1. Controlling Wild Horses with Tools Made for Zebras Kirk R. Smith School of Public Health University of California, Berkeley Plenary Presentation at the NIEHS Global Environmental Health Conference San Francisco, Jan 11-13, 2007

2. Toxic Tsunami threatening planet’s 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.

3. 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.

4. 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

5. 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.

6. 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.

7. 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.

8. 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

9. Will there be a 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.

10. Toxic Tsunami threatening planet’s 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.

11. 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

12. National Household Use of Biomass and Coal in 2000

13. Health-Damaging Air Pollutants From Typical Woodfired Cookstove in India. Typical Health-based Standards Typical Indoor Concentrations IARC Group 1 Carcinogens Best single indicator

14. Cognitive Impairment? ALRI/ Pneumonia (meningitis) Asthma Low birth weight Early infant death Chronic obstructive lung disease Interstitial lung disease Cancer (lung, NP, cervical, aero-digestive) Blindness (cataracts, trachoma) Tuberculosis Heart disease Diseases for which we have some epidemiological studies Only two qualified with sufficient evidence to be included in the WHO CRA

15. First person in human history to have her exposure measured doing one of the oldest tasks in human history Kheda District, Gujarat, India 1981 Pump Filter

16. Do we know too much; or do we know too little? A story of two conferences

17. 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!

18. Control and Intervention Traditional 3-stone open fire Plancha chimney woodstove

19. Why will nothing be done? Is it because it is day-to-day, i.e., not spectacular? –It isn’t 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

20. Why will nothing be done? Perhaps because it is scientifically mundane, i.e, not enough zebras?

21. Phil Landrigran’s Tie ‘Medical students think they see Zebras when they should be looking for horses’

22. 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

23. 2000 World DALYs in 2000 Almost all Women & Children These are the Global Disease Horses

24. What horses are still untamed for children <5? 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

25. DALDs Per Capita by Age Group Selected World Regions 2000 Annual loss per person

26. Horses for school-age children (who are 10x healthier than children <5) More than 5% –Parasites –Depression More than 1% –TB –Meningitis –Leukaemia –Violence –Asthma –Falls and fires –Iron deficiency –Dental caries

27. The most critical special health issue for school-age kids is parasites Trypanosomiasis Chagas disease Schistosomiasis Leishmaniasis Lymphatic filariasis Onchocerciasis Ascariasis Trichuriasis Hookworm disease

28. Why will nothing be done? (cont.)

29. 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”

30. “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

31. “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)

32. “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”

33. “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

34. “ 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

37. How do environmental health risks change with development?

38. Undernutrition Environment Sex and reproduction Child cluster PPP/capita Percent Of DALYs Smith, 2003

39. Addictions (Tobacco, drugs, alcohol) Diet and Physical Inactivity PPP/capita Percent Of DALYs Smith, 2003

40. Household Community Increasing Wealth Shifting Environmental Burdens Severity Local ImmediateDelayed Risks to Human Health Risks to Life Support Systems The Environmental Risk Transition Global (Modified from Smith, 1991)

41. Figure 7d Smith & Ezzati, 2005

42. Figure 8a Smith & Ezzati, 2005

43. Figure 10 Smith & Ezzati, 2005

44. Household Community Increasing Wealth Shifting Environmental Burdens Severity Local ImmediateDelayed Risks to Human Health Risks to Life Support Systems The Environmental Risk Transition Global (Modified from Smith, 1991)

45. 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

46. . Combustion Risk Factor Million Deaths Percent of Global Deaths Percent of Disease Burden Tobacco4.98.7%4.1% Indoor smoke from household solid fuel 1.62.92.6 Lead in motor fuel0.190.30.7 Urban outdoor air pollution 0.801.40.8 Climate change0.150.30.4 Fires0.240.40.7 Adjusted totals ~7.5~13.3%~8.9%

47. “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

48. “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

49. “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?

50. Since wood is mainly just carbon, hydrogen, and oxygen, doesn’t it just change to CO 2 and H 2 O 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

51. Toxic Pollutants in Biomass Fuel Smoke from Simple (poor) Combustion Small particles, CO, NO 2 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 Source: Naeher et al, J Inhal Tox, 2007 In US regulatory terminology, there are significant emissions of 3 Criteria Air Pollutants and at least 28 Hazardous Air Pollutants (HAPs)

52. “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

53. “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

54. 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

55. 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

56. 2-3 million ALRI Deaths In Children Under 5 Poor case-management 50%? No vaccines 25-50% Measles 10% Diarrhea 20% Lack of breastfeeding 10% Underweight 40% Poor Housing? 40%? Attributable Fractions do not add to 100% Rough estimates only Zn Deficiency 15% Genetic Susceptibility ? Lack of chimneys 20%? Lack of clean fuel 30%? Household solid-fuel burning? Outdoor air pollution?

57. 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.

58. Smith, et al. 2000 Household Fuel Shifting

59. Courtesy of Ross Anderson It is often lamented that there is too little connection between environmental health science and policy

60. 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.

61. Gracias Prof. Kirk R. Smith University of California Berkeley