Sam Heft-Neal is a Senior Research Scholar at the Center on Food Security and the Environment. Sam is working to identify the impacts of environmental changes on health, agriculture, and food availability around the world. His recent work combines household surveys with remote sensing data to examine environmental drivers of child health. Sam holds a Ph.D. in Agricultural and Resource Economics from the University of California, Berkeley and a B.A. in Statistics and Economics from the same institution.

Academic Appointments

  • Sr Research Scholar, Center on Food Security and Environment at FSI

Honors & Awards

  • Top 10 Clinical Research Achievement Award, Clinical Research Forum (03/03/2019)

All Publications

  • Sociodemographic and geographic variation in mortality attributable to air pollution in the United States. medRxiv : the preprint server for health sciences Geldsetzer, P., Fridljand, D., Kiang, M. V., Bendavid, E., Heft-Neal, S., Burke, M., Thieme, A. H., Benmarhnia, T. 2024


    There are large differences in premature mortality in the USA by racial/ethnic, education, rurality, and social vulnerability index groups. Using existing concentration-response functions, particulate matter (PM2.5) air pollution, population estimates at the tract level, and county-level mortality data, we estimated the degree to which these mortality discrepancies can be attributed to differences in exposure and susceptibility to PM2.5. We show that differences in mortality attributable to PM2.5 were consistently more pronounced between racial/ethnic groups than by education, rurality, or social vulnerability index, with the Black American population having by far the highest proportion of deaths attributable to PM2.5 in all years from 1990 to 2016. Over half of the difference in age-adjusted all-cause mortality between the Black American and non-Hispanic White population was attributable to PM2.5 in the years 2000 to 2011.

    View details for DOI 10.1101/2024.04.17.24305943

    View details for PubMedID 38699349

    View details for PubMedCentralID PMC11065005

  • Higher air pollution in wealthy districts of most low- and middle-income countries NATURE SUSTAINABILITY Behrer, A., Heft-Neal, S. 2024
  • Global population profile of tropical cyclone exposure from 2002 to 2019. Nature Jing, R., Heft-Neal, S., Chavas, D. R., Griswold, M., Wang, Z., Clark-Ginsberg, A., Guha-Sapir, D., Bendavid, E., Wagner, Z. 2023


    Tropical cyclones have far-reaching impacts on livelihoods and population health that often persist years after the event [1,2,3,4]. Characterizing the demographic and socioeconomic profile and the vulnerabilities of exposed populations is essential to assess health and other risks associated with future tropical cyclone events [5]. Estimates of exposure to tropical cyclones are often regional rather than global [6] and do not consider population vulnerabilities [7]. Here, we combine spatially resolved annual demographic estimates with tropical cyclone wind fields estimates to construct a global profile of the populations exposed to tropical cyclones between 2002 and 2019. We find that approximately 560 million people are exposed yearly and that the number of people exposed has increased across all cyclone intensities over the study period. The age distribution of those exposed has shifted away from children (under-5) and towards older people (over-60) in recent years compared to the early 2000s. Populations exposed to tropical cyclones are more socioeconomically deprived than those unexposed within the same country, and this relationship is more pronounced for people exposed to higher-intensity storms. By characterizing the patterns and vulnerabilities of exposed populations, our results can help identify mitigation strategies and assess the global burden and future risks of tropical cyclones.

    View details for DOI 10.1038/s41586-023-06963-z

    View details for PubMedID 38122822

  • Quantifying fire-specific smoke exposure and health impacts. Proceedings of the National Academy of Sciences of the United States of America Wen, J., Heft-Neal, S., Baylis, P., Boomhower, J., Burke, M. 2023; 120 (51): e2309325120


    Rapidly changing wildfire regimes across the Western United States have driven more frequent and severe wildfires, resulting in wide-ranging societal threats from wildfires and wildfire-generated smoke. However, common measures of fire severity focus on what is burned, disregarding the societal impacts of smoke generated from each fire. We combine satellite-derived fire scars, air parcel trajectories from individual fires, and predicted smoke PM2.5 to link source fires to resulting smoke PM2.5 and health impacts experienced by populations in the contiguous United States from April 2006 to 2020. We quantify fire-specific accumulated smoke exposure based on the cumulative population exposed to smoke PM2.5 over the duration of a fire and estimate excess asthma-related emergency department (ED) visits as a result of this exposure. We find that excess asthma visits attributable to each fire are only moderately correlated with common measures of wildfire severity, including burned area, structures destroyed, and suppression cost. Additionally, while recent California fires contributed nearly half of the country's smoke-related excess asthma ED visits during our study period, the most severe individual fire was the 2007 Bugaboo fire in the Southeast. We estimate that a majority of smoke PM2.5 comes from sources outside the local jurisdictions where the smoke is experienced, with 87% coming from fires in other counties and 60% from fires in other states. Our approach could enable broad-scale assessment of whether specific fire characteristics affect smoke toxicity or impact, inform cost-effectiveness assessments for allocation of suppression resources, and help clarify the growing transboundary nature of local air quality.

    View details for DOI 10.1073/pnas.2309325120

    View details for PubMedID 38085772

  • Emergency department visits respond nonlinearly to wildfire smoke. Proceedings of the National Academy of Sciences of the United States of America Heft-Neal, S., Gould, C. F., Childs, M. L., Kiang, M. V., Nadeau, K. C., Duggan, M., Bendavid, E., Burke, M. 2023; 120 (39): e2302409120


    Air pollution negatively affects a range of health outcomes. Wildfire smoke is an increasingly important contributor to air pollution, yet wildfire smoke events are highly salient and could induce behavioral responses that alter health impacts. We combine geolocated data covering all emergency department (ED) visits to nonfederal hospitals in California from 2006 to 2017 with spatially resolved estimates of daily wildfire smoke PM[Formula: see text] concentrations and quantify how smoke events affect ED visits. Total ED visits respond nonlinearly to smoke concentrations. Relative to a day with no smoke, total visits increase by 1 to 1.5% in the week following low or moderate smoke days but decline by 6 to 9% following extreme smoke days. Reductions persist for at least a month. Declines at extreme levels are driven by diagnoses not thought to be acutely impacted by pollution, including accidental injuries and several nonurgent symptoms, and declines come disproportionately from less-insured populations. In contrast, health outcomes with the strongest physiological link to short-term air pollution increase dramatically in the week following an extreme smoke day: We estimate that ED visits for asthma, COPD, and cough all increase by 30 to 110%. Data from internet searches, vehicle traffic sensors, and park visits indicate behavioral changes on high smoke days consistent with declines in healthcare utilization. Because low and moderate smoke days vastly outweigh high smoke days, we estimate that smoke was responsible for an average of 3,010 (95% CI: 1,760-4,380) additional ED visits per year 2006 to 2017. Given the increasing intensity of wildfire smoke events, behavioral mediation is likely to play a growing role in determining total smoke impacts.

    View details for DOI 10.1073/pnas.2302409120

    View details for PubMedID 37722035

  • Health Effects of Wildfire Smoke Exposure. Annual review of medicine Gould, C. F., Heft-Neal, S., Prunicki, M., Aguilera, J., Burke, M., Nadeau, K. 2023


    We review current knowledge on the trends and drivers of global wildfire activity, advances in the measurement of wildfire smoke exposure, and evidence on the health effects of this exposure. We describe methodological issues in estimating the causal effects of wildfire smoke exposures on health and quantify their importance, emphasizing the role of nonlinear and lagged effects. We conduct a systematic review and meta-analysis of the health effects of wildfire smoke exposure, finding positive impacts on all-cause mortality and respiratory hospitalizations but less consistent evidence on cardiovascular morbidity. We conclude by highlighting priority areas for future research, including leveraging recently developed spatially and temporally resolved wildfire-specific ambient air pollution data to improve estimates of the health effects of wildfire smoke exposure. Expected final online publication date for the Annual Review of Medicine, Volume 75 is January 2024. Please see for revised estimates.

    View details for DOI 10.1146/annurev-med-052422-020909

    View details for PubMedID 37738508

  • The contribution of wildfire to PM2.5 trends in the USA. Nature Burke, M., Childs, M. L., de la Cuesta, B., Qiu, M., Li, J., Gould, C. F., Heft-Neal, S., Wara, M. 2023


    Steady improvements in ambient air quality in the USA over the past several decades, in part a result of public policy1,2, have led to public health benefits1-4. However, recent trends in ambient concentrations of particulate matter with diameters less than 2.5 μm (PM2.5), a pollutant regulated under the Clean Air Act1, have stagnated or begun to reverse throughout much of the USA5. Here we use a combination of ground- and satellite-based air pollution data from 2000 to 2022 to quantify the contribution of wildfire smoke to these PM2.5 trends. We find that since at least 2016, wildfire smoke has influenced trends in average annual PM2.5 concentrations in nearly three-quarters of states in the contiguous USA, eroding about 25% of previous multi-decadal progress in reducing PM2.5 concentrations on average in those states, equivalent to 4 years of air quality progress, and more than 50% in many western states. Smoke influence on trends in the number of days with extreme PM2.5 concentrations is detectable by 2011, but the influence can be detected primarily in western and mid-western states. Wildfire-driven increases in ambient PM2.5 concentrations are unregulated under current air pollution law6 and, in the absence of further interventions, we show that the contribution of wildfire to regional and national air quality trends is likely to grow as the climate continues to warm.

    View details for DOI 10.1038/s41586-023-06522-6

    View details for PubMedID 37730996

    View details for PubMedCentralID 3521092

  • Global biomass fires and infant mortality. Proceedings of the National Academy of Sciences of the United States of America Pullabhotla, H. K., Zahid, M., Heft-Neal, S., Rathi, V., Burke, M. 2023; 120 (23): e2218210120


    Global outdoor biomass burning is a major contributor to air pollution, especially in low- and middle-income countries. Recent years have witnessed substantial changes in the extent of biomass burning, including large declines in Africa. However, direct evidence of the contribution of biomass burning to global health outcomes remains limited. Here, we use georeferenced data on more than 2 million births matched to satellite-derived burned area exposure to estimate the burden of biomass fires on infant mortality. We find that each additional square kilometer of burning is associated with nearly 2% higher infant mortality in nearby downwind locations. The share of infant deaths attributable to biomass fires has increased over time due to the rapid decline in other important causes of infant death. Applying our model estimates across harmonized district-level data covering 98% of global infant deaths, we find that exposure to outdoor biomass burning was associated with nearly 130,000 additional infant deaths per year globally over our 2004 to 2018 study period. Despite the observed decline in biomass burning in Africa, nearly 75% of global infant deaths due to burning still occur in Africa. While fully eliminating biomass burning is unlikely, we estimate that even achievable reductions-equivalent to the lowest observed annual burning in each location during our study period-could have avoided more than 70,000 infant deaths per year globally since 2004.

    View details for DOI 10.1073/pnas.2218210120

    View details for PubMedID 37253010

  • Geographically resolved social cost of anthropogenic emissions accounting for both direct and climate-mediated effects. Science advances Burney, J., Persad, G., Proctor, J., Bendavid, E., Burke, M., Heft-Neal, S. 2022; 8 (38): eabn7307


    The magnitude and distribution of physical and societal impacts from long-lived greenhouse gases are insensitive to the emission source location; the same is not true for major coemitted short-lived pollutants such as aerosols. Here, we combine novel global climate model simulations with established response functions to show that a given aerosol emission from different regions produces divergent air quality and climate changes and associated human system impacts, both locally and globally. The marginal global damages to infant mortality, crop productivity, and economic growth from aerosol emissions and their climate effects differ by more than an order of magnitude depending on source region, with certain regions creating global external climate changes and impacts much larger than those felt locally. The complex distributions of aerosol-driven societal impacts emerge from geographically distinct and region-specific aerosol-climate interactions, estimation of which is enabled by the full Earth System Modeling Framework used here.

    View details for DOI 10.1126/sciadv.abn7307

    View details for PubMedID 36149961

  • Daily Local-Level Estimates of Ambient Wildfire Smoke PM2.5 for the Contiguous US. Environmental science & technology Childs, M. L., Li, J., Wen, J., Heft-Neal, S., Driscoll, A., Wang, S., Gould, C. F., Qiu, M., Burney, J., Burke, M. 2022


    Smoke from wildfires is a growing health risk across the US. Understanding the spatial and temporal patterns of such exposure and its population health impacts requires separating smoke-driven pollutants from non-smoke pollutants and a long time series to quantify patterns and measure health impacts. We develop a parsimonious and accurate machine learning model of daily wildfire-driven PM2.5 concentrations using a combination of ground, satellite, and reanalysis data sources that are easy to update. We apply our model across the contiguous US from 2006 to 2020, generating daily estimates of smoke PM2.5 over a 10 km-by-10 km grid and use these data to characterize levels and trends in smoke PM2.5. Smoke contributions to daily PM2.5 concentrations have increased by up to 5 mug/m3 in the Western US over the last decade, reversing decades of policy-driven improvements in overall air quality, with concentrations growing fastest for higher income populations and predominantly Hispanic populations. The number of people in locations with at least 1 day of smoke PM2.5 above 100 mug/m3 per year has increased 27-fold over the last decade, including nearly 25 million people in 2020 alone. Our data set can bolster efforts to comprehensively understand the drivers and societal impacts of trends and extremes in wildfire smoke.

    View details for DOI 10.1021/acs.est.2c02934

    View details for PubMedID 36134580

  • Exposures and behavioural responses to wildfire smoke. Nature human behaviour Burke, M., Heft-Neal, S., Li, J., Driscoll, A., Baylis, P., Stigler, M., Weill, J. A., Burney, J. A., Wen, J., Childs, M. L., Gould, C. F. 2022


    Pollution from wildfires constitutes a growing source of poor air quality globally. To protect health, governments largely rely on citizens to limit their own wildfire smoke exposures, but the effectiveness of this strategy is hard to observe. Using data from private pollution sensors, cell phones, social media posts and internet search activity, we find that during large wildfire smoke events, individuals in wealthy locations increasingly search for information about air quality and health protection, stay at home more and are unhappier. Residents of lower-income neighbourhoods exhibit similar patterns in searches for air quality information but not for health protection, spend less time at home and have more muted sentiment responses. During smoke events, indoor particulate matter (PM2.5) concentrations often remain 3-4* above health-based guidelines and vary by 20* between neighbouring households. Our results suggest that policy reliance on self-protection to mitigate smoke health risks will have modest and unequal benefits.

    View details for DOI 10.1038/s41562-022-01396-6

    View details for PubMedID 35798884

  • Associations between wildfire smoke exposure during pregnancy and risk of preterm birth in California. Environmental research Heft-Neal, S., Driscoll, A., Yang, W., Shaw, G., Burke, M. 2021: 111872


    There is limited population-scale evidence on the burden of exposure to wildfire smoke during pregnancy and its impacts on birth outcomes. In order to investigate this relationship, data on every singleton birth in California 2006-2012 were combined with satellite-based estimates of wildfire smoke plume boundaries and high-resolution gridded estimates of surface PM2.5 concentrations and a regression model was used to estimate associations with preterm birth risk. Results suggest that each additional day of exposure to any wildfire smoke during pregnancy was associated with an 0.49 % (95 % CI: 0.41-0.59 %) increase in risk of preterm birth (<37 weeks). At sample median smoke exposure (7 days) this translated to a 3.4 % increase in risk, relative to an unexposed mother. Estimates by trimester suggest stronger associations with exposure later in pregnancy and estimates by smoke intensity indicate that observed associations were driven by higher intensity smoke-days. Exposure to low intensity smoke-days had no association with preterm birth while an additional medium (smoke PM2.5 5-10 mug/m3) or high (smoke PM2.5 > 10 mug/m3) intensity smoke-day was associated with an 0.95 % (95 % CI: 0.47-1.42 %) and 0.82 % (95 % CI: 0.41-1.24 %) increase in preterm risk, respectively. In contrast to previous findings for other pollution types, neither exposure to smoke nor the relative impact of smoke on preterm birth differed by race/ethnicity or income in our sample. However, impacts differed greatly by baseline smoke exposure, with mothers in regions with infrequent smoke exposure experiencing substantially larger impacts from an additional smoke-day than mothers in regions where smoke is more common. We estimate 6,974 (95 % CI: 5,513-8,437) excess preterm births attributable to wildfire smoke exposure 2007-2012, accounting for 3.7 % of observed preterm births during this period. Our findings have important implications for understanding the costs of growing wildfire smoke exposure, and for understanding the benefits of smoke mitigation measures.

    View details for DOI 10.1016/j.envres.2021.111872

    View details for PubMedID 34403668

  • The changing risk and burden of wildfire in the United States. Proceedings of the National Academy of Sciences of the United States of America Burke, M., Driscoll, A., Heft-Neal, S., Xue, J., Burney, J., Wara, M. 2021; 118 (2)


    Recent dramatic and deadly increases in global wildfire activity have increased attention on the causes of wildfires, their consequences, and how risk from wildfire might be mitigated. Here we bring together data on the changing risk and societal burden of wildfire in the United States. We estimate that nearly 50 million homes are currently in the wildland-urban interface in the United States, a number increasing by 1 million houses every 3 y. To illustrate how changes in wildfire activity might affect air pollution and related health outcomes, and how these linkages might guide future science and policy, we develop a statistical model that relates satellite-based fire and smoke data to information from pollution monitoring stations. Using the model, we estimate that wildfires have accounted for up to 25% of PM 2.5 (particulate matter with diameter <2.5 mum) in recent years across the United States, and up to half in some Western regions, with spatial patterns in ambient smoke exposure that do not follow traditional socioeconomic pollution exposure gradients. We combine the model with stylized scenarios to show that fuel management interventions could have large health benefits and that future health impacts from climate-change-induced wildfire smoke could approach projected overall increases in temperature-related mortality from climate change-but that both estimates remain uncertain. We use model results to highlight important areas for future research and to draw lessons for policy.

    View details for DOI 10.1073/pnas.2011048118

    View details for PubMedID 33431571

  • The effects of armed conflict on the health of women and children. Lancet (London, England) Bendavid, E. n., Boerma, T. n., Akseer, N. n., Langer, A. n., Malembaka, E. B., Okiro, E. A., Wise, P. H., Heft-Neal, S. n., Black, R. E., Bhutta, Z. A. 2021


    Women and children bear substantial morbidity and mortality as a result of armed conflicts. This Series paper focuses on the direct (due to violence) and indirect health effects of armed conflict on women and children (including adolescents) worldwide. We estimate that nearly 36 million children and 16 million women were displaced in 2017, on the basis of international databases of refugees and internally displaced populations. From geospatial analyses we estimate that the number of non-displaced women and children living dangerously close to armed conflict (within 50 km) increased from 185 million women and 250 million children in 2000, to 265 million women and 368 million children in 2017. Women's and children's mortality risk from non-violent causes increases substantially in response to nearby conflict, with more intense and more chronic conflicts leading to greater mortality increases. More than 10 million deaths in children younger than 5 years can be attributed to conflict between 1995 and 2015 globally. Women of reproductive ages living near high intensity conflicts have three times higher mortality than do women in peaceful settings. Current research provides fragmentary evidence about how armed conflict indirectly affects the survival chances of women and children through malnutrition, physical injuries, infectious diseases, poor mental health, and poor sexual and reproductive health, but major systematic evidence is sparse, hampering the design and implementation of essential interventions for mitigating the harms of armed conflicts.

    View details for DOI 10.1016/S0140-6736(21)00131-8

    View details for PubMedID 33503456

  • Fine Particulate Air Pollution, Early Life Stress, and Their Interactive Effects on Adolescent Structural Brain Development: A Longitudinal Tensor-Based Morphometry Study. Cerebral cortex (New York, N.Y. : 1991) Miller, J. G., Dennis, E. L., Heft-Neal, S., Jo, B., Gotlib, I. H. 2021


    Air pollution is a major environmental threat to public health; we know little, however, about its effects on adolescent brain development. Exposure to air pollution co-occurs, and may interact, with social factors that also affect brain development, such as early life stress (ELS). Here, we show that severity of ELS and fine particulate air pollution (PM2.5) are associated with volumetric changes in distinct brain regions, but also uncover regions in which ELS moderates the effects of PM2.5. We interviewed adolescents about ELS events, used satellite-derived estimates of ambient PM2.5 concentrations, and conducted longitudinal tensor-based morphometry to assess regional changes in brain volume over an approximately 2-year period (N = 115, ages 9-13 years at Time 1). For adolescents who had experienced less severe ELS, PM2.5 was associated with volumetric changes across several gray and white matter regions. Fewer effects of PM2.5 were observed for adolescents who had experienced more severe ELS, although occasionally they were in the opposite direction. This pattern of results suggests that for many brain regions, moderate to severe ELS largely constrains the effects of PM2.5 on structural development. Further theory and research is needed on the joint effects of ELS and air pollution on the brain.

    View details for DOI 10.1093/cercor/bhab346

    View details for PubMedID 34607342

  • Comparison of World Health Organization and Demographic and Health Surveys data to estimate sub-national deworming coverage in pre-school aged children. PLoS neglected tropical diseases Lo, N. C., Gupta, R., Addiss, D. G., Bendavid, E., Heft-Neal, S., Mikhailov, A., Montresor, A., Mbabazi, P. S. 2020; 14 (8): e0008551


    BACKGROUND: The key metric for monitoring the progress of deworming programs in controlling soil-transmitted helminthiasis (STH) is national drug coverage reported to the World Health Organization (WHO). There is increased interest in utilizing geographically-disaggregated data to estimate sub-national deworming coverage and equity, as well as gender parity. The Demographic and Health Surveys (DHS) offer a potential source of sub-national data. This study aimed to compare deworming coverage routinely reported to WHO and estimated by DHS in pre-school aged children to inform global STH measurement and evaluation.METHODOLOGY: We compared sub-national deworming coverage in pre-school aged children reported to WHO and estimated by DHS aligned geospatially and temporally. We included data from Burundi (2016-2017), Myanmar (2015-2016), and the Philippines (2017) based on data availability. WHO provided data on the date and sub-national coverage per mass drug administration reported by Ministries of Health. DHS included maternally-reported deworming status within the past 6 months for each child surveyed. We estimated differences in sub-national deworming coverage using WHO and DHS data, and performed sensitivity analyses.PRINCIPAL FINDINGS: We compared data on pre-school aged children from 13 of 18 districts in Burundi (N = 6,835 in DHS), 11 of 15 districts in Myanmar (N = 1,462 in DHS) and 16 of 17 districts in the Philippines (N = 7,594 in DHS) following data exclusion. The national deworming coverages estimated by DHS in Burundi, Myanmar, and the Philippines were 75.5% (95% CI: 73.7%-77.7%), 47.0% (95% CI: 42.7%-51.3%), and 48.0% (95% CI: 46.0%-50.0%), respectively. The national deworming coverages reported by WHO in Burundi, Myanmar, and the Philippines were 80.1%, 93.6% and 75.7%, respectively. The mean absolute differences in district-level coverage reported to WHO and estimated by DHS in Burundi, Myanmar, and the Philippines were 9.5%, 41.5%, and 24.6%, respectively. Across countries, coverage reported to WHO was frequently higher than DHS estimates (32 of 40 districts). National deworming coverage from DHS estimates were similar by gender within countries.CONCLUSIONS AND SIGNIFICANCE: Agreement of deworming coverage reported to WHO and estimated by DHS data was heterogeneous across countries, varying from broadly compatible in Burundi to largely discrepant in Myanmar. DHS data could complement deworming data reported to WHO to improve data monitoring practices and serve as an independent sub-national source of coverage data.

    View details for DOI 10.1371/journal.pntd.0008551

    View details for PubMedID 32804925

  • Dust pollution from the Sahara and African infant mortality NATURE SUSTAINABILITY Heft-Neal, S., Burney, J., Bendavid, E., Voss, K. K., Burke, M. 2020
  • Testing the socioeconomic and environmental determinants of better child-health outcomes in Africa: a cross-sectional study among nations. BMJ open Bradshaw, C. J., Otto, S. P., Mehrabi, Z., Annamalay, A. A., Heft-Neal, S., Wagner, Z., Le Souef, P. N. 2019; 9 (9): e029968


    OBJECTIVE: We sought to test hypotheses regarding the principal correlates of child-health performance among African nations based on previous evidence collected at finer spatial scales.DESIGN: Retrospective, cross-sectional study.SETTING: All countries in Africa, excluding small-island nations.PRIMARY AND SECONDARY OUTCOME MEASURES: We defined a composite child-health indicator for each country comprising the incidence of stunting, deaths from respiratory disease, deaths from diarrhoeal disease, deaths from other infectious disease and deaths from injuries for children aged under 5 years. We also compiled national-level data for Africa to test the effects of country-level water quality, air pollution, food supply, breast feeding, environmental performance, per capita wealth, healthcare investment, population density and governance quality on the child-health indicator.RESULTS: Across nations, child health was lowest when water quality, improved sanitation, air quality and environmental performance were lowest. There was also an important decline in child health as household size (a proxy for population density) increased. The remaining variables had only weak effects, but in the directions we hypothesised.CONCLUSIONS: These results emphasise the importance of continued investment in clean water and sanitation services, measures to improve air quality and efforts to restrict further environmental degradation, to promote the UN's Sustainable Development Goal 3 target to ' end preventable deaths of newborns and children under 5' and Goal 6 to ' ensure access to water and sanitation for all' by 2030.

    View details for DOI 10.1136/bmjopen-2019-029968

    View details for PubMedID 31570408

  • State of deworming coverage and equity in low-income and middle-income countries using household health surveys: a spatiotemporal cross-sectional study. The Lancet. Global health Lo, N. C., Heft-Neal, S. n., Coulibaly, J. T., Leonard, L. n., Bendavid, E. n., Addiss, D. G. 2019


    Mass deworming against soil-transmitted helminthiasis, which affects 1 billion of the poorest people globally, is one of the largest public health programmes for neglected tropical diseases, and is intended to be equitable. However, the extent to which treatment programmes for deworming achieve equitable coverage across wealth class and sex is unclear and the public health metric of national deworming coverage does not include representation of equity. This study aims to measure both coverage and equity in global, national, and subnational deworming to guide future programmatic evaluation, investment, and metric design.We used nationally representative, geospatial, household data from Demographic and Health Surveys that measured mother-reported deworming in children of preschool age (12-59 months). Deworming was defined as children having received drugs for intestinal parasites in the previous 6 months before the survey. We estimated deworming coverage disaggregated by geography, wealth quintile, and sex, and computed an equity index. We examined trends in coverage and equity index across countries, within countries, and over time. We used a regression model to compute the household correlates of deworming and ecological correlates of equitable deworming.Our study included 820 883 children living in 50 countries from Africa, the Americas, Asia, and Europe that are endemic for soil-transmitted helminthiasis using 77 Demographic and Health Surveys from December, 2003, to October, 2017. In these countries, the mean deworming coverage in preschool children was estimated at 33·0% (95% CI 32·9-33·1). The subnational coverage ranged from 0·5% to 87·5%, and within-country variation was greater than between-country variation. Of the 31 countries reporting that they reached the WHO goal of more than 75% national coverage, 30 had inequity in deworming, with treatment concentrated in wealthier populations. We did not detect systematic differences in deworming equity by sex.Substantial inequities in mass deworming programmes are common as wealthier populations have consistently higher coverage than that of the poor, including in countries reporting to have reached the WHO goal of more than 75% national coverage. These inequities seem to be geographically heterogeneous, modestly improving over time, with no evidence of sex differences in inequity. Future reporting of deworming coverage should consider disaggregation by geography, wealth, and sex with incorporation of an equity index to complement the conventional public health metric of national deworming coverage.Bill & Melinda Gates Foundation, Stanford University Medical Scientist Training Program.

    View details for DOI 10.1016/S2214-109X(19)30413-9

    View details for PubMedID 31558383

  • Women and children living in areas of armed conflict in Africa: a geospatial analysis of mortality and orphanhood. The Lancet. Global health Wagner, Z. n., Heft-Neal, S. n., Wise, P. H., Black, R. E., Burke, M. n., Boerma, T. n., Bhutta, Z. A., Bendavid, E. n. 2019


    The population effects of armed conflict on non-combatant vulnerable populations are incompletely understood. We aimed to study the effects of conflict on mortality among women of childbearing age (15-49 years) and on orphanhood among children younger than 15 years in Africa.We tested the extent to which mortality among women aged 15-49 years, and orphanhood among children younger than 15 years, increased in response to nearby armed conflict in Africa. Data on location, timing, and intensity of armed conflicts were obtained from the Uppsala Conflict Data Program, and data on the location, timing, and outcomes of women and children from Demographic and Health Surveys done in 35 African countries from 1990 to 2016. Mortality among women was obtained from sibling survival data. We used cluster-area fixed-effects regression models to compare survival of women during periods of nearby conflict (within 50 km) to survival of women in the same area during times without conflict. We used similar methods to examine the extent to which children living near armed conflicts are at increased risk of becoming orphans. We examined the effects of varying conflict intensity using number of direct battle deaths and duration of consecutive conflict exposure.We analysed data on 1 629 352 women (19 286 387 person-years), of which 103 011 (6·3%) died (534·1 deaths per 100 000 women-years), and 2 354 041 children younger than 15 years, of which 204 276 (8·7%) had lost a parent. On average, conflict within 50 km increased women's mortality by 112 deaths per 100 000 person-years (95% CI 97-128; a 21% increase above baseline), and the probability that a child has lost at least one parent by 6·0% (95% CI 3-8). This effect was driven by high-intensity conflicts: exposure to the highest (tenth) decile conflict in terms of conflict-related deaths increased the probability of female mortality by 202% (187-218) and increased the likelihood of orphanhood by 42% compared with a conflict-free period. Among the conflict-attributed deaths, 10% were due to maternal mortality.African women of childbearing age are at a substantially increased risk of death from nearby high-intensity armed conflicts. Children exposed to conflict are analogously at increased risk of becoming orphans. This work fills gaps in literature on the harmful effects of armed conflict on non-combatants and highlights the need for humanitarian interventions to protect vulnerable populations.Bill & Melinda Gates Foundation to the BRANCH Consortium.

    View details for DOI 10.1016/S2214-109X(19)30407-3

    View details for PubMedID 31669039

  • Armed conflict and child mortality in Africa: a geospatial analysis. Lancet (London, England) Wagner, Z., Heft-Neal, S., Bhutta, Z. A., Black, R. E., Burke, M., Bendavid, E. 2018


    BACKGROUND: A substantial portion of child deaths in Africa take place in countries with recent history of armed conflict and political instability. However, the extent to which armed conflict is an important cause of child mortality, especially in Africa, remains unknown.METHODS: We matched child survival with proximity to armed conflict using information in the Uppsala Conflict Data Program Georeferenced Events Dataset on the location and intensity of armed conflict from 1995 to 2015 together with the location, timing, and survival of infants younger than 1 year (primary outcome) in 35 African countries. We measured the increase in mortality risk for infants exposed to armed conflicts within 50 km in the year of birth and, to study conflicts' extended health risks, up to 250 km away and 10 years before birth. We also examined the effects of conflicts of varying intensity and chronicity (conflicts lasting several years), and effect heterogeneity by residence and sex of the child. We then estimated the number and portion of deaths of infants younger than 1 year related to conflict.FINDINGS: We identified 15 441 armed conflict events that led to 968 444 combat-related deaths and matched these data with 1·99 million births and 133 361 infant deaths (infant mortality of 67 deaths per 1000 births) between 1995 and 2015. A child born within 50 km of an armed conflict had a risk of dying before reaching age 1 year of 5·2 per 1000 births higher than being born in the same region during periods without conflict (95% CI 3·7-6·7; a 7·7% increase above baseline). This increased risk of dying ranged from a 3·0% increase for armed conflicts with one to four deaths to a 26·7% increase for armed conflicts with more than 1000 deaths. We find evidence of increased mortality risk from an armed conflict up to 100 km away, and for 8 years after conflicts, with cumulative increase in infant mortality two to four times higher than the contemporaneous increase. In the entire continent, the number of infant deaths related to conflict from 1995 to 2015 was between 3·2 and 3·6 times the number of direct deaths from armed conflicts.INTERPRETATION: Armed conflict substantially and persistently increases infant mortality in Africa, with effect sizes on a scale with malnutrition and several times greater than existing estimates of the mortality burden of conflict. The toll of conflict on children, who are presumably not combatants, underscores the indirect toll of conflict on civilian populations, and the importance of developing interventions to address child health in areas of conflict.FUNDING: The Doris Duke Charitable Foundation, and the Centre for Global Child Health at the Hospital for Sick Children.

    View details for PubMedID 30173907

  • Robust relationship between air quality and infant mortality in Africa NATURE Heft-Neal, S., Burney, J., Bendavid, E., Burke, M. 2018; 559 (7713): 254-+
  • Deworming in pre-school age children: A global empirical analysis of health outcomes. PLoS neglected tropical diseases Lo, N. C., Snyder, J. n., Addiss, D. G., Heft-Neal, S. n., Andrews, J. R., Bendavid, E. n. 2018; 12 (5): e0006500


    There is debate over the effectiveness of deworming children against soil-transmitted helminthiasis (STH) to improve health outcomes, and current evidence may be limited in study design and generalizability. However, programmatic deworming continues throughout low and middle-income countries.We performed an empirical evaluation of the relationship between deworming in pre-school age children (ages 1-4 years) within the previous 6 months, as proxy-reported by the mother, and health outcomes of weight, height, and hemoglobin. We used nationally representative cross-sectional data from 45 countries using the Demographic and Health Surveys (DHS) during the period 2005-2016. We used logistic regression with coarsened exact matching, fixed effects for survey and year, and person-level covariates. We included data on 325,115 children in 45 STH-endemic countries from 66 DHS surveys. Globally in STH-endemic countries, children who received deworming treatment were less likely to be stunted (1.2 percentage point decline from mean of 36%; 95% CI [-1.9, -0.5%]; p<0.001), but we did not detect consistent associations between deworming and anemia or weight. In sub-Saharan Africa, we found that children who received deworming treatment were less likely to be stunted (1.1 percentage point decline from mean of 36%; 95% CI [-2.1, -0.2%]; p = 0.01) and less likely to have anemia (1.8 percentage point decline from mean of 58%; 95% CI [-2.8, -0.7%]; p<0.001), but we did not detect consistent associations between deworming and weight. These findings were robust across multiple statistical models, and we did not find consistently measurable associations with data from non-endemic settings.Among pre-school age children, we detected a robust and consistent association between deworming and reduced stunting, with additional evidence for reduced anemia in sub-Saharan Africa. We did not find a consistent relationship between deworming and improved weight. This global empirical analysis provides evidence to support the deworming of pre-school age children.

    View details for PubMedID 29852012

  • Higher temperatures increase suicide rates in the United States and Mexico Nature Climate Change Burke, M., González, F., Baylis, P., Heft-Neal, S., Baysan, C., Basu, S., Hsiang, S. 2018; 8 (8): 723--729
  • Using remotely sensed temperature to estimate climate response functions Environmental Research Letters Heft-Neal, S., Lobell, D. B., Burke, M. 2017; 12 (1): 014013

    View details for DOI 10.1088/1748-9326/aa5463

  • Sources of variation in under-5 mortality across sub-Saharan Africa: a spatial analysis. The Lancet. Global health Burke, M., Heft-Neal, S., Bendavid, E. 2016


    Detailed spatial understanding of levels and trends in under-5 mortality is needed to improve the targeting of interventions to the areas of highest need, and to understand the sources of variation in mortality. To improve this understanding, we analysed local-level information on child mortality across sub-Saharan Africa between 1980-2010.We used data from 82 Demographic and Health Surveys in 28 sub-Saharan African countries, including the location and timing of 3·24 million childbirths and 393 685 deaths, to develop high-resolution spatial maps of under-5 mortality in the 1980s, 1990s, and 2000s. These estimates were at a resolution of 0·1 degree latitude by 0·1 degree longitude (roughly 10 km × 10 km). We then analysed this spatial information to distinguish within-country versus between-country sources of variation in mortality, to examine the extent to which declines in mortality have been accompanied by convergence in the distribution of mortality, and to study localised drivers of mortality differences, including temperature, malaria burden, and conflict.In our sample of sub-Saharan African countries from the 1980s to the 2000s, within-country differences in under-5 mortality accounted for 74-78% of overall variation in under-5 mortality across space and over time. Mortality differed significantly across only 8-15% of country borders, supporting the role of local, rather than national, factors in driving mortality patterns. We found that by the end of the study period, 23% of the eligible children in the study countries continue to live in mortality hotspots-areas where, if current trends continue, the Sustainable Developent Goals mortality targets will not be met. In multivariate analysis, within-country mortality levels at each pixel were significantly related to local temperature, malaria burden, and recent history of conflict.Our findings suggest that sub-national determinants explain a greater portion of under-5 mortality than do country-level characteristics. Sub-national measures of child mortality could provide a more accurate, and potentially more actionable, portrayal of where and why children are still dying than can national statistics.The Stanford Woods Institute for the Environment.

    View details for DOI 10.1016/S2214-109X(16)30212-1

    View details for PubMedID 27793587