Archive for February, 2011

Monday Miscellany

I do most of my blog writing on weekends, scheduling posts ahead of time. Last week was midterms, and last weekend I was in DC visiting friends and studying, thus I got little writing done. I’m glad to be back this week, and will kick things off with a roundup of recent fascinatingness:

  • There’s a measles outbreak in the US. Interesting fact: we know that measles transmission has been stopped within the US because every time there’s an outbreak, investigators are able to sequence the virus and eventually match it to the region from which it was imported. See the CDC’s MMWR on the subject for more.
  • Amanda Glassman of the Center for Global Development comments on proposed new rules for kidney transplant prioritization in the US — a percentage of donated kidneys would be reserved for the youngest, healthiest transplant recipients. Glassman recently hosted an event at CGD on rationing that I was able to attend. Speakers included Andrew Dillon of the UK’s NICE and Sheri Fink, who recently reported this excellent series at PRI on various approaches to health care rationing around the world. Fink’s one book, War Hospital, is a compelling look at the struggles of doctors in the embattled Srebrenica enclave (pre-massacre) during the Bosnian War.
  • Risks of rare events are hard to conceptualize. Enter the micromort, a one-in-a-million probability of death.
  • The website for Poor Economics, a forthcoming book by Banerjee and Duflo, is pretty awesome. The overview section makes it sound like they overemphasize interesting findings about behavioral priorities and downplay structural reasons (lousy governments, poor trade policies, etc) but maybe that’s now born out in the text. I’m looking forward to reading this as well as Karlan and Appel’s forthcoming More Than Good Intentions.
  • Edward Carr recently finished live-blogging Dambisa Moyo’s Dead Aid–it’s a scathing review worth reading if you haven’t read the book but run into fans. I’ll admit that I didn’t get through it — I got frustrated early on with the imprecise definitions of terms and poor logic. I hope to finish at some point, but for now it’s pretty low on my list of priorities. This review of Moyo’s new book, How the West Was Lost is pretty damning: “[Dead Aid]’s runaway success baffled many with prior knowledge of the issues, even those broadly sympathetic to its sceptical tone, consisting as it did of a tendentious one-sided account of tired and inconclusive old academic literature about aid effectiveness. How the West was Lost contrives to lower these standards yet further.”
  • “Marauding Gay Hordes Drag Thousands Of Helpless Citizens From Marriages After Obama Drops Defense Of Marriage Act” (story)
  • John Shea argues in American Scientist, more or less, that the caveman from GEICO commercials is more accurate than the current anthropological view (sort of).

28

02 2011

Incentives?

From a lab assignment for my Professional Epidemiology Methods course:

…but part of this exercise is to remember that public health practice does not happen in a vacuum.  And if you do your job well, nothing happens and you may be blamed for interrupting daily life activities.  If you do not do your job well, people get sick or die–and you still get blamed.

26

02 2011

Why World Vision should change, but won't

Note: I’ve edited the original title of this post to tone it down a bit.

World Vision has recently come under fire for their plan to send 100,000 NFL t-shirts printed with the losing Super Bowl team to the developing world. This gifts-in-kind strategy was criticized by many bloggers — good summaries are at More Altitude and Good Intentions are Not Enough. Saundra S. of Good Intentions also explained why she thinks there hasn’t been as much reaction as you might expect in the aid blogosphere:

So why does Jason, who did not know any better, get a barrage of criticism. Yet World Vision, with decades of experience, does not? Is it because aid workers think that the World Vision gifts-in-kind is a better program? No, that’s not what I’m hearing behind the scenes. Is it because World Vision handled their initial response to the criticism better? That’s probably a small part of it, I think Jason’s original vlog stirred up people’s ire. But it’s only a small part of the silence. Is it because we are all sick to death of talking about the problems with donated goods? That’s likely a small part of it too. I, for one, am so tired of this issue that I’d love to never have to write about it again.

But in the end, the biggest reason for the silence is aid industry pressure. I’ve heard from a few aid workers that they can’t write – and some can’t even tweet – about the topic because they either work for World Vision or they work for another nonprofit that partners with World Vision. Even people that don’t work for a nonprofit are feeling pressure. One independent blogger told of receiving emails from friends that work at World Vision imploring them not to blog about the issue.

While I was one of the critical commentators on the original World Vision blog post about the NFL shirt strategy, I haven’t written about it yet here, and I feel compelled by Saundra S.’s post to do so. [Disclosure: I’ve never worked for World Vision even in my consulting work and — since I’m writing this — probably never will, so my knowledge of the situation is gleaned solely from the recent controversy.]

And now World Vision has posted a long response to reader criticisms, albeit without actually linking to any of those criticisms — bad netiquette if you ask me. Saundra S. responds to the World Vision post with this:

Easy claims to make, but can you back them up with documentation? Especially since other non-profits of similar size and mission – Oxfam, Save the Children, American Red Cross, Plan USA – claim very little as gifts-in-kind on their financial statements. So how is it that World Vision needs even more than the quarter of a billion dollars worth of gifts-in-kind each year to run their programs? To be believed, you will need to back up your claims with documentation including: needs assessments, a market analysis of what is available in the local markets and the impact on the market of donated goods (staff requests do not equal a market analysis), an independent evaluation of both the NFL donations (after 15 years you should have done at least one evaluation) and an independent evaluation of your entire gifts-in-kind portfolio. You should also share the math behind how World Vision determined that the NFL shirts had a Fair Market Value – on the date of donation – of approximately $20 each. And this doesn’t even begin to hit on the issues with World Vision’s marketing campaigns around GIK. Why keep perpetuating the Whites in Shining Armor image.

So to summarize Saundra S.’s remaining questions:

1. Can WV actually show that they rigorously assess the needs of the communities they work in for gift-in-kind (GIK)? especially beyond just “our staff requested them”?

2. Why does WV use a much larger share of GIK than other similarly sized nonprofits.

3. Has WV tried to really evaluate the results of this program? (If not, that’s ridiculous after 15 years.)

4. How did WV calculate the ‘fair market value’ for these shirts? (This one has an impact on how honestly WV is marketing itself and its efficiency.)

Other commenters at the WV response (rgailey33 and “Bill Westerly”) raise further questions:

5. Does WV know / care where the shirts come from and how their production impacts people?

6. Rather than apparently depending on big partners like the NFL to help spread the word about WV is doing and, yes, drive more potential donors to WV’s website (not in itself a bad thing) shouldn’t they be doing more to help partners like the NFL — and the public they can reach — realize that t-shirts aren’t  a solution to global poverty? After all, wouldn’t it be much more productive to include the NFL in a discussion of how to reform the global clothing and merchandise industries to be less exploitative?

7. WV must have spent a lot of money shipping these things… isn’t there something better they could do with all that money? And expanding on that:

Opportunity cost, opportunity cost, opportunity cost. The primary reason I’m critical of  World Vision is that there are so many things they could be doing instead!

For a second, let’s assume that GIK doesn’t have any negative or positive effects — let’s pretend it has absolutely no impact whatsoever. (In fact, this may be a decently good approximation of reality.) Even then, WV would have to account for how much they spent on the programs. How much did WV spend in staff time, administrative costs like facilities, and field research by their local partners coordinating donations with NFL and other corporate groups? On receiving, sorting, shipping, paying import taxes, and distributing their gifts-in-kind? If they’ve distributed 375,000 shirts over the last few years, and done all of the background research they describe as being necessary to be sensitive to local needs… I’m sure it’s  an awful lot of money, surely in the millions.

Amy at World Vision is right that their response will likely dispel some criticism, but not all. But that’s not because we critics are a particularly cantankerous bunch — we just think they could be doing better. Her response shows that, at least in one sense, they are a lot better than Jason of the 1 Million Shirts fiasco, if they’re spreading the shirts out and doing local research on needs — but those things are more about minimizing potential harm than they are maximizing impact. In short, World Vision’s defense seems to be “hey, what we’re doing isn’t that bad” when really they should be saying “you know what? there are lots of things we could be doing instead of this that would be much greater impact.” So in another way World Vision is much worse than Jason, because they have enough experts on these things to know what they’re doing and that this sort of program has very little likelihood of pulling anyone out of poverty, they know there are better things they could be doing with the same money, and they still do it.

To get to why I think that’s the case, let’s go back to WV’s response to the GIK controversy. From Amy:

At the same time, I’ll also let you know that, among our staff, there is a great deal of agreement with some of the criticisms that have been posted here and elsewhere in the blogosphere.  In my conversations, I’ve heard overwhelming agreement that product distribution done poorly and in isolation from other development work is, in fact, bad aid.  To be sure, no one at World Vision believes that a tee shirt, in and of itself, is going to improve living conditions and opportunities in developing communities. In addition, World Vision doesn’t claim that GIK work alone is sustainable.  In fact, no aid tactic, in and of itself, is sustainable.  But if used as a tool in good development work, GIK can facilitate good, sustainable development.

There are obviously a lot of well-intentioned and smart people at World Vision, and from this it sounds like there are differences of opinion as to the value of GIK aid. One charitable way of looking at the situation is to assume that employees at WV who doubt the program’s impact justify its use as a marketing tool —  but if that’s the case they should classify it as a marketing expense, not a programmatic one. But I imagine the doubts run deeper, but it’s pretty hard for someone at any but the most senior of levels to greatly change things from inside the organization, because it’s simply too ingrained in how WV works. Clusters of jobs at WV are probably devoted to tasks related to this part of their work: managing corporate partnerships, coordinating the logistics of the donations, and coordinating their distribution.

One small hope is that this controversy is giving cover to some of those internal critics, as the bad publicity associated with it may negate the positive marketing value they normally get from GIK programs. Maybe a public shaming is just what is needed?

[I really hope I get to respond to this post in 6 months or a year and say that I was wrong, that World Vision has eliminated the NFL program and greatly reduced their share of GIK programs… but I’m not holding my breathe.]

12

02 2011

Global health effects of nuclear war

Some morbid weekend reading: “The global health effects of nuclear war,” by Brian Martin, published in Current Affairs Bulletin in 1982. A section on overkill:

Many people believe that the capacity of nuclear weapons for ‘overkill’ means that all or most of the people on earth would die in a major nuclear war. In spite of the prevalence of this idea, there is little scientific evidence to support it.

Many calculations of ‘overkill’ appear to be made using the nuclear attacks on Hiroshima and Nagasaki as a baseline. Estimates of the number of people killed at Hiroshima from a 13kt bomb range from 63,000 to over 200,000. Adopting a figure of 130,000 for illustrative purposes gives ten people killed for each tonne of nuclear explosive. By linear extrapolation, explosion of a third of a million times as much explosive power, 4000Mt, would kill a third of a million times as many people, namely 40,000 million, or nearly ten times the present world population.

But this factor of ten is misleading, since linear extrapolation does not apply. Suppose the bomb dropped on Hiroshima had been 1000 times as powerful, 13Mt. It could not have killed 1000 times as many people, but at most the entire population of Hiroshima perhaps 250,000. Re-doing the ‘overkill’ calculation using these figures gives not a figure of ten but of only 0.02. This example shows that crude linear extrapolations of this sort are unlikely to provide any useful information about the effects of nuclear war.

12

02 2011

History refresh: AZT and ethics

A professor pointed me to this online history and ethics lesson from the Harvard Kennedy School’s Program on Ethical Issues in International Research: The Debate Over Clinical Trials of AZT to Prevent Mother-to-Infant Transmission of HIV in Developing Nations. It’s surprisingly readable, and the issues debated are surprisingly current.

In 1994, researchers in the US and France announced stunning news of a rare victory in the battle against the AIDS pandemic. Studies conducted in both countries had shown conclusively that a regimen of the drug AZT, administered prenatally to HIV-positive pregnant women and then to their babies after birth, reduced the rate of mother-to-infant transmission of HIV by fully two-thirds. The results of the clinical trials constituted “one of the most dramatic discoveries of the AIDS epidemic,” the New York Times declared, and one of the most heartening as well.

The new regimen–known by its study name, AIDS Clinical Trials Group (ACTG) 076 or, often, simply “076”–offered the epidemic’s most vulnerable targets, newborns, their best hope thus far of a healthy childhood and a normal life span. The number of infants who might benefit from this research was significant: according to World Health Organization (WHO) figures, as many as five to ten million children born between 1990-2000 would be infected with HIV. In the mid-1990s, it was estimated that HIV-infected infants were being born at the rate of 1,000 a day worldwide.

So impressive were the findings of ACTG 076–and so substantial the difference in the transmission rate between subjects given AZT and those given a placebo (eight percent versus 25 percent)–that the clinical trials, which were still ongoing, were stopped early, and all participants in the studies were treated with AZT. In June 1994, after reviewing the study results, the US Public Health Service recommended that the 076 regimen be administered to HIV-infected pregnant women in the US as standard treatment to prevent transmission of the virus.

But while 076 was hailed as a major breakthrough, the celebration was somewhat muted. For a variety of reasons, the new treatment regimen would not likely reach those who most desperately needed it: pregnant women in the developing nations of the world and, most particularly, sub-Saharan Africa, where AIDS was wreaking devastation on a scale unimagined in the West.

I think one reason why graduate school can be so overwhelming is that you’re trying to learn the basic technical skills of a field or subfield, and also playing catch-up on everything that’s been written on your field, ever. True, some of it’s outdated, and there are reviews that bring you up to speed on questions that are basically settled. But there’s a lot of history that gets lost in the shuttle, and it’s easy to forget that something was once controversial. Something as universally agreed upon today as using antiretrovirals to prevent mother-to-child transmission of HIV was once the subject of massive, heart-wrenching debate. I tend to wax pessimistic and think we’re doomed to repeat the mistakes of the past regardless of whether we know our history, because we either can’t agree on what the mistakes of the past were, or because past conflicts represent unavoidable differences of opinion, certainty, and power. But getting a quick refresher on the history of a is valuable because it puts current debates in perspective.

10

02 2011

Microfinance Miscellany

I had a conversation yesterday with a PhD student friend (also in international health) about the evaluation of microcredit programs. I was trying to summarize — off the top of my head, never a good idea! — recent findings, and wasn’t able to communicate much. But I did note that like many aid and development programs, you get a pretty rosy picture when you’re using case studies or cherry-picked before-and-after evaluations without comparison groups. So I was trying to describe what it looks like to do rigorous impact evaluations that account for the selection biases you get if you’re just comparing people who self-select for taking out loans versus controls.

After that discussion, I was quite happy to come across this new resource on David Roodman’s blog: yesterday DFID released a literature review of microfinance impacts in Africa.

On a related note, Innovations for Poverty Action hosted a conference on microfinance evaluation last October, and many of the presentations and papers presented are available here. The “What Are We Learning About Impacts?” sections includes presentations given by Abhijit Banerjee (PDF) and Dean Karlan (PDF) of Yale. Worth reading.

Hangman for Stata

Yes, you can load a .do file and play Hangman in Stata. But only true stats nerds are allowed to play.

And on a related note, have you ever wondered how a game as morbid as hangman became so popular? Can you imagine if you visited another culture and they had a word game that everyone — adults and children — knew how to play, and it was based on the electric chair or decapitation, would you judge them? Wikipedia tells me its origins are obscure…

09

02 2011

Monday Miscellany

This week’s links worth sharing:
  • NYU’s Development Research Institute is hosting a free one-day conference on Friday, March 4th called “New Directions in Development,” including talks by William Easterly and Chris Blattman. After realizing (almost immediately) that the title is not a pun on the main show choir featured on Glee, I decided to go. If you read my blog and plan to attend let me know so we can meet up!
  • What the strange persistence of rockets can tell us about innovation.
  • Cosma Shalizi, of the blog Three Toed Sloth, is posting lecture notes from his course on “Advanced Data Analysis from an Elementary Point of View”.
  • Nancy Birdsall of the Center for Global Development thinks USAID’s new evaluation policy is really good, but isn’t getting enough attention. Sounds like a good policy (if it gets implemented, of course) and I’m especially likely to agree, since it tracks pretty closely with the ‘policy proposal’ I included with a recent grad school joint degree application.
  • Mead Over, also at CGD, writes about PEPFAR’s new scientific advisory board: “PEPFAR’s overriding objective is  “[T]ransition from emergency response to sustainable country-led programs.” Despite good intentions, AIDS programs cannot be “sustainable” in poor or even in middle-income countries unless they meet one or both of two criteria: new infections should be rare and high quality AIDS treatment should be much less costly than it is now. PEPFAR seems to realize that it does not currently know how to do this. They hope to gather evidence in order to have a better idea, and our job on the committee is to advise PEPFAR how best to proceed in gathering and analyzing this new information.”
  • Obama thinks US intelligence agencies should have done more to predict recent events in Tunisia and Egypt. Maybe Obama should read some more Timur Kuran (PDF)?
  • What other dictators does the US support?
  • Stephen Colbert calls vaccines a waste of money because his kids didn’t get sick.
  • Andrew Sullivan shares this video of a college student in Iowa talking about how he’s not that different from anyone else, even though he has two moms. Powerful:

07

02 2011

"The Modern Development Enterprise"

USAID Administrator Raj Shah recently spoke at the Center for Global Development:

h/t to the Interpreter for the video clip — I hadn’t seen it before. But the full text of the speech, which is worth reviewing for those interested in the future direction of USAID, is available here on USAID’s website. Check out how many times “evaluation” is mentioned.

02

02 2011

Review: "The Panic Virus"

Review of The Panic Virus, by Seth Mnookin. Simon & Schuster Jan 2011 (Available at Amazon) [Disclosure: I got a free copy of the Panic Virus from a friend who has a friend that works at the publisher — I wasn’t given the copy specifically to write a review, but it’s still probably better to disclose I didn’t pay for the book.]

Seth Mnookin’s The Panic Virus starts and ends with two stories of parents whose seemingly normal children come down with a serious illness. He describes their children before the episodes, and then their dread as they go downhill, are hospitalized, and fight for their lives. These stories intentionally parallel the narrative of the vaccines-cause-autism movement — “our child was normal, then he got the vaccine, and then he got autism, so it must have been the vaccine.” However, Mnookin’s carefully chosen stories don’t support the anti-vaccine movement; they do just the opposite and make you feel heartsick for the children affected by vaccine-preventable diseases.

Mnookin knows how to tug on heart strings, and how to get his readers riled up, so it’s a good thing that he comes down strongly pro-vaccine. His case studies are selected for emotional value, and they illustrate how a thoughtfully written narrative can humanize statistics about disease outbreaks and the danger of the anti-vaccine movement. But I approve of Mnookin’s tactics ultimately because his stories are true — vaccines save lives, and much harm has been done by the spread of unfounded fear.

That said, Mnookin’s book isn’t at all a fearmongering tale of what will happen if you don’t vaccinate your child — the bookend stories are just that, and he could probably have included a few more narratives throughout without stretching it. For the most part his book is a sober narrative of a social movement that goes back to the earliest vaccines, but has only come to nationwide fruition with the rise of the Internet.

Mnookin chronicles the development of early vaccines, and, to his credit, spends a good deal of time on what was done badly by the scientists and advocates. The Cutter Incident is there,  along with the 1976 swine flu vaccine. Mnookin doesn’t mince words in describing injuries that have been caused by vaccines, and at many times I found myself cringing and thinking “why weren’t better systems in place earlier?” and “they really should have done more”.

This willingness to confront unpleasant truths is a strong point for the Panic Virus, and it also gives Mnookin an opportunity to introduce the safety innovations that stemmed from each incident, all while setting the stage for the anti-vaccine movement. Another strength is that The Panic Virus also offers compelling humanizations of many of the parents of autistic children who have been involved in the anti-vaccine movement. Their despair at seeing their children suffer, their ostracization in a society where autism is not accepted, their occasionally callous treatment by physicians who have no easy answers to offer — all of this makes it impossible not to sympathize with them.

For the most part, Mnookin doesn’t present parents as the villains of his story. That role is reserved for shoddy physicians, scientists and pseuodoscientists, and most of all for journalists. Andrew Wakefield, Mark and David Geier, and journalist/author David Kirby all come in for harsh reckonings, along with many other “expert witnesses” for anti-vaccine lawsuits. This book left me quite depressed regarding the role of journalists and TV personalities in the whole fiasco. There has been so much bad reporting, and so little good.

While reading The Panic Virus, I kept thinking that its major shortcoming is a lingering uncertainty about its target audience. Is Mnookin writing for the uninitiated who want an introduction to where the anti-vaccine movement? Or is he writing a broadside for those already staunchly in the pro-vaccine community? There are sections where the rhetoric made me think it was the latter, while the majority of the book seems to be for those with little outside knowledge of vaccine science. Since Mnookin cautions so much against being led astray by charlatans who peddle fear with a thin veneer of scientific-sounding verbiage, I wish he had done a bit more to explain the science done in recent years on vaccine safety, thiomersal, MMR, and autism. I understand why an author writing a popular narrative would avoid trying to describe these subjects: they are incredibly complicated and divert the reader from the narrative. [Note that I haven’t read Paul Offit’s Autism’s False Prophets, which I understand might have a bit more of that.] And it’s not like good science writing is entirely missing from The Panic Virus. Some things are explained well, but overall there’s just a bit too much deference to the authority of  science and scientists for my tastes, especially for a book intended for lay audiences. It’s a good book, but not a great book.

I also wish Mnookin had provided a better counter-narrative in the second half of the book. Broadly speaking, the first half follows the development of vaccines and early vaccine injury scares (founded and unfounded), and the second half explores the rise of the anti-vaccine social movement. The second half is missing strong pro-vaccine characters, such as one or two scientists or policymakers who have been working to combat the anti-vaccine crowd. A lot of good research has been done to disprove fallacious claims, and to look for policy solutions aimed at decreasing opt-out rates on a state level, but none of that is here.

To date the anti-vaccine crowd has really won the narrative war: their message is simpler, and scarier, and has the added perk of being anti-establishment in appealing ways. The Panic Virus didn’t give me much hope that that would change soon — although the book itself is mostly a step in the right direction, combining a pro-science view with a few emotional narratives about vaccine-preventable diseases.

Our best hope is that eventually our scientific explanations of autism etiology will solidify a bit more, and coupled with much more demonstrably effective treatments, the snake oil appeal of the “cures” sold by the anti-vaccine movement will lose their charm. One theme of the Panic Virus is that the anti-vaccine movement arose because parents of autistic children weren’t getting the sympathy, explanations, and help they needed. Many factors including a lack of understanding by doctors and communities, isolation, weak scientific explanations, and a lack of viable treatments all created a situation like a field of dry grass. When a powerful idea — “vaccines cause autism” — arose and was amplified by the echo chambers of Internet communities, it ripped through the dry field like a wildfire, sowing panic and fear. And the fire still hasn’t been put out.

01

02 2011