Housed at the Li Ka Shing Knowledge Institute at St. Michael’s Hospital is the Centre for Global Health Research (CGHR), headed by Dr. Prabhat Jha. Dr. Jha is famous for his work on the Million Death Study (MDS), a study that has improved global understanding of how people die in the developing world. His work has also studied the growing gender gap in India due to selective abortion of female fetuses.

Dr. Jha serves as the director of the CGHR, and is also a full professor with U of T’s Dalla Lana School of Public Health. He is the recipient of a number of awards, including the Ontario Premier’s Research Excellence Award in 2004, and the Order of Canada in 2012.

The Varsity was able to speak with him on his work, and on its impact with the CGHR.

The Varsity: What is the Million Death Study, and what are its aims?

Prabhat Jha: The MDS is an attempt to understand a very simple question which is, ‘How do Indians die?’ In most of the world, deaths occur at home and without medical attention. There are 60 million deaths a year worldwide [and] 50 million a year in poor countries. And the vast majority of those we don’t have any information on their causes of death.[…]

[…]If you don’t have this information, it’s like trying to have a roadmap to improve health without a GPS, and you’re making guesses as to what the disease burden is, and what are the avoidable conditions. So what the Million Death Study has done over the last thirteen years is work with the Indian government to work within an existing study, which is called the Sample Registration System.

[The Sample Registration System] basically says [that] if you can’t get information on everybody, take a random sample of the population […] and follow those houses over ten years and ascertain the death rates and the birth rates and then figure out the causes of death[…]

[…]I like to think of the MDS as the GPS for global health. It gives simple measurements, tells you what the burdens are, what the conditions of concern [are], and it’s led to a number of surprises.

I’ll give you two examples of big relevant surprises. One is that it showed that India has a lot more malaria deaths in adults than had been previously estimated. We showed that when you get the information from the house, you find many adults who are fine, then have acute fever and [die].

The second is in smoking. We showed that smoking already causes a million deaths a year [in India] – 10 per cent of all deaths – and that was a much bigger number that had been estimated previously. And it was a surprising number, because [of] how it applies to how Indian men smoke. They don’t start smoking early in life, before age 20, they start by age 25, or 30, and they don’t smoke much per day.

But even with the late-starting, [and] not smoking many cigarettes or beedis a day, the risks in Indians are as extreme as we see in long-term smokers in Canada. They both lose about a decade of life from prolonged cigarette smoking. That was a big surprise. Importantly, it spurred action by the [Indian] Ministry of Finance to raise taxes on cigarettes.

TV: Your research has also studied female foeticide in India. What surprising findings have your research uncovered?

PJ: What we found is that is a bit concerning is that the overall boy-to-girl gap in India has grown in that time period. One way to think about it is that the estimates for how many girls that are aborted are between 6-12 million girls in the last three decades. That’s a big number, but the more startling number is that about half of that is occurring in the last decade.

We developed a simple statistical method, and we looked at the conditional sex ratio. The logic is that families, for the most part, let nature decide the sex of the first child, but if they get a boy, they don’t do anything. But if they get a girl for the first one, a significant minority says, ‘no, we need to have a boy.’ That’s where selective abortion comes in. Nature for the first, technology for the second – if you get a girl.  Sure enough, those patterns are not just seen in Indians in India, but in diaspora, in Canada and the UK, and the US. Interestingly, if you compare that to Chinese diaspora, you don’t see it. So the difference is in China, the number of missing girls is due to the one-child policy. In India, it’s a boy preference. When you move out of China, as a diaspora, you don’t take that policy with you. But it seems that in Indians, you do take that boy preference with you.

That’s a big concern, because if you look at the demographic gap that occurs 30 years hence, you had modest levels of missing girls but over time you build up enough of a population base where you have large numbers of missing girls, and that can’t lead to any good. Just lots of unmarried men. There is some concern that it spurs things like increases in AIDS, violence against women [and] social unrest. India has got a brewing demographic disaster. I’m pessimistic in thinking that it will only get worse before it gets better.

TV: Do you think this is because of an economic shift?

PJ: You raise a good point. Normally most bad things in public health occur in the poor rather than the rich. In selective abortion, it’s the opposite. The rich and the educated are the ones that have the highest use of selective abortion in the second birth. So what’s happening is that fertility is dropping in India – quite rapidly in some areas – so families, before would have said ‘well, if we have 3 kids, chances are we’ll get a boy.’But now if they only have 2, or in some cases, 1, many of them say we want to make sure we get a definite boy. And economic factors are part of that, and technology is part of that –access to ultrasound. It’s a real disaster that’s brewing in India.  A demographic disaster. Our role is to point out where the problems are and to point out the vulnerable populations, which isn’t all women, but women who have had a first girl. It is a big, brewing disaster.

TV: Do you expect the major causes of death in developing countries to change in the next 50 years? If so, which causes of death will become more prominent?

PJ: We’re already seeing that transition. For adult mortality, broadly defined as age 15-69, there’s also some good news. Malaria [rates are] going down, TB [rates are] going down. But vascular disease is going up, and that we attribute to increased urbanization that is occurring in India.

But also to a particularly Indian propensity for getting diabetes quite early in life. That diabetes substantially increases the risk. It’s also attributal to smoking. All of those suggest that governments should take those seriously.  So you have to then say, the stuff that we’ve done well for kids, figure out a technology, try to deliver it widely [and] have global alliances that make it widely accessible. The same model needs to apply to adults. At the top of the list is tobacco. There are practical strategies for every disease. What we do is point out what the diseases are, connecting them to possible interventions, and then others have to take up the call and say ‘let’s take on these diseases by creating global programs that curb them.’We’re also focused on getting the world to take tobacco seriously, and arguing that worldwide there should be a tripling of the tobacco excise tax in many countries. [This has] a substantial impact that reduce[s] chronic deaths in many populations. It’s doable. It needs the finance minister, the health minister, and the prime minister to sign off and say ‘we’ll raise the tax.’

TV: What research findings about health in developing countries tend to surprise people in the developed world the most?

PJ: If you did a survey, including at U of T, and asked ‘What’s the biggest cause of death in Africa?’ I think most would students say, ‘it’s got to be AIDS.’ Because that’s what they’ve heard. But if you point out that actually, it’s not AIDS, it’s child mortality, then adult mortality – strokes, cancers, cardiovascular disease. Having numeric and quantified evidence is just the basis for any rational scientific enterprise or public health enterprise. And like everything, you don’t know until you look. We didn’t expect to find so many malaria deaths in India in poor rural adults, but we did, and that’s a consequence. We didn’t expect to see so many smoking deaths, but we did.

TV: Does studying (and counting) deaths ever feel morbid?

PJ: It is[…]But when you particularly get these narratives […] you’re reading real stories of real people. I always find them informative, because you’re looking at a death and realize that this death was avertable. If they had the right strategies in place, these deaths could have been avertable. Death is depressing, but the alternative is even more depressing. By studying the dead, we are able to understand what is going on, and that certainly helps more programs, and prevent premature death. In that sense, no it’s not morbid. It’s not depressing. Although we’re studying the dead, we’re really helping the living.