CIA's despicable Pakistan vaccination ploy

Via Conflict Health, The Guardian reports that the "CIA organised fake vaccination drive to get Osama bin Laden's family DNA":

In March health workers administered the vaccine in a poor neighborhood on the edge of Abbottabad called Nawa Sher. The hepatitis B vaccine is usually given in three doses, the second a month after the first. But in April, instead of administering the second dose in Nawa Sher, the doctor returned to Abbottabad and moved the nurses on to Bilal Town, the suburb where Bin Laden lived.

Christopher Albon of Conflict Health writes:

If true, the CIA’s actions are irresponsible and utterly reprehensible. The quote above implies that the patients never received their second or third doses of the hepatitis B vaccine. And even if they did, there is absolutely no guarantee that the vaccines were real. The simple fact is that the health of the children of Abbottabad has been put at risk through a deceptive medical operations by the Central Intelligence Agency. Furthermore, the operation undermines future vaccination campaigns and Pakistani health workers by fueling conspiracy theories about their true purpose.

Albon notes that the Guardian's source is Pakistan's ISI... but this McClatchy story seems to confirm it via US sources:

The doctor's role was to help American officials know with certainty that bin Laden was in the compound, according to security officials and residents here, all of whom spoke only on the condition of anonymity because they feared government retribution. U.S. officials in Washington confirmed the general outlines of the effort. They asked not to be identified because of the sensitivity of the topic.

The sensitivity of the topic? No kidding. This is absolutely terrible, and not just because the kids originally involved might not have gotten the second round of vaccine (which is bad) or because it will make the work of legitimate public health officials in Pakistan even harder (which is very bad). Vaccines are amazing innovations that save millions of lives, and they are so widely respected that combatants have gone to extraordinary lengths to allow vaccination campaigns to proceed in the midst of war. For instance, UNICEF has brokered ceasefires in Afghanistan and Pakistan for polio vaccine campaigns which are essential since those are two of the four countries where polio transmission has never been interrupted.

I hope I'm not overreacting, but I'm afraid this news may be bad for the kids of Pakistan, Afghanistan, and the rest of the world. Assuming the early reports are confirmed, this plot should be condemned by everyone. If US officials who support global vaccination efforts are going to control the damage as much as possible -- though it's likely much of it has already been done -- then there need to be some very public repercussions for whoever authorized this or had any foreknowledge. What tragic stupidity: a few branches of the US government are spending millions and millions to promote vaccines, while another branch is doing this. The CIA is out of control. Sadly, I'm not optimistic that there will be any accountability, and I'm fuming that my own country breached this critical, neutral tool of peace and health. How incredibly short-sighted.

Update: In addition to the Guardian story, Conflict Health, and McClatchy stories linked above, this NYTimes article offers further confirmation and the CNN piece has some additional details. Tom Paulson at Humanosphere, Mark Leon Goldberg of UN Dispatch, Charles Kenny of CGD, and Seth Mnookin all offer commentary.

Advice not to trust

Yesterday morning I came across the gentleman pictured below in New York's Union Square. I've been meaning to take more pictures of "things you only see in NYC" -- a category which generally consists of extremes of pets and fashion -- but I think this deserves its own post:

He was either selling or trying to give away copies of a book titled Uropathy: The Most Powerful Holistic Therapy by one Martin Lara. Since the review of Uropathy on Amazon.com is from the Village Voice, I assume that the evangelist was either Lara or one of his disciples. The review:

Vitamin Pee! Urine is a natural remedy, so raise a glass! That's what alternative therapist Martin Lara wants everyone to do. In his Uropathy: The Most Powerful Holistic Therapy, pee's the ultimate cure-all. Gagging aside, it's not so unconventional: former Indian prime minister Morarji Desai guzzled ounces each morning, observing an ancient Hindu practice. Lara learned about it 11 years ago, when the self-taught therapist he's never studied traditional medicine became disenchanted with science's inability to cure his ailments. Since then he's lectured to thousands. Not any pee will do it must be your own, which Lara says is a nontoxic biofeedback stimulator that boosts immunity by activating the lymphatic system, thus restoring the body to an internally balanced state of health. Dosages range from a few drops of Lara's "Ultimate Universal Remedy" an elixir of water, urine, and white rum to several ounces for serious conditions like cancer, dysentery, or Alzheimer's. Of course, not everyone is ready for this leap of faith. On his Web site Lara argues against obsessing over taste and smell: "Urine is a sample of what is flowing through your veins and repulsive urine should be a motivation to improve the internal conditions, rather than an excuse for not using Uropathy." -- The Village Voice

He was quite earnest. I didn't engage him in conversation because two other passersby were already talking to him. A girl was explaining that urine is what your kidneys decide your body doesn't need. But she wasn't just explaining it, she was disgusted, and angry. His response was similar to a major defense of homeopathic medicine, that the "toxin makes the remedy" (or something like that). The girl got exasperated and left with her friend, and you could hear her ranting as she walked away. I chose not to continue the conversation because I was on my way to meet friends, but in hindsight I wish I had stayed because there are some questions I don't have the answers to:

• How often does he talk publicly about this? What does he do for a living? Ie, is this it, or does he have a boring day job and this is his true passion?
• Does he feel that drinking urine has cured whatever health problems that he originally sought help for? (I would guess so.)
• Why does he think drinking urine has not been more widely adopted?
• Does he think that his approach (especially the t-shirt and public 'evangelism') is the most effective way to spread his message? I would guess he enjoys the attention on some level, but also promotes his beliefs through other, more effective channels.
• What are the typical reactions he gets? How many people stay and talk with him at length, and of those how many eventually adopt his therapy?
• I'd like to talk a bit about Western medicine. Not necessarily the biomedical interventions we favor, but the scientific process by which we (ideally) establish that a practice is beneficial. Does he think urine therapy could be tested by a randomized controlled trial? If not, why not?
• If the passerby had stuck around: why did she choose to argue with him? Did she really think that a guy wearing a bright yellow "Drink Urine" t-shirt in Union Square was likely to change his mind? And for the man himself: how common is her argumentative reaction?

I think a natural first reaction to something this out of the ordinary is laughter or mockery, or the assumption that he's clinically insane. On further thought, what he believes -- in factual support and argumentative method, if not in substance -- isn't that different from much of alternative medicine, and his methods have been widely adopted by many mainstream religions and social movements as well as less-respected 'fringe' beliefs. If those are both true, why isn't his belief more widely adopted? Is it just too taboo?

I think I could have learned valuable things about the mixture of reason and emotion and belief that guide human choices if I had stayed and asked some of these questions. I don't think I'll change his mind, but I plan to look for him if I'm ever strolling through Union Square on a weekend again.

(Note: evidently "urine therapy" is a thing. The Wikipedia page starts with "In alternative medicine..." -- never a good sign.)

Tornado epidemiology

The news out of Joplin, Missouri is heartbreaking, and it comes so quickly on the heels of the tornadoes that hit Tuscaloosa, Alabama. Central Arkansas, where I grew up, gets hit by tornadoes every spring, so I have plenty of memories of taking shelter in response to warnings. College nights with social plans ruined when we had to hunker down in an interior hallways. Dark, roiling clouds circling and the spooky calm when the rain and hail stop but the winds stay strong. Racing home from work to get to my house and its basement -- a rarity in the South -- before a particularly ominous storm hit. Neighboring communities were sometimes hit more directly by storms, and Harding students often participated in clean-up an recovering efforts, but my town was spared direct hits by the heaviest tornadoes. So what does epidemiology have to say about tornadoes? Their paths aren't exactly random, in the sense that some areas are more prone to storms that produce tornadoes. Growing up I knew where to take shelter: interior hallways away from windows if your house didn't have a basement or a dedicated storm shelter. I also knew that mobile homes were a particularly bad place to be, and that the carnage was always worst when a tornado happened to hit a mobile home lot.

But there is some interesting research out there that tells us more than you might think. Obviously and thankfully you can't do a randomized trial assigning some communities to get storms and others not, so the evidence of how to prevent tornado-related injury and death is mostly observational. What do we know? I'm not an expert on this but I did a quick, non-systematic scan and here's what I found:

First, the annual tornado mortality rate has actually gone down quite a lot over the last few decades. That says nothing about the frequency and intensity of tornadoes themselves, which is a matter for meteorologists to research. The actual number deaths resulting from tornadoes would probably be a function of the number of people in the US, where they live and whether those areas are prone to tornadoes, the frequency and intensity of the tornadoes, and risk factors for people in the affected area once the tornado hits.

This NOAA site has the following graph of tornado mortality where the vertical axis is tornado deaths per million people in the US (on a log scale) and the horizontal axis covers 1875 - 2008.

Second, many of the risk factors for tornado injury and death are intuitive and suggest possible interventions to minimize risk in tornado-prone areas. Following tornadoes in North and South Carolina in 1984, Eidson et al. surveyed people hospitalized and family members of people who were killed, along with uninjured persons who were present when the surveyed individuals were hurt. The main types of injury were deep cuts, concussions, unconsciousness and broken bones. Risk factors included living in mobile homes, "advanced age (60+ years), no physical protection (not having been covered with a blanket or other object), having been struck by broken window glass or other falling objects, home lifted off its foundation, collapsed ceiling or floor, or walls blown away." Some of those patterns might indicate potential tornado education interventions -- better shelters for mobile home residents, targeting alerts to older residents, covering with a blanket, and staying in interior hallways, to say nothing of building codes to make more survivable structures.

Third, some things are less clear, like whether it's safe to be in a car during a tornado. Daley et al. did a case-control study of tornado injuries and deaths in the aftermath of tornadoes in Oklahoma in 1999. They found higher risk of tornado death for those in mobile homes (odds ratio of 35.3, 95% CI 7.8 - 175.6) or outdoors (odds ratio of 141.2, 95% CI 15.9 - a whopping 6,379.8) compared to other houses. They found no difference in risk of death, severe injury, or minor injury among people in cars vs. those in houses. And they found that risk of death, severe injury, or minor injury was actually lower among those "fleeing their homes in motor vehicles than among those remaining." That's surprising to me, and contrary to much of the tornado-related safety warnings I heard from meteorologists and family growing up. I wonder if this particular study goes against the majority of findings, or whether there is a consensus based in data at all.

Fourth, our knowledge of tornadoes can be messy. One demographic approach to tornado risk factors (Donner 2007) is to look for correlations between tornado fatalities and injuries with rural population, population density, household size, racial minorities, deprivation/poverty, tornado watches and warnings, and mobile homes. Donner noted that "Findings suggest a strong relationship between the size of a tornado path and both fatalities and injuries, whereas other measures related to technology, population, and organization produce significant yet mixed results."

That's just a sampling of the literature on tornado epidemiology. The studies are interesting but relatively rare, at least from initial perusal. That's probably because tornado deaths and injuries are relatively rare in the US. Still, the storms themselves are terrifying and they often wreak havoc on a single community and thus generate more sympathy and news coverage than a more frequent -- and thus less extraordinary -- problem like car crashes.

Update: NYT has an interesting article about tornado preparedness, including some speculation on why the Joplin tornado was so bad.

Best practices of ranking aid best practices

Aid Watch has a post up by Claudia Williamson (a post-doc at DRI) about the "Best and Worst of Official Aid 2011". As Claudia summarizes, their paper looks at "five dimensions of agency ‘best practices’: aid transparency, minimal overhead costs, aid specialization, delivery to more effective channels, and selectivity of recipient countries based on poverty and good government" and calculates an overall agency score. Williamson notes that the "scores only reflect the above practices; they are NOT a measure of whether the agency’s aid is effective at achieving good results." Very true -- but I think this can be easily overlooked. In their paper Easterly and Williamson say:

We acknowledge that there is no direct evidence that our indirect measures necessarily map into improved impact of aid on the intended beneficiaries. We will also point out specific occasions where the relationship between our measures and desirable outcomes could be non-monotonic or ambiguous.

But still, grouping these things together into a single index may obscure more than it enlightens. Transparency seems more of an unambiguous good, whereas overhead percentages are less so. Some other criticisms from the comments section that I'd like to highlight include one from someone named Bula:

DfID scores high and USAID scores low because they have fundamentally different missions. I doubt anyone at USAID or State would attempt to say with a straight face that AID is anything other than a public diplomacy tool. DfID as a stand alone ministry has made a serious effort in all of the areas you’ve measured because it’s mission aligns more closely to ‘doing development’ and less with ‘public diplomacy’. Seems to be common sense.

And a comment from Tom that starts with a quote from the Aid Watch post:

“These scores only reflect the above practices; they are NOT a measure of whether the agency’s aid is effective at achieving good results.”

Seriously? How can you possibly give an aid agency a grade based solely on criteria that have no necessary relationship with aid effectiveness? It is your HYPOTHESIS that transparency, overhead, etc, significantly affect the quality of aid, but without looking at actual effeciveness that hypothesis is completely unproven. An A or an F means absolutely nothing in this context. Without looking at what the agency does with the aid (i.e. is it effective), why should we care whether an aid agency has low or high overhead? To take another example, an aid agency could be the least transparent but achieve the best results; which matters more, your ideological view of how an agency “should” function, or that they achieve results? In my mind it’s the ends that matter, and we should then determine what the best means are to achieve that result. You approach it with an a priori belief that those factors are the most important, and therefore risk having ideology overrule effectiveness. Isn’t that criticism the foundation of this blog and Dr. Easterly’s work more generally?

Terence at Waylaid Dialectic has three specific criticisms worth reading and then ends with this:

I can see the appeal, and utility of such indices, and the longitudinal data in this one are interesting, but still think the limitations outweigh the merits, at least in the way they’re used here. It’s an interesting paper but ultimately more about heat than light."

I'm not convinced the limitations outweigh the merits, but there are certainly problems. One is that the results quickly get condensed to "Britain, Japan and Germany do pretty well and the U.S. doesn’t."

Another problem is that without having some measure of aid effectiveness, it seems that this combined metric may be misleading -- analogous to a process indicator in a program evaluation. In that analogy, Program A might procure twice as many bednets as Program B, but that doesn't mean it's necessarily better, and for that you'd need to look at the impact on health outcomes. Maybe more nets is better. Or maybe the program that procures fewer bednets distributes them more intelligently and has a stronger impact. In the absence of data on health outcomes, is the process indicator useful or misleading? Well, it depends. If there's a strong correlation (or even a good reason to believe) that the process and impact indicators go together, then it's probably better than nothing. But if some of the aid best practices lead to better aid effectiveness, and some don't, then it's at best not very useful, and at worst will prompt agencies to move in the wrong direction.

As Easterly and Williamson note in their paper, they're merely looking at whether aid agencies do what aid agencies say should be their best practices. However, without a better idea of the correlation between those aid practices and outcomes for the people who are supposed to benefit from the programs, it's really hard to say whether this metric is (using Terence's words) "more heat than light."

It's a Catch-22: without information on the correlation between best aid practices and real aid effectiveness it's hard to say whether the best aid practices "process indicator" is enlightening or obfuscating, but if we had that data on actual aid effectiveness we would be looking at that rather than best practices in the first place.

The Tea Test

If you haven't been following it, there's currently a lot of controversy swirling around Greg Mortenson, co-author of Three Cups of Tea and co-founder of the Central Asia Institute. On Sunday 60 minutes aired accusations that Mortenson fabricated the 'creation myth' of the organization, a story about being kidnapped by the Taliban, and more. The blog Good Intentions Are Not Enough is compiling posts related to the emerging scandal, and the list is growing fast. If you haven't read it already, Jon Krakauer's mini-book, Three Cups of Deceit: How Greg Mortenson, Humanitarian Hero, Lost His Way, is really worth the read. Completely engrossing. It's a free download at byliner.com until April 20. It's about 90 pages, and Krakauer has obviously been researching it for a while -- in fact, my guess is that Krakauer turned 60 Minutes onto the story, rather than vice versa, which would help explain why he was featured so heavily in their piece. In the TV interview Krakauer quotes several former employees saying quite unflattering things about how CAI is run, so it's good to see that he gets many of those people on record in his ebook.

A few disclaimers: I think it's worth pointing out that a) as a one-time supporter and donor to CAI, Krakauer arguably has an axe to grind, b) several of Krakauer's previous books (Into Thin Air, Into the Wild, and Under the Banner of Heaven) have had sections disputed factually, though to me Into the Wild is the only case where he seems to have actually gotten things wrong, and c) I'm a big fan of him as a writer and thus am possibly a bit predisposed to believe him. Admitting by biases up front like good epidemiologist.

That said, it sounds like CAI has been very poorly led. Krakauer's book levels many damning claims about Mortenson and CIA's financial management that, while less emotionally shocking than the exaggerations about the 'creation myth,' should be much more troubling. CAI and Mortenson's responses to the accusations so far on 60 Minutes have seemed superficial, and I think it's safe to say that they will not come out of this looking squeaky clean.

I believe this episode raises two broader questions for the nonprofit community.

First, Krakauer chronicles a string of board members, employees, and consultants who came in, were shocked by how things were done and/or discovered discrepancies, and ended up leaving or resigning in protest. This section (pages 50-51) jumped out at me:

After Mortenson refused to comply with CFO Debbie Raynor's repeated requests to provide documentation for overseas programs, Raynor contacted Ghulam Parvi (the Pakistan program manager) directly, instructing him to provide her with documentation. For two or three months Parvi complied - until Mortenson found out what was going on and ordered Parvi to stop. Raynor resigned.

In 2007, Mortenson hired an accomplished consultant to periodically fly to Central Asia to supervise projects. When he discovered irregularities and shared them with Mortenson, Mortenson took no action to rectify the misconduct. In 2010, the consultant quit in frustration.

In September 2007, CAI hired a highly motivated, uncommonly capable woman to manage its international programs. Quickly, she demonstrated initiative and other leadership skills the Institute sorely needed. She had exceptional rapport with Pakistani women and girls. In 2008, she unearthed serious issues in Baltistan that contradicted what Mortenson had been reporting. After she told Mortenson about these problems, she assumed he would want her to address them. Instead, as she prepared to return to Pakistan in 2009, Mortenson ordered her to stay away from Baltistan. Disillusioned, she resigned in June 2010.

Seriously -- ff this has been going on for so long, how on earth is it just coming out now? Evidently a nationally known organization can have nearly its entire board resign and multiple employees quit, and it doesn't make the news until years later? Some of this (I'm speculating here) likely results from a hesitance on the part of those former employees to speak ill of CAI, whether because they still believed in its mission or because they were worried about being the sour grape person. Were they speaking out and nobody listened, or is there simply no good way to raise red flags about a nonprofit organization?

Second, while most organizations aren't guilty of fraud -- we hope -- there's at least one other take-away here. Another excerpt that jumped out at me:

On June 13, 2010, Parvi convened a meeting in Skardu to discuss Three Cups of Tea. Some thirty community leaders from throughout Baltistan participated, and most of them were outraged by the excerpts Parvi translated for them. Sheikh Muhammad Raza—chairman of the education committee at a refugee camp in Gultori village, where CAI has built a primary school for girls—angrily proposed charging Mortenson with the crime of fomenting sectarian unrest, and urged the District Administration to ban Mortenson and his books from Baltistan.

Based on Krakauer's footnotes, Parvi may be one of his less reliable sources, but this idea -- that the people portrayed in the book were outraged when it was translated to them because of how misleading it is -- comes up several times. Yes, fabricating stories is really bad. But how many other things do nonprofits say in their advertising that would be uncomfortable or downright offensive if you translated it for (and/or showed the accompanying pictures to) the recipients or beneficiaries or their services?

I propose a simple way to check this impulse -- to write about people as if they are victims or powerless -- and in honor of Three Cups of Tea, I call it the "Tea Test":

Step One: read the website content, blog posts, or email appeal you just got from your charity of choice. Or, if you work for a nonprofit organization, read your own stuff.

Step Two: imagine arriving in the recipient city or village, with a translated copy of that text. Would you be uncomfortable reading that website or blog or email to the people you met? Would it require tortured explanations, or would it instantly make sense and leave them feeling dignified?

That's it: if Step Two didn't make you cringe, then you passed the Tea Test. If it made you uncomfortable, made them feel ashamed, or got you attacked -- re-draft your copy and try again. Or find another organization to support.

I think there are many organizations that pass the Tea Test, but probably many more that fail. These organizations don't necessarily share all the faults of CAI as laid out by Krakauer and others, but they wouldn't fare much better in this situation, because they say something for one audience that was never intended to get back to the others.

I hope the idea of the Tea Test -- reading a translated copy of that material to the people it's describing -- will be helpful for donors and nonprofiteers alike. As a former online fundraiser I know I've broken this rule, and as a donor I've found things appealing that I probably should have reacted strongly against. I'm going to try to do better.

Update: I've posted a slightly revised (and I hope easier to remember) version of the Tea Test on a permanent page here.

"Small Changes, Big Results"

The Boston Review has a whole new set of articles on the movement of development economics towards randomized trials. The main article is Small Changes, Big Results: Behavioral Economics at Work in Poor Countries and the companion and criticism articles are here. They're all worth reading, of course. I found them through Chris Blattman's new post "Behavioral Economics and Randomized Trials: Trumpeted, Attacked, and Parried." I want to re-state a point I made in the comments there, because I think it's worth re-wording to get it right. It's this: I often see the new randomized trials in economics compared to clinical trials in the medical literature. There are many parallels to be sure, but the medical literature is huge, and there's really one subset of it that offers better parallels.

Within global health research there are a slew of large (and not so large), randomized (and other rigorous designs), controlled (placebo or not) trials that are done in "field" or "community" settings. The distinction is that clinical trials usually draw their study populations from a hospital or other clinical setting and their results are thus only generalizable to the broader population (external validity) to the extent that the clinical population is representative of the whole population; while community trials are designed to draw from everyone in a given community.

Because these trials draw their subjects from whole communities -- and they're often cluster-randomized so that whole villages or clinic catchment areas are the unit that's randomized, rather than individuals -- they are typically larger, more expensive, more complicated and pose distinctive analytical and ethical problems. There's also often room for nesting smaller studies within the big trials, because the big trials are already recruiting large numbers of people meeting certain criteria and there are always other questions that can be answered using a subset of that same population. [All this is fresh on my mind since I just finished a class called "Design and Conduct of Community Trials," which is taught by several Hopkins faculty who run very large field trials in Nepal, India, and Bangladesh.]

Blattman is right to argue for registration of experimental trials in economics research, as is done with medical studies. (For nerdy kicks, you can browse registered trials at ISRCTN.) But many of the problems he quotes Eran Bendavid describing in economics trials--"Our interventions and populations vary with every trial, often in obscure and undocumented ways"--can also be true of community trials in health.

Likewise, these trials -- which often take years and hundreds of thousands of dollars to run -- often yield a lot of knowledge about the process of how things are done. Essential elements include doing good preliminary studies (such as validating your instruments), having continuous qualitative feedback on how the study is going, and gathering extra data on "process" questions so you'll know why something worked or not, and not just whether it did (a lot of this is addressed in Blattman's "Impact Evaluation 2.0" talk). I think the best parallels for what that research should look like in practice will be found in the big community trials of health interventions in the developing world, rather than in clinical trials in US and European hospitals.

Something powerful, ctd

Yesterday I posted about HU Queer Press, an online magazine published by an anonymous group of LGBTQ students at my alma mater, Harding Unviversity. Since then the issue has gotten a lot of press, including Jezebel, The New Yorker blog, KARK, and others. I got a call earlier today from a gay Harding student who is upset by HUQP's approach to the issue and says that some of what they say is factually incorrect. I said that if he wanted to write a response, I'd publish it for him and keep him anonymous as well. I'll reserve my reactions for the comment space, and would love to hear other views as well. Here's what he said:

I am a gay student currently attending Harding University who wants to voice my own experiences and give voice to the experiences of other gay students at HU.  While the accounts presented in “The State of The Gay” e-zine are compelling, sad, frustrating, and even downright infuriating, they are not representative of the current environment on campus.

Harding University does not have a rule against “being gay.”  I am open about my sexuality all over campus—to students, faculty, staff, and members of the administration.  The fact that I am a gay man is common knowledge, not just at Harding University, but also at my church (a Church of Christ). Never once have I been threatened with expulsion or forced reparative therapy.  If anyone was threatened with disciplinary action unless they received counseling, it was not for simply identifying themselves as gay.   When a rule is broken, action is taken, but there is no rule against “being gay.”  This hasn’t always been the case, and Harding isn’t a perfect place. Is there bigotry there?  Yes, and we must deal with that.  We should not blast them, however, for things that simply aren’t true.

Additionally, there is a growing impression that Integrity Ministries at Harding is a place where people are forced to go and be “fixed.”  This is simply not true.  Everyone who is a part of Integrity Ministries is there of their own free will and choice.  The names of the persons attending meetings and/or utilizing resources are not even known by anyone in the administration, faculty, or staff. Students approach the ministry, the ministry does not approach (or impose upon) students, and their identity is kept highly confidential.

If the ethic driving the current debate is freedom of choice, then we must extend that freedom to those whose faith and personal relationship with God have led them to CHOOSE to address their sexuality in the way they see fit. The reason my friends and I remain anonymous in this debate is not because we fear oppression from Harding University—but the exact opposite.  Those who are driving this debate are not allowing us our own freedom, and not creating a “safe place” for us to be honest about who we are and who we want to be.  These people who demand a safe place for themselves are guilty of denying the same thing to us.  At Harding University, we have found many, many, many people who are loving, accepting, nurturing, and inclusive.  Simply put:  HUQueerPress does not represent the majority of gay students at Harding University, and everyone at the University (administration included) is not the grotesque stereotype that HUQueerPress is trying to make them out to be.

--Joe Gay

Something powerful

I've tried to keep this blog professionally relevant, focusing on global health and development. But I want to share something a little different, and this is the best way I know how--hope you'll forgive the tangent. I went to college at Harding University, a conservative, private Christian University in my hometown of Searcy, Arkansas. Harding is strict -- you can get kicked out for dancing,* having sex, being gay, or drinking alcohol. The 5,000+ undergraduates are required to live on campus at first, with guys' dorms and girls' dorms and a nightly curfew where your RA's check to see if you're in your room. Daily chapel is required and everyone must take a Bible class each semester. It's like Footloose but with more Jesus and a lot less Kevin Bacon.

Except that earlier today, a bunch of gay and lesbian students at Harding spoke out:

We are here to share with you our struggle. We are here to be a voice for the voiceless who are quietly dying inside the walls of our campus. We want you to know us. We are your friends, co-workers, students, family members, fellow worshipers, professors, athletes, and scholars.[...] We are queer. We are gay, lesbian, bisexual and transgender. While the rest of you fall in love with the opposite sex, we share our lives and beds with those of our own gender.

All is not well for us at Harding. Our voices are muted, our stories go unheard, and we are forced into hiding. We are threatened with re-orientation therapy, social isolation, and expulsion. We are told stories and lies that we are disgusting sinners who are damned to hell, that we are broken individuals and child abusers....We have felt the pain of the deep, dark closet, and we are here to announce that we will not stand for it any longer.

That's the opening statement from HU Queer Press, a group of anonymous LGBTQ students, who are publishing a webzine about being gay at Harding. You can find the first issue, "State of the Gay at Harding University" at their website:

It's powerful stuff, ranging from the sweet to the visceral. The stories mix courage with self-hatred, love of friends and allies at Harding with hatred for its oppressive atmosphere and teachings. You really should read the whole thing, but here are a few of my favorite parts:

First is this sweet piece from "Dovey" writing about "How I Realized I Like Girls (And Why I'm Surprised I Didn't Realize Sooner.)":

When I was13, I, like most every girl my age, had a best friend (we'll call her Elle.) We spent almost all of our free time together, wrote several-page-long notes to each other that we passed when we met in the school halls, wrote stories about what our lives would be like when we grew up. We loved all the same movies, all the same books, and some of the same music....

I began to realize, though, that every time Elle had a boyfriend (and she had a LOT of them) I got immensely jealous. Even if he was someone who had always been a good mutual friend, I would begin to resent him. It wasn't just that Elle was spending less time with me, or that I felt left out. I wanted to hold her hand like they did. I wanted her to look at me the way she looked at them. I wanted to kiss her goodbye when we all left at the end of the school day.

Then "C" writes about coming out:

Most of the people I first told just kind of smiled and said "I figured." And of course they still loved me. Soon I had this great group of people encouraging me. I got enough confidence to finally tell my parents. They too already had some idea that this might be coming, but there was no smile on their face when they said so. "We were afraid of this." "I'm very disappointed."

"Z" chronicles his history:

[Age 13] Jeff kissed me... One day Jeff took me in the woods and said that he liked me, like he liked Kathleen. He leaned in and kissed me. I felt more alive in that moment than I had ever felt before. The next day in school, Jeff told the entire locker room that I tried to kiss him and that I was a Fag. I knew what it meant now. I sat alone in the lunchroom for the rest of middle school. I never had one friend from school. I turned to church....

[Age 17] Brad pulled me in the back of the room. He kissed me. I kissed him back. He unbuttoned my shirt and I pulled his off. He took off my belt and got down on his knees. He took me in his mouth and I came. I punched him in the face. I called him a Faggot and kicked him in his ribs. What had I done? God please save me. Take this away from me and I'll be a slave to you. I'll never do this again. I want you to take me under your wings and rescue me? Rescue me from whom? ME.

"K" criticizes the "Toxic Teachings" at Harding by highlighting the following course notes for a currently offered class. These were written by a Harding professor:

Certain signs of pre-homosexuality: 1) repeatedly stated desire to be other sex or act like other sex, 2) strong preference for cross dressing or pretending to dress like other gender, 3) strong and persistent desire for opposite roles.

Single Mothers: Cub Scouts and male Sunday school class is not enough to help a boy reach a clear gender identity: the boy must have one salient (good and strong) man who takes a special interest in him - one male chooses him. Men: find those fatherless boys and invite them to go fishing. Play catch with him - especially the quiet boy in the background... the one in the background - he is the one we have to go after.

Seriously? Who's recruiting who?

"K" also shares notes from a journal entry after a therapy session at Harding:

I need to make this decision. Will I go through with this or not. If so I need to truly count the cost and realize that this will cost me. If yes, that I for sure want to pursue my life as a Godly person with Him above all else:

I would have to see myself as heterosexual.

Every time I am attracted or want to look at another guy I would have to say "No. I am a heterosexual and I do not have these desires. They are not natural." I would completely have to capture my thoughts, deny them, and never intend to pursue or continue these thoughts.

There's a lot, lot more. Some amazing introspection, some self-loathing. A little coming out, a lot of the closet, some falling in love. They write a how-to for reading the Bible as gay-neutral, if not gay-friendly. They write about getting called fags.

And they write about the problems they have with "Integrity Ministries," the fairly new support group for students who "struggle with same-sex attraction." In some ways, Harding, or at least the people who are associated with it, have come a long way. The creation of Integrity Ministries a couple years ago suggest that the administration at Harding has realized it has a "gay problem" that isn't going away with denial and condemnation alone, the previous approach. I know that some of my friends saw the inception of Integrity Ministries as a step forward. But taking a tiny step forward from a wallowing pit of homophobia still leaves Harding far short of where it should be.

I really admire the authors for doing this, in part because even writing anonymously, they still face big risks. If someone rats them out they could all get kicked out, and they could lose many friends. And just because they're gay doesn't mean they can easily leave Harding. Some students can only afford college with their parents' support, and some parents will only send their kids to Christian colleges. I guess others stay at Harding because they love the institution despite its flaws and want to go to a Christian school because of their deep faith, and they hope to change it from the inside out. If it were easy and they had no other ties, they'd transfer elsewhere and start a new life with people who love them regardless of their sexuality. But it isn't that easy.

I sympathize with them because I have mixed feelings about Harding as well. My dad teaches there and I grew up around the school. I went to Harding of my own free will because I wanted to be a missionary. I deconverted during my third year there. The process was a gradual one. The more I studied theology and the Bible and war and history and science (some through courses at Harding but also much on my own) the more my views shifted towards progressive theologies. I maintained an unhappy equilibrium as a liberal Christian with a belief in a vaguely Einsteinian God for somewhat less than a year. In hindsight the shift from fundamentalist belief to liberal belief was driven by an intellectual desire to believe something that was compatible with science and history and critical thought, but the choice to go from liberal theology to discarding my faith in faith altogether was more about choosing my allegiances. In the South, and especially at Harding, the association between that particular Christian tradition and reactionary filth was just too strong for me. At some point I couldn't stomach being associated with all that was anti-science, anti-feminist, and yes, anti-gay. If it wasn't clear before you read the HU Queer Press, one reason people get turned off by Christians like many at Harding is that their beliefs and actions cause a world of pain to those they label as sinful.

I have a lot of good memories, and I still love many people associated with Harding -- family, professors and mentors, and classmates. I doubt Harding will change much, or fast. They still don't let women speak in chapel or lead prayers, and you get kicked out for having straight sex too. My hope is more for the students who go to Harding and then move on, that they will emerge more compassionate and less homophobic than they might otherwise have been. Maybe we'll get a step closer to that if everyone at Harding reads this webzine (probably on their laptops at Midnight Oil since I'm sure they'll block www.huqueerpress.com on campus!).

One last thing: Early on, like many other straight male dorm student at Harding I called everyone a fag -- man, don't be such a fag! I used to be part of that putrid homophobic culture, and for that -- to anyone who reads this who I knew at Harding -- I'm sorry. It was as if by joking about it we could make "the gays" all just disappear." But they can't. They're there and they're not going away no matter how hard you pray, and now they're finding a way to speak out. Awesome. Read it and share it with your friends.

----------------------------------------------------------------------

One note: I was not involved in the production or hosting of HU Queer Press, and I don't know who they are. I just received an anonymous email a few days ago asking me to help with getting the word out since I have a blog.  In fact I think it's more powerful not knowing because they could be anyone I knew at Harding.

*Update 1: a commenter points out that they've never heard of anyone getting kicked out for dancing, and I think that's right. My apologies for the imprecision -- I should have said that dancing is against the rules.

Update 2: I'm tracking who all has written about the zine. If you notice a blog I haven't listed please mention it in the comments. So far: Hemant Mehta, Political Cartel, Ian Thomas, NWA Equality, Don Gaines, Talk About Equality, Arkansas Times' Arkansas Blog, Coleman Yoakum, Change.org petition, Nelson Shake, 

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.]

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.

Life expectancy: what really mattered

National Geographic has a great series up on global population growth. We'll hit 7 billion people in 2011 - quite a milestone. One thing to quibble about from the article:

Moreover in 1798, the same year that Malthus published his dyspeptic tract, his compatriot Edward Jenner described a vaccine for smallpox—the first and most important in a series of vaccines and antibiotics that, along with better nutrition and sanitation, would double life expectancy in the industrializing countries, from 35 years to 77 today. It would take a cranky person to see that trend as gloomy: “The development of medical science was the straw that broke the camel’s back,” wrote Stanford population biologist Paul Ehrlich in 1968.

I've read statements like this - about increasing life expectancy and its reasons - many times, and it's almost always done in a certain order. Here, life expectancy increases result from "a series of vaccines and antibiotics that, along with better nutrition and sanitation..." It's hardly the most egregious wording I've seen. Often I'll read that "modern medicine" led to increases in life expectancy, so it's nice that the article specifically mentions vaccines, a preventive measure, instead of only the curative parts of modern Western medicine that we're more familiar with as adults.

But the even the formulation "vaccines and antibiotics along with better nutrition and sanitation" still seems problematic. Why is nutrition and sanitation always an afterthought? I don't have a citation handy, but my impression is that the vast majority of the increase in life expectancy stemmed from advances in sanitation and nutrition, while curative medicine (including antibiotics) played a much more minor role. (I would love to read a good paper outlining the relative contribution of changes in nutrition, sanitation, vaccination, antibiotics to life expectancy improvements - if you know of one, please post it in the comments.)

I think this bias stems in part from a larger bias toward seeing advances in public health as medical advances, rather than societal, economic, or political ones. Many (too many?) people working in the public health field have medical backgrounds. Modern medicine is shiny and fancy and dramatic, and (credit where it's due) has made some incredible advances.

Imagine you're given a Rawlsian choice between being born into:

• World A, with the nutrition, sanitation and vaccination of modern Europe but with all of the doctors and drugs mysteriously raptured in a giant Hippocratic tribulation, or
• World B, with the nutrition, sanitation and vaccination of ancient Rome but with Atul Gawande on standby with the latest treatments once you get sick

I'd definitely choose World A. (Though I'm glad we don't have to choose!)

To correct this bias, I think it would helpful if every time we mentioned the dramatic shift in life expectancy over the past few centuries, we emphasized that most of those gains are from reductions in child mortality, and that nutrition and sanitation deserve the lion's share of credit for those improvements. At the least, let's mention them first and then say "along with later, less important developments such as antibiotics."

Mapping Race in Baltimore

The New York Times has a new interactive feature up, called Mapping America: Every City, Every Block. It uses "local data from the Census Bureau's American Community Survey, based on samples from 2005 to 2009." The data includes income and education levels by census tract, which is interesting but not that visually stimulating, and the more striking data on race by household in each census tract. Areas with higher population density are typically easier to work with -- try New York City for starters. My current home, Baltimore, makes a great test case. On these maps, each circle represents 50 households. (As you zoom further out, you start seeing counties instead of census tracks, and each dot represents many more households.)  A screenshot:

By race, blue = black, green = white, red = Asian, yellow = Hispanic.

For those unfamiliar with Baltimore, that's the Inner Harbor at the bottom. As you can see, the neighborhoods just southwest (Federal Hill) and north (Canton, Fells Point) of the harbor are predominantly white. The relatively sparsely populated section in the center is the more commercial downtown. East and West Baltimore are predominantly black. The green (ie, white) strip in the center is Mt. Vernon, whereas the area at the center top with more green (white) and red (Asian) includes the Charles Village neighborhood, where Hopkins' Homewood undergraduate campus is located.

The Johns Hopkins medical campus, including the School of Public Health where I'm a student, is in the predominantly blue (black) area on the middle right of the map above.

One thing that struck me as odd at first is that there are a bunch of green dots (ie, white households) in the middle of Patterson Park, the big green space included in this zoomed in map:

On further thought, I think the maps are showing averages of the data from the entire census tract. The tract that includes Patterson Park also includes some surrounding blocks, which are predominantly white. The distribution of differently colored dots on the map represents the race breakdown within that tract, but the location  of the dots within the tract on this map is completely random. If you play with the tool, you'll find that tracts are highlighted when you mouseover them, and that the spacing of dots within the tract is uniform -- this also accounts for the sudden changes in density you see in some places at the edges between tracts.

Finally, below is a closeup of the area I live in. At the top center of this map is Charles Village (including the Hopkins undergraduate campus). I live near 25th street, which bisects this map horizontally, in the transition between the predominantly white and Asian area in Charles Village and the mostly black neighborhoods in between Mt. Vernon and Charles Village:

h/t @edwardcarr

Haiti: Constancy and Change

A friend of mine recently moved to Haiti to work for a local organization. I've never been to Haiti, and as with many places to which I have yet to travel, it's difficult for me to picture the reality on the ground, especially when I know how much the places I've traveled to have differed from media reports and books I've read. While my friend and I were talking about Haiti, I mentioned that it would be interesting if I could email some questions and post the answers here on my blog. While I don't think any of the sentiments below are that controversial, I hope this will be a continuing series where I can ask questions and get frank answers (and share them with my readers), so we decided to keep it anonymous. I'll call my friend "F" here. Please let me know (in the comments or by email) if you have any questions you'd like me to relay to F for follow-up posts.

Brett: Can you tell me a little about how long you've been in Haiti, how long you lived there in the past, and what you're doing now (in a vague sense)?

F: I spent a nearly a year in Haiti in 2005-06. I always knew I'd be back some time, and after the earthquake on January 12th, 2010, I regretted that I hadn't returned sooner. I finally arrived back a few weeks ago, to take up a new position with the same organization I worked for five years ago.

Brett: How have things changed since the last time you were there? Did you have a lot of expectations about how things would be post-earthquake, and if so, how does the reality compare to what you were expecting?

F: Of course it's very sad to see so many landmarks in Port-au-Prince reduced to rubble, and what used to be great public spaces packed full of thousands and thousands of people living under tents and blue tarpaulins. Walking around the city is a little creepy: I'll wander down streets I know well, and find that a house or church I used to pass every day is gone.

But I've also been surprised by how much hasn't changed. The same fruit vendor I used to buy from five years ago still sits on the same street corner with her basket of oranges - even though the grocery store behind her has completely vanished. From my first morning back in the office, catching up with old friends and co-workers, it was as if I'd never left. Knowing how Haiti had switched from being a developing country to being (in international NGO terms) a humanitarian emergency, I think I was expecting to see some kind of fundamental change in the way things happen here. In reality, while the problems are perhaps more urgent now, the way of life is just the same as before.

Brett: What's the latest on cholera? Is everyone incredibly concerned, or is it just one crisis among many?

F: I think people see cholera as yet another disaster in a terrible year for the country. It's very sad that cholera seems most probably to have been brought here by the UN "assistance" force (which was already almost-universally reviled among Haitian people). However, I have to say I've been genuinely impressed with the speed and effectiveness of the response by the government and NGOs. I'm as cynical as anyone else about how little there is to show for years and years of public health efforts by international NGOs in Haiti: but this time, they seem to have got it more or less right. I arrived only two weeks after the outbreak started, and already by then everybody I met knew exactly what the steps for prevention were. I see people living in even the most basic conditions being meticulously careful about washing their hands and chlorinating their water.

Last week I was visiting a rural community, and I met a woman who was using water from an irrigation channel to wash her pots and pans. My colleagues, and also the local woman who was showing us around, were furious, telling her in no uncertain terms that her children will die of cholera if she continues doing that. But three months ago, it would have been completely normal.

Brett: What do you think I'm missing about Haiti from reading the news and the occasional blog?

F: Wow, where to start? I don't think that the journalistic staples of tent cities, cholera, rock-throwing demonstrators, and heroic Americans battling against poverty gives you much idea of what life in Haiti is really like. Perhaps what would most surprise an outsider is just how normal life here is most of the time. For example, Haiti was again in the international headlines with post-election protests in December. It's true that most people stayed at home for a couple of days while the situation was tense. But on the third day things started quietening down - and by the fourth day, the merchants were back on the streets, children were again hurrying to school in their little checkered uniforms, and the morning traffic jams were as bad as ever. Haitian people have seen a lot of political upheaval and many natural disasters over the years, they've seen international attention come and go, and life has carried on throughout.

There's a fascinating story waiting to be told about the social and economic effects of the 2010 earthquake. Almost every newspaper article I read about Haiti starts by describing it as the poorest country in the western hemisphere. That's true - but the situation is far more complex than that. This country has a lot of very poor people, but also quite a number of reasonably wealthy people too, and some super-rich. (Port-au-Prince has long had a Porsche dealership, believe it or not.) Before the earthquake, the level of inequality in Haiti was even higher than Brazil. Of course the earthquake was indiscriminate: it hit rich and poor alike, destroying the National Palace and the Montana Hotel as well as tens of thousands of single-room block-and-tin-roof houses. But this destruction of houses (combined with an enormous influx of foreigners, who all need a place to stay) has meant a huge increase in the price of accommodation, and a boom for landlords whose property was not damaged. My landlady is frantically adding extensions to our apartment building: that means she's employing a dozen or so construction workers, which is great. Some jobs are being created, but at the same time inflation is soaring. Then there's the complication of the massive internal migrations caused by the earthquake. I don't think anyone really knows what all this means for the long term, but it would be great to see some informed analysis.

Most of all, while there's a lot that's going wrong in Haiti, I wish the media would sometimes mention some of the great things about the country: the lively kompa music which surrounds you constantly in the street, the colorful, expressive language, the way Haitian people are so scrupulously polite and courteous (even among the urban youth, or more so than you'd expect), and the way they have such a strong sense of identity and of their proud history. Coming back has also made me realise how I had missed the Haitian sense of humor. When I get on a bus in the city and ask the people next to me how they're doing, I sometimes get a response of "lamizè ap kraze nou": "we're crushed by misery" - that seems to be the sort of thing people expect foreigners want to hear. But then more often than not, before we've gone a hundred yards down the road, my neighbors are laughing and joking with me - often teasing me about my terrible Creole. People here are certainly resilient: even after all the troubles and tragedy of the last 12 months, they are still able to find reasons to be cheerful.

Circumcision to the Rescue?

The Atlantic's Shaun Raviv has a long article on the scale-up of male circumcision for HIV prevention in Swaziland online here. According to the article (and other sources I've read) circumcision is in demand in Swaziland, but that demand isn't necessarily driven by accurate information:

Many Swazi men want to get circumcised, “but most of them for the wrong reason,” says Bheki Vilane, the national director of Marie Stopes Swazi­land, a non-governmental organization performing circumcisions. He’s voicing the main concern about circumcision as an HIV-prevention strategy: will it make Swazi men even more sexually reckless than they are already? “Some of the men have the misconception that they’ll be 100 percent safe.” To dispel this myth, NGOs are ensuring that every patient goes through counseling before and after the procedure. Each man is told to use condoms, and also given the option to be tested for HIV, which about 85 percent agree to do.

This massive scale-up is of course based on three randomized controlled trials:

[In 2005] a randomized controlled trial in South Africa (later confirmed by studies in Uganda and Kenya) found that circumcised men are as much as 60 percent less likely to contract HIV through heterosexual sex.

What is often not mentioned is the difference between the intervention that was tested in those trials and the intervention that's being scaled up. I would summarize what the randomized trials intervention as "male circumcision with very intensive counseling on the risk of MC (many visits) in an environment where fewer of the participants had the expectation of it completely eliminating risk" vs. the counseling alone. They showed a strong and surprisingly consistent effect across the three studies.

But I would describe the intervention that's being scaled up as "male circumcision with much less intensive counseling (one visit) in an environment where many of the participants have unrealistically high expectations of risk reduction."

I'm worried that the behavioral dis-inhibition from circumcision will more than make up for the risk reduction from the procedure itself. Thus, I'm interested in seeing more data from evaluations of these programs, as well as population-level data that includes the less-well-supervised circumcision operations that are likely to spring up in response to demand.

The article quotes Dr. Vusi Magaula, chair of Swaziland's male circumcision task force, as saying, "With the highest prevalence of HIV in a population ever recorded, we have got to do something to intervene.” But does the urge to do something justify the programs being implemented, especially if there's a very real risk of harm?Unfortunately I don't think we really know the answer to that question, and only the data will tell.

Gates and Media Funding

You may or may not have heard of this controversy: the Gates Foundation -- a huge funding source in global health -- has been paying various media sources to ramp up their coverage of global health and development issues. It seems to me that various voices in global health have tended to respond to this as you might expect them to, based on their more general reactions to the Gates Foundation. If you like most of Gates does, you probably see this as a boon, since global health and development (especially if you exclude disaster/aid stories) aren't the hottest issues in the media landscape. If you're skeptical of the typical Gates Foundation solutions (technological fixes, for example) then you might think this is more problematic.

I started off writing some lengthy thoughts on this, and realized Tom Paulson at Humanosphere has already said some of what I want to say. So I'll quote from him a bit, and then finish with a few more of my own thoughts. First, here is an interview Paulson did with Kate James, head of communications at the Gates Foundation. An excerpt:

Q Why does the Gates Foundation fund media?

Kate James: It’s driven by our recognition of the changing media landscape. We’ve seen this big drop-off in the amount of coverage of global health and development issues. Even before that, there was a problem with a lack of quality, in-depth reporting on many of these issues so we don’t see this as being internally driven by any agenda on our part. We’re responding to a need.

Q Isn’t there a risk that by paying media to do these stories the Gates Foundation’s agenda will be favored, drowning out the dissenting voices and critics of your agenda?

KJ: When we establish these partnerships, everyone is very clear that there is total editorial independence. How these organizations choose to cover issues is completely up to them.

The most recent wave of controversy seems to stem from Gates funding going to an ABC documentary on global health that featured clips of Bill and Melinda Gates, among other things. Paulson writes about that as well. Reacting to a segment on Guatemala, Paulson writes:

For example, many would argue that part of the reason for Guatemala’s problem with malnutrition and poverty stems from a long history of inequitable international trade policies and American political interference (as well as corporate influence) in Central America.

The Gates Foundation steers clear of such hot-button political issues and we’ll see if ABC News does as well. Another example of a potential “blind spot” is the Seattle philanthropy’s tendency to favor technological solutions — such as vaccines or fortified foods — as opposed to messier issues involving governance, industry and economics.

A few additional thoughts:

Would this fly in another industry? Can you imagine a Citibank-financed investigative series on the financial industry? That's probably a bad example for several reasons, including the Citibank-Gates comparison and the fact that the financial industry is not underreported. I'm having a hard time thinking of a comparable example: an industry that doesn't get much news coverage, where a big actor funded the media -- if you can think of an example, please let me know.

Obviously this induces a bias in the coverage. To say otherwise is pretty much indefensible to me. Think of it this way: if Noam Chomsky had a multi-billion dollar foundation that gave grants to the media to increase news coverage of international development, but did not have specific editorial control, would that not still bias the resulting coverage? Would an organization a) get those grants if it were not already likely to do the cover the subject with at last a gentle, overall bias towards Chomsky's point of view, or b) continue to get grants for new projects if they widely ridiculed Chomsky's approach? It doesn't have to be Chomsky -- take your pick of someone with clearly identifiable positions on international issues, and you get the same picture. Do the communications staffers at the Gates Foundation need to personally review the story lines for this sort of bias to creep in? Of course not.

Which matters more: the bias or the increased coverage? For now I lean towards increased coverage, but this is up for debate. It's really important that the funding be disclosed (as I understand it has been). It would also be nice if there was enough public demand for coverage of international development that the media covered it in all its complexity and difficulty and nuance without needing support from a foundation, but that's not the world we live in for now. And maybe the funded coverage will ultimately result in more discussion of the structural and systemic roots of international inequality, rather than just "quick fixes."

[Other thoughts on Gates and media funding by Paul Fortner, the Chronicle of Philanthropy, and (older) LA Times.]

Randomizing in the USA, ctd

[Update: There's quite a bit of new material on this controversy if you're interested. Here's a PDF of Seth Diamond's testimony in support of (and extensive description of) the evaluation at a recent hearing, along with letters of support from a number of social scientists and public health researchers. Also, here's a separate article on the City Council hearing at which Diamond testified, and an NPR story that basically rehashes the Times one. Michael Gechter argues that the testing is wrong because there isn't doubt about whether the program works, but, as noted in the comments there, doesn't note that denial-of-service was already part of the program because it was underfunded.] A couple weeks ago I posted a link to this NYTimes article on a program of assistance for the homeless that's currently being evaluated by a randomized trial. The Poverty Action Lab blog had some discussion on the subject that you should check out too.

The short version is that New York City has a housing assistance program that is supposed to keep people from becoming homeless, but they never gave it a truly rigorous evaluation. It would have been better to evaluate it up front (before the full program was rolled out) but they didn't do that, and now they are.  The policy isn't proven to work, and they don't have resources to give it to everyone anyway, so instead of using a waiting list (arguably a fair system) they're randomizing people into receiving the assistance or not, and then tracking whether they end up homeless. If that makes you a little uncomfortable, that's probably a good thing -- it's a sticky issue, and one that might wrongly be easier to brush aside when working in a different culture. But I think on balance it's still a good idea to evaluate programs when we don't know if they actually do what they're supposed to do.

The thing I want to highlight for now is the impact that the tone and presentation of the article impacts your reactions to the issue being discussed. There's obviously an effect, but I thought this would be a good example because I noticed that the Times article contains both valid criticisms of the program and a good defense of why it makes sense to test it.

I reworked the article by rearranging the presentation of those sections. Mostly I just shifted paragraphs, but in a few cases I rearranged some clauses as well. I changed the headline, but otherwise I didn't change a single word, other than clarifying some names when they were introduced in a different order than in the original. And by leading with the rationale for the policy instead of with the emotional appeal against it, I think the article gives a much different impression. Let me know what you think:

City Department Innovates to Test Policy Solutions

By CARA BUCKLEY with some unauthorized edits by BRETT KELLER

It has long been the standard practice in medical testing: Give drug treatment to one group while another, the control group, goes without.

Now, New York City is applying the same methodology to assess one of its programs to prevent homelessness. Half of the test subjects — people who are behind on rent and in danger of being evicted — are being denied assistance from the program for two years, with researchers tracking them to see if they end up homeless.

New York City is among a number of governments, philanthropies and research groups turning to so-called randomized controlled trials to evaluate social welfare programs.

The federal Department of Housing and Urban Development recently started an 18-month study in 10 cities and counties to track up to 3,000 families who land in homeless shelters. Families will be randomly assigned to programs that put them in homes, give them housing subsidies or allow them to stay in shelters. The goal, a HUD spokesman, Brian Sullivan, said, is to find out which approach most effectively ushered people into permanent homes.

The New York study involves monitoring 400 households that sought Homebase help between June and August. Two hundred were given the program’s services, and 200 were not. Those denied help by Homebase were given the names of other agencies — among them H.R.A. Job Centers, Housing Court Answers and Eviction Intervention Services — from which they could seek assistance.

The city’s Department of Homeless Services said the study was necessary to determine whether the $23 million program, called Homebase, helped the people for whom it was intended. Homebase, begun in 2004, offers job training, counseling services and emergency money to help people stay in their homes.

The department, added commissioner Seth Diamond, had to cut $20 million from its budget in November, and federal stimulus money for Homebase will end in July 2012.

Such trials, while not new, are becoming especially popular in developing countries. In India, for example, researchers using a controlled trial found that installing cameras in classrooms reduced teacher absenteeism at rural schools. Children given deworming treatment in Kenya ended up having better attendance at school and growing taller.

“It’s a very effective way to find out what works and what doesn’t,” said Esther Duflo, an economist at the Massachusetts Institute of Technology who has advanced the testing of social programs in the third world. “Everybody, every country, has a limited budget and wants to find out what programs are effective.”

The department is paying $577,000 for the study, which is being administered by the City University of New York along with the research firm Abt Associates, based in Cambridge, Mass. The firm’s institutional review board concluded that the study was ethical for several reasons, said Mary Maguire, a spokeswoman for Abt: because it was not an entitlement, meaning it was not available to everyone; because it could not serve all of the people who applied for it; and because the control group had access to other services.

The firm also believed, she said, that such tests offered the “most compelling evidence” about how well a program worked.

Dennis P. Culhane, a professor of social welfare policy at the University of Pennsylvania, said the New York test was particularly valuable because there was widespread doubt about whether eviction-prevention programs really worked.

Professor Culhane, who is working as a consultant on both the New York and HUD studies, added that people were routinely denied Homebase help anyway, and that the study was merely reorganizing who ended up in that pool. According to the city, 5,500 households receive full Homebase help each year, and an additional 1,500 are denied case management and rental assistance because money runs out.

But some public officials and legal aid groups have denounced the study as unethical and cruel, and have called on the city to stop the study and to grant help to all the test subjects who had been denied assistance.

“They should immediately stop this experiment,” said the Manhattan borough president, Scott M. Stringer. “The city shouldn’t be making guinea pigs out of its most vulnerable.”

But, as controversial as the experiment has become, Mr. Diamond said that just because 90 percent of the families helped by Homebase stayed out of shelters did not mean it was Homebase that kept families in their homes. People who sought out Homebase might be resourceful to begin with, he said, and adept at patching together various means of housing help.

Advocates for the homeless said they were puzzled about why the trial was necessary, since the city proclaimed the Homebase program as “highly successful” in the September 2010 Mayor’s Management Report, saying that over 90 percent of families that received help from Homebase did not end up in homeless shelters. One critic of the trial, Councilwoman Annabel Palma, is holding a General Welfare Committee hearing about the program on Thursday.

“I don’t think homeless people in our time, or in any time, should be treated like lab rats,” Ms. Palma said.

“This is about putting emotions aside,” [Mr. Diamond] said. “When you’re making decisions about millions of dollars and thousands of people’s lives, you have to do this on data, and that is what this is about.”

Still, legal aid lawyers in New York said that apart from their opposition to the study’s ethics, its timing was troubling because nowadays, there were fewer resources to go around.

Ian Davie, a lawyer with Legal Services NYC in the Bronx, said Homebase was often a family’s last resort before eviction. One of his clients, Angie Almodovar, 27, a single mother who is pregnant with her third child, ended up in the study group denied Homebase assistance. “I wanted to cry, honestly speaking,” Ms. Almodovar said. “Homebase at the time was my only hope.”

Ms. Almodovar said she was told when she sought help from Homebase that in order to apply, she had to enter a lottery that could result in her being denied assistance. She said she signed a letter indicating she understood. Five minutes after a caseworker typed her information into a computer, she learned she would not receive assistance from the program.

With Mr. Davie’s help, she cobbled together money from the Coalition for the Homeless and a public-assistance grant to stay in her apartment. But Mr. Davie wondered what would become of those less able to navigate the system. “She was the person who didn’t fall through the cracks,” Mr. Davie said of Ms. Almodovar. “It’s the people who don’t have assistance that are the ones we really worry about.”

Professor Culhane said, “There’s no doubt you can find poor people in need, but there’s no evidence that people who get this program’s help would end up homeless without it.”

Culturomics

Several prominent scholars and the Google Books team have published a new paper that’s generating a lot of buzz (Google pun intended). The paper is in Science (available here) and (update) here's the abstract:

We constructed a corpus of digitized texts containing about 4% of all books ever printed. Analysis of this corpus enables us to investigate cultural trends quantitatively. We survey the vast terrain of "culturomics", focusing on linguistic and cultural phenomena that were reflected in the English language between 1800 and 2000. We show how this approach can provide insights about fields as diverse as lexicography, the evolution of grammar, collective memory, the adoption of technology, the pursuit of fame, censorship, and historical epidemiology. "Culturomics" extends the boundaries of rigorous quantitative inquiry to a wide array of new phenomena spanning the social sciences and the humanities.

It’s readable, thought-provoking, and touches on many fields of study, so I imagine it will be widely read and cited. Others have noted many of the highlights, so here are some brief bulleted thoughts:

• The authors don’t explore the possible selection bias in their study. They note that the corpus of books they studied includes 4% of all published books. They specifically chose works that scanned better and have better metadata (author, date of publication, etc), so it seems quite likely that these works differ systematically from those that were scanned and not chosen, and differ even more from those not yet scanned. Will the conclusions hold up when new books are added? Since many of the results were based on random subsets of the books (or n-grams) they studied, will those results hold up when other scholars try and recreate them with separate randomly chosen subsets?
• Speaking of metadata, I would love to see an analysis of social networks amongst authors and how that impacts word usage. If someone had a listing of, say, several hundred authors from one time period, and some measure of how well they knew each other, and combined that information with an analysis of their works, you might get some sense of how “original” various authors were, and whether originality is even important in becoming famous.
• The authors are obviously going for a big splash and make several statements that are a bit provocative and likely to be quoted. It will be great to see these challenged and discussed in subsequent publications. One example that is quotable but may not be fully supported by the data they present: “We are forgetting our past faster with each passing year.” But is the frequency with which a year (their example is 1951) appears in books actually representative of collective forgetting?
• I love the word plays. An example: “For instance, we found “found” (frequency: 5x10^-4) 200,000 times more often than we finded “finded.” In contrast, “dwelt” (frequency: 1x10^-5) dwelt in our data only 60 times as often as “dwelled” dwelled.”
• The “n-grams” studied here (a collection of letters separate from others by spaces, which could be words, numbers, or typos) are too short for a study of copying and plagiarism, but similar approaches could yield insight into the commonality of copying or borrowing throughout history.

Arkansas

I arrived back in my hometown of Searcy, Arkansas. I haven't been back in a year -- I was living in DC from January through June, then traveling in Guatemala for the summer, and most recently living in Baltimore -- so it's good to be back. Searcy is ~18,000 people in central Arkansas, where the flat plains of the Mississippi Delta meet the first foothills of the Ozarks. The town once put up a billboard that proclaimed "Searcy, where thousands live as millions wish they could." It's also the home of Harding University, a conservative Christian university affiliated with the Church of Christ. My dad's been a professor at Harding for decades, so Searcy has always been home and likely always will be. Because I lived in the same small town for the first 23 years of my life, moving to Washington, DC in May of 2008 was a huge change. I had culture shock, but mostly in positive ways. When people would ask me if I liked DC, I would answer "Yes! But... I don't really have anything to compare it to, because it's my first city." I was never sure if I just liked DC, or what I actually liked was the urban environment in general. (My friends from NYC laugh because DC hardly feels urban to them.) Now that I've lived for several months in my second city, Baltimore, I can say that I do like it, but maybe not as much as DC.

One realization I've had over the last year is that I believe the divide between urban and rural America (to dichotomize it) is as significant, or maybe more significant than the divide between liberal and conservative, religious and secular. Most of my friends from high school and college are rural, Southern, politically conservative (though often apathetic), married (some with kids on the way), and quite religious -- of the evangelical Christian persuasion. No Jews, Muslims, Hindus, or Buddhists here. All of those adjectives (except married) once described me, but now I'm a politically liberal, secular, single young professional living in a big city. Yes, these traits are correlated: there are relatively few very religious young professionals living in big cities, there are relatively few hardcore secularists in rural Southern towns. But I think the urban/rural divide has a bigger impact on my daily experience, and on shaping my views and actions, than any of the others traits.

I think I've become a thoroughly urban creature, but the small town roots linger. I like so many things about cities: the density that leads to so many people, so many jobs and so much food, culture, entertainment and transportation all being close. But I also like the space and beauty of the small town. That's kind of a universal American narrative in a way; we all like to think we were born -- and remain rooted -- in small towns, even though the majority of us live in cities. I appreciate having grown up in a small town, and it's nice to be back for an occasional visit, but it's hard for me to imagine coming back here to live.

-----------

A few random observations from my visit back to Arkansas so far:

1) Little Rock ain't that big, though it felt huge when I was growing up.

2) There's so much space around the roads and freeways, and within the towns. The space gives you a sense of openness, but it also means you have to drive everywhere.

3) I'm at my favorite coffeeshop in town (one of two, and the only other options for places to hang out are churches, a Hastings, and Wal-Mart) and the first person who walked in the door after me is wearing a t-shirt that says (only) "JESUS".

4) People are different. Strong Southern accents for one. A lot more baseball caps, and pickup trucks. Women are wearing more makeup. More overweight and obese people than you typically see on the streets in a city. Lots of white people, few of anything else.

5) Finally, today's lunch spot was the Flying Pig BBQ:

Randomizing in the USA

The NYTimes posted this article about a randomized trial in New York City:

It has long been the standard practice in medical testing: Give drug treatment to one group while another, the control group, goes without.

Now, New York City is applying the same methodology to assess one of its programs to prevent homelessness. Half of the test subjects — people who are behind on rent and in danger of being evicted — are being denied assistance from the program for two years, with researchers tracking them to see if they end up homeless.

Dean Karlan at Innovations for Policy Action responds:

It always amazes me when people think resources are unlimited. Why is "scarce resource" such a hard concept to understand?

I think two of the most important points here are that a) there weren't enough resources for everyone to get the services anyway, so they're just changing the decision-making process for who gets the service from first-come-first-served (presumably) to randomized, and b) studies like this can be ethical when there is reasonable doubt about whether a program actually helps or not. If it were firmly established that the program is beneficial, then it's unethical to test it, which is why you can't keep testing a proven drug against placebo.

However, this is good food for thought for those who are interested in doing randomized trials of development initiatives in other countries. It shows the impact (and reactions) from individuals to being treated as "test subjects" here in the US -- and why should we expect people in other countries to feel differently? That said, a lot of randomized trials don't get this sort of pushback. I'm not familiar with this program beyond what I read in this article, but it's possible that more could have been done to communicate the purpose of the trial to the community, activists, and the media.

There are some interesting questions raised in the IPA blog comments as well.

The Changing Face of Epidemiology

Unlike many scientific disciplines, undergraduate training in epidemiology is fairly rare. I've met a lot of public health students over the past few months, but only a few majored as an undergrad in public health or something similar, and I haven't met anyone whose degree was in epidemiology. For the most part, people come to epidemiology from other fields: there are many physicians, and lots of pre-med student who decided they didn't want to be doctors (like me) or still want to be. This has many implications for the field, including a bias towards looking at problems primarily through a biomedical lens, rather than through sociological, political, economic, or anthropological ones. Another interesting consequence of this lack of (or only cursory) study of epidemiology before graduate school is that the introductory courses in epidemiology at most schools of public health are truly introductory. If you're a graduate student in biochemistry and molecular biology (my undergraduate field), my guess is that it's assumed you know something about the structure of nucleic acids, have drawn the Krebs cycle at some point, and may even have heard the PCR song.

In epidemiology we're essentially starting from scratch, so there's a need to move rapidly from having no common, shared knowledge, through learning basic vocabulary (odds ratios, relative risk differences, etc.), all the way to analyzing extremely complex research. This presents pedagogical difficulties, of course, and it also makes it easier to miss out on the "big picture" of the field of epidemiology.

For one of our earliest discussion labs in my epidemiologic methods course, we discussed a couple papers on smoking and lung cancer. While "everyone knows" today that smoking causes lung cancer, it's a useful exercise to go back and look at the papers that actually established that as a scientific fact. In terms of teaching, it's a great case-study for thinking about causality like an epidemiologist. After all,  most people who smoke never get lung cancer, and some people get lung cancer without ever smoking, so establishing causality requires a bit more thought. Two of the papers we read are great for illustrating some changes that have occurred as epidemiology has changed and matured over the last 50 years.

The first paper we looked at is "The Mortality of Doctors in Relation to Their Smoking Habits: A Preliminary Report," written by Richard Doll and Bradford Hill in the British Medical Journal in 1954. (Free PDF here)  Doll and Hill followed up their groundbreaking study with "Mortality in relation to smoking: 50 years' observations on male British doctors" in 2004 (available here).

A few observations: First, the 1954 paper is much shorter: around 4 1/2 pages of text compared to 8 1/2 in the 2004 article. The 1954 paper is much more readable as well: it's conversational and uses much less specialized vocabulary (possibly because some of that vocabulary simply didn't exist in 1954). The graphs are also crude and ugly compared to the computer-generated ones in 2004.

The 2004 paper also ends with this note: "Ethical approval: No relevant ethics committees existed in 1951, when the study began."

Beyond the differences in style, length, and external approval by an ethics committee, the changes in authorship are notable. The original paper was authored by merely two people: a physician and a statistician. The 2004 paper adds two additional authors for a total of 4 (still small compared to many papers) -- and notably, the two new authors are both female. During those 50 years there was of course great progress in terms of women's representation in scientific research.  While that record is still spotty in some areas, schools of public health today are producing many more female scholars than males -- for example, current public health students at Hopkins are 71% female.

There has been a definite shift from the small-scale collaboration resulting in a paper with an individual, conversational style to the large-scale collaboration resulting in an extremely institutional output. One excellent example of this is a paper I read for an assignment today: "Serum B Vitamin Levels and Risk of Lung Cancer" by Johansson et al. in JAMA, 2010 (available here).

The Johansson et al. paper has ~8 pages of text, 47 references, 2 tables and 2 figures (all of which are quite complicated) and a number of online supplements. Its 46 authors have between them (by my count) 33 PhDs, 27 MDs, 3 MPHs, and 6 other graduate degrees! It's hard to tell gender just by name, but by my count at least half of the authors are likely female.

Clearly, epidemiology has changed a lot in the last 50 years. Gone are the days of (at least explicit) male domination. Many of the problems with the field today are related to information management and large-scale collaborations. Gone are the days of one or two researchers publishing ground-breaking studies on their own -- many of the "easy" discoveries have been made. Yet many of the examples we learn from -- and role models young public health researchers may want to emulate -- are from an earlier era.