Archive for the ‘cynical rants’Category

Merci, FIFA

This is a French-language FIFA billboard about Ebola:


It has 11 anti-Ebola messages from famous footballers, which happen to be printed small enough to be unreadable from the street or sidewalk.

Not that it would matter anyway: it’s on a major road in Monrovia, Liberia, where no one speaks French.


04 2015

Uninformative paper titles: "in Africa"

When I saw a new NBER working paper titled “Disease control, demographic change and institutional development in Africa” (PDF) pop up in the NBER RSS feed I thought the title sounded interesting, so I downloaded the paper to peruse later. Then today the new-ish (and great!) blog Cherokee Gothic highlighted the same paper in a post, and I finally took a look.

Unfortunately the paper title is rather uninformative, as the authors only used data from Burkina Faso. Sure, economics papers tend to have bigger, less formal titles than papers in some other fields, but I think this is particularly unhelpful. There are enough search frictions in finding applicable literature on any given topic that it helps to be somewhat more precise.

For reference, here’s Burkina Faso:

And here’s Africa:

Not the same.

It’s unclear from the data and arguments presented how these results — for a regional disease control program, but only using data from Burkina Faso — might generalize to the quite diverse disease environments, demographic trends, and institutional histories of various African countries. The paper doesn’t answer or even give much grounds for speculation on whether onchocerciasis or other disease control programs would yield similar results in countries as diverse as (for example) Senegal, Ethiopia, Uganda, and Angola.

A quick thought experiment: Virginia’s population is about 1.5% of the total population of North America, just as Burkina Faso’s population is about 1.5% of the total population on Africa. Can you imagine someone writing a paper on health and institutions using data from Virginia and titling that paper “Health and institutions in North America”? Or writing a paper on Vietnamese history and titling it “A history of Asia”? Probably not.


07 2013

Do they know it's Christmas? No, because it isn't.

Remember “Do they know it’s Christmas?” That’s right, the 1984 hit song intended to raise money for famine victims in Ethiopia.  If that’s not ringing a bell (See what I did there?) then here’s the video:

You probably didn’t get very far, so here are some of the inane lyrics:

And there won’t be snow in Africa this Christmas time
The greatest gift they’ll get this year is life
Where nothing ever grows, no rain or rivers flow
Do they know it’s Christmas time at all?

In addition to reinforcing all sorts of stereotypes about Africa, this video gets one very important thing wrong: Do they know it’s Christmas time? No, they don’t, because Ethiopians are Orthodox Christians and don’t celebrate Christmas until January 7th. So next time someone says they love this song, you now have an annoying know-it-all response to shut them down — which you can consider your holiday gift from this blogger. Merry Christmas!

[On a more serious note, Ethiopia has made huge strides on food security since the fall of the Derg. If you want to read more on that, MoreAltitude (an aid blogger who recently relocated to Addis) has this take.]


12 2012

The greatest country in the world

I’ve been in Ethiopia for six and a half months, and in that time span I have twice found myself explaining the United States’ gun culture, lack of reasonable gun control laws, and gun-related political sensitivities to my colleagues and friends in the wake of a horrific mass shooting.

When bad things happen in the US — especially if they’re related to some of our national moral failings that grate on me the most, e.g. guns, health care, and militarism — I feel a sense of personal moral culpability, much stronger when I’m living in the US. I think having to explain how terrible and terribly preventable things could happen in my society, while living somewhere else, makes me feel this way. (This is by no means because people make me feel this way; folks often go out of their way to reassure me that they don’t see me as synonymous with such things.)

I think that this enhanced feeling of responsibility is actually a good thing. Why? If being abroad sometimes puts the absurdity of situations at home into starker relief, maybe it will reinforce a drive to change. All Americans should feel some level of culpability for mass shootings, because we have collectively allowed a political system driven by gun fanatics,  a media culture unintentionally but consistently glorifying mass murderers, and a horribly deficient mental health system to persist, when their persistence has such appalling consequences.

After the Colorado movie theater shooting I told colleagues here that nothing much would happen, and sadly I was right. This time I said that maybe — just maybe — the combination of the timing (immediately post-election) and the fact that the victims were schoolchildren will result in somewhat tighter gun laws. But, attention spans are short so action would need to be taken soon. Hopefully the fact that the petition on gun control already has 138,000 signatures (making it the most popular petition in the history of the website) indicates that something could well be driven through. Even if that’s the case, anything that could be passed now will be just the start and it will be long hard slog to see systematic changes.

As Andrew Gelman notes here, we are all part of the problem to some extent: “It’s a bit sobering, when lamenting problems with the media, to realize that we are the media too.” He’s talking about bloggers, but I think it extends further: every one of us that talks about gun control in the wake of a mass shooting but quickly lets it slip down our conversational and political priorities once the event fades from memory is part of the problem. I’m making a note to myself to write further about gun control and the epidemiology of violence in the future — not just today — because I think that entrenched problems require a conscious choice to break the cycle. In the meantime, Harvard School of Public Health provides some good places to start.


12 2012

Alwyn Young just broke your regression

Alwyn Young — the same guy whose paper carefully accounting for growth in East Asian was popularized by Krugman and sparked an enormous debate — has been circulating a paper on African growth rates. Here’s the 2009 version (PDF) and October 2012 version. The abstract of the latter paper:

Measures of real consumption based upon the ownership of durable goods, the quality of housing, the health and mortality of children, the education of youth and the allocation of female time in the household indicate that sub-Saharan living standards have, for the past two decades, been growing about 3.4 to 3.7 percent per annum, i.e. three and a half to four times the rate indicated in international data sets. (emphasis added)

The Demographic and Health Surveys are large-scale nationally-representative surveys of health, family planning, and related modules that tend to ask the same questions across different countries and over large periods of time. They have major limitations, but in the absence of high-quality data from governments they’re often the best source for national health data. The DHS doesn’t collect much economic data, but they do ask about ownership of certain durable goods (like TVs, toilets, etc), and the answers to these questions are used to construct a wealth index that is very useful for studies of health equity — something I’m taking advantage of in my current work. (As an aside, this excellent report from Measure DHS (PDF) describes the history of the wealth index.)

What Young has done is to take this durable asset data from many DHS surveys and try to estimate a measure of GDP growth from actually-measured data, rather than the (arguably) sketchier methods typically used to get national GDP numbers in many African countries. Not all countries are represented at any given point in time in the body of DHS data, which is why he ends up with a very-unbalanced panel data set for “Africa,” rather than being able to measure growth rates in individual countries. All the data and code for the paper are available here.

Young’s methods themselves are certain to spark ongoing debate (see commentary and links from Tyler Cowen and Chris Blattman), so this is far from settled — and may well never be. The takeaway is probably not that Young’s numbers are right so much as that there’s a lot of data out there that we shouldn’t trust very much, and that transparency about the sources and methodology behind data, official or not, is very helpful. I just wanted to raise one question: if Young’s data is right, just how many published papers are wrong?

There is a huge literature on cross-country growth ‘s empirics. A Google Scholar search for “cross-country growth Africa” turns up 62,400 results. While not all of these papers are using African countries’ GDPs as an outcome, a lot of them are. This literature has many failings which have been duly pointed out by Bill Easterly and many others, to the extent that an up-and-coming economist is likely to steer away from this sort of work for fear of being mocked. Relatedly, in Acemoglu and Robinson’s recent and entertaining take-down of Jeff Sachs, one of their insults criticisms is that Sachs only knows something because he’s been running “kitchen sink growth regressions.”

Young’s paper just adds more fuel to that fire. If African GDP growth has been 3 1/2 to 4 times greater than the official data says, then every single paper that uses the old GDP numbers is now even more suspect.

"As it had to fail"

My favorite line from the Anti-Politics Machine is a throwaway. The author, James Ferguson, an anthropologist, describes a World Bank agricultural development program in Lesotho, and also — through that lens — ends up describing development programs more generally. At one point he notes that the program failed “as it had to fail” — not really due to bad intentions, or to lack of technical expertise, or lack of funds — but because failure was written into the program from the beginning. Depressing? Yes, but valuable.

I read in part because Chris Blattman keeps plugging it, and then shortly before leaving for Ethiopia I saw that a friend had a copy I could borrow. Somehow it didn’t make it onto reading lists for any of my classes for either of my degrees, though it should be required for pretty much anyone wanting to work in another culture (or, for that matter, trying to foment change in your own). Here’s Blattman’s description:

People’s main assets [in Lesotho] — cattle — were dying in downturns for lack of a market to sell them on. Households on hard times couldn’t turn their cattle into cash for school fees and food. Unfortunately, the cure turned out to be worse than the disease.

It turns out that cattle were attractive investments precisely because they were hard to liquidate. With most men working away from home in South Africa, buying cattle was the best way to keep the family saving rather than spending. They were a means for men to wield power over their families from afar.

Ferguson’s point was that development organizations attempt to be apolitical at their own risk. What’s more, he argued that they are structured to remain ignorant of the historical, political and cultural context in which they operate.

And here’s a brief note from Foreign Affairs:

 The book comes to two main conclusions. First is that the distinctive discourse and conceptual apparatus of development experts, although good for keeping development agencies in business, screen out and ignore most of the political and historical facts that actually explain Third World poverty-since these realities suggest that little can be accomplished by apolitical “development” interventions. Second, although enormous schemes like Thaba-Tseka generally fail to achieve their planned goals, they do have the major unplanned effect of strengthening and expanding the power of politically self-serving state bureaucracies. Particularly good is the discussion of the “bovine mystique,” in which the author contrasts development experts’ misinterpretation of “traditional” attitudes toward uneconomic livestock with the complex calculus of gender, cash and power in the rural Lesotho family.

The reality was that Lesotho was not really an idyllically-rural-but-poor agricultural economy, but rather a labor reserve more or less set up by and controlled by apartheid South Africa. The gulf between the actual political situation and the situation as envisioned by the World Bank — where the main problems were lack of markets and technical solutions — at the time was enormous. This lets Ferguson have a lot of fun showing the absurdities of Bank reports from the era, and once you realize what’s going on it’s quite frustrating to read how the programs turned out, and to wonder how no one saw it coming.

This contrast between rhetoric and reality is the book’s greatest strength: because the situation is absurd, it illustrates Ferguson’s points very well, that aid is inherently political, and that projects that ignore that reality have their future failure baked in from the start. But that contrast is a weakness too, as because the situation is extreme you’re left wondering just how representative the case of Lesotho really was (or is). The 1970s-80s era World Bank certainly makes a great buffoon (if not quite a villain) in the story, and one wonders if things aren’t at least a bit better today.

Either way, this is one of the best books on development I’ve read, as I find myself mentally referring to it on a regular basis. Is the rhetoric I’m reading (or writing) really how it is? Is that technical, apolitical sounding intervention really going to work? It’s made me think more critically about the role outside groups — even seemingly benevolent, apolitical ones — have on local politics. On the other hand, the Anti-Politics Machine does read a bit like it was adapted from an anthropology dissertation (it was); I wish it could get a new edition with more editing to make it more presentable. And a less ugly cover. But that’s no excuse — if you want to work in development or international health or any related field, it should be high on your reading list.

Obesity pessimism

I posted before on the massive increase in obesity in the US over the last couple decades, trying to understand the why of the phenomenal change for the worse. Seriously, take another look at those maps.

A while back Matt Steinglass wrote a depressing piece in The Economist on the likelihood of the US turning this trend around:

I very much doubt America is going to do anything, as a matter of public health policy, that has any appreciable effect on obesity rates in the next couple of decades. It’s not that it’s impossible for governments to hold down obesity; France, which had rapidly rising childhood obesity early this century, instituted an aggressive set of public-health interventions including school-based food and exercise shifts, nurse assessments of overweight kids, visits to families where overweight kids were identified, and so forth. Their childhood obesity rates stabilised at a fraction of America’s. The problem isn’t that it’s not possible; rather, it’s that America is incapable of doing it.

America’s national governing ideology is based almost entirely on the assertion of negative rights, with a few exceptions for positive rights and public goods such as universal elementary education, national defence and highways. But it’s become increasingly clear over the past decade that the country simply doesn’t have the political vocabulary that would allow it to institute effective national programmes to improve eating and exercise habits or culture. A country that can’t think of a vision of public life beyond freedom of individual choice, including the individual choice to watch TV and eat a Big Mac, is not going to be able to craft public policies that encourage people to exercise and eat right. We’re the fattest country on earth because that’s what our political philosophy leads to. We ought to incorporate that into the way we see ourselves; it’s certainly the way other countries see us.

On the other hand, it’s notable that states where the public has a somewhat broader conception of the public interest, as in the north-east and west, tend to have lower obesity rates.

This reminds me that a classmate asked me a while back about my impression of Michelle Obama’s Let’s Move campaign. I responded that my impression is positive, and that every little bit helps… but that the scale of the problem is so vast that I find it hard seeing any real, measurable impact from a program like Let’s Move. To really turn obesity around we’d need a major rethinking of huge swathes of social and political reality: our massive subsidization of unhealthy foods over healthy ones (through a number of indirect mechanisms), our massive subsidization of unhealthy lifestyles by supporting cars and suburbanization rather than walking and urban density, and so on and so forth. And, as Steinglass notes, the places with the greatest obesity rates are the least likely to implement such change.


11 2012

Our future selves will mock this (I hope)

Smiling people holding hands. Walking on the beach. Inexplicable doves flying through blue skies. Terrible side effects discussed cheerily by a honey-voiced narrator…. That’s right, this post is about direct-to-consumer pharmaceutical advertising.

Niam Hardimh, writing at Crooked Timber, shares one of the odd things about living in the US — for those who aren’t used to our TV:

One thing that is striking, compared with European TV, is what is advertised and how. In particular,  I don’t think you see ads for prescription medicines in Europe, certainly not in Ireland or the UK. They seem to be all over American TV.

I am particularly struck by the way these ads are made. The visuals  typically show someone having a happy and trouble-free life while using these drugs, overlaid with soothing music and a reassuringly bland voice-over. But clearly the US FDA requires advertisers to include all the small print in their ads as well.

Do you read all the known downsides of the medicines you take? Don’t…

It’s easy to become habituated to these since they’re everywhere, but it hasn’t always been that way, and in most places it still isn’t — the US and New Zealand are the only two countries that allow direct advertising of drugs. Here’s an exemplary ad for Vioxx, which was pulled off the market because it caused health problems (which Merck systematically lied about):

Ice skating. A minor celebrity. Inspiring music. They even note that “Vioxx specifically targets the Cox2 enzyme.” How many Americans can even define what an enzyme is? I’m sure consumers are more likely to remember that than the mentioned side effects (“bleeding can occur without warning”)… Other lovely examples include this other ad for Vioxx, and one for Zocor.

For more examples and some background on how the ads came to be, check out “Sick of pharmaceutical ads: here’s why they won’t go away” on io9.


05 2012

Facebook's brilliantly self-interested organ donation move

How can social media have a big impact on public health? Here’s one example: Facebook just introduced a feature that allows users to announce their status as organ donors, and to tell the story of when they decided to sign up as a donor. They’re — rightly, I think — getting tons of good press from it. Here’s NPR for example:

Starting today, the social media giant is letting you add your organ-donation status to your timeline. And, if you’d like to become an organ donor, Facebook will direct you to a registry.

Patients and transplant surgeons are eager for you to try it out.

Nearly 114,000 people in this country are waiting for organs, according to the United Network for Organ Sharing. But there simply aren’t enough organs to go around.

It’s an awesome idea. Far too few Americans are organ donors, so anything that boosts sign-up rates is welcome. As Ezra Klein notes, organ donation rates would be much higher if we simply had people opt out of donating, rather than opt in, but that’s another story. (And another aside: I hope they alerted some smart people beforehand to help them rigorously measure the impact of this shift!)

Call me a cynic, but I think the story of why Facebook chose to do this — and in the way they did it — is more interesting.Yes, there’s altruism, but Facebook is a business above all. Maybe they’re just trying to cultivate that Google ethos of “we sometimes spend lots of money on far-sighted things just to make the world a better place.” Facebook will certainly garner lots of public good will from this.

But I think, even more importantly, Facebook gets magnificent cover for introducing new modules on health/wellness. Check out the screenshot from their newsroom post on the new features:

That’s right — in the new Health & Wellness section you can enter not only whether you’re an organ donor, but also these categories: “Overcame an Illness,” “Quit a Habit,” “New Eating Habits,”Weight Loss,” “Glasses, Contacts, Others,” and “Broken Bone.”

All life events some people may want to share, of course. But Facebook makes money off of advertising, and just think of how much money Americans spend on weight loss, or on trying to quit smoking (or more usually, continuing it), or on glasses and contacts. Then think how much more advertisers will pay to show ads to segments of the billions of Facebook users who have shared the fact that they’re actively trying to lose weight.

Maybe Facebook has seen this sort of health data as a major growth area for some time, but was wary of introducing such features in the wrong way. On any other news day the introduction of these features would have triggered a new outbreak of the “Facebook feature prompt privacy outcry” and “Why does Facebook need your health data?” stories. Sure, we’ll get some of those this time, but I think any backlash will pale in comparison to the initial PR bump.

I don’t think there’s necessarily anything wrong with the move, and I certainly welcome any boost in organ donor registration. It may just be that this is a case where Facebook’s business interests in inducing us to share more of our personal information with them just happens to happily coincide with a badly needed public good. Either way, the execution is brilliant, because so far I’ve mostly seen news stories talking about how great organ donation is. And I just updated my Facebook status.


05 2012

Before you get all excited about male birth control

When you’re a public health grad student and something related to health hits the news, your friends make sure you see it. Since there’s a lot of bad science writing on the internet this can be rather frustrating. In the last few hours I’ve seen several people post this  to Facebook, and another emailed me with the subject line “Woh” and asked if this was too good to be true….

So what’s the story? Techcitement has a breathless article titled “The Best Birth Control In The World Is For Men” by Jon Clinkenbeard, which he followed up with “Could This Male Contraceptive Pill Make a Vas Deferens in the Fight Against HIV?” The first article starts with this hook:

If I were going to describe the perfect contraceptive, it would go something like this: no babies, no latex, no daily pill to remember, no hormones to interfere with mood or sex drive, no negative health effects whatsoever, and 100 percent effectiveness. The funny thing is, something like that currently exists.

Clinkenbeard is describing RISUG, or “Reversible inhibition of sperm under guidance.” Wikipedia explains:

RISUG is similar to vasectomy in that a local anesthetic is administered, an incision is made in the scrotum, and the vas deferens is tugged out with a small pair of forceps. Rather than being cut and cauterized, as it is in a vasectomy, the vas deferens is injected with [a] polymer gel and pushed back into the scrotum.

Sounds awesome? Why don’t we have it already? Clinkenbeard continues:

The trouble is, most people don’t even know this exists. And if men only need one super-cheap shot every 10 years or more, that’s not something that gets big pharmaceutical companies all fired up, because they’ll make zero money on it (even if it might have the side benefit of, you know, destroying HIV).

Before you go injecting something in your scrotum… not so fast! Yes, in one sense it exists. But on the other hand we don’t really know how well it works, and we don’t really know how safe it is. Clinkenbeard makes it sound like it’s a done deal, and claiming that Big Pharma is standing between you and the cure for babies (not to mention HIV!) certainly helped the article go viral. He then links to a bunch or articles and a few petitions.

While pharmaceutical companies do all sorts of things to manipulate data (start here if you don’t believe that), I think they could actually make TONS of money on this if it worked. The price of medicines isn’t usually based on how much they cost to manufacture but on how much they can be sold for, and I think there’s clearly a market for male contraception: just think how much men would pay for the insurance to both avoid pregnancy and not have to use condoms. A drug company could conceivably make a lot of money off this product by getting it to market first.

Guha’s initial studies were very small. A Phase II clinical trial published by Guha et al in 1997 featured a grand total of 12 men (PDF). (It also contains this humorous understatement: “Objective data on posttreatment frequency of intercourse could not be obtained.”) In another study 20 men received an injection, but one man’s partner still got pregnant.

Before a drug can (or should) go to market, it needs to be tested for both efficacy and safety, and everything needs to be done up to certain standards. Guha’s original work wasn’t. From a Wired article on RISUG by Bill Gifford, published this time last year:

In its report, the WHO team agreed that the concept of RISUG was intriguing. But they found fault with the homegrown production methods: Guha and his staff made the concoction themselves in his lab, and the WHO delegation found his facilities wanting by modern pharmaceutical manufacturing standards. Furthermore, they found that Guha’s studies did not meet “international regulatory requirements” for new drug approval—certain data was missing. The final recommendation: WHO should pass on RISUG.

These barriers can be overcome, if the researchers can get the investment necessary to make high quality product and run clinical trials. The Wired article describes how they’ve made progress and are now running clinical trials in India — but the results are still a few years out. In the same article we get this:

“Pharmaceutical companies are not interested in one-offs,” Weiss says. “They’re interested in things they can sell repeatedly, like the birth control pill or Viagra.”

But that’s not as true as it used to be. These arguments used to explain why pharmaceutical companies didn’t invest in developing vaccines, but then they realized they could charge obscene amounts for individual doses — orders of magnitude higher than what they charged before. They’ve managed these high prices because 1) there are always new cohorts of kids needing the vaccine (as there would be with men needing RISUG) and 2) because the health benefits are so large that even at the higher prices the vaccines are cost effective.

So are pharma companies just disinterested in male contraception? No. For quick and dirty evidence check, where US clinical trials must be registered. I find 436 studies on contraception, of which 84 are specifically about male contraception. There’s a disparity there, but it’s explained in part by the fact that many of the non-male contraception studies are about delivery methods (like this one involving text message reminders) and you can’t even start do this sort of research on male birth control before we have effective methods. Maybe they’re under-investing a bit — drug R&D is risky, as firms spend an average of $1.3 billion on research for every one drug  brought to market — but it’s not being ignored.

In closing, that Wired article from last year has some of the same breathless new-techthusiasm as the new Techcitement piece, but it’s a lot better at explaining where things stand today. Clinical trials in India are ongoing, but it will be another year or so before we hear any results. If those are considered high quality and they’re successful, it might spur the drug behemoths to up the massive amounts required for clinical trials in the US.

Generally, getting your science news from the coauthor of “The Pirate Treasure of the Himalaya” does’t seem like the best idea. Drugs and treatments fail at every stage of the clinical trials pipeline, and that’s a good thing because it means consumers will be less likely to spend money on ineffective or unsafe drugs. If everything works out with RISUG, it could be an incredible success story and a great public health tool. There might well be hope on the horizon, but contrary to Clinkenbeard’s assertions we don’t yet know very well if this works, and we don’t yet know if it’s safe. For that, we need good ole clinical trials, not petitions.


04 2012