Adventures in West Africa

Last winter, I applied for a Fulbright Public Policy Fellowship in the Cote d'Ivoire.  I was applying to a few positions at the time, and I wasn't really expecting much to come of it.  But I got called back for an interview in May and then I was recently informed that I'd been selected as a Fulbright Fellow.  It was too good an opportunity to pass up.  Sheila and I have been craving another adventure, and this is exactly the sort of work that I want to do in my career.

So we're going to the Cote d'Ivoire this September.  The fellowship lasts for 10 months, so ostensibly, I'll be in Abidjan (the de facto capital) from this September until July 2014.  Sheila will come out for my first two weeks in September, and then join me at the end of 2013 for several months.  She's still negotiating with her work, but ideally she'll be able to come out for about five months and work remotely at a reduced schedule.

The fellowship itself sounds amazing.  It's a new program, now called the Fulbright-Clinton Fellowship.  According to the State Department website:

Fulbright-Clinton Fellows serve in professional placements in foreign government ministries or institutions. Fellows gain hands-on public sector experience in participating foreign countries while simultaneously carrying out an academic study/research project.

Fulbright-Clinton Fellows will function in a “special assistant” role for a senior level official. The goal of the professional placements is to build the Fellows’ knowledge and skills, provide support to partner country institutions, and promote long-term ties between the U.S. and the partner country.

For my fellowship, I'll be working in the Ministry of Health in Abidjan as a special assistant to an official there.  It's still unclear who exactly I'll be working for, but I should hear more about that in the next few weeks.

I recently attended orientation in here in DC, and it was really inspiring, probably the first orientation I've been to that made me more excited about the job.  The people were great; all had fascinating back stories and it sounds like they'll be doing really cool stuff.  It was also useful getting to talk to the returning Fulbright alums, especially those coming back from Cote d'Ivoire.  It seems like they had great experiences and that Cote d'Ivoire was the model program among the inaugural class of Fulbright-Clinton Fellowships.  My Fulbright predecessor in the Ministry of Health conducted a couple of really cool sounding health system studies and initiated a project to rebuild the national public health library.

So I leave in September.  I'm still figuring out flights and housing and vaccinations, but I'm really excited.  I'm curious to see who I'll be working for and what they'll be like.  This is likely the single biggest factor in how successful an experience I'll have, so I'm hoping to get lucky.  Either way though, it sounds like I'll have a lot of autonomy, and that a big part of my experience will be the interchange with colleagues at the Ministry of Health.  In addition to regular work projects, last year's alums taught English to colleagues and also gave lessons on computer skills such as using Google Calendar, Excel, Word and Dropbox.  I would love to be able to have some sort of policy impact, but in many ways I think the exchange of institutional knowledge will be just as important.  I'll be in a strange and unfamiliar situation, and I'm looking forward to learning everything I can about the Cote d'Ivoire health system and about life in Abidjan.

Finally, a word about the future of this blog: for my handful of readers (Hi Dad!), fear not! I will continue to post while in Abidjan.  In fact, I'm hoping to blog more than ever.  My field of work will be changing, so I'll likely be blogging a bit more about African and global health issues, and less about U.S. health care.  But this will be a good thing; it will give me a fairly unique blogging perspective and a fun niche.  If there is a health policy blog about West Africa, I have not been able to find it.  This blog may also become a bit more personal.  I anticipate having some novel and interesting experiences working in health policy in Cote d'Ivoire, and I intend to share some of them.

What are the major medical advances of the past decade?

The past few decades have been a bit disappointing in terms of medical advances. Cancer is still a big problem, there's no cure for AIDS, and we somehow don't really understand how to help people lose weight.  But the DMCB argues that, while medical advances have been disappointing, there have been some major breakthroughs in health care delivery.  I would argue that a lot of these are closer to "potential" or "future" advances, and that some will not generate big changes. But this is a handy list and a fun look at how the health care sector will change going forward: 

1. Downjobbing: many tasks that were restricted to highly trained specialists are increasingly being performed by non-physicians, patients and technology.

2. Social Media: patients can not only access the internet for information, they can use the internet to pool input and solicit personalized advice from like-minded individuals

3. Democratized Artificial Intelligence: In addition to social media, we’re on the verge of being able to remotely access AI to generate a reasonably accurate list of diagnoses, suggested tests and recommended do-it-yourself treatments that include the option of doing nothing.

4. The Decline of the Credential: while the academic-industrial complex will continue to churn out superbly trained physicians, massive on-line education will enable persons to gain a surprising level of lay-expertise. 

9. Medical Tourism: As the rest of the globe imports the best that western medicine has to offer minus the United States’ overhead costs, the cost of overseas air travel is no longer be an impediment to patients or insurers.

The full list is here.  

Facts on the "hidden" epidemics of the developing world: road deaths, alcohol, and non-communicable diseases

This article from Oliver Balch in the Guardian is chock-full of interesting (and depressing) facts and thoughts:

• "Accidents on the road are expected to become the biggest killer of children between five and 15 by 2015, outstripping malaria and Aids."
• "Road traffic deaths in sub-Saharan Africa are predicted to rise by 80% by 2020, according to a World Bank report."
• "An estimated 24.1 people per 100,000 are killed in traffic accidents every year, according to the bank." 
• "Though seven in 10 adults abstain from drinking alcohol in sub-Saharan Africa, those who do have the highest prevalence of heavy episodic drinking globally." 
• "A study of police reports in Nigeria between 1996 and 2000 found that half of all car crashes involved drink-driving."
• "Between 2001 and 2008, funding for cancer, heart disease and diabetes in developing countries grew sixfold... Even so, programmes to combat NCDs comprise less than 3% of global development assistance."

Will Uruguay's marijuana legalization be a policy success?

Uruguay's House of Representatives have passed a bill to legalize marijuana.  It seems likely to become law.  It still has to pass through the Senate, but the Senate has an even greater left-wing majority than the House of Representatives, and the bill has the support of Uruguay's President Jose Mujica.  The BBC reports:  

The measure is backed by the government of President Jose Mujica, who says it will remove profits from drug dealers and divert users from harder drugs.

Under the bill, only the government would be allowed to sell marijuana.

The state would assume "the control and regulation of the importation, exportation, plantation, cultivation, the harvest, the production, the acquisition, the storage, the commercialisation and the distribution of cannabis and its by-products".

I once proposed legalizing and nationalizing the marijuana industry as a sort of radical centrist joke, a policy that would offend the conservatives (legalize drugs), the libertarians (let the government sell it), and the liberals (because government is so bad at running things).  Somehow Uruguay is on the verge of implementing this idea.  

It's worth noting that, unlike legalization efforts in the U.S., which have come about through voter referendums, the Uruguayan government seems to be running out ahead of its population: 

A survey carried out before the vote by polling organisation Cifra suggested 63% of Uruguayans opposed the bill.

I nevertheless support the measure and I'm fascinated to see what sort of effects the new law will have.  That being said, it will be difficult to measure the impacts of this bill.  Marijuana-related deaths could rise, but the measure would still be a success if a) alcohol-related deaths declined; or b) illicit trade is significantly reduced, thus taking money from drug traffickers or reducing drug-related violence and death.  These latter effects would be particularly difficult to measure, so there should be plenty to argue over for years to come.  Also, it is possible the government could use income from the new industry to good effect via social programs.  

How to change social norms: the person-to-person approach

Atul Gawande's latest New Yorker article is quite good.  Ostensibly, it's about innovation, but really it's about how to change social norms:  

Besides, neither penalties nor incentives achieve what we’re really after: a system and a culture where X is what people do, day in and day out, even when no one is watching. “You must” rewards mere compliance. Getting to “X is what we do” means establishing X as the norm. And that’s what we want: for skin-to-skin warming, hand washing, and all the other lifesaving practices of childbirth to be, quite simply, the norm.

To create new norms, you have to understand people’s existing norms and barriers to change. You have to understand what’s getting in their way. So what about just working with health-care workers, one by one, to do just that? With the BetterBirth Project, we wondered, in particular, what would happen if we hired a cadre of childbirth-improvement workers to visit birth attendants and hospital leaders, show them why and how to follow a checklist of essential practices, understand their difficulties and objections, and help them practice doing things differently. In essence, we’d give them mentors... 

Reactions that I’ve heard both abroad and at home have been interestingly divided. The most common objection is that, even if it works, this kind of one-on-one, on-site mentoring “isn’t scalable.” But that’s one thing it surely is. If the intervention saves as many mothers and newborns as we’re hoping—about a thousand lives in the course of a year at the target hospitals—then all that need be done is to hire and develop similar cadres of childbirth-improvement workers for other places around the country and potentially the world. To many people, that doesn’t sound like much of a solution. It would require broad mobilization, substantial expense, and perhaps even the development of a new profession. But, to combat the many antisepsis-like problems in the world, that’s exactly what has worked. Think about the creation of anesthesiology: it meant doubling the number of doctors in every operation, and we went ahead and did so. To reduce illiteracy, countries, starting with our own, built schools, trained professional teachers, and made education free and compulsory for all children. To improve farming, governments have sent hundreds of thousands of agriculture extension agents to visit farmers across America and every corner of the world and teach them up-to-date methods for increasing their crop yields. Such programs have been extraordinarily effective. They have cut the global illiteracy rate from one in three adults in 1970 to one in six today, and helped give us a Green Revolution that saved more than a billion people from starvation... 

But technology and incentive programs are not enough. “Diffusion is essentially a social process through which people talking to people spread an innovation,” wrote Everett Rogers, the great scholar of how new ideas are communicated and spread. Mass media can introduce a new idea to people. But, Rogers showed, people follow the lead of other people they know and trust when they decide whether to take it up. Every change requires effort, and the decision to make that effort is a social process. 

There is plenty of interesting detail throughout, including a good discussion of a successful person-to-person social marketing campaign in Bangladesh for improving cholera treatment.  Gawande's theory is basically that person-to-person social marketing is more successful than social marketing campaigns that use traditional marketing methods such as print, radio and television advertisements.  In itself, this is hardly a shock; marketing companies have long been aware of this and are working hard to increase their use of person-to-person marketing via new tools such as social media.  

In any case, my instinct is that, for public health interventions, campaigns that target fewer people, but with deeper interventions, will change social norms more effectively than broader, less personal campaigns.  

A website to track global health research

In an article in Lancet, the leaders of several large research and funding organizations introduce an intriguing and potentially very useful project to track international research activities in global health:

As the heads of nine major research-funding and research organisations, we have recognised the need to develop a public means to track these international research activities and partnered investments, and to share our results with the broader research and funding community. Such tracking should allow us to analyse and understand the landscape of research, to identify gaps in funding and areas where there might be a duplication of effort, and to work more effectively to synergise our investments. Local investigators could also become more aware of programmes supported in their institutions to develop local networks and collaborations; some African researchers have reported first learning about studies done in their own country by reading about them in scholarly journals. The ultimate goal of this analysis is to encourage an increase in vibrant, productive, competitive, and self-sustaining research communities in these settings.

The website, World RePORT (which is still in beta), has already turned up some interesting tidbits:

The value of the illustrative map and data table is immediately evident when seeking locations and institutions where research endeavours are concentrated and where there are gaps. For example, a search with the keyword “malaria” identifies more than 200 separate research efforts across 17 countries, funded by all nine organisations that provided data. By contrast, a search with the keyword “diabetes” reveals only 16 research activities in seven countries, funded by five organisations. Other diseases seem to receive little funding, including some that are particularly problematic in Africa, such as the neglected tropical diseases (eg, Buruli ulcer, yaws, and human African trypanosomiasis), the non-communicable diseases that are a global priority, and other diseases that are especially burdensome in African populations (eg, sickle-cell disease). World RePORT gives an overview of the clusters of investments in countries. These clusters can then be used to identify research institutes and universities that are well supported centres of excellence, and find gaps where little research is funded by our nine organisations.

Why Health Systems Are an Unworkable Mess -- Reason #423: Medical Data Is Poorly Understood and Improperly Utilized

Scientists reviewed each issue of The New England Journal of Medicine from 2001 through 2010 and found 363 studies examining an established clinical practice. In 146 of them, the currently used drug or procedure was found to be either no better, or even worse, than the one previously used. The report appears in the August issue of Mayo Clinic Proceedings.

More than 40 percent of established practices studied were found to be ineffective or harmful, 38 percent beneficial, and the remaining 22 percent unknown. Among the practices found to be ineffective or harmful were the routine use of hormone therapy in postmenopausal women; high-dose chemotherapy and stem cell transplant, a complex and expensive treatment for breast cancer that was found to be no better than conventional chemotherapy; and intensive glucose lowering in Type 2 diabetes patients in intensive care, which not only failed to reduce cardiovascular events but actually increased mortality.

From the NYTimes' Well Blog.  The pharmaceutical industry is not mentioned, but it's hard to look at this data and not think of the claims that many pharmaceutical companies spend more on marketing and sales than on R&D.