If it's for a good cause

Last week, my mom send me a list of the most influential cause marketing campaigns (by U.S. companies).

It was interesting to read as a global health person because the way in which I think about "influence" or "effectiveness", if you will, is obviously very different from how the author did.  For example, I tend to think about the administrative costs of raising money--the "feel good factor"to the donor is not at the forefront of my mind.  Cause marketing obviously relies on engaging consumers, which inherently means that resources that could have been passed along to the intended beneficiaries has to be put into the fundraising activities.  But, the question is: does that lead to greater levels of donations and/or other types of engagement that ultimately result in more resources for delivery on the ground?  A lot of people that run in a marathon as a charity runner wouldn't necessarily have picked up a checkbook to donate money to breast cancer research.  For programs that receive a lot of funding from the government, the broad-based support for the cause is an important part of sustaining political commitment.

Devil is in the details

(Note: this was also published at improvehealthcare.wordpress.com)

Harvard Medical School’s Department of Health Care Policy put an incredible event on this past Monday. The video and suggested reading are available on the website. The speakers were: David Cutler (Harvard), Allan Detsky (University of Toronto), David Goldhill (Media and Technology executive), and Daniel Kessler (Stanford).
Overall, I thought that the symposium was tremendous. Often speakers don’t want to disagree with either others ideas too much, or they disagree about minute details–at this event, there was no shortage of (very respectful) disagreement. I walked away feeling like I understand the nature and magnitude of the complexities of health care reform much better than when I entered and armed with some new language and frameworks with which to approach the issues. The longer I work in health delivery, the more I’m struck by the different sense of urgencies people feel: the speakers seemed intent of understanding the nature of the beast and saw it as a precursor to reforming health care. All except Cutler felt that the pending legislation was trivial or harmful, but failed to offer other actionable recommendations. I’m torn on this–I think history shows countless examples of how we’ve dug ourselves into a hole by not appreciating a problem fully. On the other hand, when the decision not to act may result in suffering and/or death, there does seem to be a moral imperative to get out of the ivory tower and get busy (recent post by Bill Easterly on the pointlessness of airport security makes me a little wary to assert this too confidently or with too much moral indignation).

doctors without borders

Human resources for health remains one of the most controversial areas of global health debate. Large numbers of medical practitioners, most notably doctors and nurses, trained in the developing world migrate to advanced economies, resulting in extremely inadequate levels of human resources in many parts of the world. Foreign medical professionals now make up an important percentage of our health care providers--my grandmother has commented that in her small town, none of the doctors at the hospital are U.S. born. By one estimate I found, 25% of health professionals in the U.S. hail from other countries.
As someone who spends most of the day thinking about the health problems facing developing countries, it can be a little jarring to open up the Boston Global or New York Times to learn that in fact, we in the United States are facing a "critical shortage" of doctors. These figures are a few years old, but the U.S. has roughly 1 doctor per 400 population. This of course varies regionally, but is the national average. Meanwhile, in India, where I traveled a few months ago, the ratio is closer to 1:1,700. I still can't even begin to wrap my head around Malawi, where there is one physician per 50,000 people. I have almost as many doctors in my office as they have in the entire country.

Final thoughts for 2010

I've spent the last few hours perusing global health and development websites. I wish that I had more time to do this on a regular basis.

A few comments and suggested readings from the web:

This is a blog that Bill Easterly just turned me onto: Good Intentions are not enough. I am all about people trying to start a dialog on how to improve aid and the mechanisms of how donor dollars reach the intended recipients. Great to find such a thoughtful author who is able to dedicate so much time to tackling these issues.
In particular, I wanted to highlight this series of posts:
I know a lot of students and recent graduates who are using the economic situation as an excuse to go abroad. While it's exciting that the climate may lead to a boom in interest in global health, it's important to seek responsible opportunities and think through what impact your travel and volunteering may have on organizations and their communities. Saundra does a great job of laying out some basics for the commitments you should be willing to make, the questions to think through, and common pitfalls. I'm learning a lot from this myself--I've wanted to go abroad for some time and have been wrestling with a lot of the issues that she mentions (most prominent in my internal dialog--what jobs exist that I can do better than a local? Where can I add value rather than be in the way?). These questions are not meant to be discouraging so much as a deep, honest look at what you're getting yourself into. It's okay to conclude that you're going for selfish reasons (to clear your mind, have fun before you're saddled with real-world commitments, etc.), but better to admit that up front and plan your trip accordingly.

HIV warfare: choosing the right strategy

I had a chance to participate in an “HIV warfare” simulation game in a business school class yesterday. It was pretty interesting—after a little background on the epidemiology and projections of the disease, we split into two groups: the private sector and the donor (NGO) community. I was in the first group, which was a good thing because I was a little confused about what the donor (NGO) community referred to (I would normally split those up, as donors have money and determine priorities, whereas NGOs are more likely to be implementing and have less influence).
I spend most of my time surrounded by people who are well informed about HIV and generally share my ideas about normative models of combating the disease. So, I was caught pretty off guard about how this bright but uninformed population thought about the disease. I thought I’d take the chance to offer some thoughts on what I think is well established, and some thoughts about how we could use this data to create more informed delivery models.
Separating prevention and treatment is a false dichotomy. A good program will deliver both. For a variety of reasons—people are more likely to get tested when treatment is available, stigma decreases as the diagnosis ceases to be a death sentence, BUT, treatment is expensive and preventing new cases of HIV is always a better solution. One article on PLOS medicine (open access) shows that with a combined approach, by 2020 we could potentially avert almost 30 million infections and reduce the number of people on treatment by more than 50%. As treatment has become available, relatively fewer and fewer resources have been available for prevention (in absolute terms, this may not be true. I will investigate. One article here talks a bit about funding allocation). It’s unclear as to why this is—some people say that it’s hard to measure successful prevention, whereas it’s easy to measure “number of patients enrolled on treatment” and similar indicators. Some say that the pharmaceutical company saw a huge opportunity and successfully changed the conversation. Simultaneously, many grassroots organizations had taken up the cause of people living with HIV/AIDS, both in the US and abroad, and they lobbied for treatment (one well know example is the Treatment Advocacy Campaign of South Africa). Fewer groups took up the cause of HIV-free people. For whatever reason, we’ve reached a point where treatment gets the center stage. I would argue that relatively minor investments in prevention could have great impact.
Even as I type that last sentence, I get a little uncomfortable with my confidence in our ability to do things well. HIV prevention is a HUGELY political area—HIV by its very nature requires society to think about it’s often marginalized or stigmatized populations: men who have sex with men, injection drug users, and commercial sex workers. Sex and drugs, two areas where controversies and politics are rife. Despite significant evidence that for concentrated epidemics (i.e. where HIV exists largely in certain sub populations and is not widespread) targeted prevention efforts can be very effective, politicians seem reluctant to invest in these strategies, preferring instead to educate school children and other “innocents.” This may relate back to the treatment preference, as the faithful wife who got HIV from her husband is more compelling image than the injecting drug user getting clean needles to prevent contraction of HIV. Some authors have argued that the decision to frame poverty as a cause of HIV has ultimately led to misallocation of funding and misdirected strategies. Indeed, in many countries, wealth is associated with higher rates of HIV. But, again, the full picture is obviously more complex. If nothing else, many women and men go into sex work for economic reasons (not the best cite, but some evidence). In that sense, poverty does put people at risk for HIV. Obviously poverty could prevent people from purchasing condoms, traveling to the clinic for HIV testing, or create delays and/or interruptions in treatment. But, at the end of the day, getting HIV requires one to engage in unprotected sex or injection drug use. It’s worth noting that at least in the U.S. populations, youth across all socioeconomic classes engage in “risky” behaviors at the same rates. The difference is how many potential infected partners exist in one’s sexual network. For the poor, minorities, and men having sex with men, that percentage is higher—for the former two in large part due to injection drug use and overrepresentation in the prisons. I say to just point out the fact that “risk” is relative—it’s easy to assume that Africans have more sex or poor people have less impulse control and thus don’t use condoms, but the data don’t support that. They just happen to be closer to more people with HIV. So, I would re-write the risk factors, personally, to include, “being in a neighborhood with a large prison population”, and other factors that are less focused on individual behavior. If you want cites on that, let me know. I wrote a 20-page paper about it my senior year of college!
I’m becoming more and more convinced that condoms are a really poor solution. There is little evidence to suggest that any group, any where, has really embraced them and uses them 100% of the time. With high-risk groups, such as sex workers, they are a great solution, but in the majority of cases (67% of HIV is in sub-Saharan Africa and has moved to a generalized distribution), traditional commercial sex is not how the disease is transmitted. It’s casual or serious sex partners, but usually under the auspices of a relationship. I hesitate to say too much because transactional sex, that is, sex explicitly in exchange for gifts or money, does occur with some frequently (for one in-depth look at transactional sex across 12 sub-Saharan Africa, go here). So, there is an economic dimension to sex that can’t be ignored, but by and large, sex is occurring in a context where there is trust or at least the expectation of trust, and there’s no evidence to suggest that condoms are a popular choice in those settings.
Final thought, and building on the last one, people are smart and care about their own survival. So, there’s no need to trick people into protecting themselves, and any effort that thinks withholding information will do the trick is patronizing at best, when it’s western experts deciding that Africans shouldn’t get the full story, it’s racist. All the even marginally successful HIV prevention success stories I can think of—Brazil, Thailand, Uganda, even the gay community in the U.S.—the solutions were locally developed. Uganda’s story is really interesting—the government actively promoted “zero grazing” (i.e. be faithful to your spouse(s)) and emphasized that condoms should be used as a last resort, versus a primary behavior change. The data is spotty, but it appears that young people delayed having sex for the first time, and most adults stuck with zero or one sexual partners. Condom usage remained low the whole time. HIV incidence fell dramatically. Western “liberal” “experts” (can’t resist the quotation marks) argue that partner reduction and fidelity are either impossible (which seems to imply that African men cannot control their sexual urges) or imposing morals on others (which we do all the time. Don’t we tell smokers not to smoke? Stigmatize drunk driving?). A lot of the discussion that followed the research demonstrating the efficacy of male circumcision as a HIV prevention tool (60% reduction over a two year period) was around the fact that people would assume that this was 100% effective and would thus engage in riskier behavior (example here). Part of me thinks that this is really context-specific; I’ve never heard anyone argue against making a heart medication available as fast as possible because they were worried that people who stop watching their weight and exercising. Discussions around rolling out the HPV vaccine to all teenage women in America was framed totally differently: let’s maximize protection and take full advantage of the preventive tools that exist. What’s the difference?

Why do we care?

For the last week, it’s been difficult to check the news without hearing about Annie Le, the woman at Yale who was murdered last week. The details are tragic—a young woman, days from her wedding, strangled, and the likely suspect at the moment is a co-worker of hers. At the very least, there appears evidence that the murder was not random. The medical examiner is not releasing information at the moment confirming whether or not Miss Le was sexually assaulted prior to her death.
The story is obviously sad. But what separates it from the dozens of other stories about women who are victims or attempted or completed violent crimes? If you watch the news, you’d think that Miss Le was a unique case—that the motivation for the coverage is the rarity of such an event.
We live in a society where the people most likely to hurt or kill women is the men that they know. A third of all women who are victims of homicide are murdered by their husbands or former husbands (interesting side note, intimate partner violence is one reason why women's health care costs on average are so much more than men's). If one backs up a step to include women’s friends and acquaintances, you can account for almost everyone who would hurt them. In virtually 90% of sexual assaults, the perpetrator is an acquaintance of the victim. Random violence is the exception rather than the norm.
So why are we hearing so much about Miss Le? In theory, I think greater coverage of violence against women is a good thing. But I’m troubled by the tone and motivation we see in this case. Is it that she’s beautiful? Talented? A Yale student? About to be married? I honestly don’t know. Given the photo montage that CNN and other channels have compiled, they obviously expect us to react viscerally to her beauty and youth. Last week I heard that she’d recently written a piece in the Yale newspaper about how street smarts can help you avoid being the victim of crimes, such as muggings and assaults. I’m not sure why this detail is relevant to the case. Again, I’m struggling to understand the motivations here. Also disturbing was the media’s aggressiveness in asking about whether Ms. Le was sexually assaulted prior to her death. Do we grieve for victims of rape that die, but not those that live? Is it out of empathy or morbid curiosity that we ask?
It’s an interesting contrast to look at the recent “Craig’s List killer” story, about the BU medical student who is accused of killing several masseuse/sex workers that he contact online and met in Boston hotels. There, we know so little about the victim—the entire focus has been on the perpetrator; a medical student with a girlfriend—the unexpected killer. We look for clues in his behavior to explain his actions.
Today, the coverage on the story focused a little more on Mr. Clark, the top suspect. A white male, evidently in high school he was a member of an Asian awareness group. This is the most suspicious detail that the media has been able to dig up yet; rather weak, if you ask me.
I would hypothesize about the treatment of the suspected perpetrators, I would say that society wants to demonstrate their deviance from the norm. By highlighting their differences from the average, society can continue in its habitual existence without needing to reform. The blame lies on the individual’s internal abnormalities. The average perpetrators make us the most nervous. That BU med student, and Mr. Clark, look an awful lot like normal guys. A lot of their colleagues describe them as “nice guys—the kind that would never do this kind of thing.” Now, that should scare us a bit. If violence against women has become so ingrained in our culture that normal individuals act on it, society will need to have a crisis of conscience and massive change in its standards. I doubt that such a small number of crimes will catalyze this; it’s a conclusion with a lot of implications and responsibilities (we’ve been able to ignore it this long). But, if these stories keep getting coverage, even if it’s only the ones that involve highly educated, attractive perpetrators and/or victims, maybe something will get started.
I’ve tried not to watch or read about this story; I do find it very sad. But I find particularly sad because Miss Le is representing a much larger population of victims than is immediately apparent. After September 11, 2001 Catharine MacKinnon, one of my heroines and a great advocate of women’s rights in the legal sphere (domestically and abroad) wrote a piece wondering why the government had responded with such strength to that attack, when the same number of women with killed by their husbands annually, and their lives went without notice. This essay is included in her book, “Are women human?” provocatively arguing that if the rights that we grant all humans are not granted to women, that implies that they have sub-human status. Great read.
I’m open to refute. If someone wants to challenge my decision to frame this as violence against women, I’d love to hear it. I wonder how often a man is strangled by a colleague. And whether the question of sexual assault would be such a focal issue. Or how often those stories get ignored as well. But I’m most interested in how we can begin to address the violence (against women and men) head on, perhaps specifically using opportunities created by the media.