Beyond Index in Beijing

On January 15, 2013, in Asia, China, environmental health, by Karen Grepin

Last November, I had the great pleasure to attend the 2nd Global Symposium on Health Systems Research in Beijing, China. This was my third visit to Beijing – I had visited once in 2004 and again in 2009 to attend the International Health Economics Association biannual conference (which was in the same conference center!). Visiting this city every few years or so has allowed me to witness first hand the remarkable transformation this city has undergone over the past decade. For example, I still remember the sight of thousands of cars rolling along the side of the road in 2004 but by 2009 they had all but been replaced by cars.

The view from my hotel room in Beijing, November, 2012.

The view from my hotel room in Beijing, November, 2012.

One of the biggest changes I noticed this time around was the increase in air pollution, which I would describe as a thick toxic fog. Although visibility was terrible when I was there in 2009, this time the air literally left me feeling ill (and may have contributed to me nearly visiting the emergency room of a Chinese hospital on one of the conference days). So I was not terribly surprised, although still alarmed, when I read about reports of reports of terrible air quality being reported this week in Beijing.

Despite local Chinese reports to the contrary, air quality has been deteriorating rapidly in Beijing and across the country, as it has been in many developing countries. Two year ago, an air quality sensor on the roof of the United States Embassy in Beijing recorded an air quality reading of more than 500 on a a scale of 500 on the EPA standards. It was “Beyond Index” or simply “Crazy Bad”. This reading was 20 times beyond what the World Health Organization considers safe to breath! New York City, where I currently live, will record figures under 20. To make things worse, last weekend a reading of 758 was measured. This is not only beyond index but beyond imaginable.

How much impact can this pollution have on health? I am not expert on this stuff but based on a few papers I have seen on this, it could be a lot. A colleague, Avraham Ebenstein from Hebrew University in Israel, has a fabulous study that has looked exactly at this question in China in a still unpublished paper with a series of co-authors. Using a policy that affects one part of the country and not another, they find that increases in air pollution of about 100 μg/m3 is associated with about 3 years of lower life expectancy. In the areas that they study they find increases in air pollution of about 2 times this across their study area and the levels recorded in Beijing would be even higher suggesting very large and very real decreases in life expectancy due to air pollution. Increases in child mortality from air pollution have also been documented by economists in Mexico City, India, and even in New Jersey. An emerging finding from many of these studies is that the impact on health of very high levels of exposure might be even worse than what we would predict based on what we know about exposure in developed countries today.

And it is not just the water that appears to be causing significant poor health. Avi also has another excellent paper that looks at the impact of water pollution in digestive cancers in China. He documents a 10% increase in digestive cancers due to water pollution due to industrialization.

Is this simply the price to pay for development? Is there really anything that developing countries can do to prevent this? Well, for starters, there needs to be admission that there is in a problem. Fortunately, the international attention to the issue may have actually led to officials admitting that there is an air pollution crises in Beijing – students have even been ordered to avoid outdoor activities. Plus, even small changes can help to improve health: the India paper I cite above finds that even there stricter environmental regulations can improve health outcomes, suggesting that public policies can make a difference.

What is clear that the health impact can be enormous and if one believes that real development involves more than just increases in gross domestic product per capita, than progress towards true development will be hampered until these types of issues are properly addressed.

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In this month’s Health Policy & Planning, Tamara Hafner and Jeremy Shiffman have a new article that I think should be on everyone’s reading list (and since it is open access, it can be). Their abstract:

After a period of proliferation of disease-specific initiatives, over the past decade and especially since 2005 many organizations involved in global health have come to direct attention and resources to the issue of health systems strengthening. We explore how and why such attention emerged. A qualitative methodology, process-tracing, was used to construct a case history and analyse the factors shaping and inhibiting global political attention for health systems strengthening. We find that the critical factors behind the recent burst of attention include fears among global health actors that health systems problems threaten the achievement of the health-related Millennium Development Goals, concern about the adverse effects of global health initiatives on national health systems, and the realization among global health initiatives that weak health systems present bottlenecks to the achievement of their organizational objectives. While a variety of actors now embrace health systems strengthening, they do not constitute a cohesive policy community. Moreover, the concept of health systems strengthening remains vague and there is a weak evidence base for informing policies and programmes for strengthening health systems. There are several reasons to question the sustainability of the agenda. Among these are the global financial crisis, the history of pendulum swings in global health and the instrumental embrace of the issue by some actors.

Basically their research finds that health system strengthening (HSS) became sexy due the the fact that there was a big push for disease-specific programs and addressing the MDGs and health systems were seen as a big barrier to achieving goals on other fronts. But since no one has ever really figured out what HSS is, nor how one actually strengthens a health system, it risks falling off the global health radar, especially as we take our foot off the pedal on other global health fronts. To that I would add (as suggested to me by Rob Yates on Twitter) it has been pushed out by the embrace of another related, but sometimes as nebulous, concept – Universal Health Coverage.

Don’t get me wrong, this might not be a bad thing, and current efforts might be more realistic than pushing an agenda that involves transforming so many aspects of a health system rather than focusing on what might be a more manageable piece of the puzzle. But in this time with so much up in the air in global health, it is worth asking if it is worth bringing this issue back as a central effort, in particular in the context of post-MDG discussions. Is this an idea worth saving?

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It is old news by now that while trying to capture Osama Bin Laden in Pakistan, the CIA had a Pakistan doctor infiltrate the Bin Laden compound by launching a fake vaccination campaign. What might have seem like an innocent guise has turned deadly: late last year innocent polio vaccinators in Pakistan have been attacked and a number of them have been killed. The knock-on health effect might be even greater: polio eradication efforts have been suspended in Pakistan and organizations like Save the Children have had to pull out their foreign nationals.

In what I thought was a very well written and well informed letter to the Deans of a number of American Schools of Public Health have written to President Obama condemning these actions and asking him to take action to help restore these vital public health efforts. I wanted to share the text of this letter, so it is copied below.

Can trust ever be restored in public health in Pakistan? Who knows. The Deans suggest that an executive order might be a first step in helping to restore confidence in international public health efforts. Charles Kenny at the Center for Global Development has provided some concrete suggestions how such an order can be done here.

Addendum: Brett Keller sent me a link to this petition, where you too can show your support in banning the use of public health campaigns for intelligence missions.

January 6, 2013

Dear President Obama,

In the first years of the Peace Corps, its director, Sargent Shriver, discovered that the Central Intelligence Agency (CIA) was infiltrating his efforts and programs for covert purposes. Mr. Shriver forcefully expressed the unacceptability of this to the President. His action, and the repeated vigilance and actions of future directors, has preserved the Peace Corps as a vehicle of service for our country’s most idealistic citizens. It also protects our Peace Corps volunteers from unwarranted suspicion, and provides opportunities for the Peace Corps to operate in areas of great need that otherwise would be closed off to them.

In September Save the Children was forced by the Government of Pakistan (GoP) to withdraw all foreign national staff. This action was apparently the result of CIA having used the cover of a fictional vaccination campaign to gather information about the whereabouts of Osama Bin
Laden. In fact, Save the Children never employed the Pakistani physician serving the CIA, yet in the eyes of the GoP he was associated with the organization. This past month, eight or more United Nations health workers who were vaccinating Pakistani children against polio were gunned down in unforgivable acts of terrorism. While political and security agendas may by necessity induce collateral damage, we as an open society set boundaries on these damages, and we believe this sham vaccination campaign exceeded those boundaries.

As an example of the gravity of the situation, today we are on the verge of completely eradicating polio. With your leadership, the U.S. is the largest bilateral donor to the Global Polio Eradication Initiative and has provided strong direction and technical assistance as well. Polio particularly threatens young children in the most disadvantaged communities and today has been isolated to just three countries: Afghanistan, Nigeria and Pakistan. This is only one example, and illustrates why, as a general principle, public health programs should not be used as cover for covert operations.

Independent of the Geneva Conventions of 1949, contaminating humanitarian and public health programs with covert activities threatens the present participants and future potential of much of what we undertake internationally to improve health and provide humanitarian assistance. As public health academic leaders, we hereby urge you to assure the public that this type of practice will not be repeated.

International public health work builds peace and is one of the most constructive means by which our past, present, and future public health students can pursue a life of fulfillment and service. Please do not allow that outlet of common good to be closed to them because of
political and/or security interests that ignore the type of unintended negative public health impacts we are witnessing in Pakistan.

Pierre M. Buekens, M.D., M.P.H., Ph.D.
Dean, Tulane University School of Public Health and Tropical Medicine*
John R. Finnegan Jr., Ph.D.
Professor and Dean, University of Minnesota School of Public Health* Chair of the Board, Association of Schools of Public Health*
Julio Frenk, M.D., M.P.H., Ph.D.
Dean and T&G Angelopoulos Professor of Public Health and International Development Harvard School of Public Health*
Linda P. Fried, M.D., M.P.H.
Dean, Mailman School of Public Health, Columbia University*
Howard Frumkin, M.D., Dr.P.H.
Dean, School of Public Health, University of Washington*
Lynn R. Goldman, M.D., M.P.H.
Professor and Dean, School of Public Health and Health Services, George Washington University*
Jody Heymann, M.D., M.P.P., Ph.D.
Dean, UCLA Fielding School of Public Health*
Michael J. Klag, M.D., M.P.H.
Dean, Johns Hopkins Bloomberg School of Public Health*
Martin Philbert, Ph.D.
Dean, School of Public Health, University of Michigan*
Barbara K. Rimer, Dr.P.H.
Dean and Alumni Distinguished Professor UNC Gillings School of Global Public Health*
Stephen M. Shortell, Ph.D.
Dean, School of Public Health, University of California Berkeley*

*Institutional affiliation is provided for identification only.

James W. Curran, M.D., M.P.H.
Dean, Rollins School of Public Health, Emory University*
Regina M. Benjamin, United States Surgeon General
Hillary Rodham Clinton, Secretary of State
Thomas Frieden, Director, Centers for Disease Control and Prevention Howard Koh, Assistant Secretary of Health
Michael J. Morell, Acting Director of the Central Intelligence Agency Janet Napolitano, Secretary of Homeland Security
Kathleen Sibelius, Secretary of Health and Human Services

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