Archive for the ‘ethics’Category

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 CentersHousing 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.”

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.

Afraid

Here are two semi-related articles: one by William Easterly about how aid to Ethiopia is propping up an oppressive regime, and another by Rory Carroll on the pernicious but well-intentioned effects of aid tourism in Haiti.

Basically, it’s really hard to do things right, because international aid and development are not simple. Good intentions are not enough. You can mess up by funneling all your money through a central regime, or by having an uncoordinated, paternalistic mess.

A couple confessions. First, I’m a former “aid tourist.” In high school and college I went on short-term trips to Mexico, Guyana, and Zambia (and slightly different experiences elsewhere). My church youth group went to Torreon, Mexico and helped build a church (problematize that). In Guyana and Zambia I was part of medical groups that ostensibly aimed to improve the health of the local people; in hindsight neither project could have possibly had any lasting effects on health, and likely fostered dependency.

Second, I’m an aspiring public health / development professional, and I’m afraid. I don’t want to be the short-term, uncoordinated, reinventing-the-wheel, well-intention aid vacationer — and I think given my education (and the experience I hope to continually gain) I’m more likely to avoid at least some of those shortcomings. But I’m scared that my work might prop up nasty regimes, or satiate a bloated aid industry that justifies its projects to sustain itself, or give me the false impression of doing good while actually doing harm.

I think the first step to doing better is being afraid of these things, but I’m still learning where to go from here.

Tuskegee in Guatemala

The news that a US government study in the 1940s involved injecting Guatemalans with syphilis has been circulating, and it makes my stomach turn.

Susan Reverby — the Wellesley historian who uncovered the fiasco — has made the draft paper available on her website: “‘Normal Exposure’ and Inoculation Syphilis: A PHS ‘Tuskegee’ Doctor in Guatemala, 1946-48,” which will be published in the Journal of Policy History in January.

From the introduction:

Policy is often made based on historical understandings of particular events, and the story of the “Tuskegee” Syphilis Study (the Study) has, more than any other medical research experiment, shaped policy surrounding human subjects. The forty-year study of “untreated syphilis in the male Negro” sparked outrage in 1972 after it became widely known, and inspired requirements for informed consent, the protection of vulnerable subjects, and oversight by institutional review boards.

When the story of the Study circulates, however, it often becomes mythical. In truth the United States Public Health Service (PHS) doctors who ran the Study observed the course of the already acquired and untreated late latent disease in hundreds of African American men in Macon County, Alabama. They provided a little treatment in the first few months in 1932 and then neither extensive heavy metals treatment nor penicillin after it proved a cure for the late latent stage of the disease in the 1950s. Yet much folklore asserts that the doctors went beyond this neglect, and that they secretly infected the men by injecting them with the bacteria that causes syphilis. This virally spread belief about the PHS’s intentional infecting appears almost daily in books, articles, talks, letters, websites, tweets, news broadcasts, political rhetoric, and above all in whispers and conversations. It is reinforced when photographs of the Study’s blood draws circulate, especially when they are cropped to show prominently a black arm and a white hand on a syringe that could, to an unknowing eye, be seen as an injection.

Historians of the Study have spent decades now trying to correct the misunderstandings in the public and the academy, and to make the facts as knowable as possible. The story is horrific enough, it is argued, without perpetuating misunderstanding over what really did happen and how many knew about it. What if, however, the PHS did conduct a somewhat secret study whose subjects were infected with syphilis by one of the PHS doctors who also worked in “Tuskegee?” How should this be acknowledged and affect how we discuss historical understandings that drive the need for human subject protection?

(Emphasis added.) And later:

Ironically, though, the mythic version of the “Tuskegee” Study may offer a better picture of mid-century PHS ethics than the seemingly more informed accounts. For Public Health Service researchers did, in fact, deliberately infect poor and vulnerable men and women with syphilis in order to study the disease. The mistake of the myth is to set that story in Alabama, when it took place further south, in Guatemala.

Interestingly, the episode happened during a period of hope in Guatemalan history — one of elections and land reforms, before decades of civil war that followed our overthrow of the democratically elected government:

The United Fruit Company owned and controlled much of Guatemala, the quintessential “banana republic,” in the first half of the 20th century. When the PHS looked to Guatemala for its research in the immediate post-World War II years, it came into the country during the period known for its relative freedoms; between 1944 and the U.S. led CIA coup of the elected government in 1954, there were efforts made at labor protection laws, land reform, and democratic elections. The PHS was part of the effort to use Guatemala for scientific research as they presumed to transfer laboratory materials, skills, and knowledge to Guatemalan public health elite.

And one last tidbit:

In reporting to Cutler after he returned to the States, he explained that he had brought Surgeon General Thomas Parran up to date and that with a “merry twinkle [that] came into his eye…[he] said ‘You know, we couldn’t do such an experiment in this country.’”60

Read the whole thing.

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