Happy Holidays from MethodLogical and Band Aid!

MethodLogical is going on hiatus for the holidays.  We'll be back on January 17th with regular posts from our contributors.  Over the next few weeks, we'll try to post interesting links and brief items as they arise and then pick up where we left off on the 17th.

As a holiday gift to you, our loyal readers, we offer the video below, Band Aid's "Do They Know It's Christmas?", our favorite catchy, well-intentioned, somewhat misguided, but pretty effective song to raise money for Africa.  Written in 1984 by Bob Geldolf and Midge Ure and performed by an all-star lineup of British and Irish artists (many of whom have long been forgotten), the song sold 3.5 million copies and raised millions of dollars for famine-stricken Ethiopia.

Its lyrics, appealing for African relief, feature such gems as:

• "The only water flowing is the bitter sting of tears"  (Sung, of course, by Sting himself)
• "Where nothing ever grows, no rain or river flows"
• "The Christmas bells that ring there are the clanging chimes of doom"
• "Do they know it's Christmas time at all?" (Spoiler Alert: They do.)

But hey, it's a good tune and raised a lot of money for people who really needed it.  So enjoy the song and happy holidays from the MethodLogical team:

Defining Skilled Care: Assessing the Effectiveness of Community Health Workers

The 2005 World Health Report estimated that an additional 700,000 skilled birth attendants are needed to provide universal coverage of maternal and newborn services in the 75 countries where maternal and neonatal mortality is highest. The shortage of skilled health workers is particularly salient as the interventions which have the greatest effect on neonatal deaths are most dependent on skilled assistance, rather than technology and products. Global actors advocate for a woman’s right to choose to deliver with a skilled attendant present, as well as for a reserved right to access safe professional care in case of emergencies or complications for either her or her baby. However, this right is greatly unfulfilled in developing countries. In south Asia and sub-Saharan Africa, where two-thirds of neonatal and maternal deaths occur, only about a third of women deliver in the presence of a skilled attendant. These disparities persist within developing countries as well, as the richest women have six-times higher skilled attendance coverage than the poorest women.

In response to these huge shortages—and their implications for equitable access for the poorest—the use of community health workers has long been championed as cornerstone of PHC. Surrounding Alma-Ata in the 1970s and 1980s mass training of community health workers and traditional birth attendants was promoted by the WHO and others. As conceived within the principles of CBPHC, the CHW combines promotional, preventative and curative service functions for comprehensive health and wellbeing, including intersections with agricultural and economic needs of the community. CHWs were viewed as a much-needed link between formal health services and poor and marginalized communities. Indeed, several studies show that CHWs may be the only feasible and acceptable link to improve health in the near term. And, these bridging activities can close gaps in preventative and curative care for greater effectiveness of services in the long term as well.

A village health worker in Gadchiroli, India monitors newborns' growth. 

CHWs are also less susceptible to brain-drain and co-option into vertical programs. This is because their skills are specific to their community, and less transferrable than the skills of nurses or physicians. Additionally, CHWs often work to increase community management and ownership of health-related programs, and thus are accountable to their own communities, rather than an external organization. This, and the great sense of pride CHWs feel for their work, as well as the elevated status and respect they receive, further contribute to their desire to remain within their communities over time.

While there is robust evidence that CHWs have been effective in improving health—especially child health—implementation of CHW programs has been variable. Overall, CHW programs have been faulted for insufficient focus on training and supervision, and inadequate links with the health system, e.g. via referral systems. This has severely limited CHWs impact on neonatal health. A meta-analysis of mainly observational studies notes a small decrease in perinatal mortality (8%) and birth asphyxia-specific neonatal mortality (11%) in those cared for by trained traditional birth attendants. While positive, this impact suffers from the inadequate implementation constraints mentioned above.

Due to differential quality of care in CHW programs, the 1990s witnessed a major reversal in policy, with the WHO and other UN agencies strongly discouraging the use of traditional birth attendants and exclusively promoting facility births with skilled attendants. This remains the preferred option today, with calls for major investments in scaling-up midwifery, nursing and physician programs.

While the need for quality, skilled care with linkages to the health system is crucial, the current global strategy creates a vacuum for poor communities currently experiencing the highest neonatal and maternal mortality rates. Training of midwives will take decades, and in the meantime communities will suffer.

CHW programs are still relevant; as CHWs have a role to play that can be fulfilled neither by formal health services nor by communities alone. Furthermore, unlike the purely technical functions of midwives, CHWs are much-needed advocates for social change in the systemic causes of ill-health. However, better tools for measuring progress on these goals are needed to inform and support CHWs’ work.

We can learn from failed CHW programs in the past, and develop new innovative approaches to link the role of CHWs with a strong continuum between community and facility care. This sort of linking of care has been demonstrated as much more effective in reducing maternal and newborn deaths than focusing on either the community or facility alone. For example, evidence shows that bringing traditional birth attendants into facilities for training has been effective in promoting emergency obstetric referrals. Additionally, skills of various cadres of workers can be combined into collaborative teams, with nurse-midwives supervising CHWs in community-based delivery, to raise access to skilled care over time. This “frontline health worker” team approach can also ensure focus on both maternal and neonatal health needs. For example, tasking traditional birth attendants with primary responsibility for mothers, and village health workers with the health of the newborn. The creation of new cadres of community-based health workers for more comprehensive care across the lifecycle has also been undertaken; for example multipurpose health extension workers in Ethiopia.

WHO has recently held talks revisiting the role of traditional birth attendants and other community-level health workers. How can we continue to learn from the past, and find new ways of strengthening health workforce for the future?

Smoking is Still Really, Really Bad for You

Long before I entered medical school, the harms of smoking were drilled into me.  For better or worse, as an elementary school kid, I stood by cigarette vending machines and told people not to smoke.  At the risk of confusing correlation with causation, I must have been awfully successful, because smoking rates in the U.S. fell from 44% in the 1950s to 32% to the 1980s, all the way down to 21% in 2008.  Or perhaps it had something to do with legislation, taxes, restrictions on advertising, class action lawsuits, and public health outreach campaigns.

At any rate, if I spent my childhood learning that cigarettes were bad for you, medical school has shown me that they are even worse.  Cigarettes are the cause of death in 33% to 50% of smokers.  And smokers die an average of 10 (or more) years earlier than non-smokers.  Every American schoolchild should know that smoking causes lung cancer.  Emphysema and heart disease get some attention too, though probably not enough.  But did you know that smoking also causes bladder cancer?  Pancreatic cancer?  Gangrene?  Erectile dysfunction?  Osteoporosis?  The list goes on.  I won’t even get into the fact that secondhand smoke accounts for 600,000 deaths annually, a third of those in children.

Seriously, why would you even do that?

Smoking has gone from being a problem of rich countries to a problem of the developing world.  Of the over 5 million smoking-related deaths per year, about half are in the developing world.  In India alone, almost 1 million people a year die from smoking-related causes.  All told, tobacco kills two to three times as many people a year as HIV.

These figures don’t take into account the staggering morbidity of smoking- patients living with chronic disease, unable to breath due to emphysema or demented secondary tobacco-related strokes.  All of this occurs in the context of strained health systems that lack the capacity to aid those living with disease; smoking-related illness simply taxes an already inadequate primary care infrastructure.  (If health systems in the developing world were stronger, doctors and nurses at local clinics could educate and counsel people on the harms of smoking and the benefits of quitting.)

Why is this shift happening?  Largely because of economics.  The harder it is to sell cigarettes in America or Europe, the more appealing it is for tobacco companies to set up shop in countries with more lax regulations.  Deficiencies in education and lack of knowledge of the adverse effects of smoking also help: in a survey conducted in China, 60% of people were unaware that smoking causes lung cancer and 96% of those surveyed did not know smoking causes heart disease.  To wit, heart disease accounts for a third of smoking deaths, lung cancer for 17%, and emphysema for 20%.  (As an aside, I think it merits noting that heart disease kills more smokers than lung cancer and that people may "recognize" the effects of smoking in themselves and their friends/family more readily if they connect tobacco and cardiovascular disease.)

And while it’s more than fair to attack tobacco companies, did you know that the largest producer of tobacco in the world is the Chinese government?  It’s true: the China National Tobacco Corporation peddles more cigarettes than our good friends over at Phillip Morris or R.J. Reynolds.

It’s easy to point out a problem, but much harder to solve it.  Smoking deaths are preventable, but only if the international community makes a concerted effort to curb tobacco use.  First, we need to recognize smoking as a global health problem, like HIV, cholera, and malaria.  Then, we need to enact international regulations like those we put into place in the U.S.  It won’t be easy—standing up to American corporations AND the Chinese government is a tall task—but the benefits are painfully clear.  Not without a struggle, the U.S. has decided that smoking prevention and cessation is vital to its national interests.  It’s time we take that same view on smoking in the developing world.  With the myriad health problems industrializing nations have to face, why should we tolerate millions of more deaths caused by a preventable, man-made product?

Paying for Health and Development Services for the Poor: Taking an Agnostic View

Who should pay for health and development services in poor countries, especially for the poorest of the poor? Let’s just take that question for granted and look at the major views. Essentially this comes down to a battle of: Free Services vs. Cost-Recovery. The “free services” logic goes like this: Poor people are, well, poor and they can’t really afford expensive health and development services. Human rights exist demanding that these services are provided, and therefore someone else has gotta pay. It’s an appealing argument. After all, many people believe that everyone is entitled to high quality health and education at the very least and these services are sure to cost more than the fewer than $2 a day that so many millions of people live on. But several questions can be raised. Who delivers this care? Because the care is provided free, what is the delivery organization’s incentive to provide quality care, to innovate, to be efficient? How can we transfer such large amounts of money (likely from outside poor people’s country) without resulting in corruption?

 

The “cost-recovery” logic goes like this: Poor people are poor, for sure, but health and development services need not be expensive. Just as markets have been used to improve computers and make them orders of magnitudes cheaper, so can the power of the markets be brought to bear on issues facing those at the bottom of the economic pyramid. And the only reason these markets don’t already exist is because we are only now beginning to recognize the vast fortune that could be made by businesses offering services to the poor. And this, of course would mean that we have to charge for our services (AKA have a business model that recovers costs through fees or insurance, not through external donations). This, also, is an appealing argument. After all, we have seen many governments and non-profits without a business model find themselves unable to pay for services, and worse, irresponsibly dealing with the money they do have because of perverse incentives. But again, several questions can be raised. If the service only goes to those who can pay, then how will the poorest within a country actually receive services? For services like healthcare, there are strong economic arguments against a system of fee-for-service at the point of service because the economics of healthcare are different as compared to most products. But despite these questions, there is success on both sides.

Most notably on the free care side is Partners in Health. Working with approximately $90 million a year to serve approximately 3 million people worldwide, PIH by most accounts is providing high quality, relatively comprehensive services for less than $30 a person per year while responsibly handling donations. Importantly, they have been able to use their success and human rights-based philosophy to leverage more donations. Some say PIH is unique (and with about 50% of their budget from individual, mostly unrestricted donations they are). But PIH isn’t just using their celebrity status to get their own funding. PIH is an advocacy organization in addition to a service delivery organization, and they are using this advocacy to create pots of money for other NGOs and governments to use for diseases like cancer and diabetes and for building underlying health systems, including surgical capacity.

Some of the most inspiring examples of organizations using cost-recovery are non-profits like BRAC, Aravind Eye Care Hospitals (see the TED talk), and Narayana Hospitals. These organizations have reached gigantic scale, at low-cost and high quality. Furthermore, they do serve the poorest of the poor by cross-subsidizing (charging the poorest of the poor less or nothing and getting away with it by charging more for those who can pay). While cross-subsidizing is a great model for these non-profits, it does speak to the fact that a for-profit offering these services would likely miss the truly poorest.

What do you think about this? Who should pay for these services, and how? Personally, I am agnostic. I added the word “should” to my questions because for many people this is a normative question. But for me, the only funding and delivery mechanisms that should be done are whatever funding and delivery mechanisms that actually work and in different places, that may well mean different things. We should be distrusting of any view that espouses a one-size-fits-all mentality.

Empirically speaking, some governments, some donors, some non-profits, and some business are extremely well-run, can find funds from someone (the poor, a government, an insurance program, donors), and offer a good product. Others are not capable of this. So in some places, one payment and delivery model will work great, in another place it would fail. Likely this is due to local ecologies of money, power, culture, and people. For health and development, my ideology is simple: having a bottom line that is impact for the poorest billions. When researchers look at interventions, they investigate for marked improvements to an individual or a community, but they are (or rather, should be) relatively agnostic to what the intervention is. When we look at organizations or systems, we should look to see if at scale it is offering a high quality, low cost product to the poor and that it has the capacity for adaptability, for innovation, and to be well-governed, but we can be agnostic to how it is funded and by whom. In that light, PIH, BRAC, Aravind Eye Hospitals, and Narayana Hospitals all make the cut (Who else do you know that makes it, and how have they worked on the funding issue?). So let’s stop focusing on ideologies of who should pay and how. These dialogues force us into simplistic and nonconstructive debates. We need to look at the nuances of local contexts and the nuances of various mechanisms, see what might work best, and if it fails, try try again.

But while I am ultimately agnostic, and I don’t believe in a one-size-fits-all approach, I admit that I have a bias for one approach that would seem to work in many place, and is worth a try. Here’s my personal view for making healthcare for the poor happen taking what I consider the best parts of PIH + the Global Fund + Single payer systems + Michael Porter’s value-based healthcare:

1. The PIH Step: PIH and other advocates focus their efforts on creating funds dedicated to ensuring equity in global healthcare delivery (and outside of delivery directly, these funds could be used for public goods key to health like healthcare worker training, water and sanitation, electricity, and roads).
2. The Global Fund/Single Payer Step: Donor funds are channeled to funding pools which no longer go directly to budgets for government or non-profit healthcare delivery, but instead go to government-administered (or in the case of weak governments, NGO delivered) national health insurance programs that ensure that the poor have coverage. It’s like single payer healthcare systems in poor countries, except instead of being entirely internal taxes, large contributions come from donors.
3. The Michael Porter Step: These programs reimburse any institution (be it government, non-profit, or for-profit) that provides certain standardized care that is proven to be effective. This funding environment would be fertile ground for organizations like Narayana Hospitals, Aravind Eye Care Hospitals, and other organizations that have found better business models through high volume, low cost, high quality standardized care.

This way of doing things is appealing to me because it disaggregates funding, payment, and delivery to parties that can do each well. Donors and advocates are typically better at building movements and securing funds. Governments are typically pretty good at pooling funds and reallocating them. Businesses (and some well-managed, cost-recovering non-profits) can typically achieve low-cost, high quality service delivery. And most importantly, as to our original debate, it’s a system I think human rights and market based folks can BOTH get behind because care can be free for the poor, but a market is created for service delivery. What do you think?

How Does Happiness Measure Up in Development?

Happiness is everywhere in development these days. France called in a team of hotshot economists to reorient its economic policy and now the Prime Minister of the UK says he wants to develop a happiness measurement for the UK. But before France, and before the UK, the idea of happiness was making a name for itself in a much smaller and out of the way place—Bhutan.

Gross National Happiness (GNH), the Bhutanese incarnation of the idea, came about after the 4^th King’s glib remark about the limits of Gross National Product (GNP). GNP was the dominant measurement of development at the time, one very similar to GDP. Bhutan, the king said, cared more about GNH than GNP, because economic growth alone was not what was important. Even back in the 1970s when he made the comment, Bhutan’s king was far from the first to remark on the limitations of GNP, GDP, and the models of economic growth that accompanied them. Many before had noted that GNP and its successor GDP left out negative externalities, environmental impacts, and inequality.

The main point of GNH was that it questioned the ends of development and the conventional wisdom of the time. Should we place limits on growth? Was economic output the only measurement that concerned a developing country? What should a just society look like? In Bhutan’s case these were more about Bhutan’s development and direction. In fact Bhutan developed its own vision of development that included inequality, the environment, and cultural preservation alongside economic growth. Although designed for Bhutan, the thinking behind it was more broadly relevant which is part of the reason I think it caught on globally.

Word to the wise: Do not try to pay your hotel bill in happiness.

What GNH did, essentially, was remind us that it is not wealth itself we value, but what it brings us and our concern should be on how well we are meeting those ends. To get old school for a minute, this insight goes all the way back to Aristotle. In Nichomachean Ethics Aristotle states that “wealth is evidently not the good we are seeking; for it is merely useful for the sake of something else.” It is also an insight that has not been lost on some modern economists—Amartya Sen’s work comes to mind.

However, recently in Bhutan, as well as in France and the UK, the idea of GNH has been reduced to a metric. This is, I think, a problem for several reasons. To begin, economics and economists already have alternative metrics to deal with other elements of development we may care about. For inequality, there are measurements like the Gini coefficient, and for the environment, well, there's a lot of literature devoted to just how to value the environment and its degradation. Similarly, there are a plethora of alternative measurements for development, PQLI and HDI to name two, that try to incorporate elements of development other than economic output. So, to begin with I’m skeptical about the need for another metric.

Perhaps more fundamentally, there’s the problem of measuring happiness itself. I have to admit the very idea of measuring happiness as a basis of economic policy is preposterous to me. Much like Catherine Bennet at The Guardian and Jamie Whyte at the Wall Street Journal, I find serious problems with the idea of a standardized definition of happiness, both across individuals and cultures within a society and for those individuals and cultures across time.

In Bhutan this obsession with measurement has led to some fairly absurd consequences. The GNH survey conducted here consists of thousands of questions that take a ridiculously long time to administer. To give you an idea, the shortening of the survey is described like this on the official website: “The pilot survey questionnaire, which was found to be too lengthy, was pared down to a questionnaire that took half a day to interview.” A half a day still seems like an unreasonably long survey to me. The are other problems with the survey, which I invite you to explore.

But aside from the specific problems with a GNH survey in Bhutan or the difficulty measuring happiness in general there is something else that bothers me about this way of incorporating happiness into development. To begin, it shifts development from an open and complex discussion about what the ends of development should be and whether they have been achieved to a simple calculation. Instead of discussing just or fair development, or, to note Brad’s post, whether we care about the environment and other species as ends in themselves, and then evaluating, we merely have to see if our GNH index has gone up.

The second problem is that a GNH metric opens itself up for fundamentally undemocratic misuse. On the one hand, the metric moves discussions of the good life off the table and assumes whoever designed the metric knows what happiness is. Jamie Whyte (mentioned earlier) at the Wall Street Journal notes this is fundamentally illiberal and authoritative. But the other problem is that it opens the possibility of dismissing social problems. Much to my chagrin, my American-written sociology textbook here in Bhutan told my students that people in slums in India were poor, but happy and basically okay with their lot in life. A GNH index that “proves” this with numbers, I worry, would make it all the easier to dismiss concerns like poverty or the slashing of social programs because people are "happy" without them.

What motivates one to serve?

I am probably preaching to the choir if you’re reading this blog post...as service is at the foundation of public health and social justice. Yet, I think reflecting on personal motive in any work is healthy. A business school friend recently told me about Goleman’s 4 constructs of emotional intelligence (EI), and self-awareness tops the list, followed by self-management, social awareness, and relationship management.

Why serve?
A couple months back, I had an email exchange with a friend. She had written: I do wonder what it means to be in service, at the [core], at the intention level. She was referring to a deeper attitude of selfless service, called Seva in Sanksrit. Certainly, the concept crosses religions and personal belief systems. Having grown up with an extended family that strongly believes in Seva, my motive to serve lies in a sense of duty, which inherently serves a personal function. This functional motivation of volunteering has been classified by Clary et al (1998) into 6 categories:

Function	Distinguishing elements of the function
Values	To express important values Feeling that it is important to help others
Understanding	Seeking to learn more about the world A chance to exercise skills and abilities that might otherwise go unpracticed
Social	To be with like-minded people To be engaged in an activity viewed favorably by important others
Career	To explore different career options To look good on one’s CV
Protection	To reduce guilt over being more fortunate than others To help address personal problems
Enhancement	For personal growth To develop ‘psychologically’

Table modified from://www.voluntaryaction.info/voluntaryaction/freearticles/article1_unstead-joss.pdfi

The functional theory is appropriate to explain simplistic motivation at an individual/immediate level. Below are other theory bits/concepts (not comprehensive) that describe societal factors which affect service culture and volunteerism:

• Collectivism vs. Individualism: Collectivism is more strongly related with altruistic motivation and desire to strengthen social ties, and development of a volunteer role (i.e. religious, community groups, cultural norms). Individualism is associated with career-related objectives (i.e. social service for resume)(Finkelstein 2010)
• Social origins theory: More volunteering where there is limited government social spending, a fee-dominated revenue structure, a large non-profit sector, and a small paid workforce. Volunteering is mainly service provision. (Salamon and Sokolowski 2001; Hwaung 2005)
• Role identity theory: Social norms provide the impetus to start volunteering. With continued service, the individual establishes a volunteer role identity, and this new identity drives further participation. Similar to Individualism. (Grube & Pilivin 2000)

Developing service ethic

In the US and India, I have had the pleasure of being involved with amazingly dedicated public health/medical/development workers who embody selfless service. For example, the heads of Manzil (=destination; youth empowerment) Delhi and Manav Sadhna (=devotion to mankind; community empowerment), in Ahmedabad, Gujarat, inspire others by their example. Their approach is collective (not individualistic) which results in value/social/understanding motivation functions that are adopted by those they help and the staff. These leaders are able to make local, context-specific changes, which are maintained because of high buy-in from the staff and community. In this way, they have actually produced a new generation of service-minded citizens who want to change the vices of society and improve equity.

To end, one of the boys, Raju (picture above), who grew up in the slums around Manav Sadhna and was schooled and trained by the NGO, is now in his mid-20s and has returned to his village to address public health and development issues. In the course of 1.5 years, he has implemented a waste management program, personal hygiene programs for school children, computer classes for youth, addressing alcohol abuse and sexual violence...and is going strong.

Direct Distribution

Two weeks ago I wrapped up some vacation on the island of Lamu off the coast of Kenya. Friends from Kenya recommended it to see the traditional, Swahili culture of the coast and it was really quite different from the rest of Kenya. We ended up staying in a village close to Lamu called Shela where there were no cars (lots of donkeys) and enjoyed a really relaxing few days amidst one of Kenya's hidden gems. If you're considering going to Lamu, definitely call Gabe and Susan to arrange everything.

One of the reasons I made an effort to visit Lamu this past trip is that there is a major upcoming infrastructure project to build a deep water port which many, unfortunately, fear will fundamentally change the character and culture of the area. Kenya already has East Africa's major port in Mombasa, just down the coast, where imports and exports as far as eastern Congo flow through. The Lamu port is intended to manage imports and exports from Ethiopia and South Sudan who both have neighbors to the north they're not too fond of.

All of this got me thinking about South Sudan and the upcoming secession referendum on January 9th. Like nearly all commentary out there on the vote, I can't imagine the South voting for anything other than secession. If all goes as planned, and that is a serious "if" given the North's history of violence in the South, their reliance on southern oil for the economy, and some recent bombings near the border, Southern Sudan (aka South Sudan aka New Sudan) will be the world's newest country endowed with enormous oil reserves and a quasi-functioning government run by the former rebel SPLM/A.

Todd Moss and others at the Center for Global Development have been writing and talking about an interesting concept in which countries endowed with oil resources directly distribute some or all of the revenue directly to their citizens. It's an interesting idea to attack the oil curse, drain the pool of funds that politicians find nearly impossible not to take from and align the incentives for good and accountable governance. I am not aware if there are plans to do this in South Sudan but where government is least effective, the incentive to directly distribute seems to be highest.

Of the people, by the people, for the people?

Ok, all of that is actually the prelude to 2 questions I won't answer but am curious to hear others' thoughts on:

1. Could/should we directly distribute most aid to the poor and let local NGOs, companies, and international players compete for the poor's business?
2. Given health's information asymmetries, where might this work and where might it not? When the poor are not fully informed, is it more efficient to administer funds centrally or simply spend to market and educate the poor on good practices (e.g., using malaria nets for kids, etc.)?

Public health…what is it good for?

Before we begin our journey, and before you read below, I want us to close our eyes and think of what public health means to us. What would your definition be? For what end? For whom? By whom? What is “health”, “healthy”?

What did you come up with? Did anyone expressly think of improving the health of sand flies in California ? Of the dead zone in the Gulf? Of desertification in the Sahel? 

The mouthful, but often heralded, WHO definition of public health is “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” However, it is implicitly accepted that this is anthropocentric. Do we all agree that this is ideal? Humans are animals. Evolution is not over. We are not the end of “progress”, yet we act as if we are the terminus. We tacitly accept and believe that improving the health of humans is the focus of even global public health; interpreting the global as wherever humans are. 

Now, to state my conflicts of interest outright, I believe that the environment has intrinsic value. If you ask me: “what good is it to save sand flies”, I would reply with what good are you? Humans seem to think that we have a right to life, liberty, and the pursuit of happiness, regardless of our utility: that we have intrinsic value. Even other humans which we might deem to have negative societal impact deserve these universal human rights. Perhaps this is why we are all in the field of public health, but, what I want to ask is...why are we so special? We need to move towards a treatise of universal natural or biotic rights. 

A nice sentiment, but is it lacking in scope?

Interestingly enough, it seems to becoming more and more clear that a biocentric worldview does in fact improve the health (life) and happiness of individuals more than an approach focused solely on humans. Our society and science imply that the solutions to current environmental problems are not a strong paradigm shift of human behaviors, but only more (attempted) mastery of the Earth and Earth processes. We will solve global warming by pumping C0₂ into the ground (á la Jeffrey Sachs). I don’t think there could be a more anthropocentric, arrogant-in-the-possibility-of-science-solving-our-problems-without-us-having-to-change-our-ways “solution” to our behavior caused problem. It will all come around in the end as we realize that our anthropocentric (“unnatural”, [“artificial flavoring”]) way of interacting with the earth leads to unhappiness (depression, phobias), early death (cancers), and the weakening of the rivets in our global ecosystem. We won’t be around to see the distal effects, but the proximal results are already in print, we just don’t know how to read them since we systematically eradicate thinking truly (creatively) outside the box. Let us be truly humble humans, realizing that even if we surround ourselves with concrete we are inextricably linked to nature, and with the precautionary principle winning the day. 

I need your help though. What is the answer? If I wish to live in American society I must be ready to sacrifice some of my ideals. How much do we sacrifice? How do we decide what to sacrifice and what to fight? I want to never own a car. People say "good luck". 

How do we change the paradigm? How do we get there from here? What does this mean for global biotic health?

Brad Wagenaar is a guest contributor on MethodLogical.  He is an MPH student at the Emory School of Public Health, focusing on Global Epidemiology. He is a returned Peace Corps volunteer from Cameroon who loves biking and crazy ideas.

Social Intervention as a Pre-Requisite?

When a doctor sees a patient with schistosomiasis, a common water-born parasitic disease that affects over 250 million children in the developing world, the treatment given is a single oral dose of praziquantel. But the doctor is well-aware that since transmission of schistosomiasis is through water-dwelling snails, the longer-term cure that will prevent that patient from returning next year with the same disease is quite a different treatment -- in fact, a treatment that doesn't involve medicine at all. In fact, the long-term solution lies in water sanitation -- ensuring reliable access to non-contaminated water, combined with continuous mulluscicidal treatments of that water source. Similarly, when a doctor sees a patient with another parasitic disease, such as hookworm, that has oral-fecal transmission, the treatment given is 400 mg of Albendazole. But the answer to ensuring against re-infection in the longer term lies in urban planning and engineering: the installation of a sanitary and effective sewage system. 

Rwandan Boy Infected with Schistosomiasis

Are clinicians and economists alike are too quick to tackle the problems of pandemics like schistosomiasis, hookworms, and other diseases without addressing the basic underlying causes of poverty? What we often call root causes of poverty, such as hunger, malnutrition, lack access to safe drinking water, are perhaps primary conditions that need to be addressed in order to effectively mitigate disease.

Schoolchildren in Sierra Leone Eating Before Receiving Praziquantel Treatment

Today, much of the global health literature does place more emphasis on holistic poverty alleviation efforts rather than purely clinical intervention. For example, Barnett and Whiteside argue that neither public health nor clinical medicine pays sufficient attention to what does improve health – escaping from poverty, access to good food, clean water, sanitation, shelter, education and preventative care. They go as far as to say that clinical medicine may have large effects on short-term health, but only marginal effects on people’s long-term health. Jeffrey Sachs puts forth the same argument, saying that people studying health systems should widen their perspective to include links with poverty-alleviation strategies, and vice-versa.

Contaminated Water Source in Southwestern Ethiopia

I don’t believe that poverty alleviation is a pre-requisite for clinical intervention. Neither clinical intervention nor social intervention alone can drive progress. The two are inextricably linked. Poor people view and value their health in a holistic sense, as a balance of physical, psychological, and community well-being. This view, consistent with the WHO definition of health as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity,” is remarkably consistent across ages, genders, cultures, and nationalities. In a qualitative study of over 60,000 poor women and men across the globe, the World Bank and WHO found that people overwhelmingly link disease and ill-health to poverty. No probing questions on health or disease were included in the study’s research guides, yet overwhelmingly health was central to poor people’s lives. The implications of these findings are that perhaps it does not even make sense to discuss clinical interventions in isolation. Instead, clinical interventions should be viewed as one piece of the puzzle in larger social interventions.

In his post yeseterday, Adam Schwartz expounded upon this very idea in the context of HIV/AIDS: "If there is funding to provide antiretrovirals to pregnant women with HIV, but no prenatal care, no surgical facilities for emergency caesarian sections, no trained surgeons, and no antibiotics for neonatal infections, then we may erase all the good of our initial interventions." These same sentiments are echoed by Stanford's Dr. Phyllis Tien when she is scaling up HAART distribution programs. She has a laundry list of “prerequisite conditions” that must be met beforehand -- including adequate infrastructure, minimal lab support, relatively informed communities, counseled patients, and access to OI/symptomatic treatment. She argues that without satisfying these basic economic conditions, a clinical intervention will fall short. Poor nutritional status is also a prevalent factor that can exacerbate HIV/AIDS. Malnutrition can plague the effectiveness of ARV treatment, increase vulnerability to infections or increase the severity of those infections. Coupling drug therapy treatment with good nutrition not only strengthens the immune system, but can help delay the disease progression and provide the crucial micronutrients the body needs to fight HIV. So without social interventions that fight the underlying malnutrition in HIV/AIDS patients, the clinical interventions would be significantly undermined.

HIV Negativity

Irony Alert: Today is World AIDS Day.  The publishing of this post was not timed to coincide with the event, but pretty cool, huh?

Living in Botswana, it’s hard to ignore it.  The estimates vary (as do the sampling techniques), but the most recent UNAIDS survey places Botswana’s HIV prevalence at 24.8%.  In Gaborone, the nation’s capital and largest city, the HIV rate is estimated at 40%.  Things have actually gotten better since 2002 when the government started distributing free antiretrovirals to its HIV-positive citizens.  While not curative, when taken properly these drugs can keep the virus at bay for decades.  They also have the added benefit of reducing transmission when HIV-positive individuals have sex with those who are HIV-negative.  While Botswana’s life expectancy was 32 years in 2003, today it has rebounded to 61.

There is no doubt that antiretrovirals (as well as other programs and technologies focusing on HIV treatment and prevention) can save lives.  But, without a strong health care  infrastructure we are unable to effectively deliver costly HIV interventions, severely undermining their impact.  If, as others have pointed out, there is funding to provide antiretrovirals to pregnant women with HIV, but no prenatal care, no surgical facilities for emergency caesarian sections, no trained surgeons, and no antibiotics for neonatal infections, then we may erase all the good of our initial intervention.  Like so many other medical treatments, antiretrovirals require a system of clinics, trained doctors and nurses, and supply chain management to prevent treatment interruptions, which can be disastrous in HIV treatment.  Without a primary care infrastructure, people will have a hell of a time consistently getting their HIV drugs.  Even if they do get their drugs, without a functioning health care apparatus they will be vulnerable to every other disease that plagues the developing world.  We treat their HIV only to watch them die of pneumonia, or diarrhea, or malaria, or a hearth attack, or liver disease...

It takes more than pills to keep you healthy.

Further, as I discussed in my last post, with limited funds dedicated to global health, being effective isn’t enough; interventions must be more cost-effective than the other plausible alternatives.  That way we are doing the most good for the most people.  Antiretrovirals can transform lives, but in starting a patient you are making a lifelong commitment to treatment.  These drugs can make people live a lot longer, but in doing so, necessitate more years of expensive treatment.  This is an excellent problem to have (if only we could do so much for people with lung cancer or ALS), but one with many long-term implications.  If we cannot afford to offer drugs over the long term, then patients will eventually fall ill again: levels of the HIV virus begin to rise within days of stopping the medication, undoing all the good gained from years of treatment.  Worse yet, interruptions of treatment breed resistance, making the virus harder (and more expensive) to contain in the future.  And, while it’s wonderful that there exist drugs that can keep someone with HIV alive for decades, we have to consider the cost of those drugs over that time and what we might have been able to do with all of that money over that same period.  It’s not that treating HIV is a bad deal, per se (at about $1,000 per life year gained it would be a no-brainer in America), it’s just that this money could be better spent elsewhere.

And it’s a lot of money.  In 2009, President Obama announced the Global Health Initiative, dedicating $63 billion to the developing world over six years.  Of that amount, over 70% is dedicated to HIV.  That means for every dollar spent on prenatal care, childhood immunizations, diarrheal disease, and malaria combined, two dollars are spent on HIV.  This pattern holds for countless other foundations, NGOs, and governments.  For the record, in low income countries, HIV accounts for approximately 5.7% of deaths.  In the meantime, the drivers of mortality in the developing world are underfunded, with 2,400 children dying every day of diarrhea.  November witnessed a fatal outbreak of measles—a vaccine-preventable disease!—in the Republic of Congo.

One may be forgiven for not noticing this.  After all, the New York Times runs stories like this bemoaning cuts in HIV funding, while glossing over the fact that that same money is being used for more sustainable and cost-effective interventions.  The Washington Post ran a similar article.  And Desmond Tutu’s op/ed in the Times struck a comparable chord.  But this criticism betrays a lack of understanding of the global burden of disease.

HIV is a tremendous problem in Botswana and many other countries in sub-Saharan Africa.  However, in the seven largest countries in the world by population (comprising 3.5 billion people), HIV isn’t the scourge it is in Botswana.  Sure, this list includes the United States (a decidedly rich country), but the rest of list is not so rich: Bangladesh, Brazil, China, India, Indonesia, and Pakistan.  These countries are home to some of the poorest people in the world and yet not one of them has an HIV prevalence greater than 0.6%.  (At the risk of digressing, did you know that in China HIV used to be known as aizibing, the "loving capitalism disease"?)  Pneumonia, diarrhea, and cardiovascular disease are all greater killers in these countries, but receive less funding.  By overfunding HIV interventions, we are underfunding the billions of people in these countries.

This guy's got bigger problems than HIV to worry about.

So why does HIV receive so much attention and so much money?  To address this, I have to diverge from an evidence-based approach to mere conjecture.  It is my theory that HIV simply scares us in a way that other diseases don’t.  In the late 1980s and early 1990s, we had little understanding of this new plague that was killing young people in the prime of their lives.  Uniformly fatal at the time, HIV represented something new and frightening.  On the other hand, every reader of this blog has had diarrhea and probably has a difficult time imagining it being fatal.  Even when it is extremely fatal and contagious, we call it something else like "cholera", further reinforcing the idea that "diarrhea" is not all that serious.  In our minds HIV is a harbinger of death while diarrhea is merely an inconvenience.  Perhaps we use this fear as justification for throwing money at HIV.  Or perhaps it's because today our treatments for HIV are so effective we want to share them with the world.  While noble, such an attitude fails to recognize the scarcity of global health funding and the dire need for rational spending.

These beds were designed for patients with cholera.  Still doubt the lethality of diarrhea?

I have heard the counterargument that HIV money is not fungible, that donors who give to HIV-related causes might not give anywhere otherwise.  If this is true, then please forward this article to them.  However, I believe that people aware enough to comprehend the seriousness of HIV, can also grasp the urgency of maternal and child care, the need for water and sanitation, and the importance of other elements of primary care.  I also have been told that HIV is not overfunded, but rather is only less underfunded than other diseases.  This may be true, but in a world of scarce resources, it is incumbent that we rely on cost-effectiveness to determine our priorities, and our current practices are not in line with such evidence-based decision-making.  It may be true that the increase in global health spending over the past decade has been catalyzed by the HIV pandemic—perhaps HIV has raised international awareness of the plight of the world’s poor—, however, this does not justify continuing the present imbalance.

An optimist may hope that HIV funding be spent to build sustainable public health infrastructure.  If such funds were used to build clinics and train local health workers, then they could be applied to help everyone in need, including—but not limited to— those with HIV.  Whether this is happening is an open debate—Paul Farmer and Laurie Garrett have discussed this in Foreign Affairs—, but the results have been far from encouraging.

In the end, it is essential that we have facilities, services, and personnel capable of handling all manners of disease.  If HIV is overfunded, the solution is not to increase funding of pneumonia, diarrheal diseases, or any of the other leading causes of death in the developing world.  If we’re looking for the biggest bang for our limited number of bucks, primary care infrastructure is the best bet.  Scattershot approaches to public health are ineffective for comprehensively combating disease and always leave us vulnerable to the next epidemic.  However, a firm and sustainable public health foundation equips us to deal with health challenges as they arise, be they new infections or chronic conditions such as cardiovascular disease and diabetes that are sure to increase in coming years.

The global burden of disease is strikingly conserved and ever dynamic.  Some diseases have killed for years, while each decade witnesses a new epidemic.  In our struggle to provide the best care for the most people in unpredictable environments, we must maintain a rational approach to resource allocation.  As such, we must face facts: HIV receives too much of a too small amount.

The Way of the Future for Social Services

The purpose of this post is simple. I want to point out the ridiculousness in that we have embraced high quality, low-cost production for things like shoes and cat food, but not for important products in our lives like healthcare and education. Let's think about what industrialization has done to footwear. Three hundred years ago, you probably had to go to your local shoemaker. This shoemaker had to be trained as an apprentice by another expert shoemaker. The only people that made shoes were shoe experts, and because expertise was needed, shoemaking was in their hands. This expertise was rare and hard to come by, so not everyone had access to a shoemaker or one capable of making quality shoes. This shoemaker practiced shoemaking off on his own, requiring him to own all of the tools of the trade, and these capital costs were passed on to the consumer. But eventually shoemakers realized they could make shoes cheaper, and therefore could reach more people and sell to them. They did this with industrialization. They standardized the processes, shifted tasks to non-experts, and increased volume. This lowered costs, standardized quality, and changed our footwear possibilities forever. 

We went from this...

... to this

We now have thousands of footwear choices, at different prices, for different situations. Standardization at first meant less complexity, but by building these systems we now have more footwear options than an individual shoemaker would ever be able to provide. Important to note is that in addition to footwear production being industrialized, so is the sales relationship. Foot Locker doesn't produce sneakers, but they have non-experts that can size your foot, etc. And so industrialization has gone from footwear to finance to food. With industrialization, experts build the systems and the standardized processes to make things happen at scale. But this hasn't happened in medicine and education (and development broadly). These sectors have remained cottage industries. Because of government or non-profit provision, the economic incentive to move to these delivery models hasn't occurred. Because of various professional trade groups, these shifts have been resisted. And the effects are embarrassing. We practice medicine with practically the same delivery model that we had 50 years ago. We practice education with the same delivery model as a 100 years ago.

Yet over the last few decades and centuries, other industries have embraced these shifts. Take for instance the information systems of McDonald's vs. a hospital vs. a classroom. The McDonald's has computer-based ordering which has a workflow that guides low-expertise, task-shifted employees to run a restaurant. With this system, McDonald's can operate thousands of restaurants. The hospital likely has paper records that require experts to write notes readable to other experts. If they happen to be using an electronic system, the workflow still doesn't enable lesser trained non-experts to manage diabetes or follow vaccine schedules or prescribe antibiotics - the system is simply an electronic version of the same medical notes taken by paper records. And similarly in schools, how much has technology been used to enable teachers to manage self- and peer-based learning that is far more effective? Unfortunately, not so much. But these barriers to change don't mean that if industrialized versions are built that they won't be wildly successful.

I am happy to report that this is already where we are going. Many patient safety advocates in the US like Peter Pronovost and Atul Gawande (The Checklist) have similarly been pushing for standardization, although less so for the cost benefits and more so for the quality improvement benefits. Business strategy guru Michael Porter has built an entire literature on the healthcare delivery value chain, and he makes use of these successful examples in his case studies. In India, the Aravind Eye Hospital has built a system of eyecare services that serves a population the size of the United Kingdom, with the same quality outcomes and with over an order of magnitude less cost. And so it should go for social services. Experts make a service standardized.

Standardized means task shifting. Task shifting means scale. Scale means high volume. High volume allows unit costs to be lowered. High volume, standardized, low cost. Those concerned with social services having high quality, low cost, and equitable access should embrace these trends toward industrializing social services. Yes, there will be those that will resist these changes. Some will have reasonable complaints that industrialized services will have to deal with seriously. Many people that resist will simply have vested economic interests or old-fashioned beliefs about how medicine and education should be done. But ultimately, anyone, especially those working in developing countries, who is concerned with equity, social impact, and national financial security will be forced by these successful low-cost examples to see the way of the future.