Aside

Packard on History of Global Health: devastating first chapter (we need to do better)

While i intend to write more about Packard’s new book (delightfully if uncomfortably subtitled, interventions into the lives of others) once i am through with it, a paragraph in the opening chapter seemed both so important and accurate as to merit sharing immediately — particularly given the lessons it may hold for the Universal Health Coverage (e.g.) movement. It is not that what Packard has to say here is necessarily new but rather that he sums it up in a neat, indicting list of trends, on which we would all do well to reflect:

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There have been remarkable continuities in how health interventions have been conceived and implemented over the past century… [that] have worked against the development of effective basic-health systems to address social determinants of health:

  1. Health interventions have been largely developed outside the countries where the health problems exist, with few attempts to seriously incorporate local perspectives or community participation in the planning process…

  2. Health planning has privileged approaches based on the application of biomedical technologies that prevent or eliminate health problems one at a time.

  3. Little attention has been given to supporting the development of basic health services.

  4. The planning of health interventions has often occurred in a crisis environment, in which there was an imperative to act fast. This mindset has privileged interventions that are simple, easy to implement, and have potential to quickly make a significant impact…

  5. Global health interventions have been empowered by faith in the superioity of Western medical knowledge and technology…

  6. Health has been linked to social and economic development — but this connection has focused primarily on how improvements in health can stimulate economic development, while ignoring the impact that social and economic developments can have on health. The social determinants of health have received little attention.

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Packard notes that these trends have faltered a few times, such as with the rise in interest in learning about the “social and economic causes of ill health” in the 1920s and 30s and in the Alma Ata / health for all movement at the end of the 1970s. We seem to think of ourselves as standing at a new trend-breaking moment. Hopefully we can do better.

inverted quarantines, mosquitoes & the common man in delhi

This post has been some time in the making, ever since Raul Pacheco-Vega introduced me to Andrew Szasz’s concept of an ‘inverted quarantine,’ defined further below, and fabulous Manpreet Singh and i started kicking around how the idea applied to our lives in Delhi. This week, a few events, including a desperate effort to stay awake to fend off jetlag, have conspired to help this post come together.

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i’ll start with the idea of a quarantine, since it has such a delightful etymological origin. The phrase comes from the Italian for ’40,’ the number of days a ship needed to stay in the Venetian harbor before its booty or crew came ashore, a practice put in place during the Black Death of the later 1300s. Specifically, the ships subjected to quarantine (or forced isolation) were those returning from plague-stricken countries. The idea, as Szasz elaborates, implies the following set-up: we (Venetians) are mostly in a healthy environment, from which (potentially) diseased individuals need to be kept out. It is a collective (if enforced) action to preserve the health of the environs and, therefore, the people living in it.

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An inverted quarantine is a response to a reversed scenario: an unhealthy environment in which individuals wish to stay healthy. Worse, these individuals have become “fatalistically resigned to it being a dangerous world” (2006). The response is a middle-class or elite response (in general) with two components intended to isolate individuals and their households/immediate environments from harm:

  • An individual response: Despite ‘the environment’ (air & water, in particular) having a generally public good quality, those constructing inverted quarantines are engaged in a response that “is individualistic in both goal and method.”
  • A consumeristic response: A sense that the way to isolate oneself and one’s family from harm requires the purchase of specialized commodities, such as bottled water.

It is the latter point, in particular, that converts a citizen (a political actor) into a consumer, who exercises a certain form of exit (to the market) rather than (political/public) voice, thus functioning as a political anesthesia.

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This idea of building bubbles through consumer purchases has many examples in Delhi, with bottled/canister or water filters as a prime example. The air quality in Delhi has recently taken on a similar, if (deplorably) much less wide-spread, response. If you haven’t been paying attention, the air quality in Delhi is real bad (as in, the worst by measures) and air pollution is real bad in general.

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To illustrate, here is a typical workday morning for me in Delhi, which has only been made more extreme by my recent acquisition of an air quality monitor for my house.

  1. Leave the house with my air filters (n=3) running
  2. Hope that my maid (because… India) doesn’t turn off the filters during the day
  3. Wonder how much electricity I use and therefore pollution I cause running my air filters all the time. Then promptly forget about this.
  4. Wish my maid wouldn’t leave the doors open after she makes breakfast.
  5. Chuckle about how my landlords believe that the air in their small front yard is ‘fresh’ even if the rest of the city is dirty.
  6. Get into an auto-rickshaw (open-side 3-wheeler). auto.jpg
  7. Put on my fancy, Paris-ready vog mask (mine is actually plain black — but).mask
  8. Think about how i should buy masks for my mostly faithful autowalla and then wonder if he would use them (curse my non-existant Hindi).
  9. Arrive at office, where air filters are running most of the time, except during skype calls.

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This is not a perfect bubble but it is certainly an attempt at insulating myself nevertheless: an inverted quarantine that i have tried to construct to protect me at home, at work, and in between. i have tried to make myself part of an air-istocracy.

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And, it is worth noting that there is relatively little political action around air quality. The government has experimented with car-reduction measures but, at least anecdotally, folks were far more interested in whether this reduced their commute time than whether it lowered the particulate matter in their air.

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The idea of an inverted quarantine, as presented by Szasz, rests on both the individual and the consumer response. Given both my research and the current outbreaks of dengue and chikungunya and other viral fevers in Delhi, i have been thinking about mosquitoes and whether the concept applies — both whether mosquitoes constitute the sort of unsafe air/water/land of which Szasz writes and also whether the individual/household response is sufficiently consumeristic to count as an inverted quaratine.

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To be glib, we could lump mosquitoes and the diseases they carry in with ‘bad air’ (literally the origin of ‘malaria’) and solve the first problem.

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And the idea of a consumeristic response to mosquitoes may apply to at least some of the options available. Purchasing a bednet allows me to protect my sleeping space from most night-biting mosquitoes, though we have all had the experience that one always manages to get it. Various sprays, creams, bracelets, coils, plug-ins, and electrified tennis racquets can help to ward off mosquitoes but none of them seem to keep all of them away.

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There are also non-consumer responses to limiting mosquitoes and therefore mosquito-borne diseases in the confines of one’s house and grounds, such as covering or draining standing water, as recommended by the government in posters, including this one from my neighborhood:

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It is not quite clear how to classify these individual / private-good responses to larger public health problems that don’t have a strictly product-based bent within a framework of inverted quarantines — but they are certainly an important type of response in India. A similar idea can be found in the constant cleaning of private spaces but the dirtiness of public spaces (as catalogued in Maximum City, inter alia), the intense faith put in ‘home [prepared] food’ as opposed to dirty and dangerous ‘outside food’ and other ideas that mix real ideas of toxins and pathogens with older ideas of purity and pollution (i believe relating to ideas of protecting oneself from social threat, as Szasz discusses).

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In any case, mosquitoes, unlike air quality, are getting political attention in Delhi — or at least, people are calling out the lack of political action and the over-reliance on promoting individual preventative measures in the face of an outbreak. Mosquitoes are annoying little buggers and can (visibly) get through any inverted quarantines we might construct, so perhaps this call for more public, preventative action is not surprising.

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For my thesis research in Ghana, to better understand the context in which a new malaria treatment program was being introduced, i undertook a media content analysis of how the term ‘malaria’ was deployed and discussed in online newspapers during the relevant time period. Most of the discussion was around specific malaria donations that had come in, reporting of malaria numbers at different state health facilities, or actions that the government had or would soon take around malaria prevention and ‘environmental hygiene.’ One of the presidential candidates being covered during that time was particularly concerned about environmental cleanliness and ‘filth.’

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But a few mentions cast malaria as a disease of common humanity, from which neither rich nor poor could make themselves perfectly safe — an actual or imagined inverted quarantine does not exist (especially against day-biting mosquitoes). It (vulnerability to malaria, mosquitoes) was used as a political symbol of issues that affected all Ghanaians. This idea of malaria and the mosquito as threatening a common humanity — the common man — has a slightly funny resonance with the current political situation in Delhi, where the ruling Aam Aadmi Party (literally, ‘the common man party’) has come under fire for insufficient public health action (rightly or wrongly) in the face of an outbreak of mosquito-borne viral fevers.

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The idea of the non-availability of inverted quarantines in the face of the biting mosquito as a source of political action deserves more attention, as does trying to shake people out of believing that their inverted quarantines against polluted air are sufficient (or indeed, that the air is something from which one requires protection) — ideally stimulating meaningful political action. Just thinking about Delhi, i am not yet convinced that measures need to be both individual and consumeristic to act as a political anesthesia. If the goal is to explain a lack of political action, then more conceptual work is needed. For example, as long as my landlords believe their front yard is fresh/unpolluted because they keep a nice garden (and others at their club start to get worried as well), it is unlikely they will be taking any political action about air pollution. Nevertheless, the idea of an inverted quarantine and how it limits public outrage and civic response seems like a useful concept for studying urban (perhaps in particular?) responses to environmental (and pathogen?) threats, not just in the US, where Szasz focuses, but far beyond.

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To close with a small piece from Szasz’s 2006 presentation paper for the Sustainable Consumption and Society Conference:

Inverted quarantine is a twisted and perverse sort of environmentalism. The person who engages in it clearly recognizes that there is a problem [even if misdiagnosed?], is in fact quite distressed by the problem, and intent on doing something about it. Such a person, however, is deeply pessimistic about real change, unable to imagine that things can actually improve, and therefore fatalistically resigned to it being a dangerous world.

Sounds like a lot of Dilliwallas to me.

doctor marketplace & lack of system improvement (delhi summer illness 4)

One of the first things you learn when studying health systems is how imperfect health care markets are — limited time or ability to shop around, massive information asymmetries, etc. It is interesting, then, how very marketplace-like was my experience during my most recent illness episode. It is even more interesting, i think, that this took place within the same corporate hospital system — calling into question the very benefits of such an aggregated system.

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To briefly recap,  i had (still have, actually) symptoms consistent with chikungunya,  [~chicken-goon-yuh] which is currently breaking out in Delhi but which was not actually confirmed in my case. i managed to visit three doctors in as many days to try to figure out what was going on, which is probably the most ‘shop-around’ approach i have ever taken to a single illness episode. [The desperately curious can read the previous posts on observations from navigating the hospital and health system while being sick: here, here & here.]

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First, i saw my regular GP. Then, with some urging, i saw a recommended GP. In the interim, i had also scheduled an appointment with a rheumatologist given (a) relevant family history and (b) that my only early symptoms were joint pain , weakness & fatigue — no fever nor rash. In this post, i just focus on the GP visits.

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The visit to my regular GP on Tuesday led to my being tested (IgM) for chikungunya as well as dengue and malaria (as precautions than really being indicated). i learned on Wednesday morning that the IgM was negative but as my white blood cells were high, i was put on an antibiotic (for a ‘post-viral infection’) and given the obligatory paired antacid + anti-inflammatory as well as calcium for unexplained reasons. i actually don’t think an antibiotic was indicated and was a bit annoyed when i asked if anything else could be causing the joint pain and was told no, which is of course a silly statement since plenty of things cause joint pain, not all of them infectious.

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In the interim, through the healthcare recommendation grapevine that is Delhi, i learned about another doctor who was recommending a different chikungunya test (and promoting himself as a chikungunya guru). With some urging, i followed-up there was well on Wednesday afternoon, for a (super) special clinic double-feature day.

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The second GP i saw was in the same corporate hospital system but at a different branch, less than 5 km away. i came in with high hopes for the recommended doctor, most of which were dashed over the course of the short visit. i should note that for this visit, my (male) colleague kindly accompanied and the (male) doctor spent much of the limited attention he gave to either or us (rather than his computer screen or his phone) addressed to my boss. i have never felt so blatantly part of a capitated (pay-by-patient or ‘per head’) system as i did over the course of this week of doctor visits. (A particularly endearing moment came when i asked the doctor to explain my morning’s lab report and why the white blood cells might be elevated — and i was told to google the answer.)

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The doctor spot-diagnosed me with chikungunya while i was still shuffling in the door, before i was able to sit down and say anything beyond ‘joint pain.’ Perhaps some patients are impressed by this sort of act. i was not. The doctor did very little looking at me and certainly never touched me. i had to really push to get out a description of the specific type of joint pain i was experiencing. Much of the time he addressed himself to a desktop computer screen, where he edited old case notes as mine, such that my print-out included inaccuracies, such as stating that i have no medical allergies (i do, including to some painkillers and anti-inflammatories; moreover, he never actually asked me this question).

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At first the doctor tried to talk me out of getting another blood test (PCR, this time) since it was expensive (true) and since he was so certain i had chikungunya (ass).

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He then spent at least a minute of our already poorly utilized 10-minute appointment slot to denigrate my normal GP, in a mock-humble way that acknowledged him as a junior doctor and my usual GP as a senior doctor — but also that he was much more in the trenches at his location, as opposed to her more posh and secluded (<5 km away) location. (Again, recall these are both part of the same hospital system.) He was seeing all the chikungunya cases and she wasn’t, so he knew how to spot-diagnose and which test to run.

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He then told me that when my test came back positive, as he was sure it would (it didn’t), i should switch doctors. He also poo-pooed her having prescribed me calcium and instead prescribed a multivitamin; he also prescribed a different painkiller + antacid combination for no apparent reason. (i should note that neither doctor actually asked what i was already taking in the way of vitamins before prescribing these to me — i went ahead and bought everything i was prescribed so i could show off the detritus collected for treating a suspected virus over the course of three days.)

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Perhaps to some patients, this kind of confidence and blatant salesmanship are appealing and hearken to days of doctors-as-gods. Not to me. So, at a minimum, as a salesman, this doctor has no idea how to read a customer.

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In fact, his actions seem the very definition of not working in a system or a sign that the system is not working. He could have, instead, said he would call my regular GP and tell her about the extent of the outbreak and about which test to run. Or report it upwards so that there could at least be systemic learning within the hospital system. But, no, he opted to promote himself. And perhaps this is what the ‘system’ incentivizes. But, if so, then what exactly is the benefit of being part of a hospital system if neither my personal records nor basic system- or city-wide learnings can be shared among doctors within and across sites?

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To return to the initial issue of whether healthcare functions as a market, to the extent that it does, people often rely on quality indicators that may not be directly related to accurate diagnosis or perfect treatment (which are sometimes hard to assess from the patient point-of-view). So, there is cleanliness and comfort of the surroundings (the corporate chain does reasonably well on this). There is whether you feel listened to and respected as a patient (fail). Or, if your doctor isn’t particularly nice (we all secretly want to be treated by Dr. House), you should at least trust him or her but neither GP in this case did anything particularly trust-earning (and did some things that were trust-burning from my way of thinking). There is convenience (yes in terms of online scheduling but no in terms of tracking patients through the system).

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And, one would think, there would be a benefit of aggregating learnings and best practices across the system — but this appears to not be the case. The corporates may want to think again about how they are fulfilling quality demands.

 

going viral in delhi / is diagnosis a luxury (delhi summer illness 2)

In this post, i continue to try to make research and observational hay out of my own illness in Delhi (starting here). As a quick re-cap, there was a week of severe, arthritic joint pain and weakness, which started to let us slightly right when the rash and fever kicked in. Those were mercifully short-lived but the joint pain has continued for over a month.

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When you shuffle (quite literally since my feet weren’t keen on bending and my hips weren’t into a long stride-length anyway) into a doc’s cabin in Delhi and the first words out of your mouth are ‘joint pain’ and it is dengue and chikungunya season, these are the immediate suspects (also here for news of outbreak). One of the doctors i saw  was happy to diagnose me by sight and actually, actively encouraged me not to bother with the (pcr) bloodtest, since (he was a bit of an overconfident ass and) the test is expensive (about INR 5000 or roughly US$ 75 — definitely out of reach for a lot of patients). An earlier doctor had prescribed a cheaper test, which is more sensitive to the stage of the illness (IgM).

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At this point, i have had the two different chikungunya tests, a dengue test, a malaria test, & a parvovirus b19 test, all of which have come back negative. If malaria had been positive, of course, it would have indicated a very different treatment course than any of the viruses. And it’s good to know if you have dengue rather than a different virus because it is possible you may need a transfusion. But at the patient-level, all the rest of these viruses have a similar ‘treatment’ protocol – fluids, rest & painkillers (plus, as it always seems in Delhi, an antacid to pair with the painkiller).

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There perhaps isn’t much reason, then, to explore which specific virus ails you unless you, like me, find comfort in having a named illness rather than a collection of symptoms that could be named ‘a viral fever.’ (Update 9 Oct 2016: unknown viral fevers in Delhi.)

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And anecdotally, some folks in Delhi seem comfortable just saying that they have ‘a viral’ or ‘a viral fever’  or, intriguingly, that they are going to get tested for dengue to see ‘whether it’s dengue or a viral fever.’ (See also the name of the disease and the work of many anthropologists on this kind of non-specificity vis-a-vis underlying causes.) People also don’t seem a lot of stock in the tests — colleagues and at least one of the doctors i have seen feel like i probably had/have chikungunya, blood work .

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Which raises the question of why i have sought so many different diagnostics (yes, insurance covers it) and why a person might do so more generally. For me, i have both a desire to have a name for my diseases and also a suspicion that a virus doesn’t explain the full story of what has been an extended summer of illnesses rather than a single episode. But for a regular patient paying out-of-pocket, beyond sorting illnesses with different treatment protocols (so, parsing malaria from dengue), being able to pin a particular name to the cause of feeling unwell may not be that important — or, indeed, may be a luxury.

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From a public health perspective, though, lack of clear diagnosis means no numbers to report upward, to understand how illness patterns are changing (including with zika looming on India’s doorstep), when there is a legitimate outbreak, etc. i say that without a complete understanding of how my test results in a private, corporate hospital (some of which were sent to a private path lab in Bombay) make it into any sort of public health statistics at all. The current numbers being reported in Delhi and the surrounds certainly seem too low relative to what doctors off-handedly say they are seeing.

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All of this raises a few questions:

  • During an outbreak, should people satisfied with a diagnosis not based on blood-work (if it looks and walks like chikungunya, it probably is)? Is this sufficiently successful to make up for time and money saved?
  • If diagnosis (sorting between viruses, say) has more public than private benefit (since your treatment won’t change and having ‘a viral fever’ seems satisfactory), should diagnostics be subsidized? How, for whom, etc?
  • Can anyone explain to me whether and how test results from the private sector of clinics and diagnostic centers make it to official numbers? What would need to be done to improve reporting and merging of results into city- or state-wide stats?

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  • Would i be more satisfied with a diagnosis of an unnamed virus in the States? Possibly — it’s certainly happened when down with non-specific ‘flu‘ symptoms that rule out the need to treat with antibiotics. But why am i more comfortable with this?

my black folder (delhi summer illness 1)

Since i have lost much of the two months to an extended illness — and since my original reason for getting into public health was unsatisfactory doctor-patient relationships and inadequate assistance helping patients navigate hospital and health systems — it seems to make sense to write about observations and frustrations i had seeking treatment in delhi. i offer this up in the spirit of participant-observation research — not seeking sympathy but trying to point out what is currently not/working. i definitely welcome stories from others seeking health-care in india or elsewhere in the comments: this is a conversation that requires much more attention and probably research.

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There are three disclaimers. First, i am an extremely privileged patient in Delhi and attend one of the (arguably) best private hospital chains in town. So my case should be taken as something of a ‘best case’ in terms of how i am treated and my experience navigating the system. Second, being sick has made me incredibly grumpy. Third, we are still not entirely sure what i had/have. Given the on-going outbreak of chikungunya in Delhi and my symptom set, this is a plausible guess — but in full disclosure, the test for this and multiple other viruses were negative. While many people in Delhi seem satisfied with being diagnosed with ‘a viral,’ not knowing what i have is hugely frustrating.

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Whatever i have, ‘joint pain’ does not do justice to the experience — i have had what i would classify as joint aches or pains in the past and this weren’t it. Overnight-onset arthritis begins to get to the point: too painful to walk properly thanks to weak and angry feet, ankle & knee joints; too stiff and painful to make a fist around a bottle of water and elbows too weak to support the bottle anyway; etc. Suffice it to say, rapid aging it isn’t much fun:

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While this whole illness narrative begins a month back, this blog’s story starts today, as i am preparing to go spend a bit of recovery time with my parents in TX and get a second opinion in the process. My mom is scouting for a rheumatologist there (thanks, mom!). She wondered if i could just have my doctor here in Delhi just fax over my notes so far (because the new doc wants to review them before accepting me?). Well, no.

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Which brings me to my black folder. There is no patient filing system that stays at the hospital for me here in Delhi, though i presume the hospital tracks some sort of information linked to my mobile number in the computers at which people are always tapping (they are very capable of sending via emails the status of my reports or texting to quiz me on my satisfaction).

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Each visit generates quite a bit of paper for which i am responsible, making me in a very tangible way the curator of my health history. i find this slightly stressful and, again, unlike a lot of patients, i can read and comprehend the vast majority of what is in my file (handwriting aside), can sort through and put it in date order, and so on.

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At a minimum in a visit to my hospital, there will be the consultation fee receipt, the consultation notes + script and the receipt for medicines purchased. But, likely, there will also be an additional receipt for diagnostic tests to be rendered and then, at some point, the results of that test, whether it is a printout, a scan, an xray, etc. i have to carry all of these. These papers should be ready at all times. For example, vital signs are recorded on my consultation receipt for imperfectly clear reasons. The receipt is then taken out of my possession (ack! i need to photo that for insurance claims!) to be laid before the doctor, who sometimes notes down my vitals on a fresh notepad before beginning the consultation scribbling. More paper.

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For awhile, one pretends that the soothing seafoam-green envelope proffered by the hospital/clinic along with one set of test results will suffice for the burgeoning ream of paper. But any sort of ongoing illness puts that rapidly to rest. Your makeshift, portable medical record is suddenly and literally coming apart at the seams when you have an extended illness episode, along with your feeling of being able to present your case to another doctor (or to the same doctor, since they have nothing else to which to refer back).

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Now i have upgraded fro a tattered folder to one of those report-type folders with the plastic sleeves built-in — the kind with a tab on each sleeve, which i have labelled with the month. Each month contains all the the august sleeve is pree-tty full but it is doing the job nevertheless. Mostly.

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Over the course of this illness, i have worked to keep everything as organized in this folder as possible as a way of imposing some order on the multiple visits, the multiplying symptoms, the confusing test results and their implications for yet more tests. When your fingers aren’t working properly (or more generally when you are feeling like crap), it isn’t very fun to sort through these papers and supple-ly sliding them into the slippery plastic sleeve. It also isn’t particularly fun to clutch this increasingly sweaty folder while you try to navigate your way through jostling patients, especially when your standard elbows-out strategy has been rendered impossible. Hospitals, as i contend in future posts and as others have said before me, aren’t very easy places to be sick. And, at least in Delhi, to be without a chaperone/Moses.

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But one does carry one’s plastic folder to place before the doctor: see, i am a good patient. A conscientious patient. You can tell because my files are in order that i will probably try to follow your prescriptions and that i get what is going on here. And that this whole thing has been ‘going on’ far too long. We can both see that, right?

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i can’t pinch my fingers properly to pull the sheets out for you but here, this is the August sleeve. You can just pull them out and… sure, spread them all over the desk. Gah, this is the same feeling as when you had the immigration officer with your finger marking the visa page and they insist on closing the passport booklet and then casting you disgusted glances when s/he can’t find your visa. But worse.

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Yes, i could point(-ish) you to what you’re asking about… but rifling through will work eventually as well. Taking a call while you’re looking and while i’m sitting here will definitely help as well. Oh, you’re done? Then, sure, sweep everything back into a haphazard pile and then just… OK, bypass the plastic sleeve. Just close the cover over the whole mess. That’s cool. i just spent 3 minutes explaining how painful it was to work my fingers and i assume you were listening because you prescribed multiple blood-tests and several medications of questionable necessity. You even took notes. Including those notes, altogether, that’s four more pieces of paper i am going to acquire in the next hour. To add to that mess you just made of my medical history. To clutch-ish until i get home and then sort the whole damn thing again after the next painkiller to show the next half-interested doctor that i am a good patient, it’s just that the illness isn’t going away.

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Look, it’s all here in my folder. Dammit. The folder tied the whole thing together.

i feel like an #oddeven party pooper (reducing and working are not the same)

there are two nice, evidence-informed op-ed pieces out today on delhi’s odd-even scheme to try to reduce air pollution (here and here). the results are heartening because i didn’t have a good sense of whether a two week window of implementing a policy — to which there were many exceptions — was long enough to potentially detect a statistically significant change in meaningful measures of pollution. nor, admittedly, did i feel that i was breathing cleaner air the past two weeks. as one the articles points out, much of the anecdotal chatter has been about clearer roads, not about clearer skies.

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since i live in delhi, am certainly affected by the air quality, and worried about my health accordingly (plume tells me every day that the situation is dire), i was pretty pleased to wake up to the headline “yes delhi, it worked.” and what has indeed happened is that good evidence (rigorously obtained, as laid out by suvojit) has been generated of a statistically significant reduction in nasty particulate matter (pm 2.5) (by 18%) during the hours the intervention was in effect.

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this was a policy that i wanted to see work, so i am pleased that the evidence shows a reduction in the particulate matter that is driving many of my good friends out of the city (alongside many other woes). but we must be careful — whether something “worked” is more subjective than is the evidence of a reduction, which greenstone and colleagues have nicely and rapidly documented.

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if models had predicted a 50% reduction, we wouldn’t have been so thrilled about 18%. if the government had said that every little bit counts and that even a 5% reduction would be counted by them as a success and a reason to commit to continuing the program, then indeed, 18% is quite impressive.

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moving forward, as delhi tries to clean up its act and hopefully become a model for the rest of the country, clarifying up-front decision-points and definitions of success will be important. for the next pilots — because delhi desperately needs such measures — how will we declare, in a rigorous and defensible way, that a policy effort ‘worked’ well enough to be scaled and continued?  those of us interested in promoting the use of rigorous evidence and evaluation to inform decision-making need to be slightly cautious in our interpretations and celebrations of victory when we haven’t said up front what we’ll count as a triumph.

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*as an addendum (31 jan 2016), it is not clear that the researchers themselves penned the title ‘yes delhi, it worked.’ for the benefit of the doubt, i am hoping that the researchers submitted something more along the lines of ‘yes delhi, odd-even reduced pollution’ and that the newspaper itself opted to change it. but the point holds that success is subjective and therefore requires a definition, preferentially ex ante.

Aside

delhi’s #oddeven plan had a significant effect on pollution

agree that this is a potentially good sign about individual citizens being willing to engage in collective action – note also that many were most excited about lessened traffic, which is a good reason to think about inspiring collective action in ways that bring about both a public good and a private gain, allowing the pursuit of direct and indirect policy goals. my sense is there is still a long way to go in convincing people that the pollution is a problem and getting worse.

Suvojit Chattopadhyay

Researchers Michael Greenstone, Santosh Harish and Anant Sudarshan have some news for us. Hard data that shows that the Odd-Even plan reduced pollution by significant levels in Delhi. The headline: this study finds there was an 18% reduction in PM 2.5 due to the pilot during the hours that the rule was in effect. The effect size is truly staggering, and is quite unusual for studies that use such rigorous methodology to look at the impact of policy interventions.

Starting January 1, while absolute pollution levels increased both inside and outside Delhi (for atmospheric reasons, as noted by other commentators), the increase in fine particle levels in Delhi was significantly less than in the surrounding region. Overall, there was a 10-13 per cent relative decline in Delhi.

Around 8 am, the gap between Delhi’s pollution and that in neighbouring regions begins to form and steadily increases until mid afternoon. As temperatures…

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tentative thoughts on ownership: work-in-progress

i am road-testing a few ideas from the conclusion of my thesis, in which i try to bring out two themes recurring throughout the analyses on adoption and implementation of the phase I pilot of the amfm in ghana, between 2010 and 2012. these themes are ownership and risk-taking. i have already written a bit about risk-taking here. below, i share some of my tentative ideas and questions on ownership (slightly edited from the thesis itself, including removing some citations of interviewees for now).

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delighted for comments.

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one undercurrent running throughout this thesis is the idea of ownership of: the definition of the problem and solution at hand, the process of adopting the amfm, and of the program itself and its implementation.

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in chapter 4, i introduced stakeholder ideas of paths not taken, including how the program might have “develop[ed], not negate[d], local production capacity,” including through support to local manufacturers to upgrade to meet WHO prequalification and through work to bring local government and industry (rather than global industry) into closer partnership. both those ultimately receptive and resistant to the amfm acknowledged that all national stakeholders “would have preferred to have had quality, local drugs.” the very strength of the amfm design — high-level negotiations and subsidization — precluded local, structural changes.

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in chapter 5, i highlighted that several key stakeholders refused to take — that is, to own — a stand on whether ghana should apply to the phase 1 pilot. moreover, the key, institutional decision-makers in the country coordinating mechanism for the global fund (ccm) vacillated on whether or not to send the application while a variety of circumstantial stakeholders felt they had stake in the decision and worked to influence the process. in chapter 6, i analyze how global ideas and actors played a role in ghana’s adoption of phase 1. in chapter 7, i describe the way the amfm coordination committee (amfm-cc) was set up which, in composition and process, differs from the ccm.

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these points on alternatives not considered, on vacillation, on avoidance, and on outright resistance relate to conceptions of country ownership of development initiatives, as in the paris declaration. the absence of a national politics and aligned problem stream, in particular, neatly dovetails with the ideas of david booth that clarify what should be meant by country ownership (booth 2012). he proposes that it means an end to conditionality to “buy reform” and an end to channeling aid funding through “projects” as a way of by-passing country decision-making bodies, processes, and institutions (booth 2010)

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the ccm represents an interesting example with which to examine country ownership. their explicit raison d’ětre is to foster ownership and they do indeed bring together representatives of government bureaucracy, business, and civil society, “representing the views and interests of grant recipient countries.” yet this structure allowed for vacillation within and strong views without. we must consider this and also juxtapose the make-up of the ccm versus the amfm-cc in terms of the stakeholders represented, the capacity and legitimacy to make relevant decisions, and a sense of ownership about the work ahead. having done this, it seems that, at a minimum, we must question whether the ccm composition when adopting phase 1 allowed for sufficient ownership. given the effort of ccm members to yield decision-making power to the minister of health, it seems that ccm members did not think so.

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however, it is not fair to critique apparent limited ownership without raising three additional questions:

  • would ghana have tried out the amfm if political or bureaucratic actors had to take initial responsibility for the design?
  • did limited national ownership of the design and adoption decision allow national stakeholders to better, “energ[etically]” implement the initiative, maximizing credit-seeking after minimizing risk for blame during adoption (while recognizing that policy entrepreneurs and others still felt this risk keenly)?
  • how should we interpret ghana’s decision to continue with the global fund’s private sector co-payment mechanism?

these questions offer avenues for further analysis of the role of donors, the state, and the public.

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indeed, ownership is not only an issue for capital-based elites; Fox (2015) recently highlighted that “the current aid architecture deprives both african governments and african publics of agency.” in chapter 7, I introduce views of the citizens and businesspeople at the street-level of implementation. about 20%, during in-depth interviews, spontaneously said they wanted to see the amfm continued — a view that seems to have had no way of entering any debates about the future of the amfm and is absent from the academic literature on this initiative.

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though the minority, some respondents specifically voiced that they should have learned about the amfm through a government agency or professional association. two specifically raised their position as stakeholders. one, who heard from her supplier, said “i think it wasn’t fair because as major stakeholders, we should have been briefed before.” another, who heard first from the media, said “i felt this was wrong since we are a major stakeholder. we should have met as partners.” these concerns relate to relations between ghana and the global fund as well as between accra-based elites and tamale-based retailers.

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the events of both adoption and implementation of the AMFm suggest that ownership is important (in no way a novel claim). note, though, that there may be certain amounts of freedom to innovate accorded by being just an implementer, rather than having clear ownership of a new idea, decision-making power over adopting and implementing that idea, and, accordingly, more risk if the idea does not pan out.

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also, if we accept that ownership is indeed important, which seems a plausible lesson to draw from this thesis, we also learn that simply giving decision-making power to some national stakeholders is insufficient. the right national stakeholders and their existing decision-making structures need to be in play. we may glean something about relevant national stakeholders in this case through the composition of the amfm-cc and the committee characteristics raised as important (transparency, collaboration). but, given the views of some street-level implementers, ownership may require further consideration.

Aside

Some Nuggets From the Amber: Keshavjee’s ‘Blind Spot’

Just finished Salmaan‘s Blind Spot: How Neoliberalism Infiltrated Global Health. Below, a few tidbits of his weaving of the local and personal with the global, ideological, and ideal. everything below represents a direct quote and the page numbers are marked in parentheses.

This book is intended to add to the conversation about how to more effectively bring the fruits of technology and innovation to those for whom it is a matter of life and death; how social, political, and economic forces have shaped practices in global health; and how ideological blind spots are traps along the path of achieving some of our most humane and important societal goals (xxxii).

In truth, I was confused. I was in my mid-twenties and had been convinced by seasoned development experts that this approach [a revolving drug fund in badakhshan, tajikistan] was an integral part of the transition from “humanitarian assistance” to “long term development.” Of course, as a graduate student somewhat versed in development theory, I knew that something was not right about planning a strategy with people from France and Switzerland, whose medicines were paid for by health insurance, to convince the Canadians, whose medicines were paid for by health insurance, that the Bangladeshis, whose entire life-world had collapsed, who had no access to pooled-risk insurance schemes, and who were now living in poverty, should finance medicines from their destitute communities; that they should “participate in their own health” by joining committees that defined what doctors could prescribe for them; and that their system of curative care – with hospitals, clinics, and experts trained over 70 years of soviet rule – should move towards a more “preventative” medical system in the midst of epidemic disease and hunger. But I participated in moving the strategy forward because i saw it as a means of protecting the most vulnerable (82).

The rise of NGOs as recipients of aid dollars closely followed the ascendancy of neoliberal thinking in washington and london. in their studies of the ngo sector, David Hulme and Michael Edwards described the 1980s and 1990s as a period dominated by a “new policy agenda,” which placed a premium on the untested belief that the private sector was a better mechanism for delivering services and that NGOs are more efficient than the government, especially in providing services to poor people… NGOs became a powerful global political force explicitly identified as a meeting place for economic and political aid (106).

As Ahmed and I were to see, these assumptions did not stop with the revolving drug fund. Instead, it appeared to us that the idea that privatization was the only logical path forward – an assumption made without critical assessment of the potential consequences – was manifesting itself in other ways. It was as if the aspirations of Hayek and his colleagues at the Mont Pèlerin Society were being realized in real time: ideology was operating as common sense. as to other important outcomes – reduced mortality or morbidity, or ensuring justice and dignity – they fell into what I refer to as realms of neoliberal programmatic blindness: areas of programs that are eclipsed by ideological aims (114).

I have come to the conclusion that the way out of the amber is both complex and simple. At its most complex, it will require the re-calibration of our goals as a society and the type of world we wish to create… at its most simple, this will require re-calibrating our focus in global health and development from “sustainability” and “local ownership” to an approach that puts equity and patient outcomes first… a re-calibration of focus towards equity of access and equity of outcome will allow NGOs to again take up the mantle as a vanguard of a moral order that finds poverty and structural violence unacceptable (142).

Thinking About Stakeholder Risk and Accountability in Pilot Experiments

This post is also cross-posted here in slightly modified form.

Since I keep circling around issues related to my dissertation in this blog, I decided it was time to start writing about some of that work. As anyone who has stood or sat near to me for more than 5 minutes over the past 4.25 years will know, in my thesis I examine the political-economy of adopting and implementing a large global health program (the affordable medicines facility – malaria or “AMFm”). This program was designed at the global level (meaning largely in D.C. and Geneva with tweaking workshops in assorted African capitals). Global actors invited select Sub-Saharan African countries to apply to pilot the AMFm for two years before any decision was made to continue, modify, scale-up, or terminate. It should also be noted from the outset that it was not fully clear what role the evidence would play in the board’s decision and how the evidence would be interpreted. As I highlight below, this lack of clarity helped to foster feelings of risk as well as a resistance among some of the national-level stakeholders about participating in the pilot. . . as  . .

To push the semantics a bit, several critics have (e.g.) noted that scale and scope and requisite new systems and relationships involved in the AMFm disqualify it from being considered a ‘pilot,’ though i use that term for continuity with most other AMFm-related writing. . .

In my research, my focus is on the national and sub-national processes of deciding to participate in the initial pilot (‘phase I’) stage, focusing specifically on Ghana. Besides the project scale and resources mobilized, one thing that stood out about this project is that there was a reasonable amount of resistance to piloting this program among stakeholders in several of the invited countries. I have been very fortunate that my wonderful committee and outside supporters like Owen Barder have continued to push me over the years (and years) to try to explain this resistance to an ostensibly ‘good’ program. Moreover, I have been lucky and grateful that a set of key informants in Ghana that have been willing to converse openly with me over several years as I have tried to untangle the reasons behind the support and resistance and to try to get the story ‘right’. . .

The set-up of the global health pilot experiment, from the global perspective, the set-up was a paragon of planning for evidence-informed decision-making: pilot first, develop benchmarks for success and commission an independent evaluation (a well-monitored before and after comparison) — and make decisions later. . .

In my work, through a grounded qualitative analysis, I distil the variety of reasons for supporting and resisting Ghana’s participation in the AMFm pilot to three main types: those related to direct policy goals (in this case, increasing access to malaria medication and lowering malaria mortality), indirect policy goals (indirect insofar as they are not the explicit goals of the policy in question, such as employment and economic growth), and finally those related to risk and reputation (individual, organizational, and national). I take the latter as my main focus for the rest of this post. . . . .

A key question on which I have been pushed is the extent to which resistance to participation (which meant resisting an unprecedented volume of highly subsidized, high-quality anti-malarial treatments entering both the public and the private sector) emerges from the idea of the AMFm versus the idea of piloting the AMFm with uncertain follow-up plans. . ..

Some issues, such as threats to both direct and indirect policy goals often related to the AMFm mechanism itself, including the focus on malaria prevention rather than treatment as well as broader goals related to national pride and the support of local businesses. The idea of the AMFm itself, as well as it a harbinger of approaches (such as market-based approaches) to global health, provoked both support and resistance. . . .

But some sources of resistance stemmed more directly from the piloting process itself. By evidence-informed design, the global fund gave “no assurance to continue [AMFm] in the long-term,” so that the evaluation of the pilot would shape their decision. This presented limited risks to them. At the national level, this uncertainty proved troubling, as many local stakeholders felt it posed national, organizational, and personal risks for policy goals and reputations. Words like ‘vilification‘ and ‘chastisement‘ and ‘bitter‘ came up during key informant interviews. in a point of opposing objectives (if not a full catch-22, a phrase stricken from my thesis), some stakeholders may have supported the pilot if they knew the program would not be terminated (even if modified), whereas global actors wanted the pilot to see if the evidence suggested the program should (not) be terminated. Pilot-specific concerns related to uncertainties around the sunk investments of time in setting up the needed systems and relationships, which have an uncertain life expectancy. also, for a stakeholder trying to decide whether to support or resist a pilot, it doesn’t help when the reputation and other pay-offs from supporting are uncertain and may only materialize should the pilot prove successful and be carried to the next stage. . . .

A final but absolutely key set of concerns for anyone considering working with policy champions is what, precisely, the decision to continue would hinge upon. Would failure to meet benchmarks be taken as a failure of the mechanism and concept? A failure of national implementation capacity and managerial efforts in Ghana (in the face of a key donor)? A failure of individual efforts and initiatives in Ghana? .

Without clarity on these questions about how accountability and blame would be distributed, national stakeholders were understandably nervous and sometimes resistant (passively of actively) to Ghana’s applying to be a phase I pilot country. To paraphrase one key informant’s articulation of a common view, phase I of the AMFm should have been an experiment on how to continue, not whether to continue, the initiative. . . .

How does this fit in with our ideas of ideal evidence-informed decision-making about programs and policies? The experience recorded here raises some important questions when we talk about wanting policy champions and wanting to generate rigorous evidence about those policies. Assuming that the policies and programs under study adhere to one of the definitions of equipoise, the results from a rigorous evaluation could go either way.

What risks does the local champion(s) of a policy face in visibly supporting a policy?

Is clear accountability established for evaluation outcomes?

Are there built-in buffers for the personal and political reputation of champions and supporters in the evaluation design?

The more we talk about early stakeholder buy-in to evaluation and the desire for research uptake on the basis of evaluation results, the more we need to think about the political economy of pilots and those those stepping up to support policies and the (impact) evaluation of them. Do they exist in a learning environment where glitches and null results are considered part of the process? Can evaluations help to elucidate design and implementation failures in a way that has clear lines of accountability among the ‘ideas’ people, the champions, the managers, and the implementer’s? These questions need to be taken seriously if we expect government officials to engage in pilot research to help decide the best way to move a program or policy forward (including not moving it forward at all).