The Buck Goes Here
March 6, 2010 |  by Dale Keiger

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Find a way to get essential micronutrients into mothers and newborns.

Data published by DCPP researchers in The Lancet in 2006 showed that undernutrition and nutrient deficiencies account for about a third of the disease burden in low- and middle-income countries. Analysis by Robert Black has found that 19 percent of all child deaths could be attributed to deficiencies in just four substances: vitamin A, zinc, iron, and iodine. Insufficient intake of these micronutrients has been linked to blindness, severe infection, poor growth, mental retardation, decreased work capacity in adulthood, and childhood death. In the developed world, many foods, including milk and infant formula, are fortified with all these nutrients, and women who breastfeed supply their babies with what they need. But fortified foods often are unavailable in the developing world, and many mothers do not breastfeed long term; even when they do, available weaning foods, such as rice, are low in essential nutrients.

Alfred Sommer, professor of epidemiology and the former dean of the Bloomberg School, who in the 1980s (along with Bloomberg professor Keith West) discovered the dramatic benefits of giving vitamin A to kids age 6 months to 5 years, now believes the evidence is conclusive for administering the vitamin to newborns within the first 48 hours. Says Joanne Katz, Bloomberg School professor of international health, “You get a lot of early deaths of kids who never get vitamin A because they don’t make it to 6 months of age.” Sommer says three separate studies done by his research group in Indonesia, India, and Nepal have shown a dramatic decrease in infant mortality, including one led by Bloomberg School professor James Tielsch that managed to get vitamin A to 80 percent of newborns in an area of southern India (more than 13,000 babies) with a resultant 22 percent reduction in mortality. Other studies have not produced the same results, but Sommer argues that they are not relevant because the study subjects were not sufficiently deficient in vitamin A to begin with. He anticipates that Nepal and Bangladesh will soon begin programs for administering the vitamin to newborns, and is confident additional studies will bear out what he and his colleagues have found so far.

Clean up and swaddle those newborns.

In a DCPP document titled “Using Evidence About ‘Best Buys’ to Advance Global Health,” there is a striking statement: “The problem of newborn deaths has been on policymakers’ back burner for decades, in spite of the fact that 38 percent of all deaths of children under age 5 occur in the first month of life.” That back-burner status, the authors explain, was partly because health officials assumed that intervention would require high technology which they could neither afford nor get to newborns who, in poor nations, frequently enter the world not in a hospital or clinic but in a rural home or field. But DCPP determined that simple, low-tech interventions could avert 40 percent of those early deaths: Keep newborns warm and clean; breastfeed early and exclusively; and protect against infection by using a sterile blade to cut the umbilical cord and dabbing the stump with chlorhexidine.

Bloomberg School researchers advocate wide distribution of simple birthing kits that contain a sterile ground sheet, sterile blade and string for cutting and tying off the umbilical cord, and a bar of soap. (Sommer and Katz would add vitamin A.) The central difficulty, says Katz, is finding expectant mothers in isolated rural areas so you can get the kits into their hands about a month before their due dates. Plus the kits must be used properly. For example, Katz studied their application in Nepal. “[Mothers and birth attendants] used them, pretty much,” she says. “But what we found out is that the birth attendants used the soap to wash their hands after they’d delivered the infant, not before, which made sense to them—their hands were messy. But what you really want is for them to use the soap before they deliver the infant.”

Get people to stop smoking—or never start—by raising tobacco taxes.

More than 1.1 billion people in the world smoke, and 83 percent of them are in developing nations. Cigarette smoking is especially prevalent in Asia. One method for reducing tobacco use is nicotine replacement therapy, but that’s expensive, by DCP2 estimates $55 to $751 per DALY averted, depending on the country. Much cheaper is a simple alternative measure: raising taxes on tobacco products by 33 percent. That, DCPP maintains, costs only $5 to $42 per DALY averted. (The costs result from decreased tax revenue as smoking rates decline and cigarette sales drop.)

Sommer observes that increased taxes are especially efficient at discouraging teenagers from taking up smoking. A nicotine-addicted adult will find the additional dollar or two needed to buy cigarettes. But adolescents often can’t do that. Local laws banning smoking in public buildings, workplaces, and restaurants also work, as New York has demonstrated. (Sommer notes with approval but a bit of disbelief that Ireland has banned smoking in pubs, and even the French have made a stab at curbing smoking in cafes.) Complicating the situation is that some countries with large populations of smokers, like China and Japan, stand to lose a great deal of money in taxes and trade if millions of their citizens cease smoking. Says Sommer, “You have the minister of health [in these countries] wanting to be vigorous in trying to reduce the dramatic uptake of tobacco. But the minister of health has no money or power. The minister of trade, on the other hand, has all the money and all the power, and knows his country makes a fortune off of tobacco.” Some governments actually own stakes in tobacco companies; for example, about 50 percent of Japan Tobacco Inc., which controls 70 percent of that country’s market for cigarettes, is owned by the Japanese Finance Ministry.

Illustrations by Michael Gibbs