How Do We Make Roads Safer?

Ashish Jha: 00:00:06

Hey, everybody. Ashish Jha here from Providence, Rhode Island, a little bit of a cloudy afternoon on a Saturday afternoon in Rhode Island, where we're recording this week's moment in health. Remember, this is a podcast where we talk about one data point, we discuss one study, and then we answer one question, and we have a very special guest who I will introduce in a few minutes, but let's get going with the data point. So the data point I want to talk about today is 22.6% or about one in four. That's the proportion of all for profit hospitals in America that are owned by private equity, one in four for profit hospitals. And if you want to take a different number, it's about about one in 10 of all hospitals in America are now owned by private equity. So what else do we know? And why do we care about this number? That's a pretty rapid growth of private equity taking over hospitals in the United States, majority of the of these are a focus on rural areas. Now, a lot of people have a pretty negative reaction to private equity, and I think General we want to look at each of these ownerships and transactions individually. There's no question that private equity transactions often lead to higher prices. There's a really good study couple years ago in JAMA that showed it led to lower quality with more adverse events in hospitals, presumably because they do staffing cuts after they after they buy up hospitals. And so this is an area that's gotten a lot of policy interest and a lot of people paying close attention. One of the best scholars in the country on this topic is a professor named yashwini Singh, and maybe we'll have her in a few weeks to talk about how she thinks about private equity. But the number for you for today is one in four private hospitals in America, or for profit hospitals in America, one in 10 all hospitals in America are now owned by private equity firms. All right, so that's your number of the week.

Ashish Jha: 00:02:06

Let's talk about a study. The study I want to talk about is entitled, patients specific in vivo gene editing to treat a rare genetic disease. Now this was published in the New England Journal in the May 15 issue of the New England Journal of Medicine. Now, you might have heard about this because actually got quite a bit of attention, but basically, the study looked at a child, a boy who's now nine and a half months old, named KJ, who was diagnosed days after his birth with a super rare like one in a million, very rare disease that impairs the liver s ability to process ammonia, and that means that the ammonia can build up, can cause permanent brain damage and leads to death. It's a very, very rare but very serious genetic disorder of something called CPS, one deficiency. Now, traditionally, what you try to do in these situations, you try to do a liver transplant. They're not always available. They're not always successful. What happened in this case was a group of scientists, using science and funded by the NIH for years, basically did base gene editing, edited the child's genetics to try to correct for this error. And what is truly remarkable is that they started building the gene editing compound the infusion that they gave the child after the child was born. It was designed specifically for this child. And they're in the article, they go through all the steps that went into doing this, the safety testing. Obviously, if you're going to infuse something novel in a child, even a child who's potentially quite sick, you want to be as careful as possible. And it worked. At least the preliminary data a few months after the infusion suggests that the underlying error has been pretty substantially corrected. Now it's an n of one, one case. So why do I think this is super interesting? The promise of gene editing has been with us for a while, ever since CRISPR, sort of first was identified. We have not seen that many instances where we've

Ashish Jha: 00:04:16

actually been able to implement it in people. This, I thought was a great example of how you can do this. We are starting to see similar types of gene editing for sickle cell disease. 100,000 Americans suffer from sickle cell disease, hemophilia. And really this is the beginning, in my mind, the dawn of genetic engineering as a way to deal with these horrible diseases that either lead to lifelong suffering or rapid death. And so this is a very important study, again, just a single child, not a massive study, but massive in terms of its implications for where biology is going and where biological engineering is going. So this paper from the New England Journal of Medicine is your study of the week. Much.

Ashish Jha: 00:05:06

Okay, now I'm going to get to my question of the week. And in order to answer my question of the week, we have a very special guest. And when I said that, I meant it, he is here all the way from Delhi, India. He His name is Piyush Tewari. He is the founder and chief executive officer of safe Life Foundation. And Piyush is here as the commencement speaker for the Brown School of Public Health commencement that's happening this weekend when we're recording this and save Life Foundation has been focused relentlessly on trying to improve road traffic accidents, reduce them, reduce their mortality, reduce their impact. And so my question for Piyush, and by the way, Piyush, thank you so much for being

Unknown: 00:05:51

here. Thank you. Thanks for having me. Ashish. So

Ashish Jha: 00:05:53

road traffic accidents kill more than a million people every year around the world, one of the top 10 leading causes of death, the number one cause of death among young people, among young adults. How do we make roads safer in India, around the world, what do you think is the strategy that is needed to make roads safer?

Unknown: 00:06:19

Sure? Thanks Ashish again, for having me on this podcast and for the incredible opportunity to meet your team at Brown today, of the 1.2 million people killed in road crashes each year, 93% live in low and middle income countries. So obviously we are talking about very complex challenges where safety is not just a technical issue, it's actually an equity issue. It is a it's a rights based issue. Not everybody has access to safer modes of transport, and as a result of that, they are drastically affected because of this issue. Now how do you go about solving the issue? Well, the very first step is to understand where does the ownership around the issue lie, right? Is it the road owning agency? Is it the police? Is it the health department? Who's actually in charge? And the answer is that there is, in most cases, there isn't a single person in charge. You have road building agencies, road owning agencies. You have enforcement agencies like police and transport. You have within health, there are multiple actors that you have to work with, pre hospital and in hospital, so on and so forth. So the very first step to solving a complex issue like road crashes and in my view, even other complex issues like climate, is to first, at the very first instance, at the grassroot level, create a coalition of actors, of the key actors that are involved, and we do that at save life, by bringing all of these different actors together on a single platform. We sign an MOU and so on and so forth, and bring these folks together. The second piece is to understand what is really going on on the roads, right? Where are these crashes taking place? Where are the fatalities taking place? Who are the collision partners at what time are they taking place? What are the contributing factors? What are the crash configurations? And this kind of data analysis is required for us to understand where to focus. Most of these countries have limited resources, so you have to be surgical

Unknown: 00:08:25

about where you intervene, and therefore we have to filter down to where the problem lies, between who it lies and at what time it happens. So we can act once you've understood that that's what the data sees. It's important to understand that in countries like India and many other LMICs, data is not 100% accurate, so you have to put boots on the ground, and that's where, not just by way of auditing and observations, but engagement with the community is what gives you a sense of really what's happening and why. So you understand if there are road design issues, but you also understand why people behave in a certain manner, and that's what triggers the next phase, which is the solutioning part, right? How do we prevent rear end collisions from happening on a highway where there might not be any truck stops so you still have trucks parked on the highway and people are going and ramming into them? Or how do you fix a crosswalk on a highway that passes through a village? So that's where the solutioning happens, right? And then you have to ensure that the solutioning is not just being taken care of by you as a problem solver or as a custodian, but by the institutional mechanism, so that there is long term ownership and sustainability around this entire aspect. And once you've done that, it's important to ensure that you have your metrics of measurement clear. What are you really measuring, right? So at save life, for example, we measure reduction in fatalities, morbidity, but we also measure dollars unlocked in. Institutional ownership around the issue, right? And so that's how we go about solving this, this complex, multifaceted problem, is through this, this multi pronged approach that we take that

Ashish Jha: 00:10:10

was very helpful. So let me capture a couple of points, but let me ask you one more question, and it's supposed to be one question, but I almost always end up asking a follow up, so I apologize. So first is to identify who's really the owner of this problem. And generally, for complex problems, there's rarely one owner. So then you build a coalition of owners who all have a stake in this. You get data helps you understand the problems better. You get on the ground. You engage with people in the communities who are actually most effective. You come up with some solutions, and then you try to institutionalize those solutions, but by the way, so let me ask you just one clarifying question, when you institutionalize those solutions, do they usually happen in government? Yes, it's mostly government. And can you imagine it happening elsewhere, outside of government? I mean, presumably you could create quasi governmental entities that could do this. Yeah,

Unknown: 00:10:58

absolutely. I mean, we, at this point of time, we are helping change even contracts the private sector signs with the government to build roads, because that's where you can institutionalize a lot of things that take place. We are affecting change. We are affecting change in the education system so that new civil engineers, new mechanical engineers, understand how to look at this problem more holistically. So it is a multi pronged approach, but at the end of the day, if you have to create impact at population level, the only agency that has the resources and the reach to reach every single person in our country is the government. Yeah, so you have to engage with the government to reach the population level.

Ashish Jha: 00:11:33

And let me just wrap up here by asking so 1.2 million people around the world. Let's just take India. About 150,000 deaths in India, I think 70,000 170,000, yeah, if you do these things, and if you get a government that's very activated, and if you implement those things, how much do you think you can reduce? I mean, you probably can't get to zero. That'd be great. But do you think that set of strategies gets you 30% lower, 50% lower? What is your sense of kind of what you would love to be able to achieve in a realistic time frame? Yeah.

Unknown: 00:12:07

So on. We started a program on a highway called the Mumbai Pune expressway in the first quarter of 2025, Mumbai Pune expressway. Now, after all, the interventions has experienced a 70% drop in deaths compared to the previous quarter, in the previous year overall, we're expecting that we'll achieve about 65 to 67% reduction in fatalities by the end of this year overall. So that's, that's, that's what you can do at this point of time. It is Vision Zero, though. We are hoping. We are pushing for it to reach the minimum possible level. And there are areas, there are places more hyper local where we have eliminated fatalities altogether by a combination of many of these things that we do around road engineering, police enforcement, fixing, trauma care and trying to involve the community in behavior change. So zero is the target. It's called Zero fatality corridor initiative, and 67 to 70% is what we've achieved so far, and and we will keep pushing, I think, I think zero is Sweden has shown that the zero is possible. Of course, India is not Sweden. But, you know, never say never. And we will sort of stay at it. I love

Ashish Jha: 00:13:12

that. And it's, I mean, it's 67% reduction, if you think about it from a global perspective, or just from India's perspective, that's massive. And since so many of these fatalities are in young people, not that the fatalities in older people matter less, but young people who sort of have a long life ahead of them, and the consequences can be quite substantial economically as well. It's a very, very important effort. I want to say thank you. Thanks for coming all the way to brown to give the commencement speech. Thanks for being a guest on this podcast, and really thanks for the extraordinary work that save Life Foundation is doing. Thank you drive all of this down and make make road safety a real priority for the world. Thanks a lot. Thank

Piyush Tewari: 00:13:51

you. Thank you, Ashish, for having me on this and for your leadership at Brown.

Ashish Jha: 00:13:59

So there you have it. A moment in health episode seven. And we started off with a data point. We talked about, how about one in 10 all hospitals in the United States are now owned by private equity. One in four private hospitals, private for profit hospitals, pretty big number. And we talked a little bit about what that means potentially for healthcare. We talked about a study that was patient specific, in vivo gene editing to treat a rare genetic disease from the New England Journal may 15, really extraordinary work that takes a child born with a very, very rare disease and builds a customized treatment for that child that ultimately treats the underlying genetic disorder. And then we had a fantastic conversation with my colleague and friend, buchare, who runs save life foundation in India, who's our commencement speaker this year, guest this week, talking about the very complicated issue of road traffic accidents, when you think about the 1.2 million people who die, and how you begin to address that, what Piyush. Laid out was just this very multifaceted approach. You there are no silver bullets here. Got to build coalitions, you got to get data, you got to try solutions, you got to engage communities, you got to institutionalize change. It's all hard stuff, but that's the only way you make sustained, long term progress. And he has shown through his work you can make sustained long term progress. So I was very grateful to have Piyush here a moment in health episode seven. That's a wrap. I'll be back next week with another episode of a moment in health. You.