Long-term health and human capital effects of in utero exposure to an industrial disaster: a spatial difference-in-differences analysis of the Bhopal gas tragedy

OBJECTIVES

Globalisation and industrialisation can increase economic opportunity for low/middle-income nations, but these processes may also increase industrial accidents and harm workers. This paper examines the long-term, cohort-based health effects of the Bhopal gas disaster (BGD), one of the most serious industrial accidents in history.

DESIGN

This retrospective analysis uses geolocated data on health and education from India's National Family Health Survey-4 (NFHS-4) and the 1999 Indian Socio-Economic Survey by the National Sample Survey Organization (NSSO-1999) to examine the health effects of exposure to the BGD among men and women aged 15-49 years living in Madhya Pradesh in 2015-2016 (women n=40 786; men n=7031 (NFHS-4) and n=13 369 (NSSO-1999)), as well as their children (n=1260). A spatial difference-in-differences strategy estimated the relative effect of being in utero near Bhopal relative to other cohorts and to those further from Bhopal separately for each dataset.

RESULTS

We document long-term, intergenerational impacts of the BGD, showing that men who were in utero at the time were more likely to have a disability that affected their employment 15 years later, and had higher rates of cancer and lower educational attainment over 30 years later. Changes in the sex ratio among children born in 1985 suggest an effect of the BGD up to 100 km from the accident.

CONCLUSIONS

These results indicate social costs stemming from the BGD that extend far beyond the mortality and morbidity experienced in the immediate aftermath. Quantifying these multigenerational impacts is important for policy consideration. Moreover, our results suggest that the BGD affected people across a substantially more widespread area than has previously been demonstrated.

Regional Research-Practice-Policy Partnerships in Response to Climate-Related Disparities: Promoting Health Equity in the Pacific

Although climate change poses a threat to health and well-being globally, a regional approach to addressing climate-related health equity may be more suitable, appropriate, and appealing to under-resourced communities and countries. In support of this argument, this commentary describes an approach by a network of researchers, practitioners, and policymakers dedicated to promoting climate-related health equity in Small Island Developing States and low- and middle-income countries in the Pacific. We identify three primary sets of needs related to developing a regional capacity to address physical and mental health disparities through research, training, and assistance in policy and practice implementation: (1) limited healthcare facilities and qualified medical and mental health providers; (2) addressing the social impacts related to the cooccurrence of natural hazards, disease outbreaks, and complex emergencies; and (3) building the response capacity and resilience to climate-related extreme weather events and natural hazards.

ENSO impacts child undernutrition in the global tropics

The El Niño Southern Oscillation (ENSO) is a principal component of global climate variability known to influence a host of social and economic outcomes, but its systematic effects on human health remain poorly understood. We estimate ENSO's association with child nutrition at global scale by combining variation in ENSO intensity from 1986-2018 with children's height and weight from 186 surveys conducted in 51 teleconnected countries, containing 48% of the world's under-5 population. Warmer El Niño conditions predict worse child undernutrition in most of the developing world, but better outcomes in the small number of areas where precipitation is positively affected by warmer ENSO. ENSO's contemporaneous effects on child weight loss are detectable years later as decreases in height. This relationship looks similar at both global and regional scale, and has not appreciably weakened over the last four decades. Results imply that almost 6 million additional children were underweight during the 2015 El Niño compared to a counterfactual of neutral ENSO conditions in 2015. This demonstrates a pathway through which human well-being remains subject to predictable climatic processes.

Health Impacts of the Green Revolution: Evidence from 600,000 births across the Developing World

What is the contribution of the 'Green Revolution' to improvements in child health during the 20th century? We provide global scale estimates of this relationship by constructing a novel, spatially-precise indicator of modern crop variety (MV) diffusion and leveraging child-level data from over 600,000 children across 21,604 sampling locations in 37 developing countries between 1961-2000. Results indicate that the diffusion of MVs reduced infant mortality by 2.4-5.3 percentage points (from a baseline of 18%), with stronger effects for male infants and among poor households. The sizable contribution of agricultural technology to improved welfare should inform global food and development policy.

Fertilizing growth: Agricultural inputs and their effects in economic development

This paper estimates the role of agronomic inputs in cereal yield improvements and the consequences for countries' processes of structural change. The results suggest a clear role for fertilizer, modern seeds and water in boosting yields. We then test for respective empirical links between agricultural yields and economic growth, labor share in agriculture and non-agricultural value added per worker. The identification strategy includes a novel instrumental variable that exploits the unique economic geography of fertilizer production and transport costs to countries' agricultural heartlands. We estimate that a half ton increase in staple yields generates a 14 to 19 percent higher GDP per capita and a 4.6 to 5.6 percentage point lower labor share in agriculture five years later. The results suggest a strong role for agricultural productivity as a driver of structural change.

A Malaria Ecology Index Predicted Spatial and Temporal Variation of Malaria Burden and Efficacy of Antimalarial Interventions Based on African Serological Data

Reducing the global health burden of malaria is complicated by weak reporting systems for infectious diseases and a paucity of vital statistics registration. This limits our ability to predict changes in malaria health burden intensity, target antimalarial resources where needed, and identify malaria impacts in retrospective data. We refined and deployed a temporally and spatially varying Malaria Ecology Index (MEI) incorporating climatological and ecological data to estimate malaria transmission strength and validate it against cross-sectional serology data from 39,875 children from seven sub-Saharan African countries. The MEI is strongly associated with malaria burden; a 1 standard deviation higher MEI is associated with a 50-117% increase in malaria risk and a 3-5 g/dL lower level of Hg. Results show that the relationship between malaria ecology and disease burden is attenuated with sufficient coverage of insecticide treated nets (ITNs) or indoor residual spraying (IRS). Having both ITNs and IRS reduce the added risk from adverse malaria ecology conditions by half. Readily available climate and ecology data can be used to estimate the spatial and temporal variation in malaria disease burden, providing a feasible alternative to direct surveillance. This will help target resources for malaria programs in the absence of national coverage of active case detection systems, and facilitate malaria research using retrospective health data.

Malaria ecology, child mortality & fertility

The broad determinants of fertility are thought to be reasonably well identified by demographers, though the detailed quantitative drivers of fertility levels and changes are less well understood. This paper uses a novel ecological index of malaria transmission to study the effect of child mortality on fertility. We find that temporal variation in the ecology of the disease is well-correlated to mortality, and pernicious malaria conditions lead to higher fertility rates. We then argue that most of this effect occurs through child mortality, and estimate the effect of child mortality changes on fertility. Our findings add to the literature on disease and fertility, and contribute to the suggestive evidence that child mortality reductions have a causal effect on fertility changes.

Deployment of community health workers across rural sub-Saharan Africa: financial considerations and operational assumptions

OBJECTIVE

To provide cost guidance for developing a locally adaptable and nationally scalable community health worker (CHW) system within primary-health-care systems in sub-Saharan Africa.

METHODS

The yearly costs of training, equipping and deploying CHWs throughout rural sub-Saharan Africa were calculated using data from the literature and from the Millennium Villages Project. Model assumptions were such as to allow national governments to adapt the CHW subsystem to national needs and to deploy an average of 1 CHW per 650 rural inhabitants by 2015. The CHW subsystem described was costed by employing geographic information system (GIS) data on population, urban extents, national and subnational disease prevalence, and unit costs (from the field for wages and commodities). The model is easily replicable and configurable. Countries can adapt it to local prices, wages, population density and disease burdens in different geographic areas.

FINDINGS

The average annual cost of deploying CHWs to service the entire sub-Saharan African rural population by 2015 would be approximately 2.6 billion (i.e. 2600 million) United States dollars (US$). This sum, to be covered both by national governments and by donor partners, translates into US$ 6.86 per year per inhabitant covered by the CHW subsystem and into US$ 2.72 per year per inhabitant. Alternatively, it would take an annual average of US$ 3750 to train, equip and support each CHW.

CONCLUSION

Comprehensive CHW subsystems can be deployed across sub-Saharan Africa at cost that is modest compared with the projected costs of the primary-health-care system. Given their documented successes, they offer a strong complement to facility-based care in rural African settings.

Scaling up malaria control in Africa: an economic and epidemiological assessment

This paper estimates the number of people at risk of contracting malaria in Africa using GIS methods and the disease's epidemiologic characteristics. It then estimates yearly costs of covering the population at risk with the package of interventions (differing by level of malaria endemicity and differing for rural and urban populations) for malaria as recommended by the UN Millennium Project. These projected costs are calculated assuming a ramp-up of coverage to full coverage by 2008, and then projected out through 2015 to give a year-by-year cost of meeting the Millennium Development Goal for reducing the burden of malaria by 75%. We conclude that the cost of comprehensive malaria control for Africa is US $3.0 billion per year on average, or around US $4.02 per African at risk.

Rotation of dissecting groups among different cadavers provides students of anatomy with increased opportunity to observe human variations

One way to increase medical students' awareness of anatomical variability is the dissection of different cadavers throughout laboratory coursework. This report covers such a procedure successfully instituted in a human gross anatomy course.