I would say that most people would probably be able to guess that smoking is the leading cause of preventable death in the world – directly responsible for about 5 of the 50 odd million deaths that occur in the world every year. A lot of people, in particular anyone who has ever traveled to China, could probably guess that there are more smoking related deaths in the developing world than in the developed (more people and high rates of smoking) – and that smoking rates are growing fast.

 But did you know that the region with the fastest growing rates of smoking is Africa? I didn’t until I read this excellent report in the Lancet by Adele Baleta about Africa’s struggle against smoking.


In most instances, we would generally think think that a rapidly growing economy leads to higher incomes, better social services, and thus overall better health. But smoking happens to be one of those cases where rising incomes, which brings higher purchasing power, actually leads to worse health seeking behavior as people spend more and more of their wealth cigarettes. The rapid economic growth seen in many African countries over the past decade has meant that more and more Africans are now lighting up and becoming addicted to tobacco.

While a few countries have been forward thinking on this issue and implemented some form of tobacco control legislation, overall implementation and regulation of regulations have been lagging in the region – currently 90% of Africans are unprotected by smoke-free laws. According to a report by the Global Smokefree Partnership, the biggest obstacle to implementation of stronger anti-tobacco legislation is not weak government, lack of political will, or income but rather agressive efforts from multi-national tobacco companies.

It has now been 5 years since the WHO’s Framework Convention on Tobacco Control’s (FCTC) went into effect and it is sad to see that progress towards implementing this landmark agreement has been so slow at this particular point in time. Kudos to the Lancet for publishing this great piece of global health reporting.

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I gave a lecture this afternoon to my undergraduate global health policy course at NYU (P11.0032 Global Health: Policies, Politics, and Institutions) in which we discussed progress towards the Millennium Development Goal 4 – a two thirds reduction in under five mortality from 1990-2015. I argued that one of the biggest sources of progress, and perhaps the one that is most easily attributable to a single intervention, were the declines seen in mortality from measles since the use of the measles vaccine become widespread.

A recent report by the CDC, reprinted in JAMA recently, provides the evidence to support such claims. Since 2000, it is estimated that deaths from measles have declined from about 733,000 deaths to 164,000 in 2008 – a whopping 78% decline in mortality in just 8 years. Success rates like that are relatively rare in global health. A recent paper by You and co-authors in the Lancet have estimated that child deaths declined from 10.4 to 8.8 million over the same time period, so roughly one third of the total declines seen over this time period can be attributed to this single intervention.

I was saddened to learn, however, that despite these successes, maintaining progress and sustaining this progress is at risk – so much so that the authors of the report even have estimated worst case scenarios of resurgence. Probably more so than most childhood vaccine preventable diseases really high sustained vaccination coverage is needed or else there is a significant risk of flare ups of the disease (this even happens in the US when parents forego vaccinating their children).

Measles vaccine funding has fallen off sharply in the past few years, and surprise surprise, national ministries of health are also having a hard time raising adequate funds. The Measles Initiative, one of the main funding agencies for measles vaccinations, has seen a decline in funding from about $150 million to $50 million. In the post-Global Fund/Gates Foundation/PEPFAR world, these levels of funding seem almost miniscule – in particular for such an amazing buy. Such a shame.

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I was struck by the following graph that appeared in a comment by John Bongaarts, François Pelletier, and Patrick Gerland in the Lancet last week. The graph compares estimates of HIV mortality made by the WHO in the early 2000s via the Global Burden of Disease Project (GBD), updated estimates GBD estimates from the WHO, UNAIDS, and recent projections put out by the UN.


By now, I hope most people reading this blog have realized that due to a number of changes, most notably the collection of population based estimates of HIV prevalence have led to significant decreases in the projected levels of HIV mortality globally. That along with updated models explains the difference between earlier HIV mortality estimates – including the earlier GBD estimates – (consistent with the top line in the graph) and the three bottom lines, which generally now incorporate the new prevalence estimates. (Side note: I recently saw a paper from David Canning who has suggested that non-random selection effects in DHS and other population based estimates are likely underestimating true prevalence by a significant amount…more when that paper goes public).

But why do the updated GBD WHO estimates decline so much faster than the recent estimates by the UN? The difference can largely be explained by assumptions about the scale up and impact of HIV treatment programs. The authors of the comment argue that the WHO estimates “can only be achieved by massive scale-up of antiretroviral treatment to lead to near universal access worldwide in 2015-30″. Great progress has been made on this front, true, but how realistic of an assumption is this? In particular in this new economic climate?

Given how widely these estimates are used for global health policy, I am somewhat surprised how optimistic of an assumption the WHO is using – if anything it only weakens their advocacy argument for more funding. But this comment clearly demonstrates that even the best statistics in global health are based on some very powerful – and potentially incorrect – assumptions.

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In the NYTimes this morning, op-ed columnist David Brooks makes an interesting point: In 1989, a 7.0 magnitude earthquake struck just outside San Francisco leading the loss of 63 lives. Earlier this week, an earthquake of the same magnitude struck just outside Port-au-Prince, the capital of Haiti, and although final estimates of the death toll have not been made, without hubris I can safely say that about a thousand times more lives will be lost this time around.

Wikipedia, lists the official population of the Port-au-Price metropolitan area at 1.7 million people. The International Red Cross has estimated that the death toll could exceed – perhaps by a great deal – 50,000 people. Conservatively, this means that approximately 3% of the city perished in a few minutes, a shockingly high mortality rate.

Last fall, my husband and I moved from our suburban house just outside of Boston to an apartment in Greenwich Village, in the heart of Manhattan. Public health wonk that I am, I had wondered how living in NYC might affect my probability of dying from injury and other health conditions one morning as I walked my 10 blocks from my apartment to my office. I suspected it would have declined: I had traded my daily 18 mile round-trip daily commute on the Mass Pike with a cardiovascular enhancing walk (probably calorie neutral, given the excellent choice of coffee shops I had to contend with on my walk through the Village). But, surely we would be safer from injury in NYC than in Boston.

In early December, in the wee hours of the morning, my husband hopped in a cab to go to work, Blackberry ablaze on a conference call with London. Minutes later his cab crashed into the side of a delivery truck. My husband was sent flying face first into the bullet proof glass that separated him and his driver. His front lip was split in two my his front teeth. He has been left with a permanent scar, but luckily nothing more serious happened.

The following morning on my way to work, I also came within inches of serious injury when a bicycle narrowly missed hitting me head on at top speed flying the wrong way down a one way street – although giving my outstretched arm a good clip. I fear what would have happened to me – and worse my unborn child – had I been one second further along the crosswalk (I am 5 months pregnant).

So as it turns out, my estimated risk of injury had perhaps not declined as much as I had hoped, I had simply exchanged one risk exposure for others. But the Haitian earthquake made me reflect on how where you live, can greatly affect your probability of death from injury. Haiti lies near a fault line, and has been affected by major earthquakes in the past, although none nearly this large in a few centuries. Like most impoverished nations, construction standards are no where near as high as they are in rich countries.

It would have been easy to predict that had an earthquake hit the region many buildings would have crumbled – they did in Sichuan Province in 2008, Kashmir Province in 2005, and Acheh Province in 2004. When major earthquakes strike, your chances of surviving do seem to depend on whether you live in a rich or a poor country – one more great health inequality that exists in the world.

So if these risks are so predictable, why is there not more done about it? Well, first it is expensive. Reducing the risk of injury from earthquakes would likely require rebuilding cities, which is unlikely to be cost-effective in countries where so many more cost-effective interventions are not even implemented. As well, the risks are still after all just probabilities that something will happen, and with so many other more pressing development concerns, it is no wonder that these types of concerns would take back seats other initiatives.

But does it mean nothing can be done? New building standards can be improved and existing standards can be enforced on new projects. Risk assessments can be done, disaster management plans developed, and educations campaigns could be launched against major natural disaster risks. Tsunami warning signs have sprung up all around the world in response to the Indian Ocean tsunami of 2004.

It is encouraging to see the outpouring of donations that have ensued this past week, as they did in 2004 following the Indian Ocean tsunami, but it is discouraging that these risks get so little attention before disaster strikes. Global public health should be all about the latter, and it is therefore surprising that it receives so little attention in global health dialogues. Perhaps it is time to try harder.

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I’ve been glued to the internet this a.m. waiting for news and pictures to come in from Port-au-Prince, Haiti where a powerful earthquake struck just before sunset last evening causing massive destruction and undoubtedly the loss of hundreds, and likely thousands, of innocent lives. Haiti, the poorest country in the Western Hemisphere, was already in shambles and this newest disaster is certainly not going to help. Haiti seems to go from diaster to disaster. I am praying for the citizens of this country.

When I was a student at the Harvard School of Public Health, I took a class from Professor Jennifer Leaning entitled Disaster Management. The course provided an overview of how public health professionals should think about responding when faced with disaster to minimize loss of life and morbidity. I was trying to think back to the lessons I learned in class and how they might apply to what is unfolding in Haiti: given the physical damage caused by the earthquake first responders should be mindful of obvious and non-obvious crush injuries, from broken legs to head trauma, and they should immediately begin preparations for the next phase of the response, which will likely involve significant dehydration, hunger, and food and water born illnesses from the breakdown of water, sanitation, and food supplies. I also recall being taught that the best way to manage such a response is to set up a clear centralized command and control center where the disaster response can be coordinated and managed. I suspect much of these actions are already underway.

Over the holidays, I had a chance to read the new book by Atul Gawande entitled “The Checklist Manifesto“. The basic argument articulated by the articulate Dr. Gawande is that checklists have transformed the way in which many other fields and industries deal with complexity and unpredictability and that that medicine, in particular surgery, could also benefit from the use of these simple, low-cost tools. I’ve blogged about some of the published results of a study Dr. Gawande and his colleagues at the WHO conducted on this over the past few years, but the book provides more background and insight into the value of these lists.

I had been struck while reading the book about how much he dumped upon the centralized command-and-control model to deal with disasters. He provides a example from when Hurricane Katrina stuck New Orleans. He argues that the traditional command-and-control model had failed and rather than recognizing that when faced with extraordinary complexity, which was further complicated by the breakdown of communication lines, power needed to be pushed out of the center to where people with local knowledge and expertise could be better utilized. The knowledge that was required to respond to this crises far exceeded the knowledge of any one person. Yet he also argues that individuals cannot act completely in isolation, they needed to be coordinated in some way, and he argues that a checklist could provide this overall coordination. In the book, he also provides examples of how successful general contractors and money managers also use checklists to manage this complexity.

It has now been almost 5 years since Hurricane Katrina, and the citizens of New Orleans are still rebuilding. Physically there are only about 1300 miles that separate New Orleans and Port-au-Prince but these two cities are almost a century apart in terms of their wealth and level of development. Dr. Gawande has shown that the same checklist can be effective in saving lives in rich hospitals in Boston and poor ones in Tanzania so I believe that many of the lessons from Katrina will be able to save lives in Haiti as well. Let’s hope that those in charge of this response are thinking about the past as much as the future.

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