Stesheni kumi na moja

I’m a bit late to the “social science bloggers love Station Elevenparty. Chris Blattman put it in his 2014 favorite novels list, and Jay Ulfelder shared a nice excerpt. I loved it too, so I’ll try to add something new.

Station Eleven is a novel about what happens after – and just before, and during – a flu pandemic wipes out 99% of the human population. The survivors refer to that event as the Collapse, and mostly avoid talking about or thinking about the immediate aftermath when all was a fight for survival. But Station Eleven is not just derivative post-apocalyptica. The book avoids a garish focus on the period just after the Collapse, but instead focuses on the more relatable period just as things are beginning to unravel, and much later, as bands of survivors who made it through the roughest bits are starting to rebuild. The main characters are a band of musicians and thespians who are trying to retain some of the cultural heritage and pass it on to the next generation, who have no memory of the world before the Collapse.

It’s also a novel about loss, both personal and societal. One of my favorite passages:

…No more ball games played out under floodlights. No more porch lights with moths fluttering on summer nights. No more trains running under the surface of cities on the dazzling power of the electric third rail. No more cities.… No more Internet. No more social media, no more scrolling through the litanies of dreams and nervous hopes and photographs of lunches, cries for help and expressions of contentment and relationship-status updates with heart icons whole or broken, plans to meet up later, pleas, complaints, desires, pictures of babies dressed as bears or peppers for Halloween. No more reading and commenting on the lives of others, and in so doing, feeling slightly less alone in the room. No more avatars.

Since I was reading this novel while traveling for work in Tanzania and Zimbabwe and Liberia, I was struck by its focus on Canada and the US. Nothing wrong with this: the author is Canadian* and the presumed audience is probably North American. But I kept wondering what the Collapse would have been like elsewhere. It was global, but would it have been equally catastrophic elsewhere? Urban centers like Manhattan are ludicrously unworkable in the absence of the electricity and cars and subways and other bits of the massive, distributed, and – to casual eyes – largely invisible infrastructure working to constantly feed them with supplies and people and information.

The novel implies that these urban centers fared worse, and focuses on suburbia and rural areas, where survivors re-learn how to farm, how to make things for themselves. We see nothing of the global “periphery” where the fall from wealth might be less great, where the collective psychological trauma of losing 99 out of 100 people might dominate the loss of technology. Of course, the periphery is defined by the observer and the writer, and isn’t the periphery at all to those who live in it. Maybe things would fare better, or maybe not.

Imagine the same novel, but set in Tanzania, or some other country where the majority of people are small-holder subsistence farmers. Maybe it would use the device of following two relatives, one living ‘upcountry’ or in ‘the village’ (i.e., poor rural parts) and the other living in Dar es Salaam. Relationships are established in an early chapter when the successful urban relative visits the village, or the rural relative visits the big city, and both marvel at their differences.

Then the flu hits, and things start to break down. Narrative chapters are intersperse with transcripts of SMS (text message) exchanges, demands for mPesa transfers, the realization that money doesn’t matter anymore, and finally the realization that the networks aren’t getting anything through anymore. Some city dwellers flee for the countryside but find themselves shunned as bearers of contagion. The urban protagonist makes her way, over the course of months or years, to the rural area where her relative once lived, hoping to find things are better there. Her belief that the village will be the same mirrors the readers’ belief – and common trope in writing about developing countries – that subsistence farmers today somehow live just as they did centuries or millenia ago. Bullshit, of course.

As the urbanite nears the village, her encounters reveal all the ways the modern fabric of village life was related to society and technology and has likewise broken down with the Collapse. Perhaps the power vacuum set off struggles amongst survivors and led to some new social order, where none of her skills are that useful. Nearing the village, she finds that the rural relative is now leader, revealing his situation has been reversed by the Collapse just as the once successful urbanite finds her way into his village with her last shilling.

Maybe this novel already exists. Or something else using the post-apocalyptic form to explore somewhere that’s not Canada or the US or Europe and not reliant on mechanized agriculture. Pointers, please, as I’d love to read it.

*originally I wrote the author was American. Oops. Apologies, Canada!

"The opening deal"

I liked this quote from economist Karthik Muralidharan, which is pulled from a conversation at Ideas for India with Kaushik Basu of the World Bank:

My own take on what is happening in economics as a profession, talking to people in other disciplines, is that our fundamental weakness at some level is that because the touchstone of policy evaluation is the idea of a Pareto improvement (is someone better off and no one worse off) – effectively, economists do not question the justice of the initial positions. You kind of take the initial position as granted and say that conditional on this, how do I improve things on the margin.

Given vast inequalities in the opening deal of cards, so to speak, there is obviously a deep political need to create the space for more pro-poor policy. I think because the professional economists have abdicated that space to saying that it is a philosophical debate and we have really nothing to say, the rights-based movement that has created the political space for pro-poor policy has also then occupied the space of how to design it because they are the people who have created the political movement.

My own view on this is that because economists have kind of been seen as apologists for the status quo in many settings, we have lost the credibility to say that we are as pro-poor as you are, but conditional on these objectives there are much better ways to design it.

Lots on poverty policy, inequality, etc at the link.

Adaptive Ebola vaccine trials

There’s a New York Times Room for Debate feature has an excellent discussion of the ethics of trials for Ebola treatments and vaccines. Here’s part of the essay by Nancy Kass and Steven Goodman:

Ethics is not just figuring out which side poses better arguments; often it’s best to find a third way. Given the breadth and deadly nature of the current Ebola outbreak, and unknowns about treatments, an “adaptive approach” seems most appropriate. Adaptive approaches allow researchers to plan a sequence of studies, or modify a single study in almost real time, as they learn more about a drug. In West Africa, for example, the first 40 Ebola patients in a trial could all get an experimental treatment, and nobody would take a placebo. If nearly all patients survived, in settings where most others were dying with the same supportive care, then it is possible that placebo testing could be avoided, and subsequent trials could randomize to different doses or treatments.

But if the results of the first trial, without placebos, revealed anything less than an almost certain cure, a design with proper controls would have to be initiated, and explained to those participating in the trial. Patients must be told that the drug is not a guaranteed life-saver, so they can see the point of the control group. (And given the multiple beliefs about Ebola among West Africans, creative approaches to promoting understanding and consent are important as well.) These placebo-controlled trials could themselves be adaptive in design, randomizing more patients to whichever therapy appears most effective, until the verdict is clear. If we are to design trials to minimize suffering and death in a whole population, we must temper our compassion with humility about what we think we know.

Uganda is beautiful

I’ve been in Uganda the last few weeks helping with the implementation of a large scale survey: a representative national household survey and survey of drug retailers and healthcare providers, all focused on the availability and usage of essential medicines for childhood illness. The system we’ve set up is pretty cool, with data collection on Android tablets via ODK meta and real time checks for data quality (by teams, individual interviewers, and individual interviews) and feedback to the survey group, which I hope to write up at a later date.

In the meantime, I wanted to share some photos of Uganda, which is really, really beautiful. There’s a whole album here, and below are some highlights:


Terrible choices

Les Roberts, an epidemiologist who teaches at Columbia, is currently working with WHO on the Ebola epidemic in Sierra Leone. Columbia is sharing his blog posts here.

The latest post, from 3 days ago in Freetown, details efforts to triage patients to prevent additional infections. Things just keep getting worse, and it’s to a point where there are no good choices, only terrible choices and slightly less terrible ones. An excerpt:

We are about to assist thousands and thousands of people to die an excruciating death at home without even the most mild of pain relief. We are going to set up treatment facilities in hundreds of villages for one of the most deadly of diseases to be largely run by volunteers who will be lucky to get 3 days of training. Dozens, perhaps hundreds of them will die. And the most surreal aspect of this triage for me is that I completely think that this is the right thing to do given where we are and the limited ability to respond.

Read the rest.

Overheard in Maseru

Last Friday afternoon I was leaving Lesotho via the Maseru airport. An African gentleman — country unknown — was standing in front of me in the short line for the immigration passport check. The immigration officer greeted the man in Sesotho, asking him a question. From behind his body language seemed confused, and then he asked a question in English.

The immigration officer said, “Oh! You are not Basotho. I mistook you for one of my brothers.”

“No, no,” laughing. “But I am still an African. We are all brothers.”

He takes his passport, examines it, and stamps. “Yes, we are brothers.”

“We have the same problems, so we are brothers.”

“Yes, we do have those.”

Monday miscellany: Ebola links

A couple academic articles (expect a lot more in the near future):

Maia Majumder is updating excellent charts based on the latest outbreak data: example here.

Kim Yi Donne wrote this almost a month ago now: Why West African governments are struggling in response to Ebola

Tara Smith is one of the best sources for analysis on this outbreak — you should probably just go ahead and follow her on Twitter too:

On Z-Mapp, the little-tested and completely unproven experimental serum:

Other articles:

Ebola and health workers

It starts with familiar flu-like symptoms: a mild fever, headache, muscle and joint pains.

But within days this can quickly descend into something more exotic and frightening: vomiting and diarrhoea, followed by bleeding from the gums, the nose and gastrointestinal tract.

Death comes in the form of either organ failure or low blood pressure caused by the extreme loss of fluids.

Such fear-inducing descriptions have been doing the rounds in the media lately.

However, this is not Ebola but rather Dengue Shock Syndrome, an extreme form of dengue fever, a mosquito-borne disease that struggles to make the news.

That’s Seth Berkley, CEO of the GAVI Alliance, writing an opinion piece for the BBC. Berkley argues that Ebola grabs headlines not because it is particularly infectious or deadly, but because those of us from wealthy countries have otherwise forgotten what it’s like to be confronted with a disease we do not know how to or cannot afford to treat.

However, in wealthy countries, thanks to the availability of modern medicines, many of these diseases can now usually be treated or cured, and thanks to vaccines they rarely have to be. Because of this blessing we have simply forgotten what it is like to live under threat of such infectious and deadly diseases, and forgotten what it means to fear them.

Ebola does combine infectiousness and rapid lethality, even with treatment, in a way that few diseases do, and it’s been uniquely exoticized by books like the Hot Zone. But as Berkley and many others have pointed out, the fear isn’t really justified in wealthy countries. They have health systems that can effectively contain Ebola cases if they arrive — which I’d guess is more likely than not. So please ignore the sensationalism on CNN and elsewhere. (See for example Tara Smith on other cases when hemorraghic fevers were imported into the US and contained.)

But one way that Ebola is different — in degree if not in kind — to the other diseases Berkley cites (dengue, measles, childhood diseases) is that its outbreaks are both symptomatic of weak health systems and then extremely destructive to the fragile health systems that were least able to cope with it in the first place.

Like the proverbial canary in the coal mine, an Ebola outbreak reveals underlying weaknesses in health systems. Shelby Grossman highlights this article from Africa Confidential:

MSF set up an emergency clinic in Kailahun [Sierra Leone] in June but several nurses had already died in Kenema. By early July, over a dozen health workers, nurses and drivers in Kenema had contracted Ebola and five nurses had died. They had not been properly equipped with biohazard gear of whole-body suit, a hood with an opening for the eyes, safety goggles, a breathing mask over the mouth and nose, nitrile gloves and rubber boots.

On 21 July, the remaining nurses went on strike. They had been working twelve-hour days, in biohazard suits at high temperatures in a hospital mostly without air conditioning. The government had promised them an extra US$30 a week in danger money but despite complaints, no payment was made. Worse yet, on 17 June, the inexperienced Health and Sanitation Minister, Miatta Kargbo, told Parliament that some of the nurses who had died in Kenema had contracted Ebola through promiscuous sexual activity.

Only one nurse showed up for work on 22 July, we hear, with more than 30 Ebola patients in the hospital. Visitors to the ward reported finding a mess of vomit, splattered blood and urine. Two days later, Khan, who was leading the Ebola fight at the hospital and now with very few nurses, tested positive. The 43-year-old was credited with treating more than 100 patients. He died in Kailahun at the MSF clinic on 29 July…

In addition to the tragic loss of life, there’s also the matter of distrust of health facilities that will last long after the epidemic is contained. Here’s Adam Nossiter, writing for the NYT on the state of that same hospital in Kenema as of two days ago:

The surviving hospital workers feel the stigma of the hospital acutely.

“Unfortunately, people are not coming, because they are afraid,” said Halimatu Vangahun, the head matron at the hospital and a survivor of the deadly wave that decimated her nursing staff. She knew, all throughout the preceding months, that one of her nurses had died whenever a crowd gathered around her office in the mornings.

There’s much to read on the current outbreak — see also this article by Denise Grady and Sheri Fink (one of my favorite authors) on tracing the index patient (first case) back to a child who died in December 2013. One of the saddest things I’ve read about previous Ebola outbreaks is this profile of Dr. Matthew Lukwiya, a physician who died fighting Ebola in Uganda.

The current outbreak is different in terms of scale and its having reached urban areas, but if you read through these brief descriptions of past Ebola outbreaks (via Wikipedia) you’ll quickly see that the transmission to health workers at hospitals is far too typical. Early transmission seems to be amplified by health facilities that weren’t properly equipped to handle the disease. (See also this article article (PDF) on a 1976 outbreak.) The community and the brave health workers responding to the epidemic then pay the price.

Ebola’s toll on health workers is particularly harsh given that the affected countries are starting with an incredible deficit. I was recently looking up WHO statistics on health worker density, and it struck me that the three countries at the center of the current Ebola outbreak are all close to the very bottom of rankings by health worker density. Here’s the most recent figures for the ratio of physicians and nurses to the population of each country:* 

Liberia has already lost three physicians to Ebola, which is especially tragic given that there are so few Liberian physicians to begin with: somewhere around 60 (in 2008). The equivalent health systems impact in the United States would be something like losing 40,000 physicians in a single outbreak.

After the initial emergency response subsides — which will now be on an unprecedented scale and for an unprecedented length of time — I hope donors will make the massive investments in health worker training and systems strengthening that these countries needed prior to the epidemic. More and better trained and equipped health workers will save lives otherwise lost to all the other infectious diseases Berkley mentioned in the article linked above, but they will also stave off future outbreaks of Ebola or new diseases yet unknown. And greater investments in health systems years ago would have been a much less costly way — in terms of money and lives — to limit the damage of the current outbreak.  

(*Note on data: this is quick-and-dirty, just to illustrate the scale of the problem. Ie, ideally you’d use more recent data, compare health worker numbers with population numbers from the same year, and note data quality issues surrounding counts of health workers)

(Disclaimer: I’ve remotely supported some of CHAI’s work on health systems in Liberia, but these are my personal views.)