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

[Ronal W. Larson]

Nikhil,  cc list and Crispin

	See below.


> On Jun 4, 2017, at 1:24 PM, Nikhil Desai <ndesai at alum.mit.edu> wrote:
> 
> Ron:
> 
> You too are a strange case. 

	RWL1:  Nikhil here refers to my having applied the word “strange” about Nikhil in an intended private response to Tom Miles that advertently went public to this list a few weeks ago.   He is probably correct in saying “strange” accurately applies to me.

> 
> I have no idea what you think are my prejudices and why you castigate me like a professor high on his grandiosity. 

	[RWL2: a)   I have been trying in the last few messages (still unsuccessfully) to determine whether you knew of any peer-reviewed papers that support your “ strange” perspective that the medical and public health communities have no chance of adequately allocating any deaths to specific causes.  Especially in the case of harmful emissions potentially affecting several billion users of rural biomass-based cookstoves - this list’s focus.  

	b)  The prejudice I am claiming exists is apparently yours against those in the scientific effort working to document and reduce this health relationship.  I would NOT describe this to be a prejudice if you are basing your views on published peer-reviewed reports.   I use the term similarly for climate deniers, where there is a similar rejection of and animosity toward science (and avoidance of past published peer-reviewed papers).
	
	c)   I have great admiration for those whose work you discredit:  Kirk Smith,  Michael Johnson, The Berkeley Air Monitoring Group, EPA, GACC, etc.    I am writing about your rejection of their work because I know they won’t themselves defend their work.  And because a few on this list will accept your views because your views are so strongly voiced.

	d)   Yes - I have been a professor.  If you don’t like my questioning where you derive your (strange) opinions on the inability to understand the unhealthiness of stoves, you are justified in blaming me for “grandiosity.’

> 
> If you think I use the word “super-human" in admiration of a herd of 500, you need to re-learn American English.

	[RWL3.  I guess this appears because the words “super-human” appears near the words “500 researchers” in the only (very pro-measurement) article you have thus far provided in my continuing search for published support for your “strange” anti-science view on the health impacts of cookstoves.

	I have not claimed that your ever used the words “super-human”, so I guess I don’t have to relearn any form of English.
> 
> Enough for now. I can’t tell what you hate me for.

	[RWL:  You are taking my questioning in the wrong way;  no hate involved.  But I remain increasingly concerned that your views on the inability of many thousands of people to measure and report on health-causation factors (CO and particulates) of cooks stoves will influence others on this list.

	This applies in exactly the same way for people who are climate deniers - and who see no problem with continued use of fossil fuels.

	Does anyone have any citation that supports Nikhil’s “strange” views on science’s inability to assign stove “burden of disease”.  

	I have still to visit IMHE.

Ron

> 
> Nikhil
> 
> ------------------------
> Nikhil Desai
> (India +91)909 995 2080
> Skype: nikhildesai888
> 
> On Mon, Jun 5, 2017 at 12:49 AM, Ronal W. Larson <rongretlarson at comcast.net <mailto:rongretlarson at comcast.net>> wrote:
> Nikhil and list (adding Crispin)
> 
> 	I am on the road still towards Seattle.  But my quick read says that all the cites you have given are in support - not denial - of the GBD effort.  Please give me a quote and cite to show me I am wrong.  
> 
> 	I had previously read the appended cite you gave this time.  I take it to be one of admiration for the effort of 500 researchers.
> 
> 	The message I hear from you sounds eerily similar to the claim that there is/was no proof that second-hand cigarette smoke can lead to illness and death.
> 
> Ron
> 
> 
>> On Jun 4, 2017, at 1:05 PM, Nikhil Desai <pienergy2008 at gmail.com <mailto:pienergy2008 at gmail.com>> wrote:
>> 
>> Ron:
>> 
>> You must not have read this post from last September. 
>> 
>> But you must read the attached and the following.howsoever difficult. Then perhaps revise your assumptions about my prejudices. 
>> 
>> Your complaints about my credibility are getting boring. Your gullibility may be a equally serious problem. 
>> 
>> Nikhil
>> -------------
>> 
>> 
>> 
>> 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. 
>> 
>> --------------
>> 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 those who die premature - and for some, even more so.
>> 
>> 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 did engage in quite a few. My death will be premature to some and post-mature to some others.) 
>> 
>> 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. 
>> 
>> 
>> ------------------------------ 
>> 
>> On GBD: (attached Lancet article)
>> 
>> 
>> 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
>> 
>> 
>> 
>> 
>> 
>> <GBD 2010 Superhuman Effort Lancet Dec12.pdf>
> 
> 

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