Controlling Wild Horses with Tools Made for Zebras

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Controlling Wild Horses with Tools Made for Zebras
Plenary Presentation at the NIEHS Global
Environmental Health Conference San Francisco,
Jan 11-13, 2007

• Kirk R. Smith
• School of Public Health
• University of California, Berkeley

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Toxic Tsunami threatening planets
health By OUR CORRESPONDENT New evidence
indicates that a massive wave of toxic material
may soon be affecting populations all over the
world because of faulty technology.
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It will wash across the countryside exposing the
poorest half of humanity to a toxic soup
containing

• Dozens of poisonous organic chemicals known to be
  mutagens, immune system suppressants, severe
  irritants, blood poisons, inflammation agents,
  central nervous system depressants, cilia toxins,
  endocrine disrupters, or neurotoxins.
• Several other chemicals firmly established as
  human carcinogens.
• Other toxic inorganic chemicals known to cause
  asphyxiation, stillbirth, infant death, heart
  disease, and severe acute and chronic lung
  disease.

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The Toxic Tsunami

• It will be the result of a process that pours
  this toxic soup directly into 100s of millions
  homes every day all year every year.
• It will expose families to toxic levels much
  higher those of people living on top of toxic
  waste dumps, working in most heavy industries, or
  residing in the dirtiest cities
• These toxic levels will be tens or hundreds of
  times the levels set by international and
  national organizations to protect health
• Insidiously, it will target women and young
  children in the poorest households

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Why would it happen?

• Because a technology will be widely promoted that
  takes perfectly safe natural material and
  converts 10 of it to toxins in the course of
  functioning. Sometimes as much as 20
• The efficiency of the process is extremely low,
  leading to little human benefit per unit toxin
  created as well as waste of the natural resource.
• Instead of carefully disposing of this toxic
  material in safe places, this industry will
  spread the toxic soup by air right into
  neighborhoods where people live.
• All this, in spite of there being well-known
  alternative technologies available producing very
  little toxin.

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What might be the health consequences if this
happens?

• A vast epidemic of a respiratory illness that
  kills faster than SARS or Avian Flu initiation
  to death in 2 days in some cases.
• So fast, that trying to apply medical care is
  often hopeless.
• Estimates are that soon it would be killing at
  least one thousand children a day, perhaps as
  many as a million a year
• This would be equivalent to some 1000 SARS
  epidemics per year, and would occur year in and
  year out, with no end in sight.

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What else?

• Millions of the poorest women would have their
  breath taken from them as their lung function is
  slowly eaten away by exposure to the toxins
• Thus, at tragically young ages they will become
  unable to breathe normally or do common tasks.
• Alarmingly, once a woman is affected, there is no
  known medical therapy to reverse the process.
• More than 1000 per day, maybe half a million per
  year, would soon start to die prematurely because
  their lungs would finally give out.

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Anything else?

• Although some effects are known, so little study
  has been done of this threat that we are unsure
  of even all the types of health impacts there
  would be, let alone their scale
• There are strong indications, however, that the
  burden on households would include many other
  insidious diseases, such as
• A significant increase in tuberculosis, one of
  the most important and intransigent of the
  re-emerging infectious diseases in the world
• A major negative impact on babies health and
  survival through reductions in growth before
  birth
• Increases in several types of cancer, including
  lung and throat
• Damage to the eyesight of millions
• Exacerbation of heart disease

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Will there bea massive emergency meeting in
Geneva of international agencies and donors with
unlimited authority and funds to take action?

• The answer is no indeed nothing will be done.

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Toxic Tsunami threatening planets
health By OUR CORRESPONDENT New evidence
indicates that a massive wave of toxic material
may soon be affecting populations all over the
world because of faulty technology.
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Everything stated about The Toxic Tsunami
is true, as best we know, except that it is not
predicted but already here
Household pollution from burning simple solid
fuels like wood
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National Household Use of Biomass and Coal in
2000
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Health-Damaging Air Pollutants From Typical
Woodfired Cookstove in India.
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Chronic obstructive lung disease Interstitial
lung disease
Diseases for which we have some epidemiological
studies
ALRI/ Pneumonia (meningitis)
Cancer (lung, NP, cervical, aero-digestive)
Asthma
Low birth weight
Blindness (cataracts, trachoma)
Tuberculosis
Early infant death
Heart disease
Cognitive Impairment?
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First person in human history to have her
exposure measured doing one of the oldest tasks
in human history
Filter
Kheda District, Gujarat, India 1981
Pump
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Do we know too much or do we know too little?

• A story of two conferences

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History of a RCT

• 1980 Early studies of health effects in Nepal
  and elsewhere
• 1981 First measurements of pollution levels in
  India
• 1984 International meeting to decide on needed
  research
• Chose randomized control trial (RCT) of ALRI
• 1986-89 Unfunded proposals to do RCT in Nepal
• 1990 WHO establishes committee to find best
  sites
• 1990-1992 Criteria established and site visits
  made
• 1992 Highland Guatemala chosen
• 1991-1999 Pilot studies to establish data needed
  for proposal
• 1996-1999 Unfunded proposals
• 2001 NIEHS funding secured
• 2002-2005 Fieldwork completed
• 2006 First results being published
• 22 years from deciding to conduct RCT to results!

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Control and Intervention
Traditional 3-stone open fire
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Why will nothing be done?

• Is it because it is day-to-day, i.e., not
  spectacular?
• It isnt the big or weird things that kill most,
  but the little mundane ones
• Public risk perception is quite different,
  however.
• Dread, probability neglect, familiarity, etc.
• Because it only affects the most disenfranchised
  people in the world?
• Poor
• Rural
• Developing-country
• Women and children

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Why will nothing be done?

• Perhaps because it is scientifically mundane,
  i.e, not enough zebras?

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Phil Landrigrans Tie
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Zebras and Horses

• In the journals and in the conferences, we hear
  quite a bit about some very interesting zebras
• And maybe even a few unicorns with pretense to be
  zebras
• Studying zebras is good, for we want to avoid
  being surprised by one that becomes a horse,
  i.e., really causes much ill-health
• We hear less about horses, however, i.e., the
  environmental and other risks that are really
  affecting health around the world

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2000
World DALYs in 2000
These are the Global Disease Horses
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What horses are still untamed for children lt5?In
the poorest countries (83 of all children)

• More than 5 each
• ALRI (14)
• Diarrhea (13)
• Low Birth Weight (11)
• Malaria (10)
• Child Cluster Diseases (9)
• Birth Trauma (8)
• More than 1 each
• Mental retardation from lead
• Endocrine disorders
• Drownings and road traffic accidents
• Congenital anomalies
• Protein-energy malnutrition
• HIV, Other STD

WHO GBD Database
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2000
DALDs Per Capita by Age Group Selected World
Regions
Annual loss per person
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Horses for school-age children(who are 10x
healthier than children lt5)

• More than 5
• Parasites
• Depression
• More than 1
• TB
• Meningitis
• Leukaemia
• Violence
• Asthma
• Falls and fires
• Iron deficiency
• Dental caries

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The most critical special health issue for
school-age kids is parasites

• Trypanosomiasis
• Chagas disease
• Schistosomiasis
• Leishmaniasis
• Lymphatic filariasis
• Onchocerciasis
• Ascariasis
• Trichuriasis
• Hookworm disease

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Why will nothing be done?(cont.)
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Misconceptions leading some to conclude that
horses are not appropriate for more EH research

• It is just a matter of poverty
• It is just a matter of engineering
• It is just a matter of political will
• Environmental health risks are not important
• It is just a matter of population control
• The hazards are natural and thus benign
• There is no direct benefit for the US
• There is no interesting science left, i.e., we
  understand the processes

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It is just a matter of poverty

• Yes, poverty is a large part of the problem, but
  poverty alleviation, unfortunately, is not a
  large part of the answer
• Poverty alleviation is too slow, expensive,
  uncertain, unfocused, and unethical to be an
  effective PH intervention
• World Bank analyses
• Fails to recognize the reverse causality, i.e.,
  to obtain economic growth (and probably
  democracy) requires healthy populations with
  expectations of health security for themselves
  and their children
• The single (or at least one of few) best
  definition of public health is The art and
  science of public health is finding ways to make
  people healthy before they are wealthy
• Remember the Broad Street pump

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It is just a matter of engineering

• Could be said of nearly all we do, i.e., why not
  have zero pollution emissions of all sorts
  everywhere immediately?
• Too expensive to do so.
• We need to learn which exposures are most
  important and both how to reduce them more
  effectively and exactly how much health and other
  benefits result from doing so.
• If this is true in the US, it is even more so in
  poor countries
• 7 per year per capita in India for public health
  (26 for all health)
• It also implies that the engineering approaches
  we have applied in the past are appropriate in
  the third world today. Not so because, inter
  alia
• Cost structures are different e.g., fossil fuels
  are now priced such that they are not even
  mid-term options for poor populations
• Densities are different second stage of
  environmental impacts (community impacts) are
  greater, water resources are less, etc
• Understanding of sustainability is different
  (climate change, eutrophication , renewability,
  biodiversity, life-cycle analysis, etc)

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It is just a matter of political will

• Yes, in a better world we would not have so many
  poor while the rich have so much and do so little
  to make up the difference
• In the world we have, however, poverty,
  disenfranchisement, indifference, and
  exploitation only slowly and unevenly decline
• Indeed, we have more people in abject poverty
  today than at any time in human history
• We need thus to optimize our use of the global
  systems we have to improve health, while working
  to expand them
• Thus, we need to directly respond to our
  colleagues who have just 7 per capita to make
  sure we can achieve serious benefits with their
  resources
• Ironically, in the places where problems are
  greatest, there is thus sometimes need to have
  better evidence than in places where health is
  least at risk
• We must resist the natural tendency to promote
  our interesting and technically exciting study of
  first-world zebras such that they become, by
  example and default, a high priority everywhere
• textbooks, students, reviews, policy advice,
  media interactions, etc.
• Political will starts at home

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Environmental health risks are not important

• The simple response
• Environmental risks are actually a far larger
  health threat in the third world than in the
  first
• By both relative and absolute measures
• And for the future via global environmental
  change

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How environmental health risks change with
development The Epidemiologic and Environmental
Risk Transitions revisited Smith KR, Ezzati
M, Annual Review of Energy and Resources, 30
29-333, 2005
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How do environmental health risks change with
development?
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Percent Of DALYs
Undernutrition Environment Sex and
reproduction Child cluster
Smith, 2003
PPP/capita
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Addictions (Tobacco, drugs, alcohol) Diet and
Physical Inactivity
Percent Of DALYs
Smith, 2003
PPP/capita
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The Environmental Risk Transition
Household
Community
Severity
Global
Increasing Wealth
Shifting Environmental Burdens
Local
Global
Immediate
Delayed
Risks to Human Health
Risks to Life Support Systems
(Modified from Smith, 1991)
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Smith Ezzati, 2005
Figure 7d
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Smith Ezzati, 2005
Figure 8a
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Smith Ezzati, 2005
Figure 10
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The Environmental Risk Transition
Household
Community
Severity
Global
Increasing Wealth
Shifting Environmental Burdens
Local
Global
Immediate
Delayed
Risks to Human Health
Risks to Life Support Systems
(Modified from Smith, 1991)
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Combustion Mismanagement

• Sticking burning stuff in your mouth
• In your home
• In your community
• On your planet
• Putting toxins in it
• Letting it burn down your house

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.
 
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Environmental health risks are not important

• The simple response
• Environmental risks are actually a far larger
  health threat in the third world than in the
  first
• By both relative and absolute measures
• And for the future via global environmental
  change
• The complex response
• It is true that, using the 7 bar, environmental
  health interventions often do not seem to compete
  with vaccines, antibiotics, ORT, etc., the most
  cost-effective and yet still not completely
  applied health interventions
• Unlike other interventions, however, EH
  interventions can have
• Multiple health benefits
• Significant non-health benefits
• Which, if included, change the calculus
  substantially
• This implies that to make a difference, EH
  research needs to include serious programs to
  develop rigorous and convincing ways of
  quantifying and combining multiple health and
  non-health benefits

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It is just a matter of population
control(i.e., we should not save children in
the third world because there are too many of
them already)

• Leaving aside
• the moral implications and
• that first world children are actually the
  greater threat to humanity
• The way forward to lower fertility includes lower
  child mortality and morbidity ASAP
• No one will have fewer children if children are
  dying around them (necessary but not sufficient
  condition)
• The number of averted future births from each
  averted child death is greater than 1.0, often
  much greater
• Death is not the only outcome of interest
• For every child dying unnecessarily, there are
  others with long-term chronic outcomes affecting
  their QOL, economic productivity, and ability to
  participate meaningfully in developing mature
  stable societies

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The hazards are natural and thus benign

• Some of us forget, that most of humanity has
  spent most of history trying to protect itself
  from the natural and the organic
• Consider woodsmoke, which could hardly be more
  natural how can it hurt you?

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Since wood is mainly just carbon, hydrogen, and
oxygen, doesnt it just change to CO2 and H2O
when it is combined with oxygen (burned)?
Reason the combustion efficiency is far less
than 100 Indeed, 5-20 of the fuel carbon is
actually turned into toxic materials
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Toxic Pollutants in Biomass Fuel Smokefrom
Simple (poor) Combustion

• Small particles, CO, NO2
• Hydrocarbons
• 25 saturated hydrocarbons such as n-hexane
• 40 unsaturated hydrocarbons such as 1,3
  butadiene
• 28 mono-aromatics such as benzene styrene
• 20 polycyclic aromatics such as benzo(?)pyrene
• Oxygenated organics
• 20 aldehydes including formaldehyde acrolein
• 25 alcohols and acids such as methanol
• 33 phenols such as catechol cresol
• Many quinones such as hydroquinone
• Semi-quinone-type and other radicals
• Chlorinated organics such as methylene chloride
  and dioxin

In US regulatory terminology, there are
significant emissions of 3 Criteria Air
Pollutants and at least 28 Hazardous Air
Pollutants (HAPs)
Source Naeher et al, J Inhal Tox, 2007
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There is no direct benefit for the US

• Leaving aside
• Humanitarian,
• Political, and
• Foreign investment benefits
• The US benefits directly from
• Healthier immigrants
• More stable societies able to look to the long
  term
• Healthier customer base for US exports
• Less trans-national pollution
• Less trans-national infection
• Ability to understand health impacts that are
  difficult to study in the US through, inter alia,
• High and/or simpler exposure settings
• Arsenic in water
• Benzene in workers
• Particles in air
• More chance to study interactions of pollutants
  across a range of
• Infectious agents
• Genetic variability
• Nutritional parameters

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There is no interesting science left (i.e., we
already understand all the processes)

• We actually do not know the etiology of some of
  the most important of the mundane third-world
  diseases, for example ALRI
• Organisms and their interactions
• Risk factors and their interactions
• Known parameters, including malnutrition, do not
  account for its scale
• As well as why some First World diseases are not
  found in the Third World, particularly asthma.
• Consider also, however, that the mundane diseases
  not only kill, but also must have large impacts
  on
• Mental (cognitive) and
• Lung development (COPD)
• A range of cancers
• Adverse reproductive outcomes of many kinds
• Immune system development
• Endocrine impacts
• Terrible long-term sequalae such as meningitis
• That the higher and more simple exposures can
  greatly assist in the development and testing of
• New biomarkers of exposure and outcome
• Spatial monitoring and analysis methods

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Translational Research

• You have heard of the NIMBY syndrome (maybe even
  of the BANANA syndrome)
• But a more difficult problem for our work is the
  MIMBY syndrome must be in my backyard.
• Need to do our research in ways that allow
  translation to populations in the third world,
  i.e., measuring age distributions, nutritional
  status, differences in access to medical care,
  and other effect modifiers

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Need to Do Research that Fits into the
International Health Mode

• Focus on intervention research
• Do epi if you can
• Remember RCTs are the coin of the realm
• Recognize the 7, i.e., the need to develop
  evidence for cost effectiveness
• Benefit/
• Science involved in understanding both the
  numerator and denominator

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Attributable Fractions do not add to 100
Underweight 40
Poor Housing? 40?
Lack of breastfeeding 10
2-3 million ALRI Deaths In Children Under 5
Diarrhea 20
Measles 10
Outdoor air pollution?
Zn Deficiency 15
Poor case-management 50?
No vaccines 25-50
Genetic Susceptibility ?
Rough estimates only
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The Story of the Pope and the Three Cardinals

• Climate change is coming and so is general
  recognition of its importance for nearly every
  aspect of the human condition
• There is needed environmental health research at
  both ends
• Important health impacts of the change itself,
  which are largely in the third world
• Implications for health of the potential
  mitigation measures
• NIEHS should be ready to take the lead when the
  call comes
• And develop joint programs with NSF, NOAA, NASA,
  etc.

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Household Fuel Shifting
Smith, et al. 2000
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It is often lamented that there is too little
connection between environmental health science
and policy
Courtesy of Ross Anderson
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Too little science?

• It might noted, however, that there is sometimes
  too much connection.
• Science and scientists are drawn to the new,
  unexplained, counter-intuitive, and fundamental.
• Their enthusiasm and entrepreneurship convey
  these values into policy and the press.
• None of these characteristics are thought to
  describe work on controlling horses, and thus our
  colleagues focus on zebras.
• But horses can probably be controlled even better
  with application of tools made for zebras.

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Gracias
Prof. Kirk R. Smith University of California Berke
ley