Category Archives: Politics

From my point of view, this is big “P” politics of Nation States or Provinces within Nation States.

Globalisation and health

The past has already been written and the accolades distributed. We now need to decide whether the next century is going to be good or bad for our health, and the role of globalisation in helping us to determine our destiny. People living in failed states do not enjoy utopian, anarchic freedom. They die young. Healthy populations need the goods and services of society to be shared in a broadly inclusive fashion. They need health systems that can respond rapidly and flexibly to emerging disease. They need environments that support human life.


The zombie apocalypse is our least likely but most entertaining future. [image from]

70,000 years ago our ancestors took their first steps out of Africa. With those steps they initiated the binding link between globalisation and health. The difference between then and now is a matter of temporal and geographical scale. Then, nothing moved faster than a walking pace. Now, a person can traverse the globe in 24 hours. A city thousands of kilometres away can be destroyed in 30 minutes. An idea can be everywhere in seconds.

The technological advances of the last century have been kept pace by extraordinary improvements in human health. Average life expectancy barely moved until the beginning of the last century, and over the next hundred years, it doubled. In 2016, the global average life expectancy was 71.4 years of age. We had achieved the biblical entitlement of three score and ten years promised in Psalm 90. The improvements in health were achieved because of globalisation. Reductions in poverty. Improvements in food supply. Advances in healthcare. Sophisticated infrastructure was delivering clean water and carrying away waste. Those advances have also been accompanied by large inequalities in health outcomes and significant environmental degradation.

I suggest there are three broad intersections between globalisation and health. First, there is the real (and sometimes imagined) disease outbreaks: Ebola or the Zombie apocalypse. Infectious disease, however, is only one part of the health and globalisation relationship. The second, very modern concern is the interconnection between our global activities and environmental change, and by extension the impact on human health. The final idea is our relationships with each other, and how these relationships can shift, and the effect the changes may have on the availability of health supporting resources.

I sketched these ideas out in a 3,000 word essay in early 2017 at the invitation of the Editors of “Vaguardia dossier” a Spanish language, Catalan magazine. Many people (including myself) cannot read the published, Spanish version, but you can get the slightly rough, English language preprint here.

Reidpath DD, Globalización y salud [Globalisation and health]. Vanguardia dossier. 2017; 65:76-81

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.

Prevalence of sexual assault at Australian Universities is … non-zero.

A few days ago the  Australian Human Rights Commission (AHRC) launched Change the course, a national report on sexual assault and sexual harassment at Australian universities lead by Commissioner Kate Jenkins. Sexual assault and sexual harassment are important social and criminal issues, and the AHRC report is misleading and unworthy of the gravity of the subject matter.

It is statistical case-study in “how not to.”

The report was released to much fanfare, receiving national media coverage including TV and newspapers, and a quick response from universities. “At a glance …” the report highlights among other things:

  • 30,000+ students responded to the survey — remember this number, because (too) much is made of it.
  • 21% of students were sexually harassed in a university setting.
  • 1.6% of students were sexually assaulted in a university setting.
  • 94% of sexually harassed and 87% of sexually assaulted students did not report the incidents.

From a reading of the survey’s methodology, any estimates of sexual harassment/assault should be taken with a shovel-full of salt and should generate no response other than that of the University Of Queensland’s Vice-Chancellor, Peter Høj‘s, that any number greater than zero is unacceptable. What we did not have before the publication of the report was a reasonable estimate of the magnitude of the problem and, notwithstanding the media hype, we still don’t.  The AHRC’s research methodology was weak, and it looks like they knew the methodology was weak when they embarked on the venture.

Where does the weakness lie?  The response rate!!!

A sample of 319,252 students was invited to participate in the survey.  It was estimated at the design stage that between 10 and 15% of students would respond (i.e., 85-90% would not respond) (p.225 of the report).  STOP NOW … READ NO FURTHER.  Why would anyone try to estimate prevalence using a strategy like this?  Go back to the drawing board.  Find a way of obtaining a smaller, representative sample, of people who will respond to the questionnaire.

Giant samples with poor response rates are useless.  They are a great way for market research companies to make money, but they do not advance knowledge in any meaningful way, and they are no basis for formulating policy. The classic example of a large sample with a poor response rate misleading researchers was the Literary Digest poll to predict the outcome of the 1936 US presidential election.  They sent out 10 Million surveys and received 2.3 Million responses.  By any measure, 2.3 Million responses to a survey is an impressive number.  Unfortunately for the Literary Digest, there were systematic differences between responders and non-responders.  The Literary Digest predicted that Alf Landon (Who?) would win the presidency with 69.7% of the electoral college votes.  He won 1.5% of the electoral college votes.  This is a lesson about the US electoral college system, but it is also a significant lesson about the non-response bias. The Literary Digest had a 77% non-response rate; the AHRC had a 90.3% non-response rate. Who knows how the 90.3% who did not respond compare with the 9.7% who did respond?  Maybe people who were assaulted were less likely to respond and the number is a gross underestimate of assaults.  Maybe they were more likely to respond and it is a gross overestimate of assaults.  The point is that we are neither wiser nor better informed for reading the AHRC report.

Sadly, whoever estimated the (terrible) response was even then, overly optimistic.  The response rate was significantly lower than the worst-case scenario of 10% [Response Rate = 9.7%, 95%CI: 9.6%–9.8%].

In sharp contrast to the bad response rate of the AHRC study, the Crime Victimisation Survey (CVS) 2015-2016, conducted by the Australia Bureau of Statistics (ABS) had a nationally representative sample and a 75% response rate — fully completed!  That’s a survey you could actually use for policy.  The CVS is a potentially less confronting instrument, which may account for the better response rate.  It seems more likely, however, that recruiting students by sending them emails is neither sophisticated enough nor adequate.

Poorly conducted crime research is not merely a waste of money, it trivialises the issue.  The media splash generates an illusion of urgency and seriousness, and the poor methodology means it can be quickly dismissed.

If there is a silver lining to this cloud, it is that AHRC has created an excellent learning opportunity for students involved in quantitative (social)  research.


It was pointed out to me by Mark Diamond that a better ABS resource is the 2012 Personal Safety Survey, which tried to answer the question about the national prevalence of sexual assault.  A Crime Victimisation Survey is likely to receive a better response rate than a survey looking explicitly at sexual assault.  I reproduce the section on sample size from the explanatory notes because it highlights the difference between a well conducted survey and the pile of detritus reported by AHRC.

There were 41,350 private dwellings approached for the survey, comprising 31,650 females and 9,700 males. The design catered for a higher than normal sample loss rate for instances where the household did not contain a resident of the assigned gender. Where the household did not contain an in scope resident of the assigned gender, no interview was required from that dwelling. For further information about how this procedure was implemented refer to Data Collection.

After removing households where residents were out of scope of the survey, where the household did not contain a resident of the assigned gender, and where dwellings proved to be vacant, under construction or derelict, a final sample of around 30,200 eligible dwellings were identified.

Given the voluntary nature of the survey a final response rate of 57% was achieved for the survey with 17,050 persons completing the survey questionnaire nationally. The response comprised 13,307 fully responding females and 3,743 fully responding males, achieving gendered response rates of 57% for females and 56% for males.