About Alex Quistberg

I am a post-doctoral fellow in at the Harborview Injury Prevention & Research Center at the University of Washington. My research interests are in Injury Epidemiology and Global Health. I have been researching pedestrian safety in Lima, Peru for the past few years where pedestrians are 80% of the traffic fatality victims. I also have specific interests in personal flotation device use, child passenger safety, and pediatric window falls.

‘The Idealist’ Review

Dr. Jeffrey Sachs has been one of the most prominent and outspoken figures in the movement to end extreme poverty worldwide. Nina Munk presents us with an unflinching perspective of how difficult that goal has been for Dr. Sachs and his Millennium Villages Project (MVP). While this book is not exactly biographical, it does provide us with brief glimpses at the man behind this project, how the project has progressed since its inception and its ups and downs.

The MVP are an immense undertaking that brought many revolutionary ideas and financial support to reduce and eliminate extreme poverty and its many negative outcomes, like child mortality. From the description of some of the villages in the book, one might wonder at the wisdom of supporting and/or sponsoring them in first place. The three primary examples, Dertu, Kenya, Toya, Mali and Ruhiira, Uganda, faced numerous structural, geographical, and sociopolitical challenges from the outset that seemed insurmountable. These included lack of access to fresh water (even with engineering interventions considered), remoteness, and lack of interest from local political leaders. Despite these challenges, Munk reports some initial successes, but over time it appears that these efforts were not sustainable. The higher level challenges just seemed too overwhelming to overcome, though it may provide some individual-level benefits that would not have been possible otherwise, such as education and infrastructure. By the writing of the novel, two of the villages described by Munk were caught up in local conflicts and environmental challenges beyond the control of the MVP.

I would like to think that this project might have had more success if these high level, ecological challenges had not been as overwhelming. Regardless of the challenges, it is hard to evaluate how successful this project is as Munk points out in the last chapters of the book. This is due to the poor evaluation plan and data collection. There were no control villages established at baseline, they were not randomized, and the data were not rigorously collected according to critics.

This book is well worth a read if you are interested in international development, foreign aid, global health or ending poverty. It presents a candid narrative of the difficulties of working in low-income, underdeveloped countries and challenging some of the world’s most pressing problems of human suffering.

Combis, Custers y el Transporte Público en Lima

Casi todos los días vemos en las noticias del Perú docenas de personas lesionados en accidentes de tránsito que involucran unidades del transporte público, si sean los chóferes, pasajeros, o, peor, peatones. Por lo general, los accidentes de transito representan el cuarto cargo de morbilidad más importante en el Perú. Anualmente, hay más de 3,000 fatalidades y 60,000 heridos. En 2006, alrededor de 31% de los 27,000 accidentes de tránsito en Lima y Callao involucraron una unidad de transporte público y en 154 de ellas había un fallecido (por lo menos) que representan 34% de los fallecidos en este año. Casi 75% de los muertos (113 personas) fueron peatones (otros 251 peatones perdieron la vida en otras accidentes que no involucraron transporte público). Necesitamos contar también el denominador de estas cifras para ser justo porque las unidades de transporte publico hacen muchos más viajes, corren más horas, y van distancias más largas. En 2004, 52% de los 16,508,000 viajes diarios en Lima fueron por transporte público, 25% por caminata, 13% por carro privado, y 10% en taxi. Entonces, en 2006 en Lima y Callao había 5 muertos en accidentes de tránsito que involucraron unidades de transporte público por cada 100 millones de viajes de personas en transporte público. En contraste, había 12 muertos en accidentes de tránsito que involucraron solo carros privados (incluyendo taxis y colectivos) por cada 100 millones de viajes de personas en carros privados. Si fuéremos a examinar las distancias recorridos, la diferencia sería aún más grande entre ellos.

Hay llamadas para eliminar ciertos tipos de transporte público, mayormente los combis. Sin embargo, debemos considerar los beneficios del transporte público, incluyendo los combis. Necesitamos asegurar de que puede seguir creciendo y que toda la población tiene acceso justo y equitativo. Aunque los combis y otros modos de transporte público hacen falta de muchos mejoramientos, proveen un servicio importante a segmentos de la población para movilizarse diariamente. Lima y otras ciudades en países de bajos y medios ingresos tienen niveles de uso del transporte público increíbles comparados a países de altos ingresos, especialmente a los EE.UU. dónde solo 3% de los viajes están en transporte público, 9% están por caminata y 86% están en carros privados. Las cifras de uso de transporte público y de caminata de Lima son envidiables y las políticas deben buscar a aumentar y promocionar estos modos (y bicicletas). Un nuevo estudio indica que los que usan el transporte público tienen una probabilidad mucha más alta de tener actividad física (por lo menos 12 minutos más por día). Además de los beneficios de tener más actividad física, más uso del transporte público puede reducir el tráfico vehicular que ahoga las calles. Más y más personas en Lima están comprando y usando autos para su transporte diario, reemplazando su uso del transporte público. Es una lástima que esto está pasando porque Lima y Callao, aún con más cambios viales y nuevos proyectos, nunca va poder manejar más tráfico tal como otras ciudades han encontrado. Realmente es fabuloso que hay tantas opciones de transporte público en Lima. Es barato, el servicio es mucho más regular que otras ciudades, y se puede llegar a casi cualquier parte de la ciudad en solo 1 o 2 líneas. No quiero decir que no tiene problemas: tiene mucho para mejorar, especialmente en términos de seguridad vial y el comportamiento de los chóferes.

A pesar de los beneficios del transporte público, no podemos dejar que la situación sigue en su rumbo de un sistema sin muchas reglas o cumplimiento. Hay muchas reformas necesarias (y muchas en marcha que necesitan más coordinación y cumplimiento). Es importante en ciudades como Lima a promocionar los viajes activos y seguros, y mejorar el transporte público es una manera de ayudar esta meta. Pensemos en cómo aumentar el transporte público y de como hacerlo más seguro para todos.

“No pudo evitar atropellar el peatón” – “He could not avoid hitting the pedestrian”

A common explicative narrative in Peruvian media reporting on pedestrian-motor vehicle collisions is that the driver could not avoid hitting the pedestrian because of the pedestrian’s imprudent and untimely crossing.  The driver is rarely blamed and is generally viewed quite sympathetically in the media.  There are of course exceptions to this, usually when bus drivers are the ones responsible for striking pedestrians with their vehicles or if the pedestrian is a VIP or related to a VIP. This attitude towards pedestrians needs to change.

I am not arguing that the pedestrians are completely innocent or that drivers are completely responsible; the circumstances are usually complex, but in general motorists in Peru need to adjust their attitude towards pedestrians and be more respectful of them.  A pedestrian is much more vulnerable to injury and fatality than a motorist in pedestrian-motor vehicle collisions, thus drivers have to learn to be more respectful and careful when there are pedestrians present.  In a dense urban megacity like Lima where there are over 8 million inhabitants the motorists there need to accept that the roadway is shared with both pedestrians and cyclists (a small but growing proportion of road users in Lima).  About 25% of all trips are walking trips and 50% are on public transit (as of 2004) and only 25% are in privately-owned vehicles (including taxis, personal vehicles, motorcycles, etc.).  These numbers are especially serious considering pedestrians were about 80% of Peru’s reported road fatalities in 2007 (at least of those who die on site, the surveillance system does not quite yet account for all who die later due to their injuries).

So what is the media’s role in changing these attitudes?  The narratives almost always rely only on the driver’s description of the incident; rarely do we hear the pedestrian’s side of the story because in the serious incidents getting reported in the media the pedestrian is already dead or under medical care.  Sometimes a witness or someone accompanying the pedestrian may contribute, but even they may not have directly observed what really happened.  Thus the news story being reported will be biased against the pedestrian, regardless of their culpability.  Of course a motorist does not want to be held responsible for striking someone, especially if the pedestrian dies.  I doubt most motorists had any intention of hitting a pedestrian, but they may be engaged in risky behaviors that predisposed them to being unable to control the situation when a pedestrian did try to cross (perhaps imprudently).  Journalists reporting on these incidents may lack knowledge about the biomechanics of pedestrian-motor vehicle collisions and their primary risk factors, thus they are willing to use this narrative that it was an accident that just happened without any way to change the fact that it happened.

Journalists reporting on these events need to really consider and question what the driver was doing before the incident.  If he was traveling too fast in an urban area where he could not stop in time then he could have avoided the collision if he had been going the speed limit or less.  He should have slowed down when he saw pedestrians trying to cross.  Pedestrians do often cross where and when they perhaps shouldn’t in Lima (though often they have no choice because the roads are often not designed to accommodate their transit needs) and drivers are aware of this fact, thus they need to accept that they need to travel more slowly when pedestrians are present.  If the driver speed was not the problem, it is possible he was doing some other distracting/impairing behavior like talking or texting on a mobile device, inebriated, or was tired.  The built environment cannot be ignored.  Lima’s street designs are not often conducive to safe pedestrian travel or behaviors.  I myself have at times found myself “trapped” and forced to cross unsafely because there were no options or warnings that the sidewalk I was taking would lead me directly into vehicle traffic with no options for crossing.

Overall, journalists need to consider the pedestrian perspective more and really question the driver’s motives for reporting that the collision was inevitable. 

The World Until Yesterday

The World Until Yesterday: What Can We Learn from Traditional Societies?The World Until Yesterday: What Can We Learn from Traditional Societies? by Jared Diamond

My rating: 4 of 5 stars

Dr. Diamond presents us with a wealth of anthropological stories, experiences, and insights on traditional societies which all add up to a fairly anecdotal view of what this knowledge can offer modern societies. Even the views we get of modern societies are fairly general and do not apply to everyone in those societies. Dr. Diamond does certainly acknowledge that he is speaking in generalities in the introduction, but does this hurt the story Diamond is trying to tell? The narrative often jumps from culture to culture, though mostly focuses on New Guinea where Diamond has dedicated most of his professional career. We often get a few examples of traditional societies compared to modern societies, and Diamond allows us some inference on our own of how these situations might inform possible improvements in our own society, or to allow us to contrast and consider what we give up in order to live a different, possibly better life in modern society. It is a fairly balanced approach that does not romanticize traditional life, while also critiquing faults in modern living. I agree that there are valuable lessons and behaviors from traditional societies that we could use today, but overall I think most readers could agree that the benefits of modern society far outweigh the costs. Those costs could certainly be mitigated more both through individual and societal changes.

If you are a fan of Diamond’s previous work you will probably enjoy this book. If you are also a fan of books that attempt to understand society and historical context, you would probably also find this book interesting.

View all my reviews

Why Nations Fail

Below is my Goodreads review of Why Nations Fail by Daniel Acemoglu and James Robinson.  Books like these are quite relevant to those interested in global health because they do try and look at the big picture of the status quo and how we got there.  I don’t believe this book did as well as others, though, like Guns, Germs and Steel by Jared Diamond or Why the West Rules – For Now by Ian Morris.  This book’s focus was just too narrow, like a whole book about an ecological analysis with a few variables.

Why Nations Fail: The Origins of Power, Prosperity, and PovertyWhy Nations Fail: The Origins of Power, Prosperity, and Poverty by Daron Acemoğlu

My rating: 3 of 5 stars

I could have given this book 4-stars, but I felt 3 were more appropriate in the end. I really think this book’s title is a misnomer: it should be “How Nations Fail.” I agree the extractive/inclusive dichotomy of political institutions is a useful and explanatory model of a country’s economic success and failure. I think it explains much of how a nation/political organization fails. I also like how they point out that failure can take time, and things may look good for a time before they start going downhill. I cannot, however, agree that only the extractive/inclusive dichotomy (along with creative destruction/innovation) are the only explanation for failure. The dismissive attitude towards geographic, disease, and technological factors is astounding. We may see these extractive/inclusive institutions as the medium through which nations can fail and can succeed, but I did not feel they adequately addressed how such institutions come about in the first place. Would the Spaniards and other European powers have been able to put in place the extractive institutions without most of the indigenous population of the Americas being destroyed by disease? I highly doubt it. The few thousand Spanish that conquered Latin America could hardly have done that without the advantage of disease and immunity. I also felt that many of the examples they gave were anecdotal (which I suppose is the nature of these types of books) and perhaps even extreme situations that exemplified their theory. They completely ignore the threat of Mongol invasions of Eastern Europe in the 13th century, the influence of the crusades, the occurrence of the Renaissance, and hardly mention the Scientific Revolution/Enlightenment. Could inclusive institutions have been created without such events? It seems they would lay the occurrence of all those events at the feet of inclusivity. I would argue that the Glorious Revolution could not have occurred without the scientific and philosophical progress that was occurring and accumulating at the time.

Overall, it is a book that is worth reading to those interested in these grand, sweeping books of theory that attempt to explain civilization (like Guns, Germs, & Steel), though the style of jumping from example to example is a little jarring. It was not as enjoyable as some of the other books like it because of that style. On one page you are reading about one country and on the next another country centuries later. They do provide many interesting examples, so if you are also into history this book would appeal to you. If you are a person that likes the evidence presented rather than a narrative this book will likely annoy you (as it did me). I know they are trying to appeal to a wide audience, but there was nary a chart or graph in this book. A few maps, a set of images and that was it. The narrative text did not even provide much in the way of empirical evidence to back up their claims. The authors essentially ask you to believe and go along with the story they are weaving.

View all my reviews

Hora Segura in Lima, Peru

Lima, Peru recently enacted a law to prohibit alcohol sales after 11 AM at commercial venues every day and at bars and clubs sale is prohibited Sun-Thu after 12 AM and after 3 AM on Fri, Sat and holidays.  This is an important law and a step in the right direction to help prevent and reduce alcohol-related injuries and mortality.  We can very well expect motor vehicle collisions (including pedestrians hit by vehicles) and interpersonal violence to decrease if this law is enforced.  Any law such as this should be evaluated to demonstrate its effectiveness.  Several months ago the Municipalidad Metropolitana de Lima (MML) had a press event (http://goo.gl/7ryJp, http://goo.gl/454eg, http://goo.gl/Fkvkw and http://goo.gl/D1imi)  lauding this law’s effectiveness based on road traffic incidents being reduced by 52% and fatalities by 40% between two time points before and after the law was enacted; however, the statistics and methods they used to back up their claims are very tenuous.  Using such statistics may do this law more harm than good because it casts doubt on its effectiveness.

There several reasons we should be cautious about these statistics.  First, the data come from an active surveillance system run by MINSA, the Ministry of Health.  It is a rather new system that has a good start, but is not a complete surveillance system since it only covers public hospitals, mostly in Lima, so it would only capture road traffic incident victims that visited those hospitals for medical care.  This would most likely include people with at least moderate to severe injuries, but not all of them would go to a public hospital.  Many would go to a private clinic or hospital, thus this system only captures a fraction of the victims.  The press reports cited report that the system registered a total of 150 MVC crash victims in December of 2011 (before the law was enacted) and 70 in April of 2012, only in the district of the Cercado of Lima (the central area of Lima).  These two numbers were used to calculate the reduction of 52% and 40%.  These numbers are likely underreporting the total number of victims since the police in 2006 (the most recent year of data available for this district from the police) reported 243 incidents in December and 213 in April.  We know overall the road traffic incidents in Peru are increasing based on temporal trends reported by the police (there were 1543 incidents from Jan-Jun in 2011 and 1481 in the same months in 2006 in the Cercado http://goo.gl/4yDNz), so it is likely the number of victims is still as high or more than what was reported by MINSA’s surveillance system.  We have to remember too that the police do not catch all road traffic incidents.  Some incidents are unreported because the people involved resolve the matter between themselves or if someone is in a single-vehicle collision they may not report it either.

Second, the numbers reported are not specific to the hours of prohibition of Hora Segura during which we might expect to see an effect.  They are the total number of incidents recorded.  We could reasonably expect a reduction in the number of road traffic incidents from 11 PM to 5 AM Mon-Fri and perhaps from 3-7 AM on Sat & Sun (from drinking from the previous evening/early hours of these days).  If we refer again to the 2006 data, there were 20 victims in Dec and 22 in April during the relevant hours – about 9% of the totals.  We cannot honestly apply the reductive effect of Hora Segura to all road traffic indicents in these two months.

Third, we are only observing two snapshots of road traffic incident victims, not the entire temporal trend.  Incidents can vary over time from month-to-month.  You may randomly get one month with seemingly high number of incidents and another with a low number of incidents.  Comparing the two we might think we are observing a trend, but this unfair because we are not observing the entire trend.  We need month-to-month statistics on the number of victims long before and after the passage of this law to account for temporal trends.  It could be the number of victims is decreasing before the law went into effect, that either month was an aberration, or that something else may account for the reduction. Additionally, these trends are not accounting for the number of drivers, pedestrians, passengers and other road users.  Comparing these numbers alone assumes all else is constant, but that is a strong assumption.

The issue is that the MML could have easily obtained fairly detailed records from the police commissaries that cover the Cercado rather than relying on shoddy statistical tactics.  We could have had a much more complete picture.  Now that we are over a year out from Hora Segura, we could get a better picture of its effect if we went into the commissary records to really get much more complete numbers on how 2011 and 2012 looked in terms of not only road traffic incidents during the specific hours of interest, but also other types of alcohol-related problems like assaults, homicides, suicides and such.