Allostatic Load in the age of AI

IN A NUTSHELL
Author's note


 …The radical and rapid emergence of AI as a force for shaping business and our lives in general, has gathered momentum in the last few years and created a tsunami of disruption in the world. In the long term, AI may prove to be a positive force for change and improvement, allowing people to save time and effort on those menial, repetitive and boring tasks, which were often the backbone of employment in previous decades. However, this transition to better times seems likely to be very painful, and the upheaval it generates has already impacted countless lives across the world…

By Dr. Brian Johnston

Performance Data Analyst

London, United Kingdom

By the same Author on PEAH: see HERE

Allostatic Load in the age of AI

 

In 1927, Sigmund Freud wrote; “It goes without saying that a civilization which leaves so large a number of its participants unsatisfied and drives them into revolt neither has nor deserves the prospect of a lasting existence.” Almost a century later, our world is a vastly different place, yet his words still resonate and, in many ways, are more relevant today.

We live in a world where human beings appear increasingly out of step with the physical, emotional, and mental demands placed upon them on a daily basis. As a species, we evolved from creatures that adapted over thousands of generations to a hunter-gatherer lifestyle, before adopting agriculture and embracing the “benefits” of civilisation and urbanization. As time progressed, the challenges placed on people changed and humans adapted to their new environments and conditions. Today, however, the rate and magnitude of the changes experienced by human beings is unparalleled in human history, and our ability to cope is being stretched to its limits and beyond.

When faced with such stressful conditions, human beings activate neural, neuroendocrine and neuroendocrine – immune  systems, through a process called allostasis, in which adaptive systems provide a flexible response to stressors, designed to promote resilience and the effective regulation of physiological processes. Occasionally however, these systems become maladaptive or overstimulated, leading to allostatic load (AL), and sometimes to chronic disease over time.

The current picture is dark. Life expectancies have increased in recent decades in many countries, but the quality of life for billions of people remains low, despite monumental leaps in science and technology. Major advances have been made in healthcare, as well as our understanding of disease and epidemiology, yet major killers like cancer and cardiovascular disease stubbornly persist. Obesity is on the rise in many countries, and pandemics retain the power to bring our societies to their knees.

Evidently, we still have much to learn, but in a curious way our increased knowledge engenders an arrogance which makes us blind to this fact and instead gives us an unrealistic (and perhaps overly optimistic) belief in our ability to control our destinies and the world around us. Greater knowledge does not always lead to greater wisdom.

In a world where social media is omnipresent, expansive, and intrusive, loneliness and social isolation are now on the increase. We have more channels to communicate with each other, but seemingly few opportunities to engage in real human contact. Quality of interaction is frequently overwhelmed by quantity, and deep and meaningful communication replaced by superficial and inane content. Undoubtedly this paradox of being lonely in a crowded, noisy room can have detrimental effects on our mental health.

Running parallel to this cacophony of content is a perfect storm of environmental and social stressors. We live in an increasingly uncertain world, where change, not necessarily for the good, is driven by AI. People are insecure in their jobs, poverty and economic hardship are pervasive and deep rooted, whilst war, famine and displacement of people, are constantly in the news. All this plays out against a wider background of impending climate catastrophe and political ineffectiveness.

The radical and rapid emergence of AI as a force for shaping business and our lives in general, has gathered momentum in the last few years and created a tsunami of disruption in the world. In the long term, AI may prove to be a positive force for change and improvement, allowing people to save time and effort on those menial, repetitive and boring tasks, which were often the backbone of employment in previous decades. However, this transition to better times seems likely to be very painful, and the upheaval it generates has already impacted countless lives across the world.

In the world of work, AI has quickly and radically redefined the skills necessary to succeed in many areas of employment. Highly trained professionals have found that what they do is increasingly being replaced or automated through implementation of AI. The threat of job insecurity and redundancy looms large in many workplaces, where management have adopted AI solutions with little thought of the human cost of such “efficiencies.” Add to this the development of working environments characterised by low control, ever-increasing demands, an imbalance between effort and reward, and the structural uncertainties surrounding a gig economy, and we have a potent blend of psychosocial stressors, likely to increase allostatic load (AL). Such employment conditions may have long term implications for many millions of people. Indeed, as a recent study shows, chronic stress during working life is linked to poor health, whilst patchy careers and cumulative disadvantage over long periods, is associated with AL, due to physiological processes from chronic stress reactions.

From a different perspective, since the mid-20th century the frequency of natural and climate-related environmental disasters has increased substantially. This has caused devastating human and economic costs, and whether due to floods, wildfires, major storms, or climate change, they all lead to elevated levels of stress, negatively impact mental and physical health, and damage the well-being of entire communities. Naturally, disasters also tend to increase allostatic load, since stress is an almost universal response to traumatic events. Since deprived communities tend to experience higher levels of chronic stress, effective measurements of allostatic load could be added to the arsenal of tools used to fight health inequalities, by helping to identify individuals more likely to be adversely affected by stress. In this way, assessments of allostatic load could theoretically be used to effectively target interventions aimed at reducing stress, improving health outcomes, and reducing inequalities. More research is however needed to improve the effectiveness and standardization of metrics for AL.

At a societal level, government policies that improve housing, make working life less unstable, provide adequate safety nets during periods of unemployment, and reduce deprivation, will help reduce the upstream causes of chronic stress, and thereby tend to reduce AL. Similarly, effective public health messaging about healthy use of AI, as well as legislation aimed at promoting the “socially responsible” and “human friendly” adoption and integration of new technology, may go a long way to reducing stress in modern life. In this way, change can be more effectively managed, advances in AI can complement and enhance the world of work, human fallout can be lowered, and the toxic effects of allostatic load can be reduced.

Related to this, at the level of the individual, workplace stress management, stress reduction programmes (involving mindfulness, cognitive behaviour therapy  etc.), sleep therapy, relaxation and related interventions, could be used to address rising levels of AL. In addition, advances in digital technologies, such as wearable devices and smartphone apps, may provide a way for AI to mitigate some of its negative effects by deepening our understanding of the relationships between stress, AL and the development of chronic illness.

AI is here to stay and its potential for good is enormous, if it can be harnessed as a complement to human endeavour, rather than a challenge to people’s health and potent source of allostatic load. We have a golden opportunity to enhance humanity and manage the change created by this new technological revolution if we can adopt the right mindset and take effective action now.

 

 

 

 

 

 

 

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Inequity in Antenatal Care Quality in Low- and Middle-Income Countries

IN A NUTSHELL
Author's note
Antenatal care (ANC) is a foundation of maternal and new-born health, offering an opportunity to prevent, detect, and manage complications during pregnancy. Despite global progress toward Universal Health Coverage (UHC), inequities in ANC access and quality persist across low- and middle-income countries (LMICs).

 This paper examines the contributory factors to inequity in ANC quality using evidence from recent multi-country analyses and systematic reviews. Findings reveal that disparities are driven by interrelated demand-side, supply-side, and enabling factors, including education, socioeconomic status, health system capacity, and affordability barriers. Although ANC coverage has improved globally, quality remains uneven and inequitable.

 Addressing these inequities requires policy reforms emphasizing system readiness, financial protection, and equity-sensitive monitoring mechanisms. The paper highlights the need to reframe ANC as both a maternal health intervention and a measure of social justice and health system resilience

By Dr. Hadiza Magaji Mahmoud, MBBS

Masters in Reproductive Health, MSc Public Health (LSHTM), AMRSPH

Inequity in Antenatal Care Quality in Low- and Middle-Income Countries

 

Introduction

Antenatal care (ANC) serves as a fundamental public health strategy for improving maternal and neonatal outcomes. Through regular monitoring, health education, and timely interventions, ANC reduces the risk of complications, stillbirths, and maternal mortality. However, across low- and middle-income countries (LMICs), inequities persist not only in access but in the quality of care provided. Global attention has largely focused on expanding service coverage, yet this approach often overlooks disparities in the content, timeliness, and effectiveness of ANC (The Lancet Global Health, 2018).

Equity in ANC represents more than equal access; it reflects fairness in opportunity, resources, and outcomes. Despite widespread adoption of the WHO’s recommendation for eight ANC contacts, many LMICs continue to fall short in achieving equitable, high-quality services (WHO, 2016).

This paper synthesizes emerging evidence on the determinants of ANC inequity, with particular attention to demand, supply, and enabling factors influencing maternal health outcomes.

Methodological Approach

This paper synthesizes findings from peer-reviewed articles, global reports, and household surveys published between 2018 and 2025. Emphasis was placed on large-scale analyses such as Demographic and Health Surveys (DHS), Multiple Indicator Cluster Surveys (MICS), and WHO Global Health Observatory datasets. Critical appraisal focused on how different social, economic, and systemic determinants interact to produce inequities in ANC quality.

Results and Discussion

1. Understanding Inequity Beyond Coverage

While ANC coverage has improved globally, quality gaps remain substantial. The WHO (2025) reports that between 45% and 90% of women in LMICs receive at least four ANC visits (ANC4+). However, only 18.1% achieve the recommended eight or more visits (Tegegne et al., 2024). This “coverage–quality gap” highlights a systemic challenge: presence at a facility does not guarantee adequate care.

A multi-country analysis by Jiwani et al. (2025) revealed readiness-adjusted ANC1+ coverage ranging from 64.0% in Haiti to 76.2% in Nepal, exposing significant variations in service preparedness. Similarly, a systematic review by Tamir et al. (2025) reported that non-utilization of ANC services averaged 10.6% but reached 40% in some LMICs, particularly where services were under-resourced or geographically inaccessible. These findings collectively indicate that inequity is rooted not only in access barriers but in system-level deficiencies.

  1. Demand-Side Determinants

Maternal education, age, employment status, and health literacy play significant roles in ANC utilization. Educated women are more likely to recognize the value of preventive care, seek early ANC, and demand higher-quality services. The disparity is evident when comparing Belarus where ANC quality indicators are high to Chad, where service uptake is low, largely due to differences in educational attainment and national GDP per capita (The Lancet Global Health, 2018). Poor health literacy and sociocultural norms often compound inequities by discouraging early engagement with formal care systems.

  1. Supply-Side Determinants

Health system capacity comprising infrastructure, human resources, and equipment forms the backbone of ANC quality. In many LMICs, particularly in rural or poor settings, care delivery is hindered by a shortage of trained providers, weak facility readiness, and inadequate diagnostic capacity. Countries such as Belarus and Kazakhstan, which maintain strong primary health systems, demonstrate narrow ANC inequalities. In contrast, South Sudan and Nigeria exhibit both low coverage and high inequality (DHS/MICS data), underscoring the link between system weakness and maternal health inequity.

  1. Enabling Factors and Structural Barriers

Financial protection mechanisms, such as health insurance and user fee exemptions, are critical enablers of equitable ANC. In settings without such measures, affordability remains a major barrier, particularly for women in informal employment or subsistence economies. Health insurance coverage has shown promise in mitigating inequities, promoting early attendance, and improving continuity of care (Okedo-Alex et al., 2019). Conversely, lack of coverage perpetuates cycles of underutilization and poor maternal outcomes.

Policy Implications

Tackling ANC inequity requires integrated policy approaches grounded in principles of Universal Health Coverage (UHC) and social protection. Governments and partners should prioritize the following actions:

  1. Equity-sensitive monitoring: Integrate disaggregated equity indicators (by wealth, geography, and education) into national maternal health surveillance systems.
  2. Investment in system readiness: Strengthen infrastructure, training, and logistics to ensure every contact delivers the full complement of evidence-based interventions.
  3. Financial protection mechanisms: Expand insurance coverage and remove user fees for essential maternal health services.
  4. Community engagement: Promote demand generation through education, women’s empowerment, and culturally responsive health promotion.
  5. Policy learning from success stories: Countries like Rwanda and Sri Lanka demonstrate that political commitment and equitable financing can significantly narrow ANC gaps.

These strategies must be supported by political will and accountability frameworks that promote equity from ambition to a measurable health system goal.

Conclusion

Inequities in antenatal care reflect deeper systemic injustices within health systems. The persistent gap between coverage and quality illustrates that the promise of universal maternal health remains unfulfilled for many women in LMICs. Addressing these inequities requires reframing ANC as both a clinical and social justice necessity. Governments must strengthen health systems to deliver equitable, high-quality, and respectful care ensuring that every pregnancy is supported by a system capable of protecting both mother and child. 

 

References

The Lancet Global Health. (2018). Equity in antenatal care quality: An analysis of 91 national household surveys. The Lancet Global Health, 6(11), e1186–e1195. https://doi.org/10.1016/S2214-109X(18)30389-9

World Health Organization. (2016). WHO recommendations on antenatal care for a positive pregnancy experience. World Health Organization. https://www.who.int/publications/i/item/9789241549912

World Health Organization. (2025). Antenatal care coverage – at least four visits (ANC4+). WHO Global Health Observatory. https://www.who.int/data/gho/indicator-metadata-registry/imr-details/80

Tegegne BA, Alem AZ, Amare T, Aragaw FM, Teklu RE. Multilevel modelling of factors associated with eight or more antenatal care contacts in low and middle-income countries: findings from national representative data. Ann Med Surg (Lond). 2024 Apr 16;86(6):3315-3324. https://pubmed.ncbi.nlm.nih.gov/38846896/#:~:text=6)%3A3315%2D3324.-,doi%3A%2010.1097/MS9.0000000000002034,-.  PMID: 38846896; PMCID: PMC11152864.

Jiwani SS, Rana S, Hazel EA, Maïga A, Wilson EB, Amouzou A. Building an effective coverage cascade for antenatal care: linking of household survey and health facility assessment data in eight low- and middle-income countries. J Glob Health. 2025; 15:04048 https://jogh.org/2025/jogh-15-04048/#:~:text=DOI%3A%2010.7189/jogh.15.04048

Tamir TT, Gebrehana DA, Zegeye AF, Terefe B, Tekeba B. Magnitude, distribution and determinants of non-utilization of antenatal care services among women in low- and middle-income countries: Insights for implementation of WHO recommendations. PLoS One. 2025 Aug 18;20(8):e0330596. https://pubmed.ncbi.nlm.nih.gov/40824956/#:~:text=18%3B20(8)%3Ae0330596.-,doi%3A%2010.1371/journal.pone.0330596,-.  PMID: 40824956; PMCID: PMC12360577.

Okedo-Alex, I. N., Akamike, I. C., & Ezeanosike, O. B. (2019). Determinants of antenatal care utilization in sub-Saharan Africa: A systematic review. BMJ Open, 9(10), e031890. https://doi.org/10.1136/bmjopen-2019-031890

 

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The Role of Traditional Birth Attendants in Improving Maternal Health Outcomes in LMICs

IN A NUTSHELL
Author's note
…The work of Zinure Women’s Health Foundation in Nigeria prioritizes bridging the gap between traditional and modern healthcare systems by promoting capacity-building training for traditional birth attendants (TBAs) and community health workers, fostering partnerships with local health facilities, and promoting community awareness on safe pregnancy and postpartum care. By empowering TBAs with the knowledge, tools, and networks they need, we not only honor their cultural significance but also ensure that no woman is left behind when it matters most…

By Yvonne Akukwe

Maternal Health Advocate

Co-Founder & CEO, Zinure Women’s Health Foundation

Washington, Columbia District, USA

The Role of Traditional Birth Attendants in Improving Maternal Health Outcomes in LMICs

 

According to the World Health Organization, approximately 92% of all maternal mortalities in 2023 occurred in low- and middle-income countries. Furthermore, Sub-Saharan Africa alone accounted for about 70% of these global maternal deaths. Most maternal mortalities are preventable and are primarily due to a lack of adequate emergency obstetric care and skilled healthcare providers.

Obstetric emergencies such as postpartum hemorrhage, sepsis, unsafe abortions, and eclampsia can be properly managed in health facilities with skilled birth attendants; however, in rural and underserved areas, traditional birth attendants (TBAs) are the first, and oftentimes, only source of care for women during pregnancy, childbirth, and postpartum.

Traditional birth attendants, sometimes referred to as traditional midwives, are well-respected and trusted community-based birth workers that assist mothers during pregnancy, deliver babies, and support postpartum care. Their skills are not acquired through formal medical school training but instead through informal apprenticeships, learning from other TBAs, or experience gained as a caregiver. For many women in low-resource settings who may not have access to or can’t afford formal health systems for care, the ability of TBAs to recognize complications early and refer women to health facilities can make the difference between life and death.

Linking Tradition & Evidence-Based Practices

When engaged effectively, TBAs can play a crucial role in improving maternal health outcomes. By providing TBAs with evidence-based training on safe delivery practices and emergency management – especially in managing postpartum hemorrhage, sepsis, and eclampsia – they can become valuable resources. Training modules that emphasize early warning signs and complications, safe delivery and good hygiene practices, respectful maternity care, and clear referral protocols can empower them to provide safer care.

Equally as important is integrating maternal mental health support into these trainings. In addition to the physical care provided, TBAs also have emotional access to women during the perinatal period, yet many lack the skills to recognize the signs of perinatal mood and anxiety disorders (PMADs).

Educating them on basic psychosocial support strategies ensures that mothers receive holistic care that addresses both their physical and emotional wellbeing.

The Power of a Strong Referral Network

Historically, TBAs have operated independently, disconnected from formal health networks. In times of obstetric emergencies, weak referral systems and the inability to access health facilities in a timely manner often result in adverse maternal health outcomes. Creating structured communication channels, such as WhatsApp-based networks or referral cards, can ensure women experiencing complications are sent to facilities well-equipped to manage emergencies. By leveraging their influence within the community, TBAs can encourage women to seek specialized care at health facilities once a potential obstetric complication is identified, therefore decreasing the likelihood of emergency situations and subsequently mortality. A strong referral system not only strengthens collaboration but also helps foster mutual respect between community-based and health facility-based providers.

Zinure Women’s Health Foundation’s Vision

 At Zinure Women’s Health Foundation, we believe that every woman—regardless of her socioeconomic status or geographic location—deserves a safe, healthy, and fulfilling motherhood journey. Achieving this vision requires uniting key community stakeholders around a shared mission: improving maternal health outcomes through education, empowerment, and partnership.

Currently, our work in Nigeria prioritizes bridging the gap between traditional and modern healthcare systems by promoting capacity-building training for TBAs and community health workers, fostering partnerships with local health facilities, and promoting community awareness on safe pregnancy and postpartum care. By empowering TBAs with the knowledge, tools, and networks they need, we not only honor their cultural significance but also ensure that no woman is left behind when it matters most.

Sources

  • World Health (2025, April 7). Maternal Mortality. WHO Website. https://www.who.int/news-room/fact-sheets/detail/maternal-mortality.
  • Rutledge J.D., Kiyanda A., Jean-Louis C., Raskin E., Gaillard, J., Maxwell, M., et al. Recommendations for Integrating Traditional Birth Attendants to Improve Maternal Health Outcomes in Low- and Middle-Income International Journal MCH AIDS. 2024; 12:e019. Doi: 10.25259/IJMA_16_2024. 

 

Biography

Yvonne Akukwe, MPH, PMP is a public health practitioner with almost a decade of experience leading the development and implementation of health projects across corporate, government, and non-profit entities. She studied Biology at George Mason University and obtained a Master of Public Health degree at The George Washington University. Throughout her career, she has successfully led global multi-disciplinary teams to develop strategic, locally driven solutions that drive scalable impact. She is the Co-Founder & CEO of Zinure Women’s Health Foundation, a nonprofit organization determined to improve maternal health outcomes through advocacy, education, and community engagement.

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Knowledge and Utilisation of Malaria Prevention Strategy among Pregnant Women in Some Selected Primary Health Centres in Maiduguri, Borno State, Nigeria

IN A NUTSHELL
Authors' Note
This study examined the knowledge and utilisation of Malaria prevention strategies by pregnant women attending some selected primary health centres (PHCs) in Borno State, Nigeria.

It concludes that, although pregnant women are aware of malaria prevention methods, there is a gap in their effective utilisation. To address this, targeted health education, intersectoral collaboration and supportive monitoring at PHC and community levels are recommended

 

PEAH is pleased to share an original article first published in Nigerian Postgraduate Medical Journal, 32(4):p 290-296, Oct–Dec 2025 

Knowledge and Utilisation of Malaria Prevention Strategy among Pregnant Women in Some Selected Primary Health Centres in Maiduguri, Borno State, Nigeria

 

Quotation

Samuel, Gabriel; Abdullahi, Mohammed Ibn1; Danladi, Samuel Sam2; Jonah, Japhet Haruna3; Tweneboah, Emmanuel4; Musa, Ahmed5. Knowledge and Utilisation of Malaria Prevention Strategy among Pregnant Women in Some Selected Primary Health Centres in Maiduguri, Borno State, Nigeria. Nigerian Postgraduate Medical Journal 32(4):p 290-296, Oct–Dec 2025. | DOI: 10.4103/npmj.npmj_152_25

Full Text HERE 

 

ABSTRACT

Background

Malaria remains a significant global health threat, with Africa bearing the highest burden. Pregnant women in Nigeria are particularly vulnerable due to the country’s high malaria prevalence.

Objectives

The study examined the knowledge and utilisation of Malaria prevention strategies by pregnant women attending some selected primary health centres (PHCs) in Borno State, Nigeria.

Subjects and Methods 

The study was conducted using a cross-sectional descriptive survey in two local government areas: Maiduguri Metropolitan Council and Jere, in Maiduguri, Borno state, Nigeria. Furthermore, Fisher’s formula determined the sample size, and data were collected from 407 pregnant women using a questionnaire recruited through a multistage Sampling. Finally, IBM SPSS version 27 statistical software was used for data analysis.

Results

The mean age ± standard deviation of 26 ± 4.08, and most (80.8%) of pregnant women have good knowledge of malaria prevention. The utilisation of malaria prevention strategies was low, with 79.1% showing an overall poor usage. 60.9% reported using long-lasting insecticide-treated nets, 20.6% had never used larval source management. 54.8% of the respondents were in their second trimester. Knowledge of malaria prevention was associated with the trimester of pregnancy (P = 0.0044), gravidity (P = 0.019) and education (P = 0.001). However, no relationship was found between maternal religion and knowledge of malaria prevention (P = 1.000).

Conclusions

Although pregnant women are aware of malaria prevention methods, there is a gap in their effective utilisation. To address this, targeted health education, intersectoral collaboration and supportive monitoring at PHC and community levels are recommended

 

Knowledge, Attitudes, and Practices of AI-Assisted Diagnostics Among Students of Master of Public Health in Ahmadu Bello University, Zaria, Nigeria

IN A NUTSHELL
Authors' Note 
Integrating artificial intelligence (AI) into healthcare has transformed disease diagnostics, offering opportunities to enhance accuracy, efficiency, and accessibility. However, adopting AI-assisted diagnostics depends significantly on future public health professionals' knowledge, attitudes, and practices (KAP). 

This study assessed the KAP of students of Master of Public Health (MPH) at Ahmadu Bello University (ABU), Nigeria, regarding AI-assisted diagnostics in healthcare, including the gaps in the current MPH curriculum concerning AI literacy 

 

PEAH is pleased to share an original article first published in The Nigerian Health Journal25(3), 1268 – 1275

Knowledge, Attitudes, and Practices of AI-Assisted Diagnostics Among Students of Master of Public Health in Ahmadu Bello University, Zaria, Nigeria

 

Quotation

Samuel, D., Jonah, J., Samuel, G., Amos, I., Eche, R. ., Makinta, A., & Musa, H. (2025). Knowledge, Attitudes, and Practices of AI-Assisted Diagnostics Among Students of Master of Public Health in Ahmadu Bello University, Zaria, Nigeria. The Nigerian Health Journal25(3), 1268 – 1275. https://doi.org/10.71637/tnhj.v25i3.1187

PDF HERE 

Abstract

Background: Integrating artificial intelligence (AI) into healthcare has transformed disease diagnostics, offering opportunities to enhance accuracy, efficiency, and accessibility. However, adopting AI-assisted diagnostics depends significantly on future public health professionals’ knowledge, attitudes, and practices (KAP). This study assessed the KAP of students of Master of Public Health (MPH) at Ahmadu Bello University (ABU), Nigeria, regarding AI-assisted diagnostics in healthcare, including the gaps in the current MPH curriculum concerning AI literacy.

Methods: The study adopted a quantitative cross-sectional descriptive survey design. Data from 205 ABU MPH students recruited via simple random sampling were collected using researcher-constructed 16-item questionnaires, organized into four sections, and sent via email on Google Form. KAP were measured on 3-point Likert scale. The collected data were analyzed in descriptive statistics using SPSS version 28.

Results: The response rate was 99%. The findings revealed moderate levels of knowledge about AI tools (73.3%), positive attitudes toward their use (73.8%), but limited practical experience and dissatisfaction (29.5%) with the current level of AI training in the MPH curriculum. Students supported incorporating AI-related courses and experiential learning opportunities into MPH program (72.5%).

Conclusion: These results highlight the need for targeted interventions to enhance AI literacy among MPH students and prepare them for the ethical and practical integration of AI technologies in healthcare. The study contributes to the discourse on modernizing public health education and provides actionable recommendations for policymakers, educators, and healthcare institutions. Future research should explore longitudinal trends and cross-cultural perspectives to inform AI adoption strategies in public health practice.

 

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News Flash Links, as part of the research project PEAH (Policies for Equitable Access to Health), aim to focus on the latest challenges by trade and governments rules to equitable access to health in resource-limited settings

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Rethinking Global Health Metrics Beyond the Frontier: A Response to the GBD 2023 Mortality Report

IN A NUTSHELL
Editor's Note 
This article puts under a critical lens some findings from the Global Burden of Disease 2023 report, whereby the uncertain attribution of COVID-19 deaths, YLLs and the problem of the “frontier” reference, and the arbitrary 70-year threshold are pointed out

By Juan Garay

Founder and Co-chair of SHEM. Professor of Global health. Lead of the Valyter ecovillage.  Valyter.es  

Rethinking Global Health Metrics Beyond the Frontier

A Response to the GBD 2023 Mortality Report

 

The Global Burden of Disease 2023 report represents an extraordinary global effort to compile, harmonize, and analyse mortality data across countries and decades. Its contribution to understanding health progress is invaluable. Yet, the report’s findings—especially those concerning deaths attributed to COVID-19, the use of Years of Life Lost (YLL) relative to the lowest observed mortality rates, and the reliance on the 70-year threshold for “preventable deaths”—require careful reconsideration.

Uncertain attribution of COVID-19 deaths

The report notes that COVID-19 ranked as the world’s leading cause of death in 2021 before falling to 20th place by 2023. However, these rankings are constrained by major uncertainties in data quality and attribution. During the pandemic, testing capacity, diagnostic coding, and death certification varied widely across countries. Official counts therefore reflect not only viral lethality but also the reach and reliability of national surveillance systems.

Equally important, many deaths during 2020–2022 arose indirectly from health-system disruption, economic hardship, and delayed care for chronic conditions. WHO estimated approximately 14.8 million excess deaths in 2020–2021, nearly three times the number of officially reported COVID deaths, underscoring the magnitude of indirect losses. Analyses based solely on cause-coded deaths should therefore be complemented by age-standardised excess mortality and indicators of service disruption to capture the full human cost of the pandemic, including the effects of political and economic responses.

YLLs and the problem of the “frontier” reference

The GBD’s YLL metric measures losses against a “frontier” life table derived from the lowest age-specific mortality rates observed globally. This facilitates comparability but assumes that the best-performing populations define a universal goal. In reality, those frontier rates are sustained in contexts that depend on ecological and economic conditions not feasible or sustainable worldwide.

According to the WHO Constitution, global health policy should aim for “the attainment by all peoples of the highest attainable standard of health.” This implies striving toward best feasible and sustainable levels of health for all, not replicating conditions achievable only through intensive consumption or unequal distribution of resources. Measuring losses relative to realistic and sustainable reference standards transforms YLLs from abstract deficits into ethically grounded indicators of inequity.

The arbitrary 70-year threshold

The probability of dying before age 70 (70q0) remains a core GBD indicator of “premature” mortality. While operationally convenient, this threshold is arbitrary and increasingly obsolete. The best feasible and sustainable life expectancy today is estimated around 77.5 years, not 70. Limiting the definition of preventable deaths to those occurring before 70 therefore underestimates the true scope of avoidable mortality and conceals inequalities emerging in later adulthood.

A more consistent approach is to define preventable deaths as those exceeding feasible and sustainable age-specific mortality rates. This aligns with WHO’s constitutional goal and allows for continuous measurement of progress across the life course.

Measuring equity: the Relative Burden of Health Inequity

A complementary indicator—the Relative Burden of Health Inequity (RBHiE)—expresses the proportion of all deaths exceeding feasible and sustainable mortality references. This measure provides a clear and comparable assessment of how far populations remain from the attainable benchmark of health equity. Unlike 70q0 or frontier-based YLLs, RBHiE directly reflects progress toward the WHO objective of the best feasible level of health for all.

Toward a fairer global health measurement paradigm

The GBD’s technical sophistication and transparency are commendable, but its next phase should integrate excess-mortality data, feasible and sustainable reference standards, and equity-based indicators such as RBHiE. Only then can the global health community move from describing disease burdens to assessing humanity’s collective distance from a just and sustainable standard of health.

 

References

WHO Constitution (1946). Preamble: the attainment by all peoples of the highest attainable standard of health

WHO (2022). Global excess deaths associated with COVID-19 (2020–2021)

GBD 2023 Mortality and Causes of Death Collaborators. Lancet (2025)

Sustainable Health Equity Movement (SHEM). Atlas of Global Health Inequity: Toward Feasible and Sustainable Reference Standards (2024)

 

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By the same Author on PEAH: see HERE