Unintended irony about cost-effectiveness

Some thoughts on the unspoken history in an article from the Wall Street Journal about cost-effectiveness in global health.

I have been spending more time these past several weeks on Twitter, the short-form micro-blogging platform, rather than on the blog. (I'm @cgorman.) There are obvious limitations to Twitter's 140 character limit. But I find it's a great way to quickly pass along time-sensitive information, as well as get a kind of "temperature reading" of what some of the big issues are thought to be.

It's also exactly the right format to quickly point folks to news articles--like the one that Amy Dockser Marcus of the Wall Street Journal wrote in an intriguing piece titled, "To Fix Health Care, Some Study Developing World."

But it's hard to fit into 140 characters what I thought was missing in Marcus's article. It's a perfectly fine piece of journalism, a good introduction. But there is a lot more to this story.

You get a hint of it in Marcus's praise of the Prevention and Access to Care and Treatment (PACT) Project in Boston. That program was started by Partners in Health in 1995.

The main thrust of Marcus's article is about international programs that provide better health for less money. In other words, the benefits of cost-effectiveness--as seen in poor countries.

Regarding cost-effectiveness: PIH leaders like Paul Farmer and Joia Mukherjee will tell you over and over again that too many in global health are slaves to the idol of cost-effectiveness. (Note, these are their friends they are talking about--the folks who believe in global health.) Farmer and Mukherjee see an unthinking allegiance to cost-effectiveness as a sledge hammer that is often used to deny access to health care for the poor and marginalized.

Regarding health care in poor countries. Mukherjee recently had an op-ed in the Boston Globe slamming the IMF for cutting public sector spending in health and education amongst poor countries as a condition of receiving loans in the 1980s. Part of the reason so many countries were open to working with PIH to develop the sorts of programs praised by the WSJ was because their original government health plans were destroyed by budget cuts demanded by "structural adjustment programs."

The irony, as Mukherjee and her co-author wrote, is astounding. "Today, market-based, financial-sector strategies have failed so miserably that nothing but massive public spending can rescue even the wealthiest economies. The United States itself has used trillions of dollars of public monies to stimulate the economy and secure private institutions. Yet expansionary public spending will not be possible in poor countries if the IMF is given free reign to restrict public expenditures."

So, Twitter for short bursts of information (like headlines). Blogs for looking a little deeper. All of it is a process that sometimes even produces good products.

Related Posts:
Do We Get Our Money's Worth in Global Health?
How I Use Twitter Without Being Overwhelmed

Do We Get Our Money's Worth in Global Health?

Two carefully researched reports in the Lancet argue that the world is not getting its money's worth in global health.

The first, from the World Health Organization, says that a focus on making improvements in individual diseases--like AIDS--has come at the expense of comprehensive programs that offer treatment for all the most pressing health problems.

The other, from Institute for Health Metrics and Evaluation in Seattle, documents a quadrupling of funds for global health since 1990 but shows that some of the poorest countries with the highest disease burdens have actually received less help than somewhat healthier and wealthier countries. In addition, the IHME paper documents the shift in power and influence from government and public agencies to private foundations--like the Gates Foundation, which funded the study--and individuals.

Both research articles--and the accompanying comments and editorials--are well worth reading at length and at leisure (which I plan to do this weekend). I do not know if these articles will spur any changes in direction or action on the ground but I have a feeling we will be hearing about these pieces for some time to come.

Several of the blog posts I have read so far about these studies are rehashes of the press releases that accompanied them. Given the nuances of the arguments and the complexity of the data, it may take a while for more thoughtful reviews to appear.

Maria Cheng's article for the Associated Press is a good, if basic, introduction to the papers. Kaiser Health News says they will post an aggregation soon--and here it is.

Health-Eight Meet in Seattle

Sandi Doughton of the Seattle Times lifts the lid a bit on one of the more exclusive clubs in global health--the Health-8 or H8--meeting this week in Seattle.

Her report documents one more step in the ongoing privatization of global health as power and influence drain away from public groups--like the World Health Organization--to private foundations and non-profit organizations.

Given the reactions in Doughton's article, folks don't seem too concerned about the lack of transparency. After all, it's not like Hilary Clinton having secret talks about health care during her husband's administration or Dick Cheney chatting about energy policy with petroleum execs--right?

Related Post:
Who are the Health 8 (or H8)?

Malawi Project Featured in American Journal of Nursing

I am happy to report that a photo-essay about my Malawi project is the cover story for the June issue of the American Journal of Nursing. That great cover photo of Mphatso Nguluwe was taken by my friend Eileen Hohmuth-Lemonick who joined me on my three-month Malawi trip last year.

Mphatso is a great story-teller, who likes to tell her fellow Christians that she is the mother of nine children by eight different fathers. It's a great teachable moment that I wrote about last July.

My project focused on the nursing shortage in Malawi as a kind of a kind of window into how health systems function in poorer parts of the world. Malawi is in the midst of a six-year program to address its nursing shortage by paying nurses more and supporting more nursing education and training.

Part of what I learned in Malawi is how fragmented and overly narrow most efforts at improving health turn out to be. We think that having more drugs or more nurses and doctors will automatically improve conditions without considering the need for better roads, clean running water or functioning secondary schools to make sure those efforts succeed.

Because it's easier to raise money for a single issue--like AIDS or polio vaccines or girls' education, we continue to maintain (and tell stories about) siloed efforts that don't intentionally contribute to broader, more long-term needs like primary care. There was a study about that from the Institute of Tropical Medicine in Antwerp just yesterday in the Public Library of Science.

I don't understand why--if it took me only three months to figure this out--the professionals who do this for a living still can't seem to adjust their efforts accordingly. As the PLOS study suggests, they must already know this. But then, as the saying goes, "It is difficult to get a man to understand something when his salary depends on his not understanding it."

I tried to get at some of these themes with the photos and captions that are part of the AJN essay as well as the supplemental material that is available online. When I suggested to Diana Mason, the outgoing editor-in-chief, that both be made available for free to non-subscribers as well since they reflect on health in the developing world, she readily agreed. Well, as another saying goes (two aphorisms in one post--that probably exceeds the limit), "it is better to strike even a tiny light than to curse the darkness."

Related posts:
Hiding Broken Practices Behind New Catchphrases
At Work with Malawi's Nurses

Update: Related 10-minute podcast with Christine Gorman on the AJN site

Hiding Broken Practices Behind New Catchphrases

Here is another example of why we need more independent reporting on global health and development. A study from the Public Library of Science found that many global health initiatives are still effectively siloed efforts that focus on single diseases or institutions and do not, despite claims to the contrary, support overall health systems.

And yet, as I have seen in my own travels through Malawi, Lesotho, South Africa and Zambia, improving health systems is precisely what is needed in many poor countries and impoverished areas. "Health system strengthening" has become the new catchphrase but, according to the PLOS report and the lived experience of many in the global health field, there has been no real change in action to support this goal.

One positive trend: the researchers note that while their funding came from the Institute of Tropical Medicine, Antwerp, "the funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript." This slightly more detailed conflict-of-interest statement should be adopted more widely when reporting or writing about global health.

Related post:
Who Pays for Global Health News and Why?

Who Pays for Global Health News and Why?

To maintain credibility, news coverage of global health and development issues must be independent because who pays and why dramatically influences the process of what gets told. This is a sleeper issue that does not get enough attention. As a health journalist, I know we have been down this road before—with respect to misleading consumer news coverage of medications and research studies—and it’s not pretty. In the end, it actually hurts people and wastes money.

It hit me last night why I am so passionate about this topic. I went to a presentation about how to improve health care news coverage in the U.S., which was mostly about how many health news reports don’t cover basic issues like costs, availability or provide even a hint of context about whether something is truly broadly beneficial. The event was sponsored by the New York City chapter of the Association of Health Care Journalists, of which I am a member.

One of the presenters, Gary Schwitzer, a former CNN journalist and current journalism professor who founded HealthNewsReview.org, jokingly suggested that I might throw spitballs at him while he was at the podium. (The other presenter was Harry DeMonaco, who helps Boston's Massachusetts General Hospital decide what treatments are both beneficial and cost-effective.) Instead, Schwitzer provided me with an aha! moment.

For more than 20 years, I have worked in an environment where pharmaceutical and medical device companies have a huge vested interested in getting their products covered by the mainstream media in the best possible light.

As Gary Schwitzer and Harry DeMonaco noted, the economic incentives are so great that the influence extends even to what appears in medical journals. Drugs are often compared against placebo instead of current effective treatments, for example, because the results are more dramatic that way. No one can take a chance on a new medication being scientifically shown to be just as good or only marginally better than a less-expensive one.

Add to that human nature—it is very hard to be objective about something to which you have dedicated lots of your time and energy. So naturally, someone who is a principal investigator on a study is going to be enthusiastic about the work and its potential for alleviating human suffering.

I know that—as do many of my colleagues in the health journalism field. And I hope that I have taken account of those sorts of positive psychological and economic biases in my reporting by looking for more outsides sources, bringing a respectful-but-still skeptical attitude to most research studies.

Just as importantly, I benefited from the structural divide that was set up within TIME Magazine that kept the advertising side separate from the editorial side precisely so that I could be as independent as possible in doing my job.

So here I am, trying to get more news coverage—both online and offline—of important issues in global health and development and I find the same built-in biases that make health-reporting trickier than you might at first think.

There is a built-in bias in almost any story about non-government organizations against considering what governments are doing in health. Every story about a specific disease has a built-in bias against discussing primary care systems or the non-medical interventions (like better schools or roads or robust legal and civil rights for women) that could conceivably have an even greater impact.

The consequences are very real. To give just one example, I will never again be able to read another laudatory story about the “generous donation of medical supplies” without thinking about the amount of donated material that I saw in Malawi last year that had either passed its expiration date or was actually useless—and needed to be discarded, all at the expense of the receiver. This is the sort of problem that missionaries 50 years ago dubbed “junk for Jesus.” It makes the folks back home feel virtuous but it is a burden for the supposed beneficiaries.

Given the costs and the way things are going these days in journalism, there is bound to be money coming from interested parties whether in the form of grants, advertising or even accepting a ride in an aid convoy, to cover global health issues. That’s all the more reason to set up rigorous firewalls so that funders and advocacy groups don’t get editorial approval over the final product. News organizations also need to make those policies public so that the larger community can judge for itself how well they are doing.

Budding global health news organizations—or content providers—also need to be more creative about who they tap as funders/advertisers. Maybe recruit the folks who like to fund transparency projects, for example, instead of going after global health or single-issue advocacy money.

There may also be ways of crowd-funding global health news coverage that we haven’t explored.

But I know we need to be paying as much attention to managing these conflicts within the coverage of global health news as we are to “monetizing content,” to use the current buzz-phrase. And it's just as much an issue for citizen journalists/participatory media as for legacy or professional journalists.

Related posts (updated on May 20,2009)
Click #ghnews label for other posts on covering global health
See also "Pro-Publica and Conflicts of Interest"
Read Ivan Oransky's live tweets from Monday night's AHCJ event with Schwitzer and DeMonaco.

Barbara Hogan, Paul Farmer, Eric Goosby and More

And now for a little global health gossip--in between reading dispatches from the World Health Assembly, which is meeting in Geneva this week . . .

Barbara Hogan is out as South Africa's Health Minister--just a few days after being named one of Time Magazine's 100 Most Influential People in the World. Was she too outspoken about the need for greater transparency and accountability for South Africa's AIDS treatment programs? Too critical about the government's refusal to issue a visa to the Dalai Lama? Is the ANC government that petty? Or is this just normal shuffling of cabinet positions? South Africa watchers are taking a watch-and-see approach--especially since the new Health Minister, who comes from Limpopo, is not widely known.

Paul Farmer has told colleagues he is contemplating a possible position with the U.S. government.

And in other news,

Eric Goosby, who has been tapped by President Obama to replace Mark Dybul as U.S. Global AIDS Coordinator (head of PEPFAR), will be speaking at the Global Business Coalition on AIDS annual conference June 23-24 in Washington, DC. Dybul will be there as well in his new role as co-director, with Larry Gostin, of the Global Health Law Center at Georgetown University. (Dybul joined Georgetown in February).

Thomas Frieden, New York City's health commissioner, is Obama's pick to head up the Centers for Disease Control. Revere, in his unique way, highlights some of the challenges Frieden will face.

And if you're in Washington, D.C. for the Global Health Coalition annual conference, don't miss Katrin Verclas on Wednesday morning, May 27. She organized the excellent barcamp conference on Mobile Tech For Social Change that I attended in New York City back in February and is a crackerjack organizer and advocate for what mobile phones can do for health, finance, accessing the Internet, changing the world.

Oh, and this just in. . . the London School of Hygiene and Tropical Medicine, just won the $1 million Gates Award for Global Health, given out each year at the Global Health Coalition meeting.

Afghanistan: First Acid, Now Gas Attacks Against Girls

Reuters reports that three girls' schools in Afghanistan have now been the targets of improvised gas attacks. Five girls fell into comas for a short while after the most recent attack, which occurred on Tuesday, while 100 others were hospitalized. Apparently, throwing acid at some girls, wasn't enough to convince many of their sisters to stop their education.

The news of the attacks has kept hundreds of girls from showing up at school, according to the Associated Press.

Still unclear: what kind of gas was used. Blood samples have been sent for testing. There is also a chance that a gas leak--as opposed to a premeditated attack was involved at the third school.

Also disturbing, the attacks are happening in Kapisa province, a region east of Kabul that has been relatively open and supportive of girls' education.

Related news:
Katie Couric had a piece on the CBS News about the assassination of a women's rights activist in Afghanistan and the passage of a new law that (may be changed) that would allow marriage as a defense against rape.

Crisis-Mapping the Sri Lankan Fighting

Is there a way to combine human and technological intelligence to figure out what is going on in a tiny section of Sri Lanka, which suffered heavy bombardment this past weekend? Can you, dear reader, help collect that information?

The American Association for the Advancement of Science has published satellite imagery which suggests heavy shelling and mass movement of people. (hat tip @mwmcelroy who works at the AAAS.)

According to the Associated Press (as quoted in the New York Times), "a government doctor said at least 378 civilians — and perhaps as many as 1,000 — had been killed and more than 1,100 wounded on Saturday and Sunday during intensive shelling of the combat zone on Sri Lanka’s northeastern coast, a boggy sliver of beachfront where Sri Lankan troops have surrounded Tamil separatist fighters." (Click here for the full AP report, which details three rounds of shelling on the hospital.)

Journalists report not being allowed into the area to report on what is going on.

This seems like quite a test case for folks who promote the benefits of crisis-mapping.

Crisis-mapping is an emerging technology that uses SMS or mobile texting plus other crowd-sourced pieces of information to map a crisis, while it is happening. The idea is to give folks on the ground as well as those far away some idea of what is going on and which areas are particularly dangerous in real-time. Click here for a video introduction to crisis-mapping from Patrick Meier, whose dissertation features a lot about crisis-mapping and who has been traveling the globe recently introducing folks to it.

I am asking my larger Twitter and blogging community for help in gathering resources. Will share the results here.

Human Health Effects of DDT

Several folks, after reading my last post on DDT, have asked me about DDT's health effects on people. Their point: while DDT may prevent some people from dying of malaria isn't there a cost to their long-term health?

Once again, context is key. The major negative effects of DDT have been on animals--particularly birds and fish. This is very important and not something the environment can sustain, especially since DDT accumulates in any animal's fat tissue (including people's).

As far as we know, DDT's health effects on people are minimal compared to that on fish and birds--something that was straightforwardly acknowledged last year on the website of the World Resources Institute, where Al Gore serves on the board of directors.

More recently there has been some research to indicate that DDT may act as a hormone disrupter and affect fertility as well as promote premature delivery. Animal studies have also suggested a possible cancer risk--but once again that would presumably be at very high dose.

So, if you are just going to look at health effects in people, the scales tip toward using DDT in those parts of sub-Saharan Africa in particular where it would be most helpful.

This is the same kind of cost-benefit ratio that is seen with giving polio vaccines that also sometimes cause the disease itself.

The cost to the environment is the more worrying issue--and something that needs to be addressed whenever DDT is used as part of an anti-malaria program. Fortunately, the amount of DDT that is needed for residential spraying is small. South Africa has shown the spraying can be done with minimal impact on the environment--by training sprayers and making sure no DDT is diverted to agricultural use.

It's a fascinating topic--and hard to find experts who are truly impartial. In my experience of reporting on the topic, people from both the left and right use DDT to score political points without regard to what facts are like on the ground.

Makes me think I should look more closely at the latest report that the World Health Organization has decided to work towards the total elimination of DDT, perhaps even in malarial zones.

Related posts:
Back and Forth on DDT Again
Can Malaria Be Eradicated?