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:
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:
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…
Health planning has privileged approaches based on the application of biomedical technologies that prevent or eliminate health problems one at a time.
Little attention has been given to supporting the development of basic health services.
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…
Global health interventions have been empowered by faith in the superioity of Western medical knowledge and technology…
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.
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.
8 October 2016 hlanthorn	Global health, health systems, health systems strengthening, Packard, universal health care, universal health coverage	Leave a comment
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.
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.
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:
. and
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.
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).
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.
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.
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).
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.
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.
And, .
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?
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.
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.
Look, it's all here in my folder. Dammit. The folder tied the whole thing together.
7 September 2016 hlanthorn	chikungunya, delhi, doctor-patient relationship, hospitals, india, virus	14 Comments
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…
18 January 2016 hlanthorn	air pollution, delhi, india	Leave a comment
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).
19 March 2015 hlanthorn	foucault, globalhealth, neoliberalism	Leave a comment
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).
12 March 2015 hlanthorn	accountability, ACTs, amfm, decision-making, evaluation, evidence, evidence champions, pilots, policy champions, research design, risk, stakeholders	3 Comments