[Stoves] The story of GBD 2010: a “super-human” effort, "a way of life"; still getting away with murder?

[Traveller]

Moderator: I hope you don't see this as "off-topic". There's too much talk
about "clean cookstoves" that link emissions to death. The whole chain of
argument - from emission rates to exposures, disease and death - is based
on fictitious data and dubious models.

It is plausible to treat research as "work in progress", but I am not
convinced that "some number is better than none" or that the purpose of
research is to just produce "a better estimate".

I am not qualified to assess all the elements of this exercise - Global
Burden of Disease, and its statistical assignation of "risk factors" to
"diseases" to "premature deaths" (better called "loss of statistical
life").  I will write more as and when List members raise some specific
questions I may have enough confidence to answer.

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People working on household energy ought to be concerned about
the confusion - not necessarily unintentional -  of "premature mortality" -
a statistical death - with individual biological death, and "Global Burden
of Disease" with an individual's burden of disease.

IEA seems to have learned a little. In 2006
<https://www.iea.org/publications/freepublications/publication/cooking.pdf>,
it declared, "About 1.3 million people – *mostly women and children – die
prematurely every year* because of exposure to indoor air pollution from
biomass." Now it says only
<https://www.iea.org/publications/freepublications/publication/WorldEnergyOutlookSpecialReportEnergyandAirPollution_Executivesummary_EnglishVersion.pdf>,
"the wood and other solid fuels that more than 2.7 billion people use for
cooking, and kerosene used for lighting (and in some countries also for
cooking), create smoky environments that are *associated with* around 3.5
million premature deaths each year."

I won't quibble with numbers, nor with "create smoky environments that are
associated with premature deaths." I have a small problem with "each year"
because premature mortality and risk factors it is attributable to is
specific to a cohort.

The definition of cohort is itself a serious political choice, as is one of
"life expectancy" or of "premature mortality". When a cohort-specific life
expectancy is used, we should remember that there are roughly as many
"premature deaths" as "post-mature deaths" and that those who die
post-maturely may have been exposed to the same "risk factors" as

A premature death is only a statistical death, subject to "expected
lifespan"; it is not an individual death.

A risk factor is not a disease. Abstinence from allegedly risky behaviors
is not a pill. (I do

Nobody dies of a risk factor per se. An individual cardiac arrest cannot be
said to have been caused by air pollution. An individual pneumonia death
cannot be said to have been caused by unsafe sex. An individual renal
failure cannot be said to have been caused by sugar.

A solid fuel stove doesn't kill. It may make you sick, as might other air
pollution, depending on your inhalation profile. Sex without condoms won't
necessarily transmit HIV. (Bill Clinton knows about both.)

And another solid fuel stove - blessed by the EPA/WHO priesthood - wouldn't
necessarily save lives.

Kirk Smith, whose work I largely respect and admire, writes, in The
Petroleum Product That Can Save Millions Of Lives Each Year
<http://www.forbes.com/sites/realspin/2014/05/27/the-petroleum-product-that-can-save-millions-of-lives-each-year/#444e7c07f354>,
that LPG is

"the most effective solution available for the largest environmental health
risk in the world: cooking with solid fuels." I largely agree, except that
outsourcing cooking, and piped gas or electricity - or even the variety of
coal stoves that sharply reduce emissions (presumably exposures as well,
when they are in cold regions with limited ventilation except with
chimneys) - are more effective in some regions. But that's quibbling; while
solid fuels are not necessarily evil - they CAN be burned cleaner (good
coal and good solid wood) - the aggregate market size for rapid transition
to cleaner household cooking is larger for LPG than for other available
choices to household consumers. (I will leave aside the fuel politics; we
need better geographic and demographic market definitions instead of
ideological preferences.)


Smith also writes,

"For the GBD, the pollution level equivalent to cooking with ventilated LPG
was taken as the feasible counterfactual because it is usually first clean
fuel that people use when moving away from biomass. Thus, the bar marked
“smoke from solid cookfuel” in the figure could just as easily been titled
“lack of LPG for cooking.” Almost by definition, LPG offers a full
solution."


This is plausible, and avoids the EPA bovine-headedness of "no threshold"
or equitoxicity or "concentration-response".

I am uncomfortable with the headline - "Can Save Millions of Lives Each
Year", but can live with "Can" and imprecise "Millions". To my knowledge,
there is no quantified evidence for "lives saved each year" due to the
transition to cleaner cooking, heating over the last 100 years by more than
three billion cooks (a billion or more of whom have died already and two
billion or so still around, credits for life extension beyond respective
average expectancies pending.)

GACC, however, takes the cake.

GACC said this past Ma
<http://cleancookstoves.org/about/news/05-01-2016-alliance-statement-on-indian-prime-minister-modi-s-plan-to-provide-cooking-gas-connections-to-50-million-households.html>y,
"Household air pollution is a leading cause of illness and death in India -
responsible for nearly one million preventable deaths each year." More
recently, according to Reuters, it claimed,"When burned in open fires and
traditional stoves, wood, coal, charcoal and other solid fuels emit harmful
smoke that claims 4 million lives annually, making household air pollution
the fourth greatest health risk in the world."

Claims about claiming "4 million lives annually" are intellectual smoke. Or
say, heat but no light, like a radioactive thermoelectric generator.

It claims <http://cleancookstoves.org/impact-areas/health/>, "Daily
exposure to toxic smoke from traditional cooking practices is *one of the
world’s biggest – but least well-known killers*. Penetrating deep into the
lungs of its victims, this acrid smoke causes a range of deadly chronic and
acute health effects such as child pneumonia, lung cancer, chronic
obstructive pulmonary disease, and heart disease, as well as low
birth-weights in children born to mothers whose pregnancies are spent
breathing toxic fumes from traditional cookstoves. *The evidence is robust
and compelling*: exposure to household air pollution (HAP) is *responsible
for a staggering number of preventable illnesses and deaths each year*."

This is not just hyperbole, the cake is a lie baked in models, presented
with a frosting of whipped cream (White House) and garnishing of pretense.
Nobody knows the HAP exposure profiles of those already dead or living. Nor
for that matter the disease profiles. This is a climate of hysteria.

An accurate statement - assuming that the data existed and methods were
robust (they are not) - would be, "In scientists' estimate, at the most
recent revision of the Global Burden of Disease, some 4 million deaths
under the age 86 worldwide were attributable to "household air pollution"
as a risk factor."

Risk factors are just that, risk factors. Attribution too is just that,
attribution. Not causality. Attributions can and will be changed, with new
data, new techniques, and more importantly, new paradigms.

One would never know whether "preventable illnesses and deaths" were indeed
prevented. Each year is a new cohort of deaths, identification of causes of
death, and allocation of risk factors. There will always be premature
mortality - by definition - and new allocation of risk factors to each
cohort. There is no way to forecast a baseline of causes of death, nor
corresponding risk factors, save but some cohorts for whom "big data" will
start providing extensive health and behavioral information. Even then it
would be debatable if not dubious.

The alleged "robust and compelling" evidence about "exposure" doesn't
exist. While GACC doesn't make a particular reference, I suspect it is the
Global Burden of Disease (GBD) exercise.

For now, I will comment on an interview published in Lancet with people who
cook up these numbers of "premature mortality" and "risk factors" - The
Story of GBD 2010: A "super-human" effort
<http://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(12)62174-6.pdf>
(December 2012). Particulars of household air pollution as a "risk factor"
can be subjected to some of these same criticisms and not worth too much
argument. If the overall paradigm is misleading, tweaking here and there is
just an excuse for filling labs and journals.

No doubt the GBD adventurers are well-meaning explorers - and intend to do
a lot more work to improve the quality of their estimates. They will need
better data, better models, and, er, better theories.

With super-human (divine or devilish, I can't tell) assumptions and models,
scientists cook up causes of death, causes of disease, and allocation to
risk factors.

A clown like me cannot understand what "super-human" Gods of Global Health
(incidentally, not individual or national health) do. In any case, I have a
jaundiced eye and a habit of reading between the lines, imagining things as
it were.

I will be pleased if you accuse me of hallucinating, imagining things that
do not exist.

I hope to be forgiven for my transgressions in the divine monastery of GBD.
Mere human, I am trying to alert other mere humans about the deception
generated by politically charged advocates.


------------------------------

Treating current humanity as a super-humanity, a super-race with 86 years
life expectancy, is both a divine inspiration and a devilish ploy to grab
attention and make noble promises.

Yuck. With pretentious scientists like these - praising and congratulating
themselves for their imagination - who needs Donald Trump?

One says,

"Running the programs to map the data to our cause list of 291 causes and
correcting the bias can take days, even using a powerful cluster of more
than 100 computers. The data that we have to store after the modelling
process can take 3 terabytes.” Lozano estimates that the storage needed for
the causes of death data was 400 times bigger than that for GBD 1990."


Sophomoric. (I remember programming and data entry on cards and then
boasting how heavy the cards for my econometrics term paper were.)

The corruption and bankruptcy of science by scientists. It's neurons that
matter, not computing power.

"*The worst part has been dealing with various political aspects that are
inevitable* when trying to quantify in a comparable way many different
problems. "


Quantification for the sake of quantification, leave thinking to lazy
people who can't handle 100 computers clustered.

As e e cummings said, "how numb can the world get, but number".

How much data massaging, how much fine tuning, how much ego assuaging?

"“We needed to convince scientists who were experts in particular diseases,
injuries, and risk factors to share expertise and data with us in order
that our estimates might be based on the best available evidence. That has
been demanding and moderately successful.”


Economists, computer scientists and mathematicians can dupe some of the
medical scientists some of the time.

After all, it was "“exciting”, “demanding”, and even “frustrating”." Some
medical professionals might have refused to give in or have their data and
egos massaged.

One says, "GBD is “a way of life, rather than another massive research
project."

That is, it has become an ideology, a faith construct, a religion.

Evidence? "“Better methods to better extract truth from poor quality or
missing data has fostered tremendous scientific innovation”.

Whoa!! Just as I had suspected, after a ludicrous piece by Anthony
McMichael in the 2004 GBD about regional forecasts of death due to climate
change -- the most inane paper I have ever read in 35 years (after a
Technology Review piece by Nazli Choucri, around 1981) - "truth
extraction", even if as painful as tooth extraction, is the jiggerypokery
of GBD.

"Also unique to GBD is its comparative risk assessment approach, which
tries to ensure that the methods used to estimate the burdens attributable
to major potentially modifiable risk factors such as high blood pressure,
diet, tobacco smoking, and ambient and household air pollution, are
consistent among the risk factors. “This allows their respective burdens to
be compared with regard to their importance globally and among global
regions”."


I am not at all sure whether such forced comparisons beg the question of
the quality of data, knowledge of underlying distributions and confounding
factors, around the world.

Again, the 2004 CRA, I felt, was an ideological imperative - to pretend, at
any cost, that this was a major scientific breakthrough. My suspicion then
(in early 2013 when I read it) was, this is possibly useful to get some
ballpark ranking, but I will give it no more credence than how high school
test results around the world tell us about employment and productivity at
national, regional, and age/sex levels 30-40 years hence.

Deifying methods is a sign of weak minds. We learn methods so we can
capture abuse of methods, not so we indulge in self-delusion and deception.

------------------

Let me just quote from one of the GBD 2010 reports,

"global assessments of causes of death are a major analytical challenge.
Vital registration systems that include medical certification of the cause
of death captured about 18·8 million deaths of an estimated annual total of
51·7 million deaths in 2005, which is the latest year for which the largest
number of countries (100) reported deaths from a vital registration system.
Even for these deaths, the comparability of findings on the leading causes
of death is affected by variation in certification skills among physicians,
the diagnostic and pathological data available at the time of completing a
death certificate, variations in medical culture in choosing the underlying
cause, and legal and institutional frameworks for governing mortality
reporting. For the remaining deaths that are not medically certified, many
different data sources and diagnostic approaches must be used from
surveillance systems, demographic research sites, surveys, censuses,
disease registries, and police records to construct a consolidated picture
of causes of death in various populations. Because of the variety of data
sources and their associated biases, cause of death assessments are
inherently uncertain and subject to vigorous debate." Here
<http://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(12)61728-0.pdf>


Inherently uncertain. Subject to vigorous debate. (Perhaps also rigorous
manipulation? I know how science is done.)

If even necessary. When fewer than 40% of deaths have medical certificates
for the cause of death, premature or post-mature (yes, I am going to use
that term, to show what a weak concept premature mortality really is), from
about HALF the countries, and all interpretation issues arise (Lancet and
WHO have material on this), is GBD as "superhuman" an output as the effort
allegedly is? (Weak students want to be graded by the amount of time they
put in a term paper.)

GBD depends on "garbage codes" - "methods to redistribute deaths assigned
to garbage codes to probable underlying causes of death."

Their definition:

"Garbage codes are causes of death that should not be identified as
underlying causes of death but have been entered as the underlying cause of
death on death certificates. Classic examples of garbage codes include
senility or cardiopulmonary arrest."


I reserve my definition. I haven't done garbage codes since 1986. But only
an economist would overrule doctors who for centuries have listed "old age"
as the "cause of death". (No wonder. Only when everybody is protected from
every "risk factor" for "premature mortality," everybody will die of
senility.)

Let's take particular causes of death, say malaria.

"The findings of adult deaths from malaria are consistent with data of
hospital discharge and death in endemic areas but remain controversial. Our
UI for global deaths in individuals older than 5 years from malaria was 365
356 to 643 977, partly depicting the uncertainty in the underlying data
sources."


Ah, a variance that large. Draw your own conclusions. Don't even ask what
actual data they had on hospital discharge and death in endemic areas and
elsewhere. This is "global" health; nothing to do with individual health
and medicine.

At least, they didn't consider PM2.5 as a risk factor for malaria. Or
HIV/Aids.

Not that diarrhea or respiratory pathogens are better understood.

"For example, we reported 173 000 deaths due to rotavirus in children
younger than 5 years and 78 000 deaths in individuals older than 5 years in
2010; these findings contrast with claims from WHO of 453 000 rotavirus
deaths in children younger than 5 years alone in 2008. Higher numbers were
probably reported by WHO for three reasons: higher all-cause global deaths
in children younger than 5 years than currently estimated by UNICEF or the
GBD 2010; a much higher fraction of deaths in children younger than 5 years
attributed at the time to diarrhoea; and a higher fraction of diarrhoea
attributed to rotavirus."


"For respiratory pathogens, even greater challenges exist. In many
observational studies, no pathogen is identified in a substantial fraction
of cases. Even in severe cases that lead to hospital admission, the
case-fatality rate is likely to vary substantially by pathogen, which
confounds the analysis. ... The fraction of lower respiratory deaths in
children younger than 5 years due to pneumococcal pneumonia was 35·8% (UI
16·0–50·9) in 2000 compared with 19·8% (16·1–24·8) in the GBD 2010 for
2010."


UI = Uncertainty Interval.

I am ignorant of the methods, but questioning results need not require
messing with all the data and methods. I don't understand, for instance,
how GBD allocates under-5 mortality from LRIs when the fraction due to
pneumococcal pneumonia is 16% or 50.9%. All deaths have to be allocated,
after all. (First to causes, then Lost Life Years to risk factors.)

But let's go back to the superhuman heroes and heroines.

"“GBD has also shown to the world that new ideas and methods outside the
conventional medicine and public health framework—economics, philosophy,
psychology, political science, environmental science, computer science,
engineering, etc—play a significant role in the estimation and
interpretation of the disease burden”."


Ah. As if throwing in a PhD in philosophy is enough to getting the
imprimatur of all philosophers. The less said about the economists and
computer scientists the better; they are the grunts who brought you
sub-prime lending as optimal risk management.

They will keep getting away with murders.

"“*we now joke to each other how we used to get away with murder in the
past doing burden* [studies]. We tended to make lots of not so replicable
ad-hoc decisions and few people knew what we were doing anyway. This
exercise has deliberately tried to minimise the ad-hoc decisions and
instead aimed to maximise what information we can get from the data. We
also have much more closely involved hundreds of experts and young
researchers who are very capable of looking over our shoulders and are much
more articulate at picking apart the estimates. This is mostly to the good
(and has led to many improvements in the methods and results)...although*
we have also had some experiences of disease experts taking on roles of
advocates with aim to ‘boost the numbers’ rather than being ‘impassionate’
scientific advisers”*.


Gotta give it to scientists. They are so innocently deceptive and honest at
the same time. (Or they like the rest of us enjoy poking a stake in the
hearts of those we are not fond of. I admit guilt right here.)

“Although not on the same scale, the GBD is an example of big science
applied to global descriptive epidemiology. To do the work well, requires
an enormous amount of data, huge computational machinery, tailored
statistical analytical skills, and the expert input of many from around the
world."


The coming big data revolution could undermine much of what this 2010 GBD
says, just like it probably has done to the 1990 numbers. (I vaguely recall
all this coming up in WDR 1993, based on 1990 data. I may well be wrong. I
am dying of senility.)

After all, generating data, grabbing news headlines is all for the good of
scientists, getting more research grants and students for perpetual
debates. There will always be premature mortality and risk factors, just
like we will always have climate change.

We will also always have the poor and the sick, but no matter; keep doing
GBD.

 "But with different methodologies and estimates of global burdens of
disease available in the public domain, what should countries do when
trying to work out their national health priorities? Lopez thinks that they
should debate the estimates and he encourages independent inquiry. “


After bombarding the world with IHME canon, debate and independent inquiry
may be moot. But I have made a modest effort.

Margaret Chan, then-DG of WHO made a case "From new estimates to better data
<http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)62135-7/fulltext>"
(Lancet Dec 2012) for good reason. "Better data" doesn't simply mean more
of the same or with greater accuracy and timeliness. It also means
re-thinking why we look for data and build statistical databases in the
first place, whether our theories need revisions. Data and estimates for
weak theories are a huge health hazard for researchers.

Groupthink is mental sclerosis.

One hero advises, "*policy makers would be wise to conduct more detailed
burden studies of their own populations*.”

Amen. New business line for GACC - commission detailed burden studies of
some 100+ countries where the 3 billion energy poor live. Consultants for
the promotion of consultants. (I do that too.)

>From a practical standpoint, data limits and weak estimates need not hold
up policy decisions. When theory itself is weak, however, dressing up data
in fancy models and marketing estimates as if they are the sole and whole
truth is abuse of the political process, not just science.

--------------

For all we know, the bubble of enthusiasm and overconfidence may burst.
"“As more data are made available and/or collected, the task of tracing
global health epidemiology is much more challenging than when there was
little data available. This may seem paradoxical but when there are no
data, the task is actually easier to generate a model than when there are
conflicting or complex patterns in the data that must be captured and
reflected in the results. In other words, progress in global health
measurement makes the task of tracking global health problems more complex
and time consuming—not less. We need to factor this challenge into future
efforts to maintain and expand the GBD.”

Make money quickly. IHME may get the next Nobel Peace and keep publishing
like IPCC.

At worst, GBD is another groupthink marketed as science, generating
headlines; few lay persons are going to understand that premature mortality
and risk factors are population metrics. At best, it needs to be debated
and criticized, subjected to fire tests.

GBD is an elephant that has thrown up dust storms that need to be hosed
down; too much particulate pollution.

Forgiveness from priests sought in advance. Those who take offense should
keep it.

Nikhil
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