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When it comes to public health, lives are often saved, or dramatically improved, by things that cost the least. Simple undertakings—such as washing hands, using a seatbelt or donning a bike helmet—carry little cost to the individual. But collectively such interventions can make a huge difference in global health. We've consulted experts from around the Bloomberg School to come up with 10 of the least expensive ways to save millions of lives around the world. Take a look.

Quit smoking.

$0 It costs nothing to quit cold turkey; interventions like the patch cost about the same as cigarettes

Tobacco is the second major cause of death in the world—killing one in 10 adults worldwide, or about 5 million people each year. The 2004 U.S. Surgeon General's Report concluded that cigarette smoking causes diseases in nearly every organ of the body. "If you think about smoking cessation, there are few interventions that can save so many lives and so cheaply," says Jonathan Samet, senior scientific editor of the 2004 report. The good news is that it's never too late to stop. Within hours after a smoker inhales that last cigarette, health begins to improve.

Increase vitamin A supplementation.

$0.04 per dose

In 1985, ophthalmologist and epidemiologist Alfred Sommer discovered that a capsule of high-potency vitamin A given to children in Indonesia twice a year reduced the number of child deaths by 34 percent. (The micronutrient made them less vulnerable to measles, malaria, diarrhea and dysentery.) Today, the WHO, UNICEF and their partners provide more than 400 million supplements a year for children in developing countries. That translates to hundreds of thousands of kids saved every year. But it's estimated that only one-quarter to one-third of children who need vitamin A supplements receive them.

Expand oral rehydration therapy.

$0.10 per one-liter packet

Originally developed to treat cholera, oral rehydration therapy (ORT) is effective in treating dehydration due to diarrhea from any cause. ORT is also remarkably simple: Mix one packet of a powder containing glucose and electrolytes in water, and give it to people with diarrhea until they get better. Since 1980 when WHO and UNICEF introduced ORT in the developing world, the number of deaths due to diarrhea in children has dropped from 5 million to 2 million per year. The challenge today: to see that ORT is more widely used in developing countries to reduce mortality further, and in developed countries that favor IV treatments to reduce health care costs, says R. Bradley Sack.

Build pit latrines in developing countries.

$50 per latrine, depending on materials

In areas that don't have flush toilets, ventilated pit latrines can tremendously reduce the environmental contamination by parasites such as roundworms and tapeworms and by a whole range of bacteria and viruses, says tropical disease expert Clive Shiff. Though people don't often talk about them, pit latrines hold the potential for preventing most intestinal diseases, which frequently can be deadly in the developing world.

Use bed nets treated with insecticide.

$4.80 per bed net

Malaria is transmitted to humans by the female Anopheles mosquito, which bites almost exclusively at night. Bed nets have been shown to control the spread of the disease in endemic regions. And yet they are underused. Says Clive Shiff: "At least 70 percent of people in the village need to use the net; then you see a major reduction in the transmission of malaria." The nets need to be treated with insecticide to effectively kill mosquitoes and serve as a barrier. Treated or untreated, at just several dollars each, they're a bargain.

Treat premature newborns with antiseptic baby wipes or sunflower oil.

$0.30 per treated baby wipe; Sunflower oil: $0.20 per treatment

Preterm babies with a low birthweight are often born with skin that isn't well formed, making them subject to potentially fatal infections, a major cause of neonatal mortality in developing countries. Special kinds of emollients can enhance the function of the skin barrier and reduce the incidence of life-threatening infections. Sunflower oil applied to babies' skin a couple of times a day for a few weeks resulted in a 40 to 55 percent reduction in sepsis, according to research in Egypt and Bangladesh, says neonatal health specialist Gary Darmstadt. And epidemiologist James Tielsch has found that using baby wipes (treated with a quarter percent of diluted antiseptic solution) a few hours after delivery reduced neonatal mortality 28 percent for low-birthweight babies.

Use home-based water purification systems.

$0.04 per sachet

More than 1 billion people in the world don't have access to safe water. The encouraging news: Simple household water treatment can stop the spread of deadly waterborne diseases such as cholera. Water expert Kellogg Schwab points to PUR packets from Procter and Gamble, which are very effective in purifying drinking water in developing countries. The ketchup-sized sachets contain some of the same components (chlorine and flocculent) used to treat water in the U.S. Users merely mix a packet into a bucket containing 10 liters (2.5 gallons) of water. The chlorine kills pathogens, the flocculent causes dirt and contaminants to settle out, and the decontaminated water is then filtered through a cloth before consumption.

Increase condom availability.

$1 or less per condom

Treatment for HIV/AIDS today is much more effective than it was 20 years ago, but it doesn't actually cure the disease, and we don't have a vaccine. That's why the best way to stop the disease remains prevention. Behavior change and condom use can check the global pandemic, says AIDS researcher Chris Beyrer. In Thailand, a free condom campaign reduced the HIV rate in military recruits from 10.4 percent in 1991 to 2 percent a decade later. Unfortunately, shortages of condoms exist in some developing countries that need them the most, and donor countries need to continue to subsidize their cost.

Vaccinate poor children against measles.

$0.13 per dose

The measles vaccine is safe, inexpensive and almost 100 percent effective. Yet in many developing countries, only three out of four young children are immunized. (In some of the poorest countries, less than half are.) The kids who don't get immunized also tend to come from the poorest families, and it's the poorest children who are largely at risk of dying from measles, says reproductive health researcher Michael Koenig. As a result, 500,000 to 700,000 children die annually from this preventable disease, and many others suffer lifelong disabilities, including blindness, deafness and brain damage.

Breastfeed.

$0

Breastfeeding is a vital source of nutrition for infants everywhere. In the developing world, the practice can be a matter of life or death. Feeding babies only breast milk for the first six months protects children from infection, especially diarrhea, says nutrition expert Keith West. According to UNICEF, exclusive breastfeeding until six months of age could save the lives of 1.5 million infants every year, and the health and development of millions more would be greatly improved.

SOURCES:

Chris Beyrer, MD, MPH '90, associate professor of Epidemiology, and director, Johns Hopkins Fogarty AIDS International Training and Research Program; Gary Darmstadt, MD, associate professor of International Health; Michael A. Koenig, PhD, MA, associate professor of Population and Family Health Sciences; R. Bradley Sack, MD, ScD, professor of International Health; Jonathan Samet, MD, MS, chair of Epidemiology, and The Jacob I and Irene B. Fabrikant Professor in Health, Risk, and Society; Kellogg Schwab, PhD, MS, assistant professor of Environmental Health Sciences; Clive Shiff, PhD, associate professor of Molecular Microbiology and Immunology; Alfred Sommer, MD, MHS '73, professor of Epidemiology, International Health and Ophthalmology, and former dean, Johns Hopkins Bloomberg School of Public Health; James Tielsch, PhD '82, MHS '79, professor of International Health; and Keith P. West Jr., DrPH '87, MPH '79, The George G. Graham Professor in Infant and Child Nutrition.

Note: Costs are estimates and can vary by location.

Comments

• Though the list is comprehensive for the world and there is a clarification at the bottom, I feel that a further list with regionwise distribution would really have a higher impact in terms of providers thinking seriously about themselves. As in India I feel that iron deficiency treatment and safe needle use will also hit the list somewhere at the bottom of such comprehensive list and will become more important in the coming time. Really a wonderful start. All Praise for the list.—sunil agarwal
• When it comes to adequate water supply and sanitation, three of your "ten cheap ways to save the world" need to be put into perspective. Oral rehydration therapy (#3), although serving as a quick therapeutic fix for over 20 years, is no substitute for potable water and its power to prevent disease. Procter & Gamble's relatively new product "PUR" (#7) can produce small amounts of drinkable water, but it must be imported and cannot replace a water supply system. Finally, the pit latrine (#4), while representing a long-used way to dispose of human waste (particularly in rural and village areas), may not be so useful for the millions of persons living in the densest human settlements found in peri-urban and urban areas. It surely is not as "cheap" to provide persons in developing countries with water and sewerage systems equivalent to the ones we in the more developed world have enjoyed for over 150 years. But, international water and sanitation equity would seem to support focusing our public health efforts now to ensure that all of humankind is able to benefit from full-scale water and sanitation systems.—Arthur Cohen, JD, MPH
• Wouldn't breast feeding be the first method to save the world (If the methods are in their order of importance) as it is the first and the cheapest and probably affects the resistance to most of the other diseases that the baby is likely to get e.g. measles, malaria, Vitamin A deficency, gastroenteritis—DR. SUnita Katyayan
• Editor's Note: The 10 cheap ways were not listed in order of importance. We should have clarified this in the story. Thank you for raising this issue. —Brian Simpson, Editor, Johns Hopkins Public Health
• To the editors: The claim that breastfeeding is free (Birch, Ten Cheap Ways to Save the World, Fall ’05) represents an astonishing lack of reflection about in the biological, social, cultural, and political economic levels. To whit: • On the biological level, a woman requires an additional 500 calories per day (equivalent to an extra meal) during the first six months of lactation . In addition, she would ideally add 400mg calcium daily and also supplemental vitamins such as B-6 and D to her diet. Anyone who has traveled in developing countries and seen young women who are old before their time knows what happens when this ideal diet is not available. • On the social level, the time investment involved in exclusive breastfeeding is enormous, so to say that it is “free” suggests that there are no opportunity costs involved. While it is possible to nurse a child while doing other things (ranging from gathering firewood to reading email), this multitasking does not take away from the fact that nursing is a form of labor which has time and labor costs. • Like anything else people do with their bodies, nursing is a cultural act with a complicated set of attendant meanings. The resurgence of breastfeeding among more educated women in the US is part of a redefinition of nursing as a public performance of committed mothering. Similarly, women in the developing world define themselves publicly through their choices about how to feed their children – but in many parts of the developing world, breastfeeding rates are declining among middle class women, as they did earlier mid-century in the US; in these contexts, a key ‘cost’ of breastfeeding is the risk of seeming too traditional. • Finally, aside from the costs of breastfeeding, we must remember that its effectiveness in decreasing the population attributable risk from diarrheal infections reflects our colossal failure to provide billions of people around the world with safe drinking water. This emphasis on breastfeeding rather than clean water is typical of the current tendency in public health to privilege individual-level interventions over structural ones. Research on the public health benefits of breastfeeding shows overwhelmingly that it decreases morbidity and mortality, and there are health benefits to women who breastfeed as well—but to talk about breastfeeding as “free” obscures the way that we have balanced our global epidemiological books on the backs of the world’s women. Jennifer S. Hirsch, Ph.D. ‘98 Associate Professor Department of Sociomedical Sciences Mailman School of Public Health, Columbia University —Jennifer Hirsch