said Poonsap Suanmuang of the Foundation for Labour and Employment Promotion.

Assuming that each vendor family has four to five members, the BMA's regulation may affect the lives of between 1.3 million and 1.5 million people, she said.

"All they want is a space where they can earn a living. They are not asking for any financial support from the government, or anything else," she said.

Narumol Nirathron, an academic with Thammasat University's Faculty of Social Administration, concurred with Ms Poonsap and said the BMA's regulation is a top-down policy that adversely affects a large number of people.

BMA executives tend to view street vendors as non-Bangkok residents who are causing problems with the city's cleanliness and waste management, according to Ms Narumol.

Natdanai Kulthatchayakaranan, a street vendor on Silom Road, said many vendors like him have been cooperating with the BMA's efforts to better regulate the use of Bangkok's pavements.

They were always willing to move when asked to stay away from roads and keep the pavements clean, but in the end they were told to leave nonetheless, he said.

Aom, a street food vendor who works on Soi On Nut 70, said the area has won numerous awards for being an outstanding place to get street food.

But when the BMA implemented its strict policy, street vendors in the area were forced to move away from the pavements to a new location, where the rent is simply too high, she said.

"We are living solely on the income we earn from selling things," she said.

"They are taking the money that we have set aside for our children's education, as well as to pay off our household debts."

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Street vendor rules in Bangkok 'hurting tourism'

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Expert takes aim at pavement evictions Under the military-appointed Bangkok governor, City Hall has banned most street vendors in many parts of the city including the Yaowaraj (Chinatown) area. (File photo) City Hall's efforts to regulate the use of pavements is damaging one of Thailand's biggest tourism draws, an expert at Chulalongkorn University's Urban Design and Development Centre (UCDC) has warned.

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title: organic or starve: can cuba's new farming model provide food security
source: The Guardian
source bias: liberal bias
factual reporting : highly factual +first hand accounts

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In the town of Hershey, 40 miles east of Havana, you can see the past and the future of Cuban farming, side by side.

The abandoned hulk of the Camilo Cienfuegos sugar plant, shut along with 70 other cane refineries in 2002, towers over the town. But in the lush hills and grasslands around Hershey, fields of cassava, corn, beans, and vegetables are a sign that there is life after sugar.

Once owned by the famous Pennsylvania chocolate maker, the Cienfuegos plant supplied the sugar that sweetened Hershey's candy bars. After the 1959 revolution, it was nationalised by Fidel Castro's government and became property of the state, its sugar shipped to the Soviet Union and allies.

As the world's largest sugar exporter, Cuba relied on pesticides and fertilisers and heavy mechanisation to produce up to 8.4m tonnes of sugar - its peak harvest, in 1990 - nearly all of it exported to the Communist bloc. The collapse of the Soviet Union in 1991 eliminated Cuba's preferential market and, coupled with a tightening of the US trade embargo, sent the Cuban economy into an extended coma. The sugar industry muddled along for another decade until the government ordered the closure of 71 of the island's 156 sugar refineries. Places that had depended on sugar for a century became ghost towns.

The trains that once carried Hershey's sugar to port sit idly on the tracks, apparently abandoned. Old timers rest under a tree reminiscing and drinking rum from a bottle. Yoanki Valdés lives across the street from the carcass of the plant where, for 30 years, he went to work every morning at the sound of the 7am whistle. He was dedicated to the job, received training in industrial engineering in Czechoslovakia and had risen to the position of foreman by the time he heard the news: the plant was closing. A week later it was shut.

"The most normal thing for everyone was to work in the sugar plant. Sugar gave work and a way of life," said his son, also named Yoanki. Yet the two men don't sound bitter. They understand the reasons for the closure: sagging prices, inefficiencies, dependence on a single, distant market, and the continued refusal of the United States to restore Cuba's sugar quota long after the ostensible reason for revoking it - the alliance with the Soviet Union - was gone.

In the wake of the Soviet collapse, Cuba lost 80% of its international trade in under three years. The result was severe food shortages. Castro dubbed it "the special period in peacetime," a euphemism for what many Cubans describe as one of the worst traumas of their lives. It dragged on for five years, but its psychological effects lasted much longer.

One woman I met remembered people fainting in the street from hunger. An artist remembered regular rations for children, but, for adults like himself, an endless diet of sugar water. Another stressed years of blackouts and boredom, relieved only by lots of marijuana. An agronomist described to me the death of hundreds of thousands of farm animals due to the loss of imported feed. "We came very close to starvation," he said.

Out of the special period came a resolve that it must never happen again, and so Cuba's food-focused farming movement was born.

"The way people thought about food and agriculture changed drastically with the special period," said Miguel Angel Salcines, who runs a 25-acre organic farm in the outlying Havana district of Alamar, which started in those years. "Boats had arrived from the Soviet Union full of chemicals and fertilisers and suddenly there were no more boats from the Soviet Union, and people asked, do we need all those chemicals?"

The farm fields around Hershey don't employ many people, but they sell their produce to local cooperatives so residents can buy them to supplement their meagre monthly rations of state-produced or imported food. In the revolutionary heyday, all this farmland was used to cultivate sugar.

Cuba has never been able to feed itself. It currently imports 60-80% of the food it consumes, at a cost of about $2bn a year. Two-thirds of its corn is imported and a similar amount of its rice, the latter mainly from Vietnam and Brazil. At markets around the country, sacks of rice can be seen piled to the rafters. Cubans love bread, but wheat doesn't grow well in the tropical climate, so that has to be imported as well - mostly from the United States, which, in an exception to the Cold War-era trade embargo, sells food to Cuba for cash.

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Manioc crops (foreground) and fruit trees (rear) thrive at an organic farm in Pinar del R'o province, western Cuba. Photograph: Roger Atwood

In response to this dependency, officials are promoting small, local farms as one way - perhaps the only way - for the country to finally start feeding itself. Although it has happened gradually, the shift to smaller, often organic farming marks a radical change from the monocrop sugarcane economy that ruled Cuba for a century. Small-scale farming is receiving the blessing of once-sceptical agricultural officials who set food priorities in this tightly controlled society.

Urban farming, with its backlot gardens and rooftop chicken coops, took hold in Havana and other Cuban cities in the early 1990s. That movement, also promoted by the government, brought greenery and fresh vegetables to Cuba's dilapidated inner cities. However, while tourists love to visit them, urban farms have had little impact on Cuba's overall farm output.

The new organic movement is different. Its goal is high yields in rural settings, with an eye toward a reliable, systematic output of staple crops at farms that are close to consumers and usually smaller than 40 hectares (100 acres) or so. Rather than a reaction to a crisis, the current push into organics is planned and promoted on the ruins of the industrial sugar economy.

"Organic farming does not bring the kind of large yields that will solve all our problems. But it solves many of our problems, and it is starting to become important," said Juan José León, an official at the Ministry of Agriculture. "Ecological farming arose as a response to a reality that smacked us," he continued. That reality was the collapse of the Soviet Union. "They were difficult years. We had to produce food somehow, somewhere."

Tall, lean and bald as the farmer with the pitchfork in American Gothic, Agustín Pimentel takes a knife and cuts open one of his organic pineapples. It's the size of a grapefruit, and its meat is a heavenly mix of sweetness and tart.

"It's sad that the immense majority of farmers in Cuba still use pesticides and chemical fertilisers. They're poison, and they enter our food," says Pimentel, who raises 45 different crops on four hectares in an isolated valley in western Cuba. He's proud of the fact he never uses chemicals of any kind. Yet he's not sure his farm could ever gain certification as organic. The land, in Pinar del Río province, was once planted with tobacco, which has a reputation for high reliance on pesticides. Chemical residues from other crops wash in from neighbouring farms with the rain.

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Organic farmer Agusti'n Pimentel uses a machete to slice open a coconut on his organic farm in a remote valley in western Cuba. Photograph: Roger Atwood

Pimentel is part of a small, intensely committed movement of organic farmers on this tropical island of red soil and royal palms. Numbering from 40,000 to a quarter of a million, depending on whom you ask. What exactly is meant by "organic" is not clear. Standards are not always known or consistently followed. But this movement of farmers sees locally grown, non-industrial farming as a vital part of the solution to Cuba's chronic food shortages. Many of them see organic farming as nothing less than the future of Cuba's socialist revolution; others see the potential for exports to European and eventually US markets.

Miguel Angel Salcines hopes that former US president Barack Obama's restoration of diplomatic relations presages the day when Cuba can export high-quality organic crops to American supermarkets, though the tough talk from Obama's successor Donald Trump may make that a distant prospect. American consumers would welcome the quality and variety of Cuban organics, he says, and Cuba needs the cash. "I would love to export my mint leaves to Miami so they could put them in their mojitos. I'm sure they grow mint there, too, but it's not the same," said Salcines, half-jokingly.

For now, vegetables for domestic consumption are the mainstays of Cuban organics. Those crops are almost the only area of farm production that has grown in Cuba, by about 15% in the last decade to 5.3m tonnes, according to official figures released in June.

The central government issued farm titles to 223,917 people in the three years up to April, covering nearly 2m hectares, said León. They're not ownership titles - 79% of Cuba's land is owned by the state - but they give the holder the right to till the land in perpetuity. They're not all necessarily organic. But nearly all are small, family farms, and each one marks a sharp break from the way Cuba conducted its agriculture in the sugar heyday.

Much of the impetus for small-scale farming has come from the Programme for Local Agricultural Innovation (Pial). The initiative started around 2002 as a way of getting organic farming beyond urban plots in favour of larger-scale, locally-geared agriculture to relieve food shortages and bringing fresh produce and meats to Cuban tables. It's a very Cuban mix of organisation, idealism and state direction, with help from sympathetic foreigners. Pial is regulated by Cuba's agriculture ministry but funded largely by European and Canadian foundations. Its founder, Humberto Ríos Labrada, won the Goldman environmental prize in 2010.

Pial has helped small, organic farmers share knowledge, get good-quality seeds and connect with buyers, said Sandra Miranda, a biochemist and one of the programme's designers. But Pial's main achievement, she said, was to show farmers that organic production was no locavore foodie fad. It was, rather, Cuba's food future.

Today about 250 farm cooperatives across Cuba are enrolled in the programme, Miranda said, or about 50,000 farmers. Each cooperative can include anywhere from half a dozen to hundreds of small farms.

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Organic or starve: can Cuba's new farming model provide food security?

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In the town of Hershey, 40 miles east of Havana, you can see the past and the future of Cuban farming, side by side. The abandoned hulk of the Camilo Cienfuegos sugar plant, shut along with 70 other cane refineries in 2002, towers over the town.

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title: sustainable agriculture to end world hunger
source:  IPS
source bias: liberal
factual reporting: quotes from experts of the field, statistics, scientific explanation

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The weakness of poor farmers and the growth of low-nutrition crops have been, until now, some of the deterrents of efficient agriculture. Esmilda Sánchez picks string beans on the Finca de Semillas farm. © Jorge Luis Baños/IPS

By Carmen Arroyo
UNITED NATIONS, Jul 24 2018 (IPS) - Significantly more investment is needed to lift hundreds of millions rural poor out of poverty and make agriculture environmentally sustainable, according to Rob Vos, director of the markets, trade and institutions division at the International Food Policy Research Institute (IFPRI).

With a growing world population, hunger and undernutrition are on the rise, and governments are looking for private alliances to alleviate these issues.

During the 2018 High-Level Political Forum on Sustainable Development at the United Nations Headquarters in New York, this July, IFPRI organised a side event called "Investing for Reshaping Food Systems".

Speakers included Claudia Sadoff, director general for the International Water Management Institute; Nichola Dyer, from the Global Agriculture and Food Security Programme at the World Bank; Gerda Verburg, coordinator at the Scaling Up Nutrition Movement (SUN); and Chantal-Line Carpentier, chief at the U.N. Conference on Trade and Development.

They all emphasised the urgency of investing in sustainable agriculture, defined by the Barilla Centre for Food and Nutrition as "the efficient production of safe, healthy, and high-quality agricultural products, in a way that is environmentally, economically, and socially sustainable."

While the world population will reach over eight billion people in 2025, the amount of cultivable land will remain the same. Decimated by pesticides, non-sustainable agricultural techniques, and water waste, healthy nutrients will become harder to access for the growing population. This issue, along with food waste (20 percent of every food purchase is wasted), is a major concern for Verburg, who highlighted the need to rethink food systems and stop blaming agriculture.

The relationship between the private sector and agriculture isn't new. On the contrary, many farmers-especially the poorest ones-are members of the private sector.

"The majority of poor and hungry people are small-scale farmers. They are in fact members of the private sector, albeit the weakest. And some corporate investments in agriculture can hurt them," John Coonrod, executive vice-president at the Hunger Project, told IPS.

The weakness of poor farmers and the growth of low-nutrition crops have been, until now, some of the deterrents of efficient agriculture.

"The world has over-invested in low-nutrition staple crops, driving up the relative price of nutrition rich-foods. Empty calories is the food system of the poor. To overcome malnutrition, we need to increase the dietary diversity of the poor to include many more fruits and vegetables, which means increasing their local production and reducing their price to local consumers," Coonrod explained.

How can private investment develop sustainable agriculture? Vos from IFPRI said that a first priority should be to provide incentives for investments beyond farms "in infrastructure like roads, electricity and cold transportation and agri-food processing."

"This will help provide better and more stable market conditions for farmers, create lots of new jobs, and limit the risks of investing in agriculture itself," he said.

He also added that "the second priority is to provide incentives for investing in sustainable practices and crop diversification, including towards fruits and vegetables."

Brian Bogart, senior regional programme advisor for South Africa to the U.N. World Food Programme, agreed with Vos.

"Key areas for investment to equity in food systems include rural infrastructure, access to markets, knowledge and technology, and improved storage and transport capacity to reduce post-harvest losses," Bogart said.
What about governments?
During the event, Verburg, from SUN, pointed out the importance of political commitment and leadership within countries to reduce hunger and reshape food systems.

When asked about the role of national governments, Bogart said: "Member states have a responsibility to lead such efforts by developing effective partnerships with the private sector and fostering an enabling environment for investment."

"With shrinking public investment in agriculture (according to the Secretary General's progress report on the SDGs, government expenditure as a percentage of GDP declined from .38 to .23 between 2001 and 2016 and international aid allocations for agriculture declined by 20 percent between the mid-1980s and 2016), the question is how public-private partnerships can unlock opportunities for private investment to complement public resources and capacity to generate improved food security, particularly for the most vulnerable populations," he added.

Some countries are already doing this. The Barilla Centre for Food and Nutrition's Food Index on sustainable agriculture, which ranks 25 countries according to 58 indicators, reveals that Germany and Canada are among the states that rank highest with regards to sustainable agriculture.

However, responsibility does not lie solely with the state, but with civil society also. Coonrod, from the Hunger Project, explained what his organisation does in this regard: "We promote good nutrition through education, promoting better local farming methods, increasing local food processing and, in indigenous communities of Latin America, we've opposed junk food and helped communities reclaim their nutritious traditional foods."

Finally, Vos highlighted the importance of research in reducing hunger.

"We undertake research to better understand the causes underlying the deficiencies in the present food systems and test out the effectiveness of interventions that aim to overcome these shortcomings. We know far too little on what is driving food system change, not just in agriculture, but in all stages of the food chain, from farm to fork."

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Sustainable Agriculture To End World Hunger - World

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By Carmen Arroyo UNITED NATIONS, Jul 24 2018 (IPS) - Significantly more investment is needed to lift hundreds of millions rural poor out of poverty and make agriculture environmentally sustainable, according to Rob Vos, director of the markets, trade and institutions division at the International Food Policy Research Institute (IFPRI).

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title: Informal Economy street vending in Asia
source: TERRAVIVA
Source bias: moderately liberal
factual reporting: high (first hand interviews, accounts and statistics)

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TERRAVIVA: informal economy street vending in Asia

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A special edition of the independent newspaper TERRAVIVA on an ILO theme seminar focusing on the informal economy and labour protection of street vendors in Asia.

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title: Bangkok Street Food Phenomenon
source: Institute of metropolitan development
credibility evaluation: group 1

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title: Cadmium and its adverse effects on human health
source: NCBI
credibility evaluation: group 1

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Cadmium & its adverse effects on human health.