# Projects

In today’s interconnected world global health is more important than ever with serious implications for trade, security, well being and development. The Global Strategy Lab's work centres around three core thematic areas: 1) global health law; 2) global governance; and 3) institutional design. Many research projects are currently ongoing, with the following examples drawn from those that have been externally funded.

## Institutional Design

Antimicrobials

Amongst higher income level countries with greater access to antimicrobial drugs, the risk of antimicrobial resistance is rapidly increasing. Antimicrobial resistance arises when overuse of antimicrobials leads to the development of drug-resistant pathogens. As a result, thousands of deaths occur every year due to bacterial infections, as the drugs prove to be ineffective amongst these resistant pathogens. Contrarily, there is a lack of secure access to necessary antimicrobials in low and middle- income nations, again making populations susceptible to varying types of bacterial infections and diseases. Hence, in this two-pronged issue posed by antimicrobials, much innovation, collaboration, and attention is required amongst all global health actors.

Through recent project developments and publications, GSL has strived to bring more attention to the issue of antimicrobial resistance and formulate ways to assess and address it. For instance, Steven J Hoffman (GSL Director) and Julia Belluz (GSL Journalism Fellow) released an article in 2015  called “There's a superbug outbreak in California. But it's really a global problem,” as part of their Vox column series “Burden of Proof”. In June 2015, GSL Director co-edited and published a series of 11 journal articles on international legal approaches to antimicrobial resistance in the Journal of Law, Medicine & Ethics. Five of these articles plus the introduction was co-authored by the director and several of the GSL colleagues.  Additionally, the GSL international team is continuing its work in this area, particularly as part of the Consortium on Strengthening International Collaboration for Capitalizing on Cost-Effective and Life-Saving Commodities (i4C) project, under the 8th subsection, Antimicrobials.

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International Law & Treaties

A popular proposal for addressing many global health issues has been to implement new treaties. This concept is supported in areas ranging from chronic diseases to nutrition, research and development, and overall holistic global healthcare. With so many calls for treaties, it is imperative that a closer look is taken at their overall potential effectiveness and value for the future.

GSL has released many journal articles discussing this issue. In 2012, Steven J Hoffman (GSL Director) and John-Arne Røttingen (GSL Senior Fellow) published an article titled “Assessing implementation mechanisms for an international agreement on research and development for health products” in the WHO Bulletin, to discuss the effectiveness of utilizing agreements to address specific global health issues. Similarly, in 2015, the American Journal of Public Health released the article “Assessing the Expected Impact of Global Health Treaties: Evidence from 90 Quantitative Evaluations” co-authored by Hoffman and Røttingen. The GSL team is making further progress in addressing this issue through the Consortium on Strengthening International Collaboration for Capitalizing on Cost-Effective and Life-Saving Commodities (i4C) project, under the 5th subsection, Treaties. Two studies include the Impact Evaluation of the WHO Framework Convention on Tobacco Control and a systematic review on the impact of international law on health and its social determinants.

Systematic Analysis of Global, Regional and National Trends in Tobacco Consumption (1985-2013) and Impact Evaluation of the WHO Framework Convention on Tobacco Control

Researchers: Steven J. Hoffman (PI), G. Emmanuel Guindon and Julio Frenk

Description: Responsible for approximately six million deaths and nearly $500 billion worth of economic damage each year, the global tobacco epidemic is the leading preventable cause of death worldwide. Although many efforts have been made to support global tobacco control, relatively little information is easily available about the nature of the epidemic at a global scale, with most existing databases limited to a small number of countries and years. This lack of readily-available data has impeded efforts to understand the tobacco epidemic and evaluate tobacco control interventions’ effects. Many interventions have been shown to be efficacious at a national level, but their global effectiveness has largely been presumed. This project will address these gaps by: 1) systematically reviewing and analyzing global tobacco consumption data available from 1985- 2013; 2) developing a publicly available database of these data; 3) analyzing global trends in tobacco consumption across region, income-economy and other stratifying factors; 4) evaluating the conditional effects of the 2003 international tobacco control treaty (FCTC) on state policy and tobacco consumption with a robust quasi-experimental design; 5) estimating the impact of the FCTC on smoking-related deaths; and 6) assessing the cost-effectiveness of the FCTC as measured in per years of life saved. This project will contribute to a better understanding of the tobacco epidemic on multiple fronts and better equip policymakers with the knowledge they need to create more effective evidence-informed policies, supporting tobacco control efforts globally. Start date: April 2014 – Present Funder: Canadian Institutes of Health Research grant of$256,200 CAD

International Law’s Effects on Health and its Social Determinants: Protocol for a Systematic review, meta-analysis, and meta-regression analysis

Researchers: Steven J. Hoffman, Matthew Hughsam, Harkanwal Randhawa, Lathika Sritharan, Gordon Guyatt, John N. Lavis and John-Arne Røttingen

Description: In recent years, there have been numerous calls for global institutions to develop and enforce new international laws. International laws are, however, often blunt instruments with many uncertain benefits, costs, risks of harm, and trade-offs. Thus, they are probably not always appropriate solutions to global health challenges. Given these uncertainties and international law’s potential importance for improving global health, the paucity of synthesized evidence addressing whether international laws achieve their intended effects or whether they are superior in comparison to other approaches is problematic.

Start date: June 2014 – Present

Funder: Research Council of Norway

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Global Health Architecture

There has been a dynamic shift with regards to global health governance and operations. Primarily, global health is no longer limited to the scope of state-level interactions; it also includes the relationships amongst state and non-state actors (such as the private sector and CSOs). Therefore, in light of these emerging organizations and interactions it is important to develop an understanding of each actor’s exact role and degree of involvement in the global health system. In addition, the next challenge is adapting current global health architecture and institutions to suit the requirements of today’s governing system.

Over the past few years GSL has incorporated different projects and utilized a variety of media sources, including journal articles, international reports, and books, to bring light to this matter. For example, Steven J Hoffman (GSL Director) was the Principal Investigator of the project “Learning from SARS and H1N1 to Strengthen Health System Governance, Information Sharing and International Cooperation during Health Emergencies”, with funding from the Canadian Institutes of Health Research grant of $25,000 CAD. This project sought to bring together an interdisciplinary team of researchers, policymakers, and healthcare leaders to study national, regional and global responses to SARS and H1N1 during their first 100 days so as to strengthen health system governance arrangements for future health emergencies. Steven and John-Arne Røttingen (GSL Senior Fellow) also released an article in The Lancet titled “Global health governance after 2015”. In 2014 Steven and John-Arne collaborated again to co-author “Split WHO in two: strengthening political decision-making and securing independent scientific advice” in the Public Health Journal, discussing international institution reform to promote better international health governance and development processes. In addition, Chatham House (Royal Institute of International Affairs) has released two GSL reports related to this issue. First, there is the “Lessons for Global Health from Global Governance”, which examined how global health’s institutional architecture should be matched with its governance needs by drawing lessons from the field of global environmental governance. Second, “Mapping Global Health Architecture for the Future” has found that some functions in the global health system are performed by a greater concentration of actors than others, which may not be the best configuration to match the future challenges that the global health system will face. Finally, GSL has collaborated with other international scholars to release the book “To Save Humanity”: What Matters Most for a Healthy Future”, edited by Steven Hoffman and Julio Frenk (member of International Advisory Board). ----------------- Celebrities Celebrities have a strong influence on both health and health-seeking behavior by the general population. Of course, in many instances this influence has been shown to be positive, such as Sir John Elton John’s charity, which has raised hundreds of millions of dollars for AIDS research. However, matters can become quite dangerous when celebrities provide advice that strongly contradicts medical research. This has been shown by instances such as Katy Perry’s publicized support for improper vitamin supplements and Suzanne Sommers’ advertising of her own anti-aging medication without proof of effectiveness. Hence, based on the value the general public places on celebrities’ ‘medical advice’, is important to examine why and how these celebrities have such an influence, how far these influences reach, and what measures can be taken to address this issue. Through many popular news items and journal publications, GSL has been making impactful developments in addressing this matter. First, Steven J Hoffman (GSL Director) and Julia Belluz (GSL Journalism Fellow) have collaborated to co-author articles on their own Vox column, “Burden of Proof”, such as “What all patients can learn from Angelina Jolie” and “Stop Googling your health questions. Use these sites instead”, both published in 2015. Moreover, they also co-authored many articles in 2013 such as “Don’t Believe Medicine’s Wizard of Oz” in The National Post; “Why Celebrities and TV Can be Bad for your Health” in The C2C Journal; “Katie Couric and the Celebrity Medical Syndrome” in The Los Angeles Times; and “Dr.Oz’s Miraculous Medical Advice” in Slate Magazine. Furthermore, Charlie Tan (McMaster Univeristy) and Steven collaborated on two journal articles, “Biological, psychological and social processes that explain celebrities' influence on patients' health-related behaviors” in the Archives of Public Health in 2015 and “Following celebrities' medical advice: meta-narrative analysis” published in the British Medical Journal in 2013. GSL is currently working on a systematic review funded by the Canadian Institutes of Health Research, that explores the impact of celebrities on public health. Celebrities’ Impact on Health-Related Knowledge, Attitudes, Behaviours and Status Outcomes: Protocol for a Systematic Review, Meta-Analysis and Meta-Regression Analysis Researchers: Steven J. Hoffman, Yasmeen Mansoor, Navneet Natt, Lathika Sritharan, Julia Belluz, Timothy Caulfield, Yoni Freedhoff, John Lavis and Arya Sharma Description: Celebrities are highly influential people whose actions and decisions are watched and often emulated by wide audiences. Many celebrities have used their prominent social standing to offer medical advice or endorse health products, a trend that is expected to increase. However, the extent of the impact that celebrities have in shaping the public's health-related attitudes and behaviours is unclear. This systematic review seeks to answer the following questions: 1) Which health-related outcomes are influenced by celebrities?; 2) How large of an impact do celebrities actually have on these health-related outcomes?; and 3) Under what circumstances do celebrities produce either beneficial or harmful impacts? Starting Date: June 2014 - Present Funder: Canadian Institute for Health Research of$100,000 CAD

How Much Do Celebrities Impact Health? A Quasi-Experimental Evaluation Quantifying the Influence of Three Celebrities on Health Knowledge, Information-Seeking and Behaviours in India, UK and US

Researchers: Steven J. Hoffman, Lathika Sritharan and Tanishq Suryavanshi

Description: As the world becomes more globalized, the reach of celebrities is no longer confined within their home country’s borders; celebrities now often have worldwide influence. While some public health messages may only be relatable to viewers of celebrities’ home countries, others may resonate with people elsewhere. Given this enormous potential for celebrities to influence large populations transnationally, it becomes necessary to quantify the depth of this influence. Likewise, it is also important to assess the extent to which celebrities may affect people of different countries and whether this influence is restricted to one type of celebrity or one kind of disease.

Starting Date: September 2014 - Present

Funder: none

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Institutional design

Global Health Institutions play an important role in global health governance. GSL is working on several projects that look at the roles of institutions and is investigating this topic as part of the Consortium on Strengthening International Collaboration for Capitalizing on Cost-Effective and Life-Saving Commodities (i4C) project, particularly the 4th subsection, Institutions.

Optimizing the Institutional Design of Scientific Advisory Committees for Quality, Salience, and Legitimacy

Researchers: Steven J. Hoffman, Trygve Ottersen, Gaelle Groux, Patrick Fafard, Lathika Sritharan, Unni Gopinathan

Description: Scientific panels are often used during decision-making processes because they are meant to represent the overall scientific community’s state of knowledge in a specific issue. Although scientific panels have the potential of bringing scientific evidence to bear on policy choices, thereby facilitating better and more legitimate decisions, knowledge about what makes such panels effective is sparse and scattered. There have been few studies of scientific panels, and even fewer evidence-based or quantitative studies that evaluate the effectiveness of scientific panels. There is no systematic overview of the determinants for effectiveness commonly emphasized in the literature. This issue is of high importance in today’s world where scientific panels are becoming increasingly common.

GSL has been working towards addressing this issue through systematic search efforts on factors that influence the effectiveness of scientific panels. In the future this work will be important in informing the design and assessment of scientific panels across disciplines.

Starting date: Sept 2015 – Present

Funder: Research Council of Norway

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Pandemics

Learning from SARS and H1N1 to Strengthen Health System Governance, Information Sharing and International Cooperation during Health Emergencies.

Canadian Institutes of Health Research grant of \$25,000 CAD to Steven J. Hoffman (PI), Colleen Flood, Julio Frenk, John N. Lavis and Trudo Lemmens from July 2012 to June 2013.

There is so much attention given to preparing for the next pandemic, yet relatively little focus is given to the health system governance arrangements needed to mount an appropriate response. In addition to antiviral medicines and vaccines, effective pandemic responses depend on governments and healthcare facilities to obtain, analyze, share and act upon the latest information and coordinate their actions with domestic and international partners. Effective health system arrangements for making tough decisions, sharing information and cooperating globally are particularly important during the initial days of a pandemic which are characterized by uncertainty, confusion, fear and extremely high-stakes. This planning grant will help bring together an interdisciplinary team of researchers, policymakers and healthcare leaders to study national, regional and global responses to SARS and H1N1 during their first 100 days so as to strengthen health system governance arrangements for future health emergencies. This grant will also allow the team to survey available data and request privately-held documents for study. We hope to include six types of documents: 1) bilateral communications; 2) multilateral communications; 3) government analyses of communications; 4) public announcements; 5) scientific messages; and 6) media reports. In addition to requesting private documents, the diplomatic cables released by WikiLeaks will also be mined for relevant content. These initial data gathering and partnership efforts will be focused on North America, namely Canada, United States, Mexico, Pan-American Health Organization and the World Health Organization. A full grant application is expected to follow.