Category Archives: Global Health

The wikipedia pithy definition is: the health of populations in a global context. https://en.wikipedia.org/wiki/Global_health

Play with Big Tobacco and you will be tarred

Philip Morris International (PMI), profits by selling the world’s leading cause of preventable death — tobacco. The Foundation for a Smoke-Free World (FSFW) recently handed PMI a public relations coup by accepting a $1 Billion donation. Who now could credibly work with FSFW?

PMI is the world’s largest, international tobacco company.  It is quite explicitly not interested in a tobacco-free world and it works hard and secretly to subvert tobacco control. Its raison d’être is the sale of tobacco products, and the “smoke-free world” cover provided by FSFW looks like a Big Tobacco tactic in a long line of them.

There is little doubt that FSFW as an organisation has placed itself in moral jeopardy by accepting PMI’s money: “Moral jeopardy occurs when a person or an organisation attempts to do good using resources from a source that involves harm.” And here is the rub.  One of FSFW’s stated goals is to support global research through the support of “Centers of Excellence”.  Any research group, however, that accepts FSFW money is exposing itself to moral jeopardy. And like other health and medical research outputs from conflicted industry sources, the results cannot be trusted — no matter how genuine the researchers are in their belief of independence.

PMI’s money laundering scheme for researchers may provide a scent of freshness, but the tobacco tar will stick.

Beware of Big Tobacco bearing gifts

Two days ago it was announced to much fanfare that the international tobacco giant, Philip Morris International (PMI) pledged $1bn over the next 12 years to the Foundation for a Smoke-Free World (FSFW) to fund scientific research designed to eliminate the use of smoked tobacco around the globe. The Lancet editor, Richard Horton tweeted a challenge to the health community: how should we respond? My tweeted response is shown below, but the challenge drew a range of (usually negative) responses, and the whole announcement is worthy of further unpacking and analysis.

First, it is worth pondering PMI’s motivation. Would turkeys vote for Christmas? Would tobacco companies vote for a world without tobacco?  And the answer is no, they wouldn’t.

The announcement of the funding was picked up by, among other media outlets, Bloomberg, the Guardian, the Financial Times, Fortune, and CNBC.  Most of the headlines start with two words, “Philip Morris”, which means the corporate social responsibility team at PMI can expect a big elephant stamp on their performance appraisals and an end-of-year bonus. This kind of positive publicity for a tobacco company is extraordinary and under other circumstances I would have said they couldn’t buy it, but apparently they can.

If you visit the PMI corporate web-site you will be presented with a glossy video of talking heads with overlaid text that PMI is “Designing a smoke-free future”. Some time in the future PMI will be out of (less reliant on) their cigarette business — not their tobacco business, but their cigarette business.

We’re dedicated to doing something very dramatic – replacing cigarettes with the smoke-free products that we’re developing and selling. That’s why we have a total of over 400 dedicated scientists, engineers, and technicians developing less harmful alternatives to cigarettes at our two Research & Development sites in Switzerland and Singapore. It’s the biggest shift in our history. And it’s the right one for our consumers, our company, our shareholders, and society.

That is clearer.  PMI is still deeply committed to the manufacture and sale of an addictive, harmful substance, but in the future they hope it will be less harmful.  The level of PMI’s commitment to the shift away from smoked tobacco can be gauged by the allocation of 400 of their 80,000 staff to the innovation of smoke-free products, or about 0.5% of their workforce.  It should also be noted that when countries have attempted to interfere with PMI’s capacity to trade in a lethal product, it has fought those measures vigorously.  This means that PMI will fight extremely hard (as is required by its fiduciary duty to investors) to maintain its profitability even at the expense of the life and health of its consumers.  If PMI can develop a range of successful proprietary tobaccos products/technology that are smoke free, it is entirely in PMI’s interest to throw its weight behind anti-smoking initiatives, because competitors will be forced to use PMI technology under license.

Having got a sense of PMI, I will shift focus, more directly to the funding for FSFW.  In the light of the PMI pro-tobacco, smoke free agenda, ponder the name of FSFW.  This is a foundation dedicated to a smoke-free, but not a tobacco-free world. This is consistent with the commercial goals of PMI. For some, the argument is one of harm reduction. If the world moves to smoke free products, harm will be reduced. The fact that PMI is funding it, is proof of the excellence of public-private-partnership models.

Would it reduce harms? Yes.  The harms, however, may not be reduced to the extent that might be hoped. There are some indications that the use of smoke-free products carry an increased risk of mortality over non-smoking, non-use of smoke-free products.  Nonetheless, for those who would have become smokers, or switch from smoke to smoke-free products, harm will be reduced over being a smoker.

Does FSFW have a conflict of interest? They say, no.

Importantly, as established in the Foundation’s bylaws, PMI and the tobacco industry are precluded from having any influence over how the Foundation spends its funds or focuses its activities. Independence and transparency are core principles of the Foundation and all activities will be conducted with full transparency, free of tobacco industry influence. The Foundation has, constituted in its bylaws, an independent research agenda, independent governance, ownership of its data, freedom to publish, and protection against conflict of interest. Furthermore, strict rules of engagement will be put into place to ensure any interactions with the tobacco industry are fully transparent and publicly reported.

This is naive.

PMI has pledged about $80 Million per year over 12 years.  this represents about 0.11% of of PMIs annual net revenue. The money is not paid up-front or held in an escrow-type account, and the continued payment will be decided up by PMI — presumably factoring in PMI’s satisfaction with FSFW’s activities. And $80 Million buys a lot of loyalty.

The loyalty that funding from corporate giants garners was well illustrated recently by the New America Foundation (NAF). “New America is a think tank and civic enterprise committed to renewing American politics, prosperity, and purpose in the Digital Age. We generate big ideas, bridge the gap between technology and policy, and curate broad public conversation.”  Like FSFW they also boldly proclaim their independence from funders, stating under their Gift Guidelines:

New America steadfastly adheres to its mission of developing independent, non-partisan analysis and recommendations reflective of rigorous scholarship and promoting those ideas through broad public discourse. New America maintains full authority regarding project agendas, events, budgets, editorial content, and personnel decisions.

NAF receives substantial funding from Google.  One of the NAF Fellows commented (as part of his work) positively about a decision by a European Union antitrust regulator that went against Google. The employee was subsequently fired by NAF, after Eric Schmidt the Executive Chairman of Alphabet, Google’s parent company, spoke with the head of NAF and made his displeasure known.  This is instructive for two reasons, first Google was famous for its internal corporate motto “Don’t be evil” and later in Alphabet, “Do the right thing”.  If a company that had “do the right thing” as an explicit part of its self image can’t leave independent foundations to be independent, what hope does a tobacco company have?  Second, companies react negatively to things that they perceive as a threat to profit, without regard to the legitimacy or moral rectitude of the threat.

One would have to be foolish or naive to believe that one could be independent of the hand that feeds them. Even if someone at FSFW felt truly unshackled and unconstrained, the invisible thread of funding would moderate the independence of judgment.

Mitch Zeller the director of the Center for Tobacco Products at the US Federal Drug Administration regards this approach to harm reduction as a positive step forward, because Public Health has been “stunningly unsuccessful“, at selling harm reduction thus far.  Unfortunately, government and industry are often tightly bound, ensuring that harm reduction does not work unless, as in this case, the industry can continue to make money from a (less) harmful addiction.

If government wants harm reduction to be successful, then government needs to get serious about tobacco control. Ban all forms of tobacco advertising. Ban the sale of cigarettes in locations frequented by children.  Enforce uniform, plain packaging. Ban smoking in public places. Tax the product heavily.  Place all taxation revenue from tobacco products into health promotion, quit campaigns, interventions, and tobacco related research.

Low cost reproducible microscopy

There has been growing interest in reproducible research.  The interest arises from the idea that scientific discoveries that are one off, isolated and never to be repeated have limited value.  For research to inform future science other must be able to reproduce the results. There are even courses on reproducible research. However, a look at the courses and a quick search of PubMed will reveal that when people refer to reproducible research, they often mean shared data or shared analytic code.   And when I write “shared data”, I don’t even really mean any data, I mean electronic data … a spreadsheet, a database, etc.  Of course, the Methodology section of journal articles are supposed to support reproducible research, but these are often hints and teasers for what was done, rather than a genuine “how to”.

Reproducibility becomes more challenging when all one has to work with is a one-off observation.  How do I show you what I saw?  The question became particularly relevant to me in a recent discussion with a colleague about reproducible microscopy.  The obvious answer is, “a photograph” — and with a professional set up, one can achieve spectacular results — but what should be done in resource poor settings where money and equipment are limited?

I am one of the investigators on a Wellcome Trust funded “Our Planet Our Health” award led by Rebekah Brown at the Monash Sustainable Development Institute.  The “Revitalisation of Informal Settlements and their Environment” (RISE) study involves the collection of large quantities of diverse data from informal settlements in Makassar, Indonesia and Suva, Fiji.  Most of the samples will be collected by in-country teams, and they will not have access to high-end equipment.  Nonetheless, some of the samples will have to be examined under a microscope in Makassar and Suva.  It is likely that we will have to rely on basic equipment and Lab Technicians with limited skills in microscope photography.  From my SEACO experience, I would be looking for a low-cost solution that can be implemented with basic training. The solution “works” if the images are appropriate; that is, they are the thing of scientific interest, and are of sufficient fidelity that a researcher somewhere else in the world can interpret them appropriately.   It is not necessary for the technician to be brilliant, just adequate.

I decided to play.  I am neither a good photographer nor am I good at microscopy.  I reasoned that if I could get something approximating a reasonable image, then a Lab Technician with some actual training would have no problems.  The best low-cost camera solution is not to buy another piece of equipment at all. We are already committed to using a smartphone/Tablet solution in the RISE project and plan to use them for capturing photographs, tagging photographs, and uploading them to a server.  The only challenge was getting the smartphone camera to “peek” into the microscope.  Fortunately, there is a broad range of solutions, and I opted for the very cheapest I could find on eBay.  It cost me USD$5.99, brand new, including postage and handling.

The mount is straightforward to use, although my first attempt was pretty awful.  I found a weevil crawling around the kitchen (welcome to the tropics!) and that became the first portraiture subject.

A photograph of a weevil taken with a google phone using a smartphone-microscope adapter

The images are of much higher resolution than I have posted here.  I didn’t know what I was doing, and most of the image is taken up with the microscope surrounds rather than the subject of the photograph.  I tried the next day, this time using a peppercorn as the subject — it didn’t move as quickly.

A photograph of a peppercorn taken with a google phone using a smartphone-microscope adapter

The only real difference in my approach was that this time I zoomed in slightly on the peppercorn.  I will never look at peppercorns the same way.  What appears to be (to my unqualified eyes) fungal mycelium is less than appealing.  Nonetheless, it also seems like the general approach to capturing microscope images might be a reasonable.  As long as the technician knows what to photograph, the quality of the images is almost certainly good enough for others to view and interpret.  This is potentially quite exciting because it does allow science (and quite basic science) to be virtual and shared.  A photograph of a microscopic image taken in Makassar could be shared with the world within hours giving scientists anywhere an opportunity to look, think, interpret, question and suggest.

 

 

Software for cost effective community data collection

In 2012 we started enumerating a population of about 40,000 people in the five Mukim (sub-districts) in the District of Segamat in the state of Johor on peninsular Malaysia.  This marked the start of the data collection for establishing a Health and Demographic Surveillance Site (HDSS) — grandly called the South East Asia Community Observatory (SEACO).

When establishing SEACO we had the opportunity to think, at length, about how we should collect individual and household data.  Should we use paper-based questionnaires? Should we use Android Tablets?  Should we use a commercial service, or should we use open source software?  When we eventually collect the data, how should we move it from paper/tablets into a usable database?  In thinking about this process, one of the real challenges was that HDSS involve the longitudinal follow-up of individuals, households, and communities.  Whatever data collection system we chose, therefore, had to simplify the linking of data about Person_1 at Time_1 with the data about Person_1 at Time_2.

I eventually settled on OpenDataKit (ODK).  ODK is a marvellous piece of software developed by a team of researchers at the University of Washington, it runs on Android Tablets and it was released under an open source license. We hacked the original codebase to allow the encryption of data on the Tablet (later it became a mainstream option in ODK), I wrote a small Python script for downloading the data from the Tablets, and the IT Manager wrote a PHP script to integrate the data with a MySQL database. We managed the entire process from collection to storage, and it worked extremely well.  I hate the idea of using proprietary software if I don’t have to, and when we set up SEACO we decided that as much as possible we would use open source software so that others could replicate our approach.

 

SEACO data collector using an Android Tablet with ODK completes a household census, 2012

Recently we moved to away from ODK to a proprietary service: surveyCTO.  Unlike ODK, we have to pay for the service and for reasons I will go into, it has thus far been worth the move.

ODK did not do exactly what we needed and this meant that the IT team regularly made adjustments to the code-base (written in Java).  The leading hacker on the team moved on.  That left us short-handed and also without someone with the familiarity he had with the ODK codebase. I was torn between trying to find a new person who could take on the role of ODK hacker versus moving to proprietary software.  The final decision rested on a few factors — factors that are worth keeping in mind should the question arise again.  First, our operation has grown quite large. There are multiple projects going on at any one time, and we required a full-time ODK person.  SurveyCTO maintained most of the functionality we already had, and it also had some additional features that were nice for monitoring the data as they came in, and managing access to data.  Second, the cost of using surveyCTO was considerably lower than the staff costs associated with having an in-house developer.  We would lose the capacity for some of our de novo development but benefit by having a maintained service at a fraction of the cost.

If I had more money, my preference would be to maintain the capacity for in-house development.  If I were only doing relatively small, or only one-off cross-sectional studies, I would use ODK without hesitation.  For a large, more complex operation, a commercial service made economic and functional sense.

One of the other services I considered was Magpi. At the time I took the decision, it was more expensive than surveyCTO for our needs. If you, however, are just beginning to look at the problem, you should look at all options. I am sure there are now other providers we had not considered.