ebola and public health ethics (ebolaethics?)

via reuters, KFF recently posted a short article about the ethics of giving experimental treatment to the ‘hero doctor’ Sheik Umar Khan — and, really, to any of the trained health professionals who continue to show up to work even though they were at very real risk in Sierra Leone, in Liberia, in Nigeria and, now, contemporaneously but apparently unrelatedly, DRC.

there’s a complex of issues at stake, here, around rationing a scarce (and experimental) resource when need is greater than supply. i only going to wade in on the one issue i feel comfortable putting a point on; questions of ethics related to the nationality of who has been treated and where they were treated, or the ethics of using an experimental drug once other options were exhausted are important issues — but beyond the scope of this post.

but whether human resources for health (HRH) — Dr. Khan, medical volunteers from abroad, Sierra Leonean nurses, etc —  should be given priority in the face of a health crisis raises the Kantian issue of whether people should be used as means for ends (with Kant saying “no.”). if HRH are prioritized because of their ability to save more lives by having their own life saved, it is because they are being viewed as a means to an end — namely, the end of potentially saving more lives. this does not, inherently, treat all individuals of being of equal moral worth.

the case above at least keeps things within the “sphere” of health, rather than raising questions about favoring saving the young versus the old, or the powerful (say, the president or prime minister) over other citizens in the face of disaster. these too are difficult questions.

the debate will continue about whether and how Dr. Khan and others should have been treated with the experimental ZMapp, of which there is expected to be a long-term (rather than a quickly resolved) scarcity relative to need. demand significantly and dauntingly and heartbreakingly outweighs supply. but the question of whether Dr. Khan — or other HRH still fighting the fight — should be given priority to receive the treatment needs to be answered along several lines: should HRH be given preference? if so, should that preference be given based on whether, once cured, they will continue to treat patients? what happens once there are no more treatments to continue treating with — does the prioritization scheme shift?

this is a separate — but important — set of questions from the more politically charged question of the nationalities of recipients of the limited supply of ZMapp. i suspect these questions of power and race and exploitation, of where drugs were developed and where they were tested, will dominate the discourse. but other questions of ethics, desert, scarcity, and priority-setting require consideration for dealing with the present crisis and planning for future outbreaks.

further reading on these topics include: Norm Daniels, Frances Kamm, and Dan Brock. i hope these scholars will discuss and debate these issues in the near future.

 

nimboo pani: challenges and triumphs

there has been some complaint from some quarters that i have not recently provided any update about my life, reserving blog posts for slightly more wonky topics.

this post will be a small antidote.*

in delhi, one way of dealing with the energy-sapping heat is nimboo pani — literally “lemons water” but in actuality lemonade that is salty and possibly spicy/masala-ed in addition to sweet. (some people add mint but, of course, such frippery is not welcome in this household. i have only recently found a source for basil leaves, which is a far more sensible option.) in this salty way, nimboo pani approximates ORS and can help combat creeping dehydration, which seems to happen even if you are not noticeably sweating or doing anything at all.

i am curious as to why similarly salty lemonades did not catch-on in other hot places, for example, the southern US, which goes heavy on the sweet drinks in summer but, to my knowledge, doesn’t add salt (granted, the food may provide plenty, so things may balance out).

in any case, to celebrate having my flat nearly in order (yes, i know, people want pictures; patience is a virtue), i had a small open-house party at the beginning of july (HOT). i wanted to have nimboo pani on hand but was uncertain how to have ample drink prepared given the constraints of the refrigerator space and the need to have other drinks and food chilled as well.

one small triumph came in finding a shop that sold pre-squeezed lemon juice. nimboo (lemon) here are generally about golf- ball sized and the prospect of squeezing enough to quench thirst for 5+ hours was unappealing, no matter how many martha stewart points i would earn.

my first thought to dealing with the space issue was to make a lot of nimboo pani in advance and then freeze it. this seemed briefly promising until i thought about using salt to melt ice in the winter. this led to a string of probably unnecessarily dramatic texts to pop of the nature “I HAVE  A CHEMISTRY CRISIS.” it was agreed that freezing salty water would be difficult. (it was also likely, tacitly agreed that this was not a crisis.) (follow-up point, auto-correct suggested i might have meant “nimboo panic.” it does fit.)

the ice idea remained promising but how to dissolve all the ingredients on the spot? a friend (thanks, @urmy_shukla!) pointed out that sugar was particularly difficult to mix, given the temperature of the drink. simple syrup presented itself as a solution (ha!). so, in the end, i had frozen lemon cubes and frozen ice tea cubes (in hopes of nimboo pani palmers (go deacs) catching on, but must admit that brown ice has limited appeal, especially in a place where water quality and sanitation are such a serious concerns. perhaps green tea represents a future way forward.) so, people could drop lemon cubes into their glasses of water, which worked out well. i had bowls of rock salt, ground cumin, and ground ginger out so that people could salt and spice their drinks as per their own taste buds. and, i made plain and cardamom simple syrup, which veered slightly towards caramelized but seemed to be ok. this set-up was also good but there is at least one person in our midst who does not agree that drinks should be salty or spicy ever. i may have needed to add a little instruction on how sweet simple syrup is, as @sg402 discovered with VERY sweet nimboo pani.

anyway, party was a success, make-your-own nimboo pani seemed to be a success — so, the world’s problems are nearly solved. basil simple syrup will be pursued in the future.

please do be impressed that i smuggled two public health references into this post.

 

*a problem with blog-writing is that any word can be a rabbit hole. in typing “antidote,” i wondered if at any time “dote” was used to mean “poison,” in which case, antidote would be a sensible word. “dote” in the sense that we use it now, seems to be derived from the word for foolish. etymology.com implies that dotum comes from the greek “to give,” so that antidote was “to give against.” there you go.

 

some posts… no shit

some posts maybe you are never ready to write. nevertheless, the news of marc roberts‘s death over the weekend seems to warrant both an immediate response and the response that is just right. he seemed to usually be able to manage these simultaneously but, given the sense of time that follows a completion of a life well-lived and well-said, i’ll err on the side of the former.

i won’t claim to have known marc as well as many but i knew him well enough to respect him, which means, perhaps, seeing past rough first impressions. he pronounced himself a reformed economist at some point early enough to influence me: politics and the realities of implementation and the curves of ethics-in-real-life became the subject of his writing and his teaching and we are better for it.

marc had a standard line — a bit of a trap — that he would lead you  into (funnier to watch others go than to realize you had followed in). you might make a comment; maybe even one you thought useful. then he would start. he grew up in jersey. [fill in a few lines about the roughness of growing up in a steel town in jersey.] they had a saying back then, he’d say, that would apply to the point you’d just raised.

no shit.

familiar and biting each time (after the first, which was less pleasant). what always made it ok was the sense that he was, and wanted you to be, in pursuit of the right questions. he raised questions of distribution when everyone else was looking at average treatment effects. he was a reformed economist when the economist profession was booming. he wanted to know about implementation when everyone was looking at theoretical equations. and wanted to know about practical theory when everyone was looking at the sexy result of the moment.

we were through “pinning butterflies,” i was told indirectly by marc. categorizing of treatments or results wasn’t what we needed — we needed to explain things and try to make sense of them.

and then to do better.

some posts you are never ready to write. but some some are scratched in before you even sit down to it and some give you a sense that you shouldn’t wait. with marc, the gist sank in early, so one doesn’t have to do much work to imagine he’s still around. which is quite a good thing.

we need his voice. it’ll be missed but, as with all good teachers, it, with its gruff accent, is hardly gone.

thank you, marc. (http://www.bostonglobe.com/metro/obituaries/2014/07/29/marc-roberts-chestnut-hill-harvard-school-public-health-professor-had-global-reach-economics-teacher-and-consultant/v41p3cyjbSEjNH2YONAE6J/story.html)

 

 

data systems strengthening

i have been saying for some time that my next moves will be into monitoring and vital registration (more specifically, a “poor richard” start-up to help countries to measure the certainties of life: (birth), death, and taxes. (if village pastors could get it done with ink and scroll in the 16th c across northern Europe, why aren’t we progressing with technology??! surely this is potentially solid application of the capacity of mobile phones as data collection and transmission devices?).

i stumbled onto a slightly different idea today, of building backwards from well-financed evaluation set-ups for specific projects to more generalized monitoring systems. this would be in contrast to the more typical approach of skipping monitoring all together or only working first to build monitoring systems (including of comparison groups), followed at some point by an (impact) evaluation, when monitoring is adequately done.

why don’t more evaluations have mandates to leave behind data collection and monitoring systems ‘of lasting value,’ following-on an impact or other extensive, academic (or outsider)-led evaluation? in this way, we might also build from evaluation to learning to monitoring. several (impact) evaluation organisations are being asked to help set up m&e systems for organizations and, in some cases, governments. moreover, many donors talk about mandates for evaluators to leave behind built-up capacity for research as part of the conditions for their grant. but maybe it is time to start to talking about mandates to leave behind m&e (and MeE) systems — infrastructure, plans, etc.

a potentially instructive lesson (in principle if not always in practice) is of ‘diagonal’ health interventions, in which funded vertical health programs (e.g. disease-specific programs, such as an HIV-treatment initiative) be required to also engage in overall health systems strengthening (e.g.).

still a nascent idea but i think one worth having more than just me thinking about how organisations that have developed (rightly or not) reputations for collecting and entering high-quality data for impact evaluation could build monitoring systems backwards, as part of what is left behind after an experiment.

(also, expanding out from DSS sites an idea worth exploring.)

have evidence, will… um, erm (6 of 6, enforcing accountability in decision-making)

this is a joint post with suvojit, continuing from 5 of 6 in the series. it is also cross-posted here.

 

a recent episode reminded us of why we began this series of posts, of which is this is the last. we recently saw our guiding scenario for this series play out: a donor was funding a pilot project accompanied by a rigorous evaluation, which was intended to inform further funding decisions.

in this specific episode, a group of donors discussed an on-going pilot program in Country X, part of which was evaluated using a randomized-control trial. the full results and analyses were not yet in; the preliminary results, marginally significant, suggested that there ought to be a larger pilot taking into account lessons learnt.

along with X’s government, the donors decided to scale-up. the donors secured a significant funding contribution from the Government of X — before the evaluation yielded results. indeed, securing government funding for the scale-up and a few innovations in the operational model had already given this project a sort-of superstar status, in the eyes of both the donor as well as the government. it appeared the donors in question had committed to the government that the pilot would be scaled-up before the results were in. moreover, a little inquiry revealed that the donors did not have clear benchmarks or decision-criteria going into the pilot about key impacts and magnitudes — that is, the types of evidence and results — that would inform whether to take the project forward.

there was evidence (at least it was on the way) and there was a decision but it is not clear how they were linked or how one informed the other.

 

reminder: scenario

we started this series of posts by admitting the limited role evidence plays in decision-making — even when an agency commissions evidence specifically to inform a decision. the above episode illustrates this, as well as the complex and, sometimes, messy way that (some) agencies, like (some) donors, approach decision-making. we have suggested that, given that resources to improve welfare are scarcer than needs, this approach to decision-making is troubling at best and irresponsible at worst. note that it is the lack of expectations and a plan for decision-making that are troublesome as the limited use of outcome and impact evidence.

in response to this type of decision-making, we have had two guiding goals in this series of posts. first, are there ways to design evaluations that will make the resultant outcomes more useable and useful (addressed here and here)? second, given all the factors that influence decisions, including evidence, can the decision-making process be made more fair and consistent across time and space?

to address the second question, we have drawn primarily on the work of Norm Daniels, to consider whether and how decisions can be made through a fair, deliberative process that, under certain conditions, can generate outcomes that a wide range of stakeholders can accept as ‘fair’.

Daniels suggests that achieving four key criteria, these “certain conditions” for fair deliberation can be met, including deliberation about which programs to scale after receiving rigorous evidence and other forms of politically relevant feedback.

 

closing the loop: enforceability

so far, we have reviewed three of these conditions: relevant reasons, publicity, and revisibility. in this post, we examine the final condition, enforceability (regulation or persuasive pressure).

meeting the enforceability criterion means providing mechanisms to ensure that the processes set by the other criteria are adhered to. this is, of course, easier said than done. in particular, it is unclear who should do the enforcing.*

we identify two key questions about enforcement:

  • first, should enforcement be external to or strictly internal to the funding and decision-making agency?
  • second, should enforcement rely on top-down or bottom-up mechanisms?

 

underlying these questions is a more basic, normative question: In which country should these mechanisms reside — the donor or the recipient? the difficulty of answer this question is compounded by the fact that many donors are not nation-states.

we don’t have clear answers to these questions, which themselves likely need to be subjected to a fair, deliberative process. Here, we lay out some of our own internal debates on two key questions, in hopes that they point to topics for productive conversation.

 

  1. should enforcement of agency decision making be internal or external to the agency?

this is a normative question but it links with a positive one: can we rely on donors to self-regulate when it comes to adopted decision-making criteria and transparency commitments?

internal, self-regulation is the most common model we see around us, in the form of internal commitments such as multi-year strategies, requests for funds made to the treasury, etc. in addition, most agencies have an internal but-independent ‘results’ or ‘evaluation’ cell, intended to make sure that M&E is carried out. in the case of DFID for instance, the Independent Commission for Aid Impact (ICAI) seems to have a significant impact on DFID’s policies and programming. it also empowers the British parliament to hold DFID to account over a variety of funding decisions, as well as future strategy.

outside the agency, oversight and enforcement of achieving relevancy, transparency, and revisibility could come from multiple sources. from above, it could be a multi-lateral agency/agreement or a global INGO, similar to a Publish What You Pay(?). laterally, the government in which a program is being piloted could play an enforcing role. finally, oversight and enforcement could come from below, through citizens or civic society organizations, both in donor and recipient countries. this brings us to our next question.

 

  1. should enforcement flow top-down or bottom-up?

while this question could be answered about internal agency functioning and hierarchy, we focus on the potential for external enforcement from one direction or the other. and, again, the question is a normative one but there are positive aspects related to capacity to monitor and capacity to enforce.

enforcement from ‘above’ could come through multilateral agencies or through multi- or bi-lateral agreements. one possible external mechanisms is where more than one donor come together to make a conditional funding pledge to a program – contingent on achieving pre-determined targets.however, as we infer from the opening example, it is important that such commitments should be based on a clear vision of success, not just on political imperatives or project visibility.

enforcement from below can come from citizens in donor and/or recipient countries, including through CSOs and the media. one way in which to introduce bottom-up pressure is if donors adhere to the steps we have covered in our previous posts – agreement on relevant reasons, transparency and revisibility – and thereby involve a variety of external stakeholders, including media, citizens, CSOs. these can contribute to a mechanism where there is pressure from the ground on donors in living up to their own commitments.

media are obviously important players in these times. extensive media reporting of donor commitments is a strong mechanism for informing and involving citizens – in both donor and recipient countries; media are also relevant to helping citizens understand limits and how decisions are made in face of resource constraints.

 

our combined gut feeling, though, is that in the current system of global aid and development, the most workable approach will probably include a mixture of formal top-down and informal bottom-up pressure. from a country-ownership point of view, we feel that recipient country decision-makers should have a (strong) role to play here (more than they seem to have currently), as well as citizens in those countries.

however, bilateral donors, will probably continue to be more accountable to their own citizens (directly and via representative legislatures) and, therefore, a key task is to consider how to bolster their capacity to ensure ‘accountability for reasonableness’ in the use of evidence and decision-making more generally. at the same time multilateral donors may have more flexibility to consider other means of enforcement, since they don’t have a narrow constituency of citizens and politicians to be answerable to. however, we worry that the prominent multilateral agencies we know are also bloated bureaucracies with unclear chains of accountability (as well as a typical sense of self-perpetuation).

while there is no clear blueprint for moving forward, we hope the above debate has gone a small step towards asking the right questions.

 

in sum

in this final post, we have considered how to enforce decision-making and priority-setting processes that are ideally informed by rigorous and relevant evidence but also, more importantly, in line with principles of fairness and accountability for reasonableness. these are not fully evident in the episode that opened this post.

through this series of posts, we have considered how planning for decision-making can help in the production of more useful evidence and can set up processes to make fairer decisions. for the latter, we have relied on Norm Daniel’s framework for ensuring ‘accountability for reasonableness’ in decision-making. this is, of course, only one guide to decision-making, but one that we have found useful in broaching questions of not only how decisions are made but how they should be made.

in it, Daniels proposes that deliberative processes should be based on relevant reasons and commitments to transparency and revisibility that are set ex ante to the decision-point. we have focused specifically on decision-making relating to continuing, scaling, altering, or scrapping pilot programs, particularly those for which putatively informative evidence has been commissioned.

we hope that through these posts, we have been able to make a case for designing evaluations to generate evidence useful decision-making as well as for facilitating fair, deliberative processes for decision-making that can take account of evidence generated.

at the very least, we hope that evaluators will recognize the importance of a fair process and will not stymie them in the pursuit of the perfect research design.

*in Daniels’s work, which primarily focuses on national or large private health insurance plans, the regulative role of the state is clear. in cases of global development, involving several states and agencies, governance and regulation become less clear. noting this lack of clarity in global governance is hardly a new point; however, the idea of needing to enforce the conditions of fair processes and accountability for reasonableness provides a concrete example of the problem.

have evidence, will… um, erm (5 of 6, revisibility)

this is part of a series of joint posts with suvojit. it is also cross-posted at people, spaces, deliberation.

throughout this series of posts (1, 2, 3, 4), we have considered two main issues. first, how can evidence and evaluation be shaped to be made more useful – that is, directly useable – in guiding decision-makers to initiate, modify, scale-up or drop a program? or, as recently pointed out by Jeff Hammer, how can we better evaluate opportunity costs between programs, to aid in making decisions. second, given that evidence will always be only part of policy/programmatic decision, how can we ensure that decisions are made (and perceived to be made) fairly?

for such assurance, we primarily rely on Daniels’ framework for promoting “accountability for reasonableness” (A4R) among decision-makers. if the four included criteria are met, Daniels argues, it brings legitimacy to deliberative processes and, he further argues, consequent fairness to the decision and coherence to decisions over time.

the first two criteria set us up for the third: first, decision-makers agree ex ante to constrain themselves to relevant reasons (determined by stakeholders) in deliberation and, second, make public the grounds for a decision after the deliberation. these first two, we argue, can aid organizational learning and coherence in decision-making over time by setting and using precedent over time – an issue that has been bopping around the blogosphere this week.

these criteria, and an approach ensuring A4R more generally, are also a partial response to increasing calls for donor transparency, made loudly in Mexico City this week via the Global Partnership for Effective Development Co-operation. these calls focus on the importance of public availability of data as the key ingredient of donor (and decision-maker) transparency. we concur on their importance. but we argue that it is incomplete without an inclusive process of setting relevant reasons on how those data are used (recognizing that they will always only be part of the process) and making the decision criteria as well public.

the publicity and transparency around decision-making opens the door for A4R’s third criterion (and the subject of this post): the possibility to appeal and revise decisions. as Daniels notes, this condition “closes the loop between decision-makers and those who are affected by their policies.”

as a quick reminder of our guiding scenario: we specifically focus on the scenario of an agency deciding whether to sustain, scale, or shut-down a given program after piloting it with an accompanying evaluation — commissioned explicitly to inform that decision.

in most decision-making of this kind, some stakeholders — often would-be beneficiaries — will not agree with the decision and even feel or be adversely affected. while we suggest that stakeholders be involved in the earlier process of setting relevant reasons, a grievance-redressal or dispute-resolution mechanism, as provided by the revisibility criterion, gives these stakeholders an opportunity to voice their perspectives, based on the original grounds of the decision.

they can do this because the decision-criteria are made public, via criterion 2. this “visible and public” space for further deliberation provides stakeholders have a route “back into the policy formulation process.” stakeholders can use evidence available to them to advocate a certain way forward; it also allows for stakeholders to revisit the decision-making criteria and the decisions they fostered. stakeholders therefore have the opportunity to make a case for a change in the decision.

why might past decisions be questioned? since the appeals process is largely based on the original decision criteria, appeals come if circumstances around those reasons changed. for example, in considering relevant reasons, feasibility was one category of criteria we proposed, such as government’s capacity to scale a program or their interest in the program. one can imagine that over time, over changes in regime, and over changes in politics and policy, the original answers to these criteria could change, opening space for appeals. an additional set of proposed relevant reasons related to cost, effectiveness, and cost-effectiveness. the costs of technologies and materials may change over time or fresh evidence could come out about long-term benefits of programs. this alters the original cost-benefit ratio, again, opening a space for appeals against the original decision.

such appeals may come from members of civil society (or government) that would like to see the program brought back to life (or to see it go away). these may also come from donors themselves wanting to look at their decision-making over time and implement changes in line with the changing context.

Daniels is careful to note, and we emphasize, that the power and purpose of this criterion is not that citizens will always overturn prior decisions.* decisions on limits are requisite, as needs generally outstrip resources. rather, the revisability criterion allows for reconsideration and reflection on those decisions by those knowledgeable about the topic and empowered to alter decisions, if seen fit and feasible. this can, Daniels notes, bring further legitimacy to decision-making processes and, again, improved decision-making over time.

we want to stress that these deliberations over decision-making and their ‘revisibility’ have to be situated in a rational and ethical decision-making framework, predicated on meeting needs fairly when not all can be met (distinct from, say, a legal framework). appeals will have to be judged on the original merits of the arguments as well as with recognition that aid resources have limits (although obviously, a different argument can be made that aid budgets should simply be bigger).  moreover, appeals need to be judged by people who understand the original decision and have the power to change it, if that is the decision taken. when decision-making criteria are set, they set the roadmap for a possible appeals process and should be accordingly discussed and agreed upon.

we started this series of posts by admitting the limited role evidence plays in decision-making — even when those commissioning evidence intend specifically to inform that decision. we considered how planning for decision-making can help in the production of more useful evidence and also how decisions can be made fairly, through the delineation of relevant reasons, the publicity of the decision criteria ultimately used, and now, the possibility of revisiting through criteria and revising decisions.

our thoughts in this series of posts should not make fair decision-making seem like an impossible task. not all aspects of each of these considerations can be taken into account – the constraints of the real world are not lost on us and A4R remains an ideal, though we think one that can be approached. in our final post of this series, we therefore attempt to close the loop by looking at enforcement – asking how these ideas can be enforced and decision-makers held accountable.

*see. e.g., Richard Horton’s recent slide about the limit-breaking decisions by courts and the effects on health care systems, as in cases like Colombia. experiments with health courts may be instructive. picture via @fanvictoria, citing @richardhorton1.

Allowing ‘revisibility’ in decisionmaking

Originally posted on Suvojit Chattopadhyay:

This is a joint post with Heather - fifth in our series on decisionmaking

***

Throughout this series of posts (1, 2, 3, 4), we have considered two main issues. First, how can evidence and evaluation be shaped to be made more useful – that is, directly useable – in guiding decision-makers to initiate, modify, scale-up or drop a program? Or, as recently pointed out by Jeff Hammer, how can we better evaluate opportunity costs between programs, to aid in making decisions. Second, given that evidence will always be only part of policy/programmatic decision, how can we ensure that decisions are made (and perceived to be made) fairly?

For such assurance, we primarily rely on Daniels’ framework for promoting “accountability for reasonableness” (A4R) among decision-makers. If the four included criteria are met, Daniels argues, it brings legitimacy to deliberative processes and, he…

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