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.

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.

this post is specifically about priority-setting for who gets treated: those who work in health care and those who do not. 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 and who paid for them in what ways, 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, as well as strengthening health systems and equipping them to make decisions more generally.

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.

 

see wound, insert (new, improved, foreign) salt

perhaps like many people in public health, i take the fortification of salt with iodine – the prevention of several thyroid-related disorders and the widespread return of the neck ruff – as one of public/global health’s major achievements. up there with smallpox, water treatment (for sanitation and potentially with fluoride) and really-we-are-nearly-there-but-stuff-keeps-happening polio. 

the WHO declared a universal salt iodization strategy in 1993 (in quito, if you try to keep up with the location-names of these declarations). there have been recent successes in central asia, among other places, in reversing the cognitive and other negative effects of iodine deficiency. iodization of salt is an appealing strategy to promoting public health because it requires very little effort from front-line workers or potential users. fortification is a neat, technocratic solution to a serious problem. people use salt regularly, out of necessity (though often use more than is necessary), and – viola! – unconsciously ingest something extra that’s good for them. salt’s pretty important; of course, it used to be traded for gold (and human beings) and as a recent poetic-wax highlighted, salt is constitutive of human emotions and activities, in the form of sweat and tears. and, though i am not sure it has inspired poetry (perhaps among campers?), iodine has to be ingested because human bodies do not produce it on their own though they need it.

but iodization is a technocratic solution only right up till you recognize the politics behind it (as with most technical solutions to development). it had not fully registered to me until i re-read kurlansky’s salt – despite the proliferation of a rainbow of artisanal and heirloom sea salts, rock salts, probably moon salts, at whole foods and trader joe’s – precisely what mass iodization meant for local salt works around the world. kurlansky notes that country decisions to ban non-iodized salt are “popular with health authorities, doctors and scientists, but very unpopular with small independent salt producers.” India banned iodized salt in 1998, only to repeal the ban in 2000. among other arguments for repeal, the ban went against “Gandhi’s assertion that every Indian had a right to make salt.” oops. that old controlling-salt-production-is-and-always-has-been-super-political thing.

kurlansky suggests that small salt works have neither the money nor the knowledge to iodize their own salt up to government standards, so good salt comes from large national manufacturers and from outside. but deficits of knowledge and money are generally fixable problems, so this answer to combating iodine deficiency seems… deficient. 

partly, at issue is the silo-ed approach to development, where very few projects link directly with national strategies for economic development, though many projects note that poverty reduction and growth promotion *are* national priorities. we might just skip the contents of their actual strategy. we talk about country ownership (hey paris, hey accra), we talk about local capacity-building, we talk about alignment with, say, national health and education priorities, but we don’t talk enough about furthering development through all these projects by buying local (meaning more than that one shirt you bought from that one women’s co-op that one time you were visiting that one project in that one country — which especially doesn’t count if that project was focused on SMEs or entrepreneurship and your shirt is not from one of them).

we don’t, i believe, talk as much as we should about the use of locally manufactured products in global health and development projects more generally. there are, to be sure, political and economic difficulties to a work-local-buy-local approach, since donor countries also have national self-interest to consider. and there are technical and logistical difficulties because many places arguably in need of development projects also don’t have manufacturing processes that are up to global standards, perhaps coddled too long by import substitution strategies that did not have an eye towards exporting and competing. it would take time and effort to build local production capacity and supply chains — and we need to work quickly!

so, health commodities come in, building materials come in, food supplies come in, machinery and equipment comes in, often human capital comes in — and development is meant to logically follow. but bringing stuff ‘in’ has big implications for local livelihoods. a comment this week about a large development project in timor-leste describes the “lost opportunity” of not using local materials that would support local employment or small businesses. earlier this year, julie walz and vijaya ramachandran at cgd wrote about promoting local procurement in haiti, noting that this would do “double duty” by “purchas[ing] immediately needed goods or services [and helping] grow the private sector, creat[ing] jobs, and encourag[ing] entrepreneurs.”

two-birds, one stone sounds pretty good. so… can we start talking about this as part of the post-2015 discussions? over probably-not-iodized but tres-good gourmet sel gris popcorn? it supports this adorable old french salt harvester.

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.