Posts tagged “health”

The Return of London's Fog

London’s fogs may be about to make a comeback. Christine Corton, in the NYT:

In January, researchers at King’s College London announced that pollution levels on Oxford Street, in central London, had exceeded limits set for the entire year in just the first four days of 2015. Similarly alarming numbers have been recorded for other streets in the city — and yet the mayor, Boris Johnson, has delayed implementation of stricter air-quality measures until 2020.

What’s happening in London is being played out in cities worldwide, as efforts to curtail the onslaught of air pollution are stymied by short-term vested interests, with potentially disastrous results.

I just experienced a particular, particulate version of this hell first-hand in Delhi. For the last few days of my trip, a dense, thick haze - clearly not an innocuous fog - permeated the city and surrounding environs. On one trip back to our flat, all of my fellow taxi passengers complained of burning eyes and sore throats.

The closest PM monitor during that drive back — actually quite far from us — read over 250 �g/m3. That’s around 10x higher than a ‘bad’ day in the US. Moreover, we guessed that the levels we were experiencing were closer to 350 �g/m3. As a point of reference, the maximum mean hourly PM2.5 concentration in London since 2008 was approximately 30 �g/m3.

Corton points to a behavioral component to the historic London Fog episodes — a parallel I find particularly interesting:

There was a cultural component, too. The British were wedded to their open fires. Closed stoves, popular throughout much of Europe, especially in Germany, were shunned by Londoners. During World War I, Britons were exhorted, in the words of the famous song, to “keep the home fires burning.” Politicians were simply not willing to risk unpopularity by forcing Londoners to stop using coal and go over to gas or electric heating instead. In Britain today, in an echo of these earlier concerns, the government is cutting subsidies for onshore wind and solar farms, anxious not to offend voters in rural areas where such facilities would be built.

It took a disaster to force London to change direction. In 1952, a “great killer fog” lasted five days and killed an estimated 4,000 people. In a Britain trying to turn a corner after the death and destruction of the Blitz, this was unacceptable. A Clean Air Act was passed in 1956, forcing Londoners to burn smokeless fuel or switch to gas or electricity, power sources that had become much cheaper as these industries expanded.

Let’s hope that policy levers and momentum — not a disaster — can help transition away from solid fuels in India and beyond.

Conditional cash transfers for energy poverty... and murder reduction

Conditional cash transfers — paying people to change behavior, usually to spur positive ‘social’ outcomes — continue to be in the news. Much of the focus is on their use as poverty reduction tools (Bolsa Familia in Brazil, JSY in India) through encouraging behaviors like antenatal care visits and sending children to school.

Two recent article — one in the NYT, one in Mother Jones — highlighted the use of CCTs and other targeted cash transfer tools for dramatically different outcomes.

In the NYT, poverty and energy issues were at the fore:

The Indian government subsidizes households’ purchases of cooking gas; these subsidies amounted to about $8 billion last year. Until recently, subsidies were provided by selling cylinders to beneficiaries at below-market prices. Now, prices have been deregulated, and the subsidy is delivered by depositing cash directly into beneficiaries’ bank accounts, which are linked to cellphones, so that only eligible beneficiaries — not “ghost” intermediaries — receive transfers.

Under the previous arrangement, the large gap between subsidized and unsubsidized prices created a thriving black market, where distributors diverted subsidized gas away from households to businesses for a premium. In new research with Prabhat Barnwal, an economist at Columbia University, we find that cash transfers reduced these “leakages,” resulting in estimated fiscal savings of about $2 billion.

There’s even more “smart” targeting coming soon. My advisor and colleagues in India have been working to “[describe] how the LPG subsidy could be even more completely targeted to the poor without any actual ‘taking away’ of the subsidy from the rich and middle class, which would likely trigger heavy political push back. As a result, several hundred million additional poor Indians could have affordable access in the next decade without increasing subsidy costs to the government (indeed probably reducing them) or LPG imports — both not likely to be popular.”

In Mother Jones, CCTs were being used to reduce murders:

Richmond hired consultants to come up with ideas, and in turn, the consultants approached [Devone] Boggan. It was obvious that heavy-handed tactics like police sweeps weren’t the solution. More than anything, Boggan, who’d been working to keep teen offenders out of prison, was struck by the pettiness of it all. The things that could get someone shot in Richmond were as trivial as stepping out to buy a bag of chips at the wrong time or in the wrong place. Boggan wondered: What if we identified the most likely perpetrators and paid them to stay out of trouble?

It seems to be working.

It was a crazy idea. But since ONS was established, the city’s murder rate has plunged steadily. In 2013, it dropped to 15 homicides per 100,000 residents—a 33 year low. In 2014, it dropped again. Boggan and his staff maintained that their program was responsible for a lot of that drop-off by keeping the highest-risk young men alive—and out of prison. Now they have a study to back them up.

On Monday, researchers from the National Council on Crime and Delinquency, a non-profit, published a process evaluation of ONS, studying its impact seven years in. The conclusion was positive: “While a number of factors including policy changes, policing efforts, an improving economic climate, and an overall decline in crime may have helped to facilitate this shift, many individuals interviewed for this evaluation cite the work of the ONS, which began in late 2007, as a strong contributing factor in a collaborative effort to decrease violence in Richmond.”

Susanna Hertrich's Risk Perception Art

Susanna Hertrich:

A reflection on common fears in societies where anxieties have become a lifestyle choice (2010 - ongoing).

Regarding the piece above:

Public dread and actual deaths caused by most common sources of energy. Based on a longterm study by the International Atomic Energy Agency (IAEA).

via @darbyjack

Introducing HAPIT

I’ve lead recent efforts to create a web-based tool to estimate the impacts of household air pollution interventions (like stoves, gas dissemination, etc) using methods based on what’s known about household air pollution and its contribution to the Global Burden of Disease. The project began as an Excel-based spreadsheet before moving to the web leveraging Shiny, R, and a fair amount of javascript. From the site:

HAPIT estimates and compares health benefits attributable to stove and/or fuel programs that reduce exposure to household air pollution (HAP) resulting from solid fuel use in traditional stoves in developing countries. HAPIT allows users to customize two scenarios based on locally gathered information relevant to their intervention, which is the recommended approach. This will normally require preliminary field work at the dissemination site to demonstrate pollution exposures before and after the intervention in a representative sample of households. If no local information is available, however, HAPIT contains conservative default values for four broad classes of household energy interventions based on the available literature — liquid fuels, chimney stoves, rocket stoves, and advanced combustion stoves. As each country’s health and HAP situation is different, HAPIT currently contains the background data necessary to conduct the analysis in 55 countries — those with more than 50% of households using solid fuels for cooking and China, which has a lower percentage of households using solid fuels for cooking, but a high number in absolute terms. See the drop down list on the left and the Info tab for more details.

HAPIT also estimates program cost-effectiveness in US dollars per averted DALY (disability-adjusted life year) based on the World Health Organization’s CHOICE methodology (see Info tab for more detail). It takes a financial accounting approach in that it 1) does not take into account the household costs such as fuel and health expenses or time spent cooking or acquiring fuel and 2) assumes that programs are covering the cost of fuel-based interventions (such as annual LPG costs per household). For custom scenarios, users can adjust the per-household maintenance or fuel cost based on the characteristics of their programs. All program costs should be entered in current US dollars.

There are a number of nice features of HAPIT, but one I’m particularly fond of is the customized, session-based pdf generated by clicking “Download Report.” HAPIT’s a work in progress and will continue to evolve in the coming months.

Water, Salt, and Sugar

Nice, brief origin story of Oral Rehydration Salts and their deployment in Bangladesh. In particular, I enjoyed the parts describing the challenges of translating the science into practice in the field. Many of the lessons are relevant to our work in household energy and health.

  1. Use competent, well-trained field workers — and figure out clever ways to incentivize good, thorough work.

So how did BRAC tackle this daunting challenge? A three-month field trial in 1979 tested whether mothers recalled BRAC field workers’ instructions on how to prepare O.R.S. This was no easy task considering that poor, illiterate households did not have measuring spoons or cups.

BRAC’s verbal guidelines included the dangerous symptoms of diarrhea, when to administer O.R.S. and how to make it with a three-finger pinch of salt, a handful of sugar and a half liter of water. In another critical step, monitors returned to villages days or weeks after the initial instruction to quiz the mothers. Health workers were paid according to how many questions their subjects answered correctly, thus incentivizing quality instruction and not just the number of lessons. The trial found that verbally trained illiterate and semi-literate rural mothers could make properly formulated O.R.S. that passed laboratory tests.

  1. Ensure that field workers believe in and, when appropriate, use the items and practices they are promoting.

[Mr. Fazle Abed, BRAC’s founder and chairperson] identified other early hurdles that slowed the adoption of O.R.S. by mothers. After inquiring about slow adoption in some villages, he found that only a fraction of health workers believed in O.R.S. themselves; they didn’t even use it to treat their own diarrhea. To dispel doubts among trainers, BRAC brought them from the field to research labs in Dhaka to scientifically show how O.R.S. worked. Health workers were then advised to convince distrustful villagers by sipping O.R.S. during household training sessions.

  1. Don’t ignore the men, who have disproportionate sway over household decisions in many parts of the world.

After this breakthrough, adoption of ORS increased but then plateaued. Again, Mr. Abed tried to find the root of the problem. He enlisted anthropology students in Dhaka to interview people about why they weren’t using O.R.S. They found that men were alienated from the discussions between female health workers and mothers and so withheld support for O.R.S. In villages, “we had to take men into confidences so we told them exactly how O.R.S. worked,” Mr. Abed recalled. When men were included in discussions, adoption of O.R.S. increased significantly.

Obviously not a perfect analogy. ORS is curative — a response to ill-health — and requires a change in treatment behavior. Arguably the need for ORS decreases in a world with adequate access to clean water and sanitation — but absent that panacea, removing barriers to affordable, easy treatment is essential. The shift we seek to encourage, towards clean cooking, is meatier — it requires big changes to routine behavior. The lessons above still hold, though. We need field workers who believe in the interventions (and, conversely, interventions worthy of their belief), we need to compensate them well, and we need buy-in from whole communities.

Gates Notes: Two Videos That Illuminate Energy Poverty

Bill Gates, at his blog:

Many developing countries are turning to coal and other low-cost fossil fuels to generate the electricity they need for powering homes, industry, and agriculture. Some people in rich countries are telling them to cut back on fossil fuels. I understand the concern: After all, human beings are causing our climate to change, and our use of fossil fuels is a huge reason.

But even as we push to get serious about confronting climate change, we should not try to solve the problem on the backs of the poor. For one thing, poor countries represent a small part of the carbon-emissions problem. And they desperately need cheap sources of energy now to fuel the economic growth that lifts families out of poverty. They can’t afford today’s expensive clean energy solutions, and we can’t expect them wait for the technology to get cheaper.

Gates links to two videos from political scientist Bjorn Lomborg. They’re interesting and decent encapsulations of issues we grapple with regularly. We know what works, and indeed most of us in the developed world use either gas or electricity — or both — to cook everyday. Offering solutions that only partially protect health seems morally dubious, a point Lomborg and Gates make. Lomborg’s videos are embedded below. Grist for the mill.

Nature: Deadly Dinners

A decent journalistic piece in Nature about household energy use and health. My favorite bit, from the one-two punch of Kirk Smith & Kalpana Balakrishnan:

After decades of battling to get people to use improved cooking-stoves, many researchers worry that such devices will never win over consumers and thus never achieve the desired health and climate gains. “My bottom line is that nothing works,” Smith says. “The only thing we know that’s ever worked is gas and electric.”

Balakrishnan makes a moral argument against improved cooking stoves, which still produce harmful amounts of pollutants compared with LPG or electric ones, powered by remote energy plants that comonly use fossil fuels. “Are you justified in saying that it’s OK to be just a little bit better?” she asks. “If it’s OK for 40% of the population to use fossil fuels, then why is not OK for the other 60% of the population? How can we have dual standards?”

Nature chimes in on clean cookstoves

Today, in Nature:

Even though high-profile programmes have distributed millions of stoves to households in south Asia, Africa and Latin America, it is hard to find signs that the stoves are being widely used. There is a vast gap between reported accomplishments and what researchers see when they step into people’s homes.

The crux of the problem is that simply supplying the stoves does not establish demand for them.


Efforts could be redirected to providing people with the energy they most aspire to: not a stove designed by someone in the developed world to cook cleaner, but the actual stoves used in the developed world, which run on electricity or hydrocarbons such as liquefied petroleum gas (LPG).

This is not an absurd goal. The International Energy Agency (IEA) estimates that bringing electricity and clean-cooking facilities to every person on Earth by 2030 will cost US$49 billion a year. Although that is a considerable sum, the agency points to major commitments by Indonesia, Ghana and Nigeria to aggressively switch large portions of their population to cooking with LPG.

Where will all this new energy come from? It will require some additional consumption of fossil fuels, and that will increase the emissions of carbon dioxide into the atmosphere. But the extra pollution would be minimal at the global scale: the IEA estimates that it would boost CO2 emissions by just 0.7% above its base scenario.


EIA: World petroleum use sets record high in 2012 despite declines in North America and Europe

U.S. Energy Information Administration:

The world’s consumption of gasoline, diesel fuel, jet fuel, heating oil, and other petroleum products reached a record high of 88.9 million barrels per day (bbl/d) in 2012, as declining consumption in North America and Europe was more than outpaced by growth in Asia and other regions (see animated map). A previous article examined regional trends in petroleum consumption between 1980 and 2010; today’s article extends that analysis through 2012.

Some other specific points of interest:

Between 2008 and 2012, Asia’s consumption increased by 4.4 million bbl/d. The rapidly industrializing economies of China and India fueled much of Asia’s demand increase, growing 2.8 million bbl/d and 800,000 bbl/d, respectively. If China’s use of petroleum continues to grow as projected, it is expected to replace the United States as the world’s largest net oil importer this fall.

Petroleum use in Europe has declined in every year since 2006. Part of this decline was related to a reduction in overall energy intensity and government policies that encourage energy efficiency. Europe’s weak economic performance has also affected its petroleum use, with declines of 780,000 bbl/d in 2009 and 570,000 bbl/d in 2012 occurring at a time of slow growth and/or recessions in many European countries.

Air Pollution Linked to 1.2 Million Premature Deaths in China

As Kirk pointed out in an email this morning, the NYT missed half of the problem. He wrote:

Remarkable narrow vision to fail even to mention that household air pollution has about an equal impact in the country. Even though the GBD study shows both on the same graphs, journalists and policy makers see one, but not the other. These is also an estimated 0.2 million overlap, what we call secondhand cookfire smoke, which is the portion of outdoor air due to cooking fuels in the country. If you account that to household air pollution, than the total impact of household air pollution is greater than that from outdoor air pollution due to all other sources combined (1.2 million premature deaths compared to 1.0 million).

Our work has been showing — in India and in China — that outdoor air pollution isn’t just an urban problem; it is simply measured most commonly (and thus identified most easily) in urban areas. We’re working to quantify that contribution and to make the case that cleaning up households can help clean up ambient air — in urban and rural areas.

Nature, Nurture, Medication, Arrogance

A pretty terrifying article from the NYT about prescriptions of psychotropics - regardless of ADHD diagnosis - in school age children. I couldn’t read the article in any light but one of utter disbelief; I’m not sure if that’s me imposing my bias on it or if its actual paints the practice as problematic.

Some excerpts below, but read the whole thing.

Although A.D.H.D is the diagnosis Dr. Anderson makes, he calls the disorder “made up” and “an excuse” to prescribe the pills to treat what he considers the children’s true ill — poor academic performance in inadequate schools.

“I don’t have a whole lot of choice,” said Dr. Anderson, a pediatrician for many poor families in Cherokee County, north of Atlanta. “We’ve decided as a society that it’s too expensive to modify the kid’s environment. So we have to modify the kid.”

The Drug Enforcement Administration classifies these medications as Schedule II Controlled Substances because they are particularly addictive. Long-term effects of extended use are not well understood, said many medical experts. Some of them worry that children can become dependent on the medication well into adulthood, long after any A.D.H.D. symptoms can dissipate.

According to guidelines published last year by the American Academy of Pediatrics, physicians should use one of several behavior rating scales, some of which feature dozens of categories, to make sure that a child not only fits criteria for A.D.H.D., but also has no related condition like dyslexia or oppositional defiant disorder, in which intense anger is directed toward authority figures. However, a 2010 study in the Journal of Attention Disorders suggested that at least 20 percent of doctors said they did not follow this protocol when making their A.D.H.D. diagnoses, with many of them following personal instinct.

You can argue either way about this — that helping struggling students perform is a good thing; that riddling younger kids with drugs that we know are addictive AND for which we don’t know the long-term side effects of is insane. I tend toward two seemingly sensical principles here — 1) the precautionary principle, something largely eschewed in this country and 2) finding better ways to engage students in school beyond medication. Medication is appropriate when the prescription is made with a valid medical diagnosis. In some of the cases described, however, the diagnosis is flimsy, the ethics questionable, and the end-result hardly what we want, as a society, for our youth. I can’t help but think there must be another way.

Drink Coffee*, Reduce Heart Failure

The health benefits of coffee [joe, java, brown sludge, nectar of the gods, liquid happiness] have been widely unproven in the peer-reviewed scientific testing. Studies have flip-flopped on the impact of coffee consumption on various health endpoints more than Mitt on… everything.

A recent systematic review and dose-response meta-analysis in Circulation, a journal of the American Heart Association (AHA), found that moderate coffee consumption — of around 2 US cups per day (between 295 - 590 mL) — was health protective and decreased the risk of heart failure by 11%. This flies in the face of the current statement on coffee by AHA, based on a single study, which states that coffee may increase the risk of heart failure. The previous study failed to control for potential characteristics of the evaluated population that may also contribute to heart failure.

The systematic review looked across the medical literature beginning in 1966 and found 5 valid studies that followed a cohort of people over time. These studies, when combined, included 6522 heart failure events among 140,220 participants. Four of the studies were conducted in Sweden; one was conducted in Finland. The relationship between coffee consumption and heart failure did not vary by sex, history of myocardial infarction, or diabetes.

There are some shortcomings to the study, of course. The 5 studies included in the analysis relied on self-reported coffee consumption. The type of coffee consumed — that is, the strength of the coffee, whether it was caffeinated or blasphemous decaffeinated, and the brewing method — were not noted in the original studies.

All that said, the review convincingly argues that moderate coffee intake is healthful and heart-protective.

I’m off to sound my barbaric yawp over the roofs of the world with mug o’joe in hand.

* in moderation

Affordable Care Act Upheld, Explained in a single paragraph

From SCOTUSblog, via the Atlantic:

In Plain English: The Affordable Care Act, including its individual mandate that virtually all Americans buy health insurance, is constitutional. There were not five votes to uphold it on the ground that Congress could use its power to regulate commerce between the states to require everyone to buy health insurance. However, five Justices agreed that the penalty that someone must pay if he refuses to buy insurance is a kind of tax that Congress can impose using its taxing power. That is all that matters. Because the mandate survives, the Court did not need to decide what other parts of the statute were constitutional, except for a provision that required states to comply with new eligibility requirements for Medicaid or risk losing their funding. On that question, the Court held that the provision is constitutional as long as states would only lose new funds if they didn’t comply with the new requirements, rather than all of their funding.

From the ruling:

Today we resolve constitutional challenges to two provisions of the Patient Protection and Affordable Care Act of 2010: the individual mandate, which requires individuals to purchase a health insurance policy providing a minimum level of coverage; and the Medicaid expansion, which gives funds to the States on the condition that they provide specified health care to all citizens whose income falls below a certain threshold. We do not consider whether the Act embodies sound policies. That judgment is entrusted to the Nation’s elected leaders. We ask only whether Congress has the power under the Constitution to enact the challenged provisions.

From the New Yorker:

On the last possible day, the Supreme Court upheld most of the Affordable Care Act. (Here’s a pdf of the opinion.) Who won, then? John Roberts, the Chief Justice, who put himself in the majority with the Court’s four liberals, and may have changed the definition of what we call “the Roberts Court”; President Barack Obama, whose first term was defined by it; our sense of how the balance of powers ought to work, and against, perhaps, our growing cynicism about the Court’s politicization (although there is a fine line between cynicism and simple prudence). A conservative court, and a conservative justice, upheld a law passed and treasured by liberals. This is not the way the Court has worked in recent years, for either side. “The Court does not express any opinion on the wisdom of the Affordable Care Act,” according to the majority opinion, written by Roberts. No one asked it to.

But, really, the winners are Americans—the more than fifty million of them who don’t have health insurance, but also the rest. Income and well-being have increasingly come to define each other; this is a victory for our sense of fairness, and that there need not be two Americas—one where, say, a mother can get good prenatal care and a cancer patient has choices, and another where pregnant women show up at emergency rooms, “preëxisting conditions” can be a death sentence, and medical costs are one of the leading causes of bankruptcy and foreclosure. It won’t be immediate. This is a major step toward American fairness.

And (surprisingly, from error/spoiler CNN), a nice page collecting lines from the justices.

Assessing Willingness to Pay for Environmental Health Interventions

Attended a great lecture today by Isha Ray and Jack Colford as part of a new BERC IdeaWorks series. It was a discussion of "Water resources for sustainability and health", focusing mainly on water quality issues in the developing world. A number of interesting studies were described (amazingly clearly, given the complexity of them on the ground) by Dr. Ray and Dr. Colford - both masterful professors. Dr. Colford's undertaking a multi-country assessment of water, sanitation, and hygiene interventions (individually and combined) to see their effects on height, weight, diarrhea. The challenge of doing this kind of randomized trial is not to be underestimated; they plan a year of pilots before the full study begins. A heady undertaking.

Dr. Ray described a couple studies that try to understand how people use these services, how they pay for them, and how they weigh options for water and sanitation. The most striking example she gave is a study kicking off shortly in Tanzania. Her research team is assessing how willing people are to use and pay for six commercially available point-of-use water treatments (like chlorine, a safe-water bucket, a UV filter, a biosand filter, etc). Her approach is novel. As with all studies of this sort, intervention devices will be given to participants. At the end of the study, she'll try one of the following two things: (1) randomly give participants an envelope with a cash amount her team will pay to buy back the point-of-use device or (2) plan the study so that at its conclusion all devices are returned to the researchers; participants are given the option to buy the device back, again at a randomized price. Its an elegant solution to figuring out how much a person would be willing to pay for a technology that is available on the local market.

Our work in the stove world needs to look towards these kinds of assessments to help us frame the issue of poor uptake and compliance of cookstove usage. Both of these types of environmental health interventions often run into the same issues - the technology is poorly designed for the target population, or the population doesn't perceive a need for it. Trying out locally available technologies and helping NGOs and governments figure out which ones people are willing to pay for -- which we hope is a proxy for willing to use -- is one step in the right direction.

This discussion ignores the impact of the devices on the market -- it assumes they work. That's a second, additional wrinkle that plays into the technology adoption.

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