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:

moquito

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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.

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?

learning by asking: a modest proposal to engage those who did the doing

this post was originally published at innovations for poverty action. it represents an effort to follow-through on some themes i have raised before and hope to continue to raise.

most development interventions are carried out and delivered by local research staff and residents. such implementation is rarely a straightforward ‘technical’ operation but, rather, there is social and political nuance in translating an idea into practice. on-the-ground partners therefore often have important insights about research engagement and implementation processes. but researchers often do not solicit such feedback as a requisite part of their work. moreover, even when such questions are asked, the results are often not synthesized into the lessons learnt from the project, either in terms of setting the future research agenda or in terms of tweaking on-going programs and interventions.

the Preserving ACTs (PACT) impact evaluation used text messages (via this code, built by @eokyere and @slawarokicki) to encourage the completion of the most effective anti-malarial treatment (artemisinin-based combination therapies, or ACTs (e.g.)) in and around Tamale, Ghana. as the study drew to a close, we wanted to thank the malaria-drug vendors for implementing the text-message intervention under investigation and for hosting the study’s surveyors. in addition, we wanted to solicit their feedback about the project and research process. our goals were to better understand their experience working with the research team and the study process, of the intervention process, and whether, how, and with what changes they thought the intervention should be scaled following the study.

photo credit: alidu osman  tuunteya

photo credit: alidu osman tuunteya

in mid- to late- 2011, one of our field managers went back to all 73 vendors – hospitals, clinics, pharmacists, and licensed chemical shops, both public and private – that had hosted our study, to thank them and to solicit their feedback on the study process and PACT intervention. 65 vendors were available and willing to be interviewed. these follow-ups took place in the third and fourth week of October 2011 and provide a unique set of data for considering the implementation of this and future studies. they also shed some light on the program that provided the context and basis for this operational research study – the Affordable Medicines Facility – malaria (AMFm) — discussed more at the end of this post.

as a token of our appreciation for their hosting PACT and our surveyors (and the only incentive provided to vendors for hosting the study and intervention), we provided a thank you note / certificate of participation. a few of the vendors noted that our follow-up was appreciated, such as “we thought you left without a goodbye” and  “I really never thought you would be back again after that long time.  But it is great you still remembered us and even come to officially say goodbye to us.”

as described in the paper, drug vendors played an important role in the study, which spanned much of the rainy season in northern Ghana as well as the Muslim fasting period of Ramadan, as mentioned in some of the follow-up interviews.

first, vendors were in charge of distributing the flyers to patients acquiring a malaria treatment. from this flyer, the patient would know to call or ‘flash’ (ring once for no charge) into our ‘mobile health information system,’ from which they were randomized to receive reminder text messages.

second, vendors provided an IPA surveyor a place to sit and talk to patients about their anti-malarial treatment and, if eligible, to recruit them into the study. Sometimes this meant giving them a chair in a hospital waiting room; other times, it meant the IPA team providing a chair for a surveyor to sit in the limited space offered by a one-man or one-woman drug shop.

given the study design, the distribution of flyers and the text messages were kept conceptually and, as feasible, spatially, separate from the IPA surveyor and his or her questions about the patient’s malaria medication. we included a question about this in the follow-up: the full range of vendor responses can be viewed here [link to the spreadsheet], as well as an overview of how responses were coded.* in short, the codes used to categorize responses emerged from the responses themselves in light of themes or ideas repeated across several answers.

given the sample-size needs of the study, surveyors were only placed at vendors that had ACTs in stock and were selling at a reasonable volume. this often meant longer stays at some of the hospitals, clinics, and popular pharmacies and LCSs but shorter stays with other vendors. some of the vendors expressed disappointment about this, such as, “I felt the surveyors did not spend much time in my shop.  You should have stationed a surveyor at my shop for at least three weeks or 4 weeks” and “I did not experience much due to a lack of patients during the study period at my shop.”

experiences with PACT.

though we did not explicitly ask vendors if PACT addressed a problem they thought was important, three-quarters volunteered that non-completion of ACTs was a problem they faced and many welcomed the support of a program like PACT to try to encourage people to finish their medication and to strengthen whatever advice they already gave to their patients – for example, saying that the text messages “made patients to take my advice more seriously” and that they “increase our credibility and patients to stick to these advice we give as a health service provider”.

others felt that the text messages led to patients feeling they were receiving addition concern for their wellbeing. one noted that PACT “gave patients the courage to come back to us and ask questions of the drugs given to them, and then some do come back later to report other issues” and another that “patients that did initially not want to participate have come later to commend the text reminder.”

prior to agreeing to host PACT, some vendors were concerned that the flyer and survey process would interrupt the patient flow, affect their business, or lead to an over-focus on malaria patients at the expense of other clients. after the study, about 40% felt their sales stayed normal during the study while about 20% felt their sales had increased, which they attributed to PACT. Nobody reported a disruption in their sales. about 40% did note that the questionnaires administered by surveyors were long and were uncomfortable for patients who were sick and tired – hence, being at a drug vendor in the first place.

about 20% also felt their status or credibility increased when they were offering the program, such as “business was normal but on social grounds, I earned respect from individuals that were sent SMS…  It was a remarkable experience of the concern they achieved from your end. So, I gained more credibility to my advantage.” some of these benefits may, of course, reflect a novelty effect and would not offer any one vendor an advantage if the program scaled-up to all vendors.

there were also a few unexpected benefits of the program likely not to be replicated in a scaled-up version of the program — for example, one vendor reported that “your surveyor also helped me track a thief that came to steal from me”!

several vendors highlighted that it’s not always easy for them when a study like this – which facilitates their providing an addition service to patients and clients — ends, noting, for example, that “some patients still ask me if they will get the SMS” and that “now I have to explain to my clients that I cannot send SMS to remind them now, which is sort of sad”.

continuing and scaling-up program.

most vendors (97%) explicitly said that it would be good the PACT program – or something like it – could be extended beyond Tamale and the time period of the study but also to other medications. for example, one noted “it should be scaled up so that at least I know my family that does not reside here in Tamale would also benefit from this great experience and education” while another said “the program should be nationwide because I know this attitude” – “the bad attitude of not completing the dosage” – “is widespread” and another similarly stated “the issue of people not completing their dosage is nationwide, so the program must be nationwide”.

about half saw no predictable barriers in being able to continue a program like PACT on their own; nearly a quarter thought that during busy times, it might be hard to make time to explain the program to patients and enroll them. 42% said they would need more training. Half noted that materials (such as flyers) and money for credit would need to be provided to them and several noted that extra components, such as t-shirts, would help motivate them and advertise the program better. for example, “I would also love to be given [something extra], like t-shirts, that could help motivate the vendors to do the work diligently.”

vendors also had a variety of suggestions on how enrollment into the text messaging system could be encouraged. One set of suggestions including removing any costs to patients, such as making the enrollment line toll-free as a way of encouraging more patients to enroll. to clarify what happened in practice, if patients texted into the program, their phone balance was deducted the cost of a text message. for people to ‘flash’ (dial and allow one ring) into the system, it did not cost them any money but phones (rather than our messaging system) required a positive balance to make this call.

more generally, 37 vendors (60%) suggested ways of increasing enrollment into the text messaging program, including the vendor or PACT team doing the actual enrollment as well as providing more information to patients about the program and why it was important. for example, one noted “if people are educated well, they will charge their phones and enroll later.” given the goal of the study — to see whether and how many people would enroll with a limited amount of encouragement and input — vendors provided limited (and surveyors provided no) information to the patient along with the flyer. in retrospect, however, some vendors saw this as a missed opportunity to educate patients about an important problem.

fourteen of the vendors raised concern that the text messages excluded illiterate patients – some suggested using voice calls as well as TV and radio to better educate about the importance of completing an ACT once it is started.

distinctions with AMFm (and implied suggestions for future AMFm-like programs).

the Affordable Medicines Facility – malaria (AMFm) provided the context for the PACT study, although the text messaging program was meant to be seen as independent of the ‘green leaf’ efforts explicit to AMFm marketing. as such, we asked questions of vendors to assess whether they saw the programs as distinct. In so doing, they ended up commenting on differences in the program in a way that may shed light on future AMFm-like efforts. for example, “programs for the ‘green leaf’ have more TV and radio coverage than your PACT program, but then you made more impact of encouraging people to take their drugs.  The other programs only encourage buying and awareness” or that with AMFm, “people do not get education on usage or encouragement to complete dosage”.

to clarify, the AMFm-linked advertisements focused on telling people to act fast when they suspected they had malaria, to look for the “green-leaf” quality logo, and what price these logoed ACTs should cost. as such, one vendor noted “the ‘green leaf’ programs don’t have any sort of attachment to the patient but your intervention seemed to involve and appreciate the patients more, so they felt respected and began to place some emphasis on their health.”

also, it is worth noting that elements of PACT seemed to alter the way patients viewed ACTs as well as the perceptions and stocking decisions of the vendors themselves. overall, 65% of vendors reported such changes. as part of AMFm, vendors should have received trainings provided by various government and professional bodies, as well as the mass media “green leaf” advertisements — but this seems to have not always been the case, at least by the time the PACT study was carried out.

for example, one vendor noted that “people are now more confident in the ACT drugs” and that “I now keep more stock of ACTs and on days that I do not have ACTs, the clients disturb me so much.  So for now, I make sure to keep more stock of ACTs.” Another said, “to be honest, it was the start of your study and the subsequent positioning of a surveyor at your shop that made me to purchase ACTs, and now I have many varieties of ‘green leaf’ drugs” while another reported “we were a bit skeptical about the new ACTs, so we had few in stock, but your presence also made us want to be more serious and also keep different types of ACTs.”

overall, the data presented above and in the spreadsheet (available below) suggest there is much that can be learned from soliciting feedback from program implementers, which can be taken into account in designing future studies and interventions. this type of engagement can ensure that humanity and humility remain part of the implementation and learning process.

you can download the spreadsheet with more information and responses here (excel format).

*where a vendor directly identified themselves or their workplace in their response, we have slightly altered the response, using italics in place of the missing word or phrase.

**important thanks go to Jeff Mosenkis, Corrina Moucheraud, Elianne Oei, John Quattrochi, and the late Elif Yavuz for encouragement in writing-up and thinking-through these results. the data and photographs above were collected by Usama Salifu and Alidu Osman Tuunteya. the biggest thanks go to the vendors for taking the time and energy to provide additional insight.

Mo money, mo problems? AMF does not make Givewell’s top-three for 2013 #giving season

This blog is a cross-post with Suvojit. Update 21 December: the conversation has also continued here.

Recently, Givewell has revised its recommendation on one of its previously top-ranked ‘charities,’ the Against Malaria Foundation (AMF), which focuses on well-tracked distributions of bednets.  Givewell “find[s] outstanding giving opportunities and publish the full details of our analysis to help donors decide where to give.” This approach seems to have succeeded in moving donors beyond using tragic stories and heart-wrenching images to raise funds, looking rather at effectiveness and funding gaps.

In their latest list, AMF does not rank amongst the top three recommended charities.  Here, based on the experience with AMF, we outline the seeming result of Givewell’s attention on AMF, consider the possible lessons and ask whether Givewell seems to have learnt from this episode, taking clear steps towards changing their ranking methods to avoid similar mishaps in future. As it stands, around US$ 10m now lie parked (transparently and hopefully temporarily) with AMF as a result of its stalled distributions, a fact for which Givewell shares some responsibility.

Givewell lays out its thinking on revising AMF’s recommendation in detail.  As a quick re-cap of that blog post: when Givewell looked at AMF two years ago, AMF was successfully delivering bednets at the small- to medium-scale (up to hundreds of thousands in some cases) through partnerships with NGOs (only the delivery of health products such as bednets and cash transfers meet Givewell’s current eligibility criteria). Following Givewell’s rating, a whole bunch of money came in, bumping AMF into a new scale, with new stakeholders and constraints. The big time hasn’t been going quite so well (as yet).

This is slippery ground for a rating service seeking credibility in the eyes of its donors. Currently, Givewell ranks charities on several rating criteria, including: strong evidence of the intervention’s effectiveness and cost-effectiveness of intervention; whether a funding gap exists and resources can be absorbed; and the transparency of activities and accountability to donors.

In its younger/happier days, AMF particularly shone on transparency and accountability. Recognizing that supplies of bednets are often diverted and don’t reach the intended beneficiaries, AMF is vigilant about providing information on ‘distribution verification’ as well as household continued use and upkeep of nets.

These information requirements – shiny at the small scale – create a glare at large-scale, which is part of the problem AMF now faces. ‘Scale’ generally means ‘government’ unless you are discussing a country like Bangladesh with nationwide NGO networks. The first hurdle between information and governments is that the required data can be politically sensitive.  Distribution and use of information is great for donors’ accountability but it can be threatening  to government officials, who want to appear to be doing a good job (and/or may benefit from distributing nets to particular constituents or adding a positive price, etc).

As a second, equally important, hurdle: even if government agencies intend to carry out the distribution as intended (proper targeting etc), data collection has high costs (monetary, personnel, and otherwise)  – especially when carried out country-wide. AMF doesn’t actually fund or support collection of the data on distribution and use that they require of the implementing agencies. AMF is probably doing this to keep its own costs low, instead passing collection costs and burdens on to the local National Malaria Control Programmes (NMCP), which is definitely not the best way make friends with the government. Many government bureaucracies in Sub-Saharan Africa are constrained not only by funds but also capacity to collect and manage data about their own activities.

What do these data needs mean for donors and what do they mean for implementers? For donors, whose resources are scarce, information on transparency and delivery can guide where to allocate money they wish to give. Givewell, by grading on transparency of funding flows and activities, encourages NGOs to compete on these grounds. Donors feel they have made a wise investment and the NGOs that have invested in transparency and accountability benefit from increased visibility.

At issue is that there seems to exist a tension between focusing on transparency and the ability to achieve impact on the ground. If the donor, and possibly Givewell, do not fully take into account institutions (formal and informal), organizational relationships and bureaucratic politics, the problem of a small organization not being able to replicate their own successful results at scale may resurface. Givewell says that it vets a given charity but it is not clear what role potential implementing partners play in this process. Givewell likely needs to account for the views of stakeholders critical to implementation, including those people and organizations that may become more important stakeholders given a scale-up. The fact that NMCPs (or the relevant counterpart) as well as bilaterals and multilaterals are hesitant to work with AMF could have been weighed into Givewell’s algorithm.

Givewell seems to be listening and recognizing these challenges, first by its publicly reasoned response to AMF’s performance, second by posting reviews (in particular, this recent review by Dr. de Savigny) and third, updating its selection criteria for 2013, including a consideration of scalability. de Savingny’s review raises AMF’s strategies in working with governments, both coordinating with donor governments and supporting ‘recipient’ governments with determining data needs and collecting data.

What else can Givewell do now? Expand the criteria beyond need, evidence-base (intervention and organization) and commitment to transparency by also including:

  1. Feedback from previous implementing partners.

  2. Specific project proposals from applicants, in which they lay out a plan to implement their activity in a specific country. Potential funding recipients should think through and detail their government engagement strategy and gain statements of buy-in from likely implementing partners  – global and local – in that context.

  3. Givewell should more carefully calibrate how much money goes to organizations for proposed projects. Funding based on engagement in a particular country can help avoid problems of getting too much too fast: funding can be pegged to the requirements of the specific project that has been put up, for which the organization has need and absorptive capacity.

dear sir – response to AMFm article in the economist

on 24 novemberthis article was published in the economist on AMFm and the Global Fund. below is the response i would have liked to have published because a few things in the article were maddening. particularly frustrating are those celebrating the end of AMFm as though ending a subsidy on ACTs in the private sector are the same thing as removing ACTs from the private sector. it’s not. so far as i know, we have not yet heard whether pharmaceutical companies intend to keep their ACT prices low, in order to tap into the non-premium market uncovered in AMFm. in any case, malaria programs moving forward need to address the reality of treatment-seeking behavior and expectations for fever in the wake of AMFm. 

‘Sir – At least two things on the horizon for malaria treatment – for both the Global Fund and the larger global health community – are not cloudy in the dust of the Affordable Medicines Facility–malaria (AMFm). Yet these points remain under-discussed.

First, the end of the AMFm subsidy for malaria treatment does not eliminate the obligation to scale-up malaria and broader fever diagnosis in both the private and public sectors. The globally recommended treatment for malaria – ACTs – are legally available over-the-counter in three of the seven countries that piloted AMFm. This includes Nigeria, which accounts for one-quarter of global malaria deaths. It also includes Ghana and Uganda.

Even where citizens cannot legally access ACTs over-the-counter, they can often obtain these treatments as easily as if the laws supported such access. Unless the global discussion shifts to changing and enforcing national drug regulations – which it has not – we need to continue talking about scaling-up diagnosis at the gamut of fever-treatment points. This remains the case with or without a subsidy.

Second, it is a false dichotomy that aid money be directed to either a drug subsidy or a community health worker (CHW) effort. Instead, we need to discuss how to apply lessons from successful CHW programs to the variety of workers on the front-lines of treating fevers. Again, those in both the private and public sectors who are, in reality, treating fevers. Researchers working with community health workers suggest that, where in place, CHWs can appropriately distinguish and treat fevers, as well as encourage their charges to complete treatment. However, the CHW model has not proved viable in each context it has been tried. As such, not every malaria-burdened country has trained, scaled-up, and maintained CHWs, despite attempts since the late 1970s. We need to discuss the current realities of safely treating fevers in countries shouldering malaria burdens in order to develop both short- and long-term plans.

AMFm post over at CGD – a few thoughts on the conversation

here’s the series:

http://blogs.cgdev.org/globalhealth/2012/09/what-the-pre-post-evaluation-of-amfm-can-tell-us.php

http://blogs.cgdev.org/globalhealth/2012/11/the-future-of-amfm-making-sense-from-all-the-noise.php

http://blogs.cgdev.org/globalhealth/2012/11/the-future-of-amfm-realpolitik-and-realistic-options-part-ii.php

@altmandaniel pointed out that our position on what the Board should decide in the final post was not entirely clear. this is true – our goal was to lay out the positions and process rather than take a strong stance on the outcome. with regard to outcomes, the matching-based funding model would be the preferable option if you support facilitating private-sector delivery of drugs, while the integrated model represents a likely vote against intervention in the the private sector – at least absent a strong mandate for the TRP.

what @fanvictoria and i take a stand on is who and what needs to be considered by the Board. we further take a stand on the requisite transparency of the Board’s consideration.

this is a Big Moment for how evidence-based policy making plays out – and the decision at the end of the large-scale pilot period is neither as clear nor as technical as many people seem to have expected. both continuing AMFm and abruptly terminating it have strong implications for access to malaria drugs – but also in the political and policy spheres within implementing countries.

frankly, despite fast-paced and extensive evaluation efforts, what we learn about the AMFm is not really enough to say whether it is the ‘best’ approach to increasing access to malaria treatment. it is a reasonable proof-of-concept that the world does not fall apart when the private sector is used as a supply mechanism for increasing access to aid-subsidized drugs. beyond that, the debate remains both largely speculative and, in place of evidence about the relative impact on malaria morbidity and mortality, ideological.

given this, we step back in order to lay out the actual options and trade-offs that should be considered. some of these – how to improve dosing practices, how to encourage proper completion of doses by patients, how to strengthen in-country regulatory mechanisms and monitoring capacity, how to improve demand generation & information dissemination, how to include local pharmaceutical manufacturers – all often seem to be drowned out by either rancor over whether the private sector (in low and middle income countries) is an appropriate target for aid dollars or by discussions of specific types of subsidies and diagnostics. these are important moving parts in the bigger picture but they are not the only moving parts.

as a closing point on the Board’s decision, i‘d like to point out that many countries have already made a choice on whether it is right for ACTs to be sold in the private sector  because they have given ACTs over-the-counter status. this is not a decision about where people do seek treatment for fever and whether that is the ‘right’ place. rather, the discussion should proceed from the positive reality that the private sector is utilized for fever treatment. thus, the needed normative and positive discussions are about

(a) whether it is ‘right’ for aid-subsidized drugs to be distributed in the private sector;

(b) whether people in low- and middle-income countries should pay for medicine at all;

(c) how aid money can be used most effectively to strengthen front-line worker and patient practices across sectors, including learning lessons from experiments with community health workers, nurses and pharmacists in the public sector, and drug shop staff in private sector; and, finally,

(d) how we can better design, test, evaluate, and cooperate on an approach or combination of approaches to reduce malaria morbidity and mortality that also strengthens systems for supplying treatment more generally.

magic bullets are bad and silver bullets are hard to come by (agenda for approaching resistance to malaria treatments)

i have previously discussed the bizarre origin of ‘magic bullets’ as a phrase used positively and aspirationally in public health – as well as the folly it represents: relying on a single approach to a public health problem rather than doing multiple, hopefully coordinated, activities.*

my feeling is that something silver-bullety is going on right now in discussions about addressing malaria treatment and parasite resistance to that treatment.

there is a big push — both to wisely spend malaria-treatment resources and to stave off parasite resistance to ACTs (artemisinin-based combination therapies, the current WHO-recommended first-line treatment for uncomplicated malaria**) — towards using rapid diagnostic testing (RDTs); further, towards coming up with incentives for people to choose a treatment commensurate with those test results (and to incentivize drug vendors to encourage clients to choose treatments that correspond with the diagnosis).***

diagnosis is awesome. those issues need attention. but

there are other big components in effectively treating malaria and fighting resistance that seem to be getting too little attention because they lack a fancy acronym and cool technology aspect? because they are unsexy? and/or because they are hard to do and measure?

in any case, counterfeiting and improper dosing and usage of ACTs are also important issues and i just don’t hear them getting the same buzz.

first, whether it is the public sector or the private sector that ultimately delivers the drug to an end-user, ‘health systems strengthening’ needs to include increasing government (or private?) monitoring, testing, and regulatory — pharmaco-vigilance — capacity to test drugs and check prices at port and mid-way through the supply chain, not just with the front-line workers. companies like sproxil offer one way to approach this problem, though monitoring and regulation seems like the sort of thing you might want a state to be able to do.

second, just because good drugs get to front-line workers, it doesn’t mean the end user is getting the right drug for his/her body weight. but that’s actualized access: affordable, available, acceptable, adaptable, AND USED. there’s evidence that workers with even limited training can make the right decisions about diagnosis and weight-class (including here and here).

but there is not a lot of evidence that most front-line workers possess this information, say, via regular government trainings. certainly my experience in northern ghana suggests that many vendors do not know about weight classes for drugs (preferring, if anything, to assign treatment by age) these private vendors are a major interface with the population seeking treatment for fever.

i recently heard someone promote pediatric formulations – syrups or enemas – to help guide vendors and users toward the right dosing decision even without understanding weight-classes (‘syrups are for kids’ is a relatively easy message). this seemed like very sage advice from shunmay yeung.

third, even though ACTs are only a 3-day (6-time) course of meds, people don’t finish them for all kinds of reasons.**** i was surprised at this problem when i first started looking at malaria after much more work on behavior around TB and chronic diseases – it seemed like such a short treatment course! but, it turns out a lot of people (including ex-pats!!! looking at you, JoT) don’t finish their malaria treatment course: like, 30% of people, in some endemic countries. there have been efforts at addressing this, for example here and again here, using follow-up text messaging. but, again, this just doesn’t seem prominent on the malaria agenda.

the last mile isn’t just getting affordable drugs into remote areas: it’s about getting good, affordable, and appropriate drugs in the right amounts into the bodies of the people who need and want them.

i have become quite fond of the ‘silver buckshot‘ metaphor to use in place of ‘silver bullets.’ in this case, treating malaria and protecting the effectiveness of malaria treatments requires looking at diagnosis, pharmaco-vigilance, and appropriate dosing and use. (and that’s without opening the prevention can of worms!)

keeping this bigger, balanced, and un-acronymed package of items on the malaria treatment agenda is difficult — but i hope it can be done.

*recognizing, of course, the problems with ‘planning’ and ‘coordination’ without allowing for ‘searching’ in terms of design and implementation.

**”it’s complicated” may be less-than-ideal as a relationship status on facebook — but it is definitely no good as a status update on your malaria.

***also, there is the tricky follow-up question of what to do if someone tests negative for malaria (moreover, what else to do if someone tests positive for malaria, given the potential for co-morbidities; these are topics for another time).

****too many pills, feeling better, saving the pills for the next illness, feeling nausiated from the pills, and so on