It would seem remiss not to honor the passing of a former pirate

I need to do a serious resume comparison and start making some improvements.

Thanks for the inspiration.

toilets: the importance of ownership (also, really, the iPad of commodes?)

there are some cool ideas about local maintenance and ownership in the reported community-led total sanitation.

we shouldn’t be too hasty to overlook the ‘conceptual ownership’ aspect, though. It’s really important that there is responsibility delegated for taking care of a toilet or latrine. i have encountered plenty of toilets – and lines for toilets – in many places that make going outside the clearly superior alternative. any time i see an initiative for building a large number of new latrines or toilets (like this), i worry about that all-important maintenance component that turns the toilets into a permanent improvement.

among other experiences, an unregistered slum in bombay in which i did some research had only a few latrines, privately owned by households. The households charged money but did not maintain the latrines. It was clear why many people still preferred to use the ocean. and those who did wait for the latrine often faced a morning before-school rush that was daunting, often resulting in kids being late for school.

so, yes, there is a very important element of ownership related to aspirations and feeling good about your latrine and bad about the alternative. but don’t forget the cleaning-duty chore wheel and check-list.


If it doesn’t kill them, it makes them stronger (II)

Yes, adding antibiotics to animal feed can spur the development of super-bugs.

“It’s like watching the birth of a superbug,”  says Lance Price of the Translational Genomics Research Institute, or TGen, in Flagstaff, Arizona.

“Initially we could always trace it back to livestock exposure,” Price says. “But now we are starting to see cases of resistant strains that we can’t trace back. So we think it may be changing gears, so to speak, and gaining the capacity to be passed from person to person.”

Price says the new data provide an early warning of what might become a major public health problem. “We’re seeing this one coming,” he says. “The question is how often will this occur in the future if we don’t start controlling antibiotic use?”

Additional info (28 Feb 2012)

Further comment (4 Jan 2013)


It would seem remiss not to honor the passing of a former pirate

I need to do a serious resume comparison and start making some improvements.

Thanks for the inspiration.

Rethinking the use of the word ‘simple’ in global health solutions

Karen had a nice post this week about how we talk about ‘simple’ solutions to global health problems, here.

There are at least four reasons that we might apply the word simple when we are talking about global health solution concepts:

1. The concept is relatively obvious because it relates to basic aspects of life, such as eating and drinking, and/or has been known for a long time

2. The concept has relatively few moving parts (i.e. does not call to mind Rube Goldberg-like steps (or that game mousetrap that NEVER worked))

3. The concept is low-tech (both information and biomedical technologies)

4. The concept is an easy change to get people to adopt

I suspect that when people refer to ‘simple’ solutions, it is some combination of 1, 2, & 3 on the list. If ‘basic’ or ‘low-tech’ is what we mean, we should probably say it as such. ‘Simple‘ has a wide variety of interpretations, so when you hear it, it may not always mean what you think it means or others may misinterpret your intention. Also, even if a concept has few moving parts, if the surrounding health system and infrastructure are thin, over-burdened, or non-existent, it can be quite tough to implement.

Basic and low-tech solutions have been put forward as part of the primary health care and then the selective primary health care (and GOBI-FFF) movements, spanning roughly the last 50-60 years. Calls for improvements in vital registration systems and disease surveillance span a similar time period. The fact that we are still talking about them suggests the solutions are not ‘simple’ (as in, ‘easy’) and that we need to be a lot smarter when it comes to changing behavior (giving up an old behavior *and* adopting a new one). This requires not only making the new behavior appealing and the old one unappealing but building an entire supportive and enabling environment around it. And as Karen rightly points out, even in what should be highly supportive environments, basic ideas can still be tough to implement on an individual level.

From a branding perspective, ‘basic’ and ‘low-tech’ may not be enough to garner (donor) attention to ‘mundane’ causes of morbidity and mortality (malnutrition, diarrheal disease, & acute respiratory infections) and the preventative and curative measures needed to address these problems.  But the gloss ‘simple’ is definitely insufficient and misleading.


Quick insurance thoughts (mandates and exemptions)

“The core problem is that inserting employers between health insurers and individuals created an unnecessary tension between the provision of certain goods and the consciences and preferences of employers.” More in response to 13 Feb’s The Daily Show. Bottom line: de-coupling insurance from employment would likely be a positive step.

Why the individual mandate was deemed important and a consideration of whether it is the right tool for the job. But if it isn’t, then what is?

The link between the mandate and interstate commerce is the claim…that the individual mandate will discourage people from “free riding”… But what if the individual mandate actually doesn’t accomplish that goal? That is, suppose the individual mandate, as written into the law passed by Congress, doesn’t actually apply to most of the people who obtain health care without paying for it (e.g. accessing the emergency room)?… Uninsured patients may be broadly divided into two groups – (1) those with (a) low income or (b) preexisting conditions, who can’t afford insurance; and (2) those who are generally healthy, have moderate or high incomes, and choose not to obtain insurance. The individual mandate will impact mainly the latter group – a group with very low rates of uncompensated care, and very low consumption of health care at all… Of the (1a) low-income uninsured, most will be either covered by the health reform law’s vast expansion of Medicaid eligibility… Individuals with (1b) expensive pre-existing conditions will be able to obtain coverage at premiums substantially below their health care expenditures, and thus have a powerful incentive to obtain insurance even without that mandate. This leaves those with (2) income high enough that their health insurance premium is less than 8% of their income, too high to qualify for Medicaid, and healthy enough that they are likely to find health insurance a bad deal financially.”

you’re not helping: seriously, CIA, we have enough problems convincing people to get vaccines, polio and otherwise

“At the behest of CIA officials, Afridi reportedly launched a fake polio vaccination campaign in Abbottabad last year, using it as a front to gather DNA samples from people thought to be relatives of the elusive Osama Bin Laden. This elaborate scheme would later contribute to the frenetic manhunt for and subsequent assassination of the Al Qaeda leader.

“(Before this) happened, one could brush aside negative perceptions about the polio vaccine, terming them baseless and ‘agenda-driven’, but not this time,” Fazal Shah, a development sector professional based in the northern district of Mardan, told IPS.

Religious leaders and tribal elders who had hitherto been highly successful in generating public support for the polio vaccine – by breaking myths about the vaccine being life-threatening, made of haram (forbidden) ingredients or causing infertility among both male and female recipients – found their efforts seriously hampered by Afridi’s hoax vaccination drive.”

Rest of article. (h/t KFF)

Update 6 March 2012 (h/t KFF)

“The CIA’s use of the cover of humanitarian activity for this purpose casts doubt on the intentions and integrity of all humanitarian actors in Pakistan, thereby undermining the international humanitarian community’s efforts to eradicate polio, provide critical health services, and extend life-saving assistance during times of crisis like the floods seen in Pakistan over the last two years,” the InterAction coalition wrote to the CIA director, David Petraeus.

Update 18 Oct 2012 (h/t Humanosphere)

“News reports out of Pakistan on the polio efforts there vary wildly, saying two very different things. Some say the efforts to vaccinate against polio are moving forward despite opposition from the Islamists, and from locals still mistrustful of health workers thanks to an ill-conceived fake vaccine ploy by the CIA… This report seems to indicate things are actually getting worse.”

Update 24 December 2012

“Yesterday, a male polio worker was fatally shot, and today four women were killed within about 20 minutes of each other in three apparently coordinated attacks in poor Karachi neighborhoods, including Gadap, where the July shootings occurred. Another woman was killed in Peshawar. Taliban insurgents have repeatedly threatened campaign workers, but so far no one has claimed responsibility for the current or previous attacks.”

Nice editorial 3 Jan 2012

“Pakistan now has a three-fold responsibility: addressing systemic polio eradication impediments, getting vaccination back on track with appropriate security cover for more 90,000 vaccinators, and reaching out to the masses with the right information to ally mistrust. At a minimum this would demand the will to prioritize action, the intent and ability of political factions to work collaboratively, and the ongoing injection of resources. With parliamentary elections forthcoming, all these will be in short supply.”

Further comment on recent polio worker killings via the lancet 4 Jan and 4 Jan.

Nice post from Amanda Glassman and Charles Kenny (19 Dec 2012).

This situation unfortunately follows allegations that US security agencies used a Hepatitis B vaccination campaign as a vehicle for intelligence gathering (see here).  And it is clear that such allegations have had a chilling effect on vaccination programs—for example in Nigeria (see here)–even when completely baseless.

Given that, it is in our own interest to make crystal clear that the US supports global public health programs to improve global health alone and that US-backed public health interventions will not be used to gather intelligence. While far from a panacea, it might help persuade a few more parents to get their kids vaccinated, or a few more local leaders to back down from a boycott.  In the battle against global communicable diseases like polio and measles, every little bit helps.

Wired update 11 January 2013 (h/t humanosphere)

Worldwide, the polio campaign depends on the efforts of volunteer and low-paid vaccinators who work solo or in small teams, and there are signs that the Taliban intimidation has kept those teams at home. In Pakistan, both The News and The Frontier Post are reporting that “lady health workers” are staying home out of fear or as a result of family pressure… The crisis in Pakistan is not just about the changeable fortunes of the polio campaign, which has waxed and waned in public opinion since its launch in 1988. It is specifically in response to the admitted-to ruse by the CIA