A Few Good Links (August 16, 2010 Edition)

This Guardian UK Special Report looks at the alarming increase of bacteria resistant to all known antibiotics  and the dearth of new antibiotics in the drug development pipeline.  One reason cited for this dearth is the economics of antibiotics with many short duration courses.

Atul Gawande, of the Checklist Manifesto fame, examines the complex nature of end-of-life care in the New Yorker Magazine. With the backdrop of the death panel talk that arose from the United States Healthcare Reform legislative battle, Gawande chooses to examine end-of-life decisions from the perspective of the patient and their families and not the cost implications.

Wired Magazine recounts Sergey Brin’s quest to improve the quality of Parkinson’s research.  He uses his money and approach from Google to collect massive amounts of data and search the data for patterns and hypotheses that can then be tested using more traditional scientific techniques.  Big Data vs. Big Science is the theme.

New Global Health Blog

We have the new feed subscription ready at the new global health blog website, please update your feed subscription using the link below.

You can subscribe to our blog feed from the following link: http://globalhealthideas.org/?feed=rss

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THD has a New Home: GlobalHealthIdeas.org

It is amazing that we are almost 3 years old and we are still ticking. As we continue to grow we decided to move to a more permanent home. In that process we also decided to re-brand as our scope has also grown. We are now at a new domain with a new name – Global Health Ideas (globalhealthideas.org). I’ll post more details shortly, in the meantime please join us at the new site and excuse the temporary dust up over the next week as we transition the blog over. Thanks!

Of Pandemics, Fear, the Facts and You

It seems that an influenza virus can survive on money for up to 10 days, and the New York Times has an interesting article on modeling virus spread on dollar bills.

But one thing remains true: “People have a very weird perception of large numbers,” [Dr. Brockmann] said. “If you have 2,000 cases of flu in a country of 300 million, most people think they’re going to be one of the 2,000, not one of the 299,998,000.”

I think people have a wierd perception of risk, and that is often influenced by media attention. Which reminds me of a memorable article from the New York Times Op-Ed page in 2003 – remember West Nile Virus? “Never Bitten, Twice Shy – The Real Dangers of Summer” by Ropeik and Holmes.

Never Bitten, Twice Shy - The Real Dangers of Summer (2003)

Yes, the graphic is not perfect (see this critique at Edward Tufte’s blog), but does get across the idea that risk perception is not always influenced by the facts. And is expanded in this article in Health Affairs “Dealing with the Dangers of Fear: The Role of Risk Communication” by Gray and Ropeik.

Ok, but what about the facts? The fast moving breaking news often plays fast and loose with the truth, and can spread alarming information. Early reports of the swine flu in Mexico seemed to have extremely high mortality reports, especially among young adults. Now, with new evidence of confirmed cases, the virus is looking alot milder. When I first read that influenza virus could survive for 10 days on money, I thought it was another casualty of the truth, as the avian-human-swine flu reported in a press briefing by the CDC. However, in this case, the facts seem to check out (Survival of Influenza Virus on Banknotes, Thomas et al), unlike the potluck origins of the swine flu which ProMED reported to be, upon closer examination – just swine flu.

More on risk perception:

Here’s a conversation with David Ropeik in the New York Times, and he wrote a book with George Gray – Risk: A Practical Guide for Deciding What’s Really Safe and What’s Really Dangerous in the World Around You

Reckoning with Risk: Learning to Live with Uncertainty – Gerd Gigerenzer

Can’t get enough of risk? Check out the Risk-0-meters and calculate your own health risk at the Harvard Center for Risk Analysis

Finding Fever – Flu and Border Controls

A quarantine officer monitored a thermal scanner Tuesday at Incheon International Airport in South Korea. Jung Yeon-Je/Agence France-Presse — Getty Images

Thermal scanners purchased after the SARS outbreak have been mobilized for border screening. Super-cool, but do they work to stop the spread of an epidemic?

The New York Times led with this image, but now the story link has been updated. Here’s the original text by Donald G. McNeil, Jr. on border controls:

Given extensive human-to-human transmission, the World Health Organization raised its global pandemic flu alert level on Monday, but it recommended that borders not be closed nor travel bans imposed, noting that that the virus had already spread and that infected travelers might now show any symptoms.

However, many countries are tightening border and immigration controls, and on Tuesday Britain advised against any nonessential travel to Mexico. Japan announced that it would no longer allow Mexican travelers to obtain visas upon arrival. The United States, France and Germany have also warned against nonessential travel to Mexico.

Here’s my understanding of how it works: the thermal scanner camera detects infrared radiation (IR). Basically any object emits IR which intensifies as it gets hotter. The camera has a sensor which detects IR and converts it into a temperature reading. In this system it does it visually.

However, when you first get flu, you don’t have a temperature, and the thermal scanner only measures skin temperature on your face, so an early fever (which raises your core temperature) is also not detectable.

So – does it work? Work done by Bitar et al as a followup to SARS control was published in February 2009: International travels and fever screening during epidemics: a literature review on the effectiveness and potential use of non-contact infrared thermometers In the early stages of a pandemic when less than 1% of people will be feverish, fever screening at the border is of limited use – from the paper “When we fixed fever prevalence at 1% in all studies to allow comparisons, the derived positive predictive value varied from 3.5% to 65.4% ” So thermal scanners aren’t very useful when very few people have fever.

However, check out this view from William Saletan in Slate: Heat Check – Swine Flu, Body Heat and Airport Scanner

On another note, I’m wondering why journalists don’t seem to have quick access to infectious disease specialists. In the New York Times, an environmental health epidemiologist is quoted in the debate, and here in the Cape Times, a sociologist who now specializes in the public understanding of biology. Where are the infectious disease experts? Maybe the CDC needs to draw up a list of media contacts among their top virologists and infectious disease specialists. Maybe part of science education should be a course in writing on science for the public, as well as how to write (and read!) papers.

Laurence Altman wrote a nice article in the New York Times about assessing the flu threat: Sound the Alarm? A Swine Flu Bind

For ongoing info: here’s the WHO, the CDC and if you really want to geek out: ProMED-mail.

Swine Flu Exposes Limits of Google Trends

Many thanks to Dweep Chanana for this post (cross posted from The Discomfort Zone )
After reading the below check out our previous review of Google Flu Trends.

Swine flu is in. In the rush to cover this latest possible pandemic, newswires are alive with activity, blogs and social networking sites are buzzing, and the CDC and WHO are back in the limelight. This despite the fact that the number of cases are limited (only 40 confirmed infections have occurred in the US).

The rush of news has been accompanied by a rush to track that news. The WSJ, amongst others, has a tracking website, including a map of infections in North America. Best of all, Google has a map showing how the infection is traveling.

This rush was started by Google Flu Trends, a website that tracks flu-related search queries to estimate influenza levels in different US states. Further studies suggested the same approach might work for other diseases as well.

Analyzing Google Trends

So how has Google Trends, the broader application of the Flu Trends concept, performed in the current scenario? A quick analysis shows that Google search results did in fact increase over the past few days (see chart – source: Google Trends).

A quick analysis shows three items worth mentioning:

• First, while Google Trends does show an increase in search activity on “swine flu,” the first uptick in activity only occurred on April 23. By contrast, the first news stories appeared on April 21 when two cases were confirmed in California.
• Second, Google Trends reports that the majority of search queries were from New Zealand, USA, UK, Canada, and Australia. Only a very small minority were from Mexico. Yet, Mexico is the country supposedly at the heart of the pandemic.

Explaining the Discrepencies

I had used a Google Trends like methodology two years ago to track the evolution of climate change as an issue in news coverage. Having worked on that, I can propose a few general reasons that explain why Google Trends is limited in this case.

First, it appears that Google Trends follows with some time lag, actual infections. This should not be surprising, as people are not likely to search for a disease before having had some exposure to it. This does not mean that it is not a useful tool for tracking diseases over the long term. At the very least, the response time of a system based on GT might be lower.

Second, the current scenario shows that Google Trends is highly susceptible to “noise.” Prior to this outbreak, swine flu was probably not a commonly known disease, and queries on it were extremely rare (if not non-existent). Thus, even the slightest uptick in search activity would show up as a major change. That uptick was provided by the highly charged media coverage of the subject. Given this, one wonders if the search results are more “noise” and less people with a genuine interest in the subject. So, Google Trends is likely to be more accurate where general knowledge of a subject (the baseline) is high, and media coverage (noise) is low.

Finally, and most interestingly, why is it that most of the search results came from the US, while Mexico is more exposed to it? Not surprisingly, this methodology only works where both a large number of the population and media are on the internet.

What Next for Google Trends?

When discussing why most search queries occurred in the US, it is worth noting another fact about the swine flu outbreak – that it has traveled extremely fast. Originating in Mexico, it has been carried to the USA, Spain, and New Zealand. This brings into question the validity of using the geographic source of search queries as a reliable indicator of where the disease actually is.

Still, it may also offer a way to enhance Google Trends. What if Google Trends data was combined with travel data on the number of people traveling from a “hotspot” of an infectious disease. It would be logical to assume that popular destinations, or ones which receive travel groups, would be the most likely next locations for further infections. Thus, a map could potentially be created of not only where the disease is generating interest, but where it might be headed.

Of course, Google does not have access to such data – though at some point it may decide to acquire a travel operator. But the general lesson is simply that to make Google Trends more useful, search query data needs to be looked at together with real-world data (such as travel data or hospital records).

It is still early days for the swine flu outbreak, but some commentators are already suggesting the “social web” has actually created hysteria rather than help track the disease. That may be true, but it is hardly a problem of the “social web.” As a reader on the FP pointed out, “Twitter is only a natural extension of a typical neighborhood.”

So, in this “typical neighborhood,” what the swine flu outbreak has done is illustrate where Google Trends does well – in tracking general interest amongst heavy Internet users. But it also exposes limitations – the methodology is (not surprisingly) susceptibility to “noise” from media coverage and is biased towards countries and issues that are online. This does not mean that the idea itself is flawed. Just that it must be taken with a pinch of salt, and that it needs work – especially interfacing it with real-world data streams – to make it really useful.

Graphic Stats: How to (Mis)Tell a Story

How one communicates a message is critical to what you are trying to accomplish. It amazes me how little upfront investment some organizations/campaigns put into this kind of thing. This recently came to mind when I saw the work of Toby Ng, who has “used information graphics to re-tell the story in another creative way” with the commonly used theme – if the world was 100 people then…Some examples below:

HT (The Atlantic)

Cautionary Note and Counterpoint
The comment thread at Flowing Data suggests an alternate critical argument about using this  technique  because it is not a “serious attempt to convey information” and it is easy to distort data when you manipulate in such a manner. I am not a graphic design expert and I haven’t read Tufte but this is certainly a fundamental principle (don’t distort the data). Given this warning, this specific style is attractive and can be useful depending on the audience and the goals you have. There is a lot more that can be said on this theme and it would be great to have global health folks brainstorming different ways of communicating messages beyond doom and gloom.

For some inspiration and ideas check out sites like Flowing Data and Jaspal’s previously related post on “Why Bad Presentations Happen to Good Causes“. For audio visual storytelling the talk by Hans Rosling at TED 2006 is a global health classic that pushes us to be more creative story tellers. This has to be one of the best global health videos I have ever seen (which we posted 2 years ago):

Internet: Revolutionizing the Detection of Disease Outbreaks

First, a bit of housekeeping – we are tinkering with the look of the blog and considering moving it to another platform, if you have any feedback about what you like and don’t like, let us know.

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Published today in the CMAJ, Early detection of disease outbreaks using the Internet, is worth skimming:

“The Internet…is revolutionizing how epidemic intelligence is gathered, and it offers solutions to some of these challenges. Freely available Web-based sources of information may allow us to detect disease outbreaks earlier with reduced cost and increased reporting transparency. Because Web-based data sources exist outside traditional reporting channels, they are invaluable to public health agencies that depend on timely information flow across national and subnational borders. These information sources, which can be identified through Internet-based tools, are often capable of detecting the first evidence of an outbreak, especially in areas with a limited capacity for public health surveillance.”

The limitations section includes the below list, but I wish they went into much more detail about what the internet is not good for (probably detecting trends among the elderly for example) and more examples of misinterpreting the data. On a related note to using ICTs for surveillance, Jaspal wrote a fairly detail post on Google Flu Trends that you should also check out.

Art for Global Health

I recently discovered the UCLA Art|Global Health Center, the mission of which is to “unleash the transformative power of the arts to advance global health“. The arts have the ability to capture issues and tell a story in a way that can make a profound impact on our (social) consciousness and is not something we talk about enough as a tool. One of the more famous examples of this is the AIDS quilt which was conceived of in 1985 by an AIDS activist in memory of Harvey Milk. That quilt has had over 14 million visitors and is the largest community arts project in the world.

The UCLA center has some ongoing projects and last year opened “Make Art | Stop AIDS” that featured traditional art as well as things like condom dresses. Make Art/Stop AIDS “is organized around a series of seven interconnected and at times overlapping concerns expressed in the form of open-ended questions, some of which include direct art historical references to the epidemic: What is AIDS?; Who lives, who dies?; Condoms: what’s the issue?; Is it safe to touch?; When is the last time you cried?; What good does a red ribbon do?; Are you angry enough to do something about AIDS?; and, finally, Art is not enough. Now it’s in your hands.”

Creative art projects have the ability to move the human mind unlike the constant barrage of issues, numbers and headlines that desensitize us over time. If you have seen or heard of any interesting arts based global health projects let us know.

More Sources
Adriana Bertinin’s condom dresses

Addressing HIV/AIDS-Related Grief and Healing Through Art

History of the AIDS Memorial Quilt

Condom fashion show, China

Vote for mHealth Project: ClaimsMobile in Uganda

Please vote for Ben’s mobile payment for health systems project. Voting closes Friday.

VOTE – NETSQUARED: By introducing a smartphone and web-application system for submitting and reviewing claims, we hope to reduce the delays and errors, increase clinics’ profitability and improve communication. Below is a related post by Melissa Ho who is working with Ben on this project which fills a critical gap. Cross posted from ICTDCHICK:

First HealthyBaby Birth

The mother receives the baby from the nurses at the clinic.

As I have been pre-occupied with writing lectures for my class, and setting up my research, my collaborating partners at Marie Stopes International Uganda have been busy launching a new phase of the output-based aid voucher program, financing in-hospital delivery of babies, in addition to the in-clinic treatment of sexually-transmitted infections (STIs). The new program, called HealthyBaby is eligible to mothers who qualify under a specific poverty baseline and covers four antenatal visits, the delivery, and a postnatal visit. Last week they just started distributing vouchers, and this past weekend was the delivery of the first baby whose birth was covered by the program.

Like the HealthyLife program, the mother purchases a voucher for 3000 USh (approximately 1.50 USD, the HealthyLife program charges 3000USh for a pair of vouchers treating both sexual partners). The voucher then can be broken into several sticker stubs, one of which is submitted with a claim form on each visit.

The first mother puts her thumb print on the HealthyBaby claim form

The hospital then submits the claim form with the voucher to the funding agency (my collaborating organization), who then pays the hospital for the cost of the visit – labs, any prescriptions given, the consultation fee, etc. You can see in the picture to the right the nurse filling out the paper form and the mother putting her thumbprint on it. Filling out the forms can be tedious and error prone – this particular clinic had almost 18% of their STI claims rejected for errors last October. In the same month another clinics had 38.6% of their claims rejected. I am trying to work on digital systems that can help improve communications between the clinics and the funding agency, and also decrease the cost and burden of claims administration.

The Claim Mobile project actually focuses on the HealthyLife program – the STI treatment program, rather than the HealthyBaby program, but I hope to demonstrate the sustainability and replicability of the system that I’m developing by training the engineers here to retool my system for HealthyBaby – so by the time I leave, I am hoping it will be in place for both programs.

By coincidence, this first birth occurred in one of the two clinics where I’m running the pre-pilot of the Claim Mobile system.

World Health Day: The Future of Global Health

The WHO has decided to focus this World Health Day on hospital infrastructure during times of emergency. The folks over at Global Health Progress have a good round of what some bloggers are saying and include health journalism folks as well as thoughts from the AvianFlu diary. I thought I would go off theme and briefly throw out some thoughts on the bigger picture and encourage you to use this day to think about what is the future of global health? In this context of thinking about the future in 10, 20 or 30 years, the world is in turmoil and we are questioning the fundamental nature of market driven economies, why not use this as an opportunity to do the same for global health in a forward looking way? Think about where we are and whether we are prioritizing the right things and moving in the right directions?

Approximately 10 (only TEN!) years ago there was no Google, Kiva, Gates Foundation or knowledge about the cost differences between generic and brand name drugs (see this great talk on the Future of Global Health by Jim Yong Kim and his discussion of how they reduced the price of treating MDR TB patients by 80-90% in 1999) amongst major care organizations (absolutely stunning). Mobile phone penetration was less than 1% in developing countries and social entrepreneurship wasn’t hot, the vast majority of us probably hadn’t even heard of that term.

Where we were ten years ago is arguably a profoundly different world from where we are today and per the video below “we are living in exponential times“. To give you further inspiration to think differently today definitely watch the below (via 2173):

The acceleration of technology for social change and global health is going to increase, in this decade alone the convergence of movements in philanthropy, entrepreneurship and technology all enabled by the internet and mobile phone revolution have allowed people to collaborate, innovate and communicate on an entirely different level. I don’t know what the future of global health is – but I wonder how open source collaborations will contribute to solutions and whether twittering for global health will be around in five years and for whom and what purpose? Or will we just be doing more of the same. I wonder if we will be doing entire marketing and health education campaigns via mobile phones and how this will evolve. Will there be convergence of people and ideas working on global and domestic health? Will the flow of innovation and products from “South” to “North” become the next hot topic? I wonder if we will have a TED just for Global Health?

We might face a global crisis in 2030 but we will also be better equipped to face that crisis.Today is a day we should be thinking about what all the possibilities are and how we can get there in the fastest way possible.  The last idea I will throw out as food for thought is to think about what have been the top 10 biggest developments in global health in the last decade and how will these shape the future?

Other thoughts on World Health Day:
UN Dispatch, link
Human Rights Watch, link
The Lancet Student, link
Global Institute Blog, link
Charity Navigator, link

Social challenges

Update: Voting opened Monday and will close Friday 3pm Pacific time. We are expecting a high turnout. Your support will be critical. To cast a ballot voters need to select three projects.

NetSquared has a new social challenge “N2Y4“. Voting opens Monday and Melissa and I submitted a proposal called “ClaimsMobile” to the new competition. “ClaimsMobile” is a mobile phone and web database application for management of patients’ medical and financial information in a Uganda output-based healthcare project. We have been working with partners at the Mbarara University, the NGO Marie Stopes International Uganda, and small private clinics in the region. Check it out. Voting starts April 6th (Monday) 11 AM California time and runs for five days. If you like our idea, vote for it… and be sure to look through the range of amazing proposals – everything from education to international justice to community programs. The word cloud says it all.

There seem to be a lot of “social challenges” these days. In the past nine months, I’ve been asked to vote for a Peace Corps projects photo idea at NameYourDreamAssignment, a girls’ tuition fund in Burkina Faso, a geotourism project in Ecuador, a women in sport challenge, as well as support a handful of ideas among the 7875 proposals submitted to the popular Ideas for Change in America campaign; all hosted on platforms like Ashoka ChangeMakers, GlobalGiving, NetSquared, and Change.org.

These challenges, like California ballot initiatives, work best if voters take the time to learn the issues. Spend some time to select projects from an area you know or have a great deal of interest – the NetSquare’s word cloud is a useful first step to sort ideas. If that fails, Stoltz at Web2…Oh Really recommends picking the project with the least votes… and I’ll close by suggesting “ClaimsMobile” for your short list.

Quote of the Day – g20 in perspective

“In London, Washington and Paris, people talk of bonuses or no bonuses…in parts of Africa, South Asia and Latin America, the struggle is for food or no food…the greatest price for incompetence at the summit will be borne by the poorest people in the world.

Oxfam has calculated that financial firms around the world have already received or been promised $8.4 trillion in bailouts. Just a week’s worth of interest on that sum while it’s waiting to be deployed would be enough to save most of the half-million women who die in childbirth each year in poor countries.”

Nicholas Kristoff, NY Times, At Stake are More than the Banks, April 1, 2009

A different more pro-active spin on the above comes from Lynne Twist:
“This is a time that I think history will look back on and say, ‘These are the people, this is the generation of humankind that went through a transformation that made the future of life possible. These are the people who had the courage to make profound changes in the way they were thinking, as well as in the way that they were behaving, that gave the future to life itself.”

Milwaukee: hub of water technology in global health?

It’s been more than two years since we reported on Seattle as the new Geneva, that is, as the new epicenter of global health activity. An article in this morning Journal-Sentinel (Water-engineering firms see potential, challenge in developing countries) – which includes an exclusive interview with the Acumen Fund’s chief executive Jacqueline Novogratz – suggests that Milwaukee is angling to do the same for water technology:

It’s an issue that almost certainly will preoccupy business leaders in metro Milwaukee in their strategy to brand the region as an international hub of water technology. The metro area is home to scores of water-engineering companies. Gov. Jim Doyle and the University of Wisconsin-Milwaukee this month announced plans to invest millions of dollars for UWM to become a center of freshwater research.

An 2008 article from the same newspaper (Area’s tide could turn on water technology) provides more evidence:

[F]our of the world’s 11 largest water-technology companies have a significant presence in southeastern Wisconsin, according to an analysis of data from a new Goldman Sachs report.

…

Wall Street has tracked automakers, railroads and retailers almost since there were stocks and bonds. But water remains a novelty. Goldman Sachs Group Inc. didn’t begin to research water treatment as a stand-alone industrial sector until late 2005.

While several large MNCs have shown an active interest in clean water in developing countries (e.g., Procter and Gamble, Vestergaard Frandsen, Dow) open questions remain as to what role large MNCs will play in providing access to safe water for the one billion people who don’t have it.

(Thanks to Dr. Jessica Granderson for sending the link)

Innovation as a Learning Process

Cross-posted from Design Research for Global Health.

The California Management Review recently announced the winners of the 2009 Accenture Award: Sara Beckman of Berkeley’s Haas School of Business and Michael Barry, founder of design consultancy Point Forward and Adjunct Professor at Stanford, for their article, Innovation as a Learning Process: Embedding Design Thinking (Fall 2007, Vol. 50, No. 1).

From the award website (which is still on the 2008 winner as I write this): “The Accenture Award is given each year to the author (or authors) of the article published in the preceding volume of the California Management Review that has made the most important contribution to improving the practice of management.”

The paper makes a compelling argument that innovation can be achieved by management and provides a model for cross-functional, cross-disciplinary teams to engage in this process. The relevance to global health as I’ve discussed before (really what this entire blog is about) is that the process can help us improve health systems through innovation.

The challenge in coming years will be how to get organizations and institutions working in global health – foundations, Ministries of Health, NGOs, development programs, health research centers, etc. – treating innovation as a way of working, not simply an input or an output.

The abstract/lead-in isn’t openly available online so I’m copying it here:

Companies throughout the world are seeking competitive advantage by leading through innovation, some — such as Apple, Toyota, Google, and Starbucks — with great success. Many countries – such as Singapore, China, Korea, and India — are investing in education systems that emphasize leading through innovation, some by investing specifically in design schools or programs, and others by embedding innovative thinking throughout the curriculum. Business, engineering, and design schools around the U.S. are expanding their efforts to teach students how to innovate, often through multi-disciplinary classes that give students a full experience of the innovation process. However, what does leading through innovation really mean? What does it mean to be a leader, and what does it mean to engage in innovation?

There is a vast literature on leadership covering a wide range of topics: the characteristics of a good leader, how leadership is best displayed in an organization, leadership and vision, authority, leadership styles, and so on. There is also a growing body of literature on innovation and its various facets, much of it focused by application of the innovation process. Hundreds of publications describe the process of innovation for products — both hardware and software — and a growing number of publications focus on innovation in services. Further, there are dozens of books on innovation in building and workplace design.

Here we examine a generic innovation process, grounded in models of how people learn, that can be applied across these sectors. It can be applied to the design and development of both hardware and software products, to the design of business models and services, to the design of organizations and how they work, and to the design of the buildings and spaces in which work takes place, or within which companies interact with their customers. The model has evolved through two streams of thought: design and learning.

This video, which seems to be unaffiliated to the authors, summarizes the article [correction – I just found out that Shealy did work with the authors on this video – Tues-24-Mar-2009 12:18PM PDT]:

 
[Innovation as a Learning Process from Roger H. Shealy on Vimeo]

Here are slides from Beckman and Barry’s presentation at the Inside Innovation 2007 Conference and the Google scholar view of who is citing this work.

[(Dis)claimer: Sara Beckman served on my dissertation committee and Michael Barry provided guidance on my applied research in Mongolia]

Why bad presentations happen to good causes

Cross-posted from Design Research for Global Health.

Giving talks is not one of my strong suits, but it seems to be a part of the job requirement.  Earlier this month, I had the opportunity (even though I’m no good, I do consider it an opportunity), to give a couple talks, one to the Interdisciplinary MPH Program at Berkeley and one to a group of undergraduate design students, also at Berkeley.  Despite the difference in focus, age, and experience of the two groups, the topic was roughly the same: How do we effectively use design thinking as an approach in public health?

The first session was so-so, and I suspect that the few people who were excited about it were probably excited in spite of the talk.  It started well, but about halfway through, something began to feel very wrong and that feeling didn’t go away until some time later that evening.  Afterwards, I received direct feedback from the instructor and from the students in the form of an evaluation.  I recommend this if it is ever presented as an option.  Like any “accident”, this one was a “confluence of factors”: lack of clarity and specificity, allowing the discussion to get sidetracked, poor posture, and a tone that conveyed a lack of excitement for the topic.

It’s one thing to get feedback like this, another to act on it.

The second session went much better, gauging by the student feedback, the comments from the instructor, and my own observations.  This in spite of a larger group (60 vs. 20) that would be harder to motivate (undergraduates with midterms vs. professionals working on applied problems in public health).  I chalk it all up to preparation and planning.  Certainly there are people that are capable of doing a great job without preparation – I just don’t think I’m one of those people.

Most of that preparation by the way was not on slides.  I did use slides, but only had five for an hour session and that still proved to be too many.  Most of the time that I spent on slides, I spent developing a single custom visual to convey precisely the information that was relevant to the students during this session (see image).  The rest of the preparation was spent understanding the audience needs by speaking to those running the class; developing a detailed plan for the hour, focusing on how to make the session a highly interactive learning experience; designing quality handouts to support the interactive exercise; and doing my necessary homework.  For this last one, I spent 20 minutes on the phone with a surgeon friend, since the session was built around a case study discussing surgical complications and design.

Three resources I found really useful:

1. Why Bad Presentations Happen to Good Causes, Andy Goodman, 2006. This commissioned report was developed to help NGOs with their presentations, but I think there is value here for anyone whose work involves presentations. It is evidence-based and provides practical guidance on session design, delivery, slides (PowerPoint), and logistics.  Most importantly, it is available as a free download. I was fortunate enough to pick up a used copy of the print edition for US$9 at my local bookstore, which was worth the investment for me because of the design of the physical book.  It’s out-of-print now and it looks like the online used copies are quite expensive – at least 3x what I paid – so I recommend the PDF.
2. Envisioning Information, Edward Tufte, 1990. I read this when I was writing my dissertation. Folks in design all know about Tufte, but I still recommend a periodic refresher.  This is the sort of book that will stay on my shelf.  Also potentially useful is The Visual Display of Quantitative Information. For those working in global health, don’t forget how important the display of information can be: (a) Bill Gates and the NYTimes, (b) Hans Rosling at TED.
3. Software for creating quality graphics.  The drawing tools built into typical office applications, though they have improved in recent years, are still limited in their capability and flexibility, especially if you’re looking at #2 above.  In the past 10 days, three people in my socio-professional network have solicited advice on such standalone tools, OmniGraffle (for Mac) and Visio (Windows): a graphic designer in New York, an energy research scientist in California, and a healthcare researcher in DC.  Both are great options.  I use OmniGraffle these days, though I used to use Visio a few years back.  If cost is an issue, there are open-source alternatives available, though I’m not at all familiar with them (e.g., the Pencil plug-in for Firefox).

One Rural Town’s Battle with Obesity

I heard this fascinating case study on indigenously driven innovation and how this rural community has come together to tackle obesity. Don’t read the story, listen to it. We need more stories like this from the local community level (see our previous post on the global obesity index).

Global Hunger Hearing and Rwanda’s MCH Week

I got a couple of requests to post two informative efforts. Note the Senate hearing tomorrow and the tie made to global food security. Second various agencies are linking up to administer 4 million anti-worm medication, that’s an impressive amount:

GLOBAL HUNGER HEARING
As a reminder, tomorrow, Tuesday, March 24th, the Senate Foreign Relations Committee will hold a hearing entitled “Alleviating Global Hunger: Challenges and Opportunities for U.S. Leadership” at 9:30 a.m. in room 419 of the Dirksen Senate Building (AGENDA). The committee has invited Dan Glickman, former secretary of agriculture, and Catherine Bertini, former executive director of the World Food Program to testify at the hearing, offering their insight as co-chairs of a recent Chicago Council on Global Affairs’ report entitled “Renewing American Leadership in the Fight Against Global Hunger and Poverty:  The Chicago Initiative on Global Agricultural Development.”

Congress has recently recognized the importance of this global food security (2009 Foreign Operations Appropriations bill). This legislation mandated that $75 million in Development Assistance funding be spent “to enhance global food security, including for local or regional purchase and distribution of food, in addition to other funds otherwise made available for such purposes and notwithstanding any other provision of law.”

RWANDA’S MOTHER AND CHILD HEALTH WEEK KICKS OFF MARCH 24

The Global Network for Neglected Tropical Diseases’ Control Program Teams with Rwandan Government and International Organizations to Deworm More Than 4 Million Children Nationwide, Covering Nearly Half of the Country’s Population

NTD Prevalence Rates Up to 95% Among Rwandan School-Children

Over the course of the week-long initiative, representatives will administer albendazole to a targeted population of 4 million children under five, school-aged children, and post-partum women, to treat for soil-transmitted helminthes (STHs). Additionally, in the high prevalence areas, praziquantel will be administered to an estimated 100,000 people for schistosomiasis infection. The goal of the campaign is to treat all pre and school-aged children nationwide – covering approximately one-half of Rwanda ’s population.  Vitamin A, immunizations, family planning services and health education messages will also be delivered throughout the country during the course of the campaign.

Why: Research has shown that eliminating the burden of NTDs could lift millions out of poverty worldwide by ensuring children stay in school to learn and prosper and improving maternal and child health. NTDs infect over 400 million school-aged children throughout the developing world. Treating their infections is the single most cost-effective way to boost school attendance. Controlling intestinal worms alone will help to avoid 16 million cases of mental retardation and 200 million years of lost primary schooling

When: Tuesday, March 24th – Friday March 27th

The Girl Who Silenced the UN

This video has been floating around recently, I thought it was worth sharing. This took place 16 years ago, I wonder where this girl is now? Hat tip Humanity in Focus.

CATER NYU Workshop on Technologies for Humanity (April 10)

I’ll be in New York attending the health portion of the following workshop. Please pass the word and if you are around and want to meet up send us an email (thdblog AT gmail).

“The CATER research group cordially invites you to attend the 2009 workshop on “Technologies for Development” which showcases our ongoing research efforts in the space of appropriate technologies that aid development in under-developed areas around the world.

Cost-Effective Appropriate Technologies for Emerging Regions (CATER) is a new multidisciplinary research initiative at NYU that focuses on developing appropriate, low-cost Information and Communication Technologies (ICT) for addressing pressing problems in developing regions. CATER is a joint initiative comprising faculty from Computer Science, the School of Medicine, the Wagner Graduate School of Public Service, NYU’s Economics Department, and NYU-Polytechnic.

This workshop will feature a combination of invited talks from accomplished researchers and short talks by student researchers within
CATER on their ongoing research efforts. The talks will cover four important areas:”

·         Technologies for improving access to communications in rural areas
·         Technologies for enhancing rural healthcare
·         Technologies for enhancing financial and commerce services
·         Technologies for enhancing rural education

FULL SCHEDULE

The End of the Era of Generosity? Global Health Amid Economic Crisis

If you only read one thing this week, the below article deserves your attention. I have excerpted only bits and pieces, the full piece is worth reading. Co-authored by Laurie Garrett, this is a much better, more cohesive and articulate encapsulation of the current economic crisis than what I wrote last week (if I only had 1/4 of the writing ability of Garrett!).

The End of the Era of Generosity? Global Health Amid Economic Crisis
Kammerle Schneider email and Laurie Garrett
Philosophy, Ethics, and Humanities in Medicine, Jan 2009
Global Health Program, Council on Foreign Relations

For too long, the international community has responded to global health and development challenges with emergency solutions that often reflect the donor’s priorities, rather than funding durable health systems that can withstand crises…The global health community must now objectively evaluate how we can most effectively respond to the crises of 2008 and take advantage of this moment of extraordinary attention for global health and translate it into long term, sustainable health improvements for all. Over the past eight years global health has taken center stage in an era of historic generosity as the wealthy world has committed substantial resources to tackle poverty and disease in developing countries…there has been a massive swell in the number of nonprofit organizations (NGOs), faith based groups, and private actors contributing to this boon.

Past is prelude
The emergence of HIV/AIDS fundamentally transformed the way in which the world engaged global health. It shook world leaders…It awoke the average citizen to gross disparities… The fight against HIV/AIDS rallied tremendous financial support for global health, while at the same time, moving investments in health from infrastructure: clinics, roads, sanitation, and personnel, to funding disease specific initiatives with emergency, short term targets, and often unsustainable results.

International institutions and governments heavily reliant on steady inflow of foreign donor funding are now frantically trying to resolve how to continue the operations of their health programs… Undoubtedly, the economic crisis will crimp humanitarian aid, and international efforts to fight disease and alleviate poverty.

The special challenge of HIV
Increased focus on the urgent management of specific diseases has weakened the ability of health systems to respond to crises. To respond to the AIDS epidemic, the share of global health aid devoted to HIV/AIDS more than doubled between 2000 and 2004 – reflecting the global response to an important need, yet, the share devoted to primary care dropped by almost half during the same time period...In many of the countries hardest hit by the pandemic, a large portion of their funding for AIDS medications come from outside donors. For example, in Mozambique, 98 percent of all funding for the country’s HIV/AIDS programs comes from outside donors…the nation’s extraordinary dependence on external support begs questions about the efforts’ sustainability, and country ownership and control… As we enter an economic downturn, the sustainability of emergency initiatives, such as PEPFAR, that are 100 percent dependent on a never ending supply of donor dollars, are called into question.

Moral hazard amid complexity
Instead of making things simpler and more efficient on the ground, in many cases, the rapid increase in funding and number of global health players has made the mechanisms for delivering aid even more complex. At the developing country level, hundreds of foreign entities are competing for the attention of local governments, civil society interest, and the desperately short supply of trained healthcare workers…

A moral path forward
Given the scale of the world’s healthcare workers deficit, no progress can be made in the creation of universal primary care systems if models continue to be doctor-based. Even if the world committed today to the most massive medical training exercise in history, the deficit would not be overcome for more than two generations. Only a substantial commitment to building genuinely viable health infrastructures centered on community based workforces, coupled with local profit incentive systems, and global scale supply and inventory management…The crises of 2008 have brought together committed government officials, UN agency leaders, NGOs, faith-based groups, and corporate actors to collectively think about new ways to break out of patterns of charitable giving and move towards real sustainable investments in health…A number of promising initiatives are beginning to emerge. In this time of financial catastrophe, the onus sits squarely on the shoulders of global health advocates living in the wealthy nations: push your governments and philanthropic institutions to not only maintain their technical and financial commitments to the poor nations of the world, but actually increase the scale of investment to reflect the rising costs of doing good in a troubled world. It is conceivable that 2008 will mark the beginning of the end of the Era of Generosity. But it is equally probable that the economic crisis will usher in a bold new era of investment in the public goods of poor and emerging market nations worldwide. Successful navigation of these turbulent waters will require a shift from the morality of “charity,” to that of “change”…

Join Us! Online Chat: OBA and Vouchers in Kenya and Uganda

On March 19th I will be participating in an online conversation about output-based aid hosted by PSP-One. Output-based aid (OBA) financially empowers patients to make choices about where they receive their healthcare and incentivizes providers to deliver high quality services. The management of OBA systems builds institutional capacity to provide cost-effective care to targeted populations. However, OBA is by no means a panacea to what ails health systems in low-income countries. Join in on the discussion to find out more! Once again it is March 19th:

9:30 am Eastern (United States)
1:30 pm (13:30) Greenwich Mean Time
2:30 pm West Africa Time Zone
3:30 pm Central Africa Time Zone
4:30 pm East Africa Time Zone

If you would like to receive details about the chat or would like to suggest questions for discussion, please email the organizers at: n4a@abtassoc.com. You will need to register beforehand on the Network for Africa. Registration takes 30 seconds at the following link: http://www.conferences.icohere.com/vouchers

Video Games for Health: Tetris Therapy for Trauma?

Very early fascinating research, which will hopefully be developed further. This is not a top 10 list you want to be on, but considering the global burden of disease projections for 2020 include depression (#3) and war (#8) in the top 10 contributors to disability, greater understanding of the mind and brain function is desperately needed. Additionally, considering mental health is such a complex and difficult issue, it’s great to see potential innovation in this area. Source: BBC News

(sorry I cannot find the blog I read this on, send me a note and I’ll add your link in):

Previous related posts:
Where are the games (to educate on HIV/AIDS risks)? Link
Donate computation time …on your PS3? Link
Free Rice Word Game. Link

Mobile Phone & Development Link Drop

Mobile Phone & Global Development Link Drop

• New Mobile Health Newsletter launches, full story, newsletter
• MIT Course: mobile technologies for social change, link
• Mobile Phones fighting Cholera, link
• So You Want to Quit Smoking: Have You Tried a Mobile Phone? link
• The Cellphone That Could Change the World, SE Change blog
  
• Phones for Health: Great Idea But Where’s the Evidence? Center for Global Development
• UC Berkeley Human Rights Center Mobile Challenge, [deadline March 20] link
• Foundations announce Mobile Health, Banking Initiatives, we have blogged about the UN-Vodafone-Rockefeller alliance before, link
  • For a full list of all projects in the mHealth for Development alliance see 3G Doctor, link
    
• New article on the bandwidth threshold needed to diagnose stroke remotely (telemedicine), link
• Mobile Phone Quick Hits Around Africa, link
• Remittance estimate via mobile phones cut by 50%, link
• International Women’s Day: Women in Mobile and Mobile for Women, MobileActive
• iPhone Apps for Nonprofits, HaveFunDoGood (hat tip ckreutz)
• Bullet Point on the Challenges with Mobiles Phones for Human Development, link
• Are Hospital Mobile Phones Dialing Up Superbugs?, link (hat tip ckreutz)
  

Previous link drops:
Mobile Phones and Global Health Link Drop
Mobile Phones and International Health Links Part II
Mobile Phones & Global Health III: Ultrasound, Imaging & ECG to Go! Link

How will the Economic Crisis Change Global Health?

I feel compelled to throw out some slightly disjointed thoughts about the global economic meltdown, especially since the discussion with respect to global health is just beginning. One of the other voices discussing this is Lucy Bernholz, she has a series of fantastic posts on the impact of this downturn on philanthropy and I link to some of her posts below which is must reading.

Backdrop
Global wealth has been destroyed to the tune of 50%; Microsoft and NPR are laying off people for the first time in a long time; Google, Disney, WSJ and the NY Times are laying off and NYC Mayor Bloomberg is suggesting he might have to cut 20,000 city workers; the nation of Iceland has declared bankruptcy and tens of millions have been laid off in China where they are facing a gargantuan commercial real estate bust in Beijing coupled with dwindling job prospects. And if you think the US is in bad shape, Europe is facing a whole lot more pain. The point is that the economic meltdown is having an impact far beyond the usual suspects; this economic crisis is wide and deep and no one knows how long it will last. There is no question that we are entering a fundamentally different world on many levels – dialogue is needed now on what can be done and how this will reshape giving, accountability, fiscal responsibility, priority setting, and of course what counts at the end of the day – health and poverty. The global health community should have discussions on how we can all be more accountable and how we are using funding. We need to be aware of the coming impact on global health funding and beyond.

Pillars of the Global Health Complex
Capital flows and financial support for global health comes from a spectrum of actors (governments, foundations, NGOs, private donations, and many others – see our previous post here on R&D funding flows). These agents are the threads that provide patchwork netting for funding and capital injections through a range of channels, whether that is via medical donations, immunization campaigns, pilot projects, research, education, training programs or remittances. Make no mistake, all of these channels have been or will be impacted. “CGD fellow David Roodman has shown that after each previous financial crisis in a donor country since 1970, the country’s aid declined…“Aid for health is no exception.” But don’t expect governments to announce cuts in foreign assistance; the contraction will be invisible, with disbursements quietly dragged out and a contracting seeing a slowdown…” (Source: Global Health Magazine). With regards to US based foundations, a March 2009 research report found that “of the largest 100 foundations ranked by total giving, only two with announced intentions to grow their funding in 2009–the Gates Foundation and the MacArthur Foundation…six of the largest 100 foundations have so far announced plans to reduce their giving in 2009.” (Source Foundation Center).

I have blogged previously on the University based global health bubble (?) and I would like to see some hard numbers on global health jobs placement, impact on these new programs, whether the programs are halting building construction and staff hiring (as many universities are). Endowments at top universities in the US have taken a beating, so much so that some are considering selling prized art collections. Even one of the world’s richest business schools, with a $1 billion endowment, is cutting back. What will be the impact on schools of public health or all the newly opened schools of global health? Will all this promised global health funding actually materialize? Will students rethink spending tens of thousands on graduate programs in global and public health? Will there be scholarship funding for international fellowships and the development of new ideas and products for global health populations? The university system is of course just one corner of the global health complex but an important one – one that is a foundation for research into neglected diseases or developing human resource capacity in developing countries through education and exchange programs. Steven Davidoff, a professor at the Univ. of Connecticut, has a must read breakdown of why schools like Harvard are cutting back and are facing a worsening economic picture in 2010 and beyond (NY Times, 3/3/09, Harvard, Private Equity and the Education Bubble). In short, below are five obvious trends to watch, by no means is this a comprehensive list.

Impact on pillars of the global health/development sector:
1. Foundations/Philanthropy – many will suffer due to unprecedented (poor) investment returns and reduced donations.
2. Corporate Sector – reduced giving and less leverage to engage in partnerships or development of new products (drugs, etc).
3. Government Aid – some countries rely on massive amounts of aid for even basic things like immunization programs.
4. Remittances – with global job losses this will continue to erode.
5. Universities – endowments have been drastically reduced, classes cut and hiring freezes implemented.

Reorientation to Infrastructure Spending
This crisis is an opportunity to recognize bigger picture global health issues and perhaps with the relatively recent shift in thinking and the push to reshape the global health agenda to emphasize health system infrastructure and workforce development, there may be more interest in funding long range macro level projects (as with some of items included in the US stimulus package for infrastructure). Even small amounts of money for infrastructure can have large impacts, like building bridges to reduce malaria, for example.

And let’s not forget, that one of the best things Cuba did for population health after its economy collapsed was to invest in its health system. Obama has called for massive infrastructure spending and I am wondering if poor economies will be able to do the same. There is some hope for this because low income nations know they must continue to build roads, bridges, and highways in order to continue “development”. Hopefully this will largely be positive for global health efforts (especially if some of that includes public health and medical infrastructure). Perhaps this economic meltdown will be an opportunity to take stock and shift some funding towards long term capacity building.

Reason for Hope
On the positive side, the Gates Foundation is actually increasing their payout, not decreasing it by $300 million as we first discussed a few months ago. Additionally the new center of gravity for global health (Seattle) is going to be adding 2400 global health jobs over the next few years. The World Bank is going to double their health loans and as of now very few ministries of health are reporting they will cut back on health spending (although I am not sure I believe this entirely). There is also some evidence that giving actually rose through the depression, perhaps because people still give to causes that are part of their core belief sets (as opposed to nixing discretionary spending like holidays or eating out).

Conclusion
I believe the pain is going to be severe (with 2010 being worse) and we are already seeing major cracks in the social fabric in various locations. The velocity and violence of this global economic downturn will have serious widespread impacts. Over the past decade the Gates Foundation along with others have brought unprecedented financial resources that helped fuel a boom in certain sectors and innovation in the development of appropriate technology, social ventures and the growth of areas like microfinance, all of which generated tremendous energy and buzz. We have now entered a new era with a drastically different macroeconomic backdrop, yet we are equipped with these new tools (think Kiva) developed during what might be have been a golden age of global health funding/philanthropy in comparison to what might happen over the next decade. A discussion is needed on how to prepare for the worst, how to fund and spend more wisely, how to allocate resources, and how to spot vulnerabilities (e.g. what areas or diseases are especially sensitive to funding flows). I welcome your thoughts and discussion on this.

Additional Reading
1.  Some nonprofits can’t touch their money, link
2.  Global Financial Crisis, Global Issues
3.  How to Get Funding for Your Global Health Activity, Change.GlobalHealth.Org (my new favorite blog)
4.  Economic crisis fueling social unrest, link
5.  Aid Agency Budgets Go Bye-Bye, Change.org
6.  Global Health tv: Global Economic Downturn, video
7.  Philanthropy in a Global Economic Crisis, link
8.  The Economic Crisis: A Generation of Reproductive Health “Horror Stories”, RH Reality Check
9.  Migration in light of the economic crisis, NextBillion
10. Hard Times for Health Charities, link
11. WHO on the crisis, WHO
12. The global financial crisis: an acute threat to health, Lancet
13. No relief: Red Cross hit with tough times, ChemistsWithoutBorders
14. World Bank offers dire forecast for world economy, link