Making Change Making More Change Bit by Bit

One pathway of exploration that this blog has taken me is global health delivery. It was initially an interest in how business management systems could improve the efficiencies of social beneficial delivery systems such as global health. It has been a fairly frequent topic of contemplation both here and at Milestones for a New Millennium. Over time I have become interested in participating, first by blogging about the Millennium Development Goals, participating in collective actions such as BlogAction Day Against Poverty and BloggersUnite for Refugees and World AIDs Day, and now by participating with Change.org and creating a fundraising page for FightAIDSTuberculosisMalaria. There is still the internal conflict of having so much to do with the "Real World/Day Job" and not relegating one's self to mere slacktivist mode. Below is the more or less official pitch.

Hello,

I am raising money for FightAIDSTuberculosisMalaria.

Please take a moment to visit my online fundraising page and make a donation. It's really easy - you can donate by credit card and receive an immediate tax receipt for your donation.

Thanks and best wishes,
Brian

Here's my page:

http://www.change.org/myfundraising/FightAIDSTuberculosisMalaria

Now LA Times Recognizes That Africa's Anti-malaria Campaign Is Showing Results

Africa's anti-malaria campaign showing results
--------------------

Infection rates drop as nations take action against the disease. In Tanzania, Bush announces a venture to provide enough mosquito nets to protect every child between the ages of 1 and 5.

By James Gerstenzang
Los Angeles Times Staff Writer February 19 2008

BWEFUM, ZANZIBAR;-- Like clockwork, particularly on Mondays after his office had been closed for the weekend, the patients would line the concrete benches outside Mininyi Othman's tiny health center 10 miles from the nearest paved road.

It is good to read in the Los Angeles Times that malaria is finally diminishing its deadly impact in Africa and hearing that our President is committed to providing "mosquito nets to protect every child between the ages of 1 and 5", is inspiring, but the article does very little to tell us how we got to this stage. Not to be overly skeptical, but are we to believe that George W. Bush is a significant savior of Africa?

The Los Angeles Times article "Unintended Victims of Gates Foundation", which was the primary focus of the Best Intentions Unintended Consequences post, was the second most popular item link of this weblog so far. What are the key health dangers for children?, has been the most popular. The previous LA Times article provided an indepth analysis of failure. An equally indepth analysis of success would be appreciated.

Helping To Pave Over The Health Equity Gap

As a quick look would likely show, this weblog has a high regard for the work that is being done at MIT. I only recently learned of their motto and its meaning though. This weblog has long held the view that social-entrepreneurs and activists have a good deal to learn from business and private-entrepreneurs. MIT is taking a lead in making that a reality. They are now applying that effort to global health care.

Mens et Manus - Home (Annotated with diigo)

Welcome to mens et manus

mind and hands describes the Massachusetts Institute of Technology approach to learning by doing. Part of a rich tradition of real-world engagement at MIT, mens et manus may be more important than ever as an approach to transforming the world by combining rigor, innovation, action and learning. Start here to join some exciting projects emerging at MIT, and to nurture new ones.

Their current focus: global health delivery (learn more)

Dean's Innovative Leader Series - MIT Sloan School of Management Corporate Connection

Achieving Health Equity Requires Bridging The Delivery Gap

This weblog featured Paul Farmer in the Global Health Equity From MIT World post. This current post features Jim Yong Kim's lecture on Bridging the Delivery Gap to Global Health from MIT World Annotated

Jim Kim - DSMHI Annotated

Jim Yong Kim, MD, PhD holds appointments as François Xavier Bagnoud Professor of Health and Human Rights at the Harvard School of Public Health and Professor of Medicine and Social Medicine at Harvard Medical School. He is chief of the Division of Social Medicine and Health Inequalities at Brigham and Women’s Hospital, a major Harvard teaching hospital; director of the François Xavier Bagnoud Center for Health and Human Rights; and chair of the Department of Social Medicine at Harvard Medical School.

Some of his many writings include:

• Dying for Growth: Global inequality and the health of the poor at Amazon.com
• Beyond Bellagio: addressing the challenge of sustainable child health in developing countries

What I find even more fascinating is that this endeavor that MIT is undertaken combines business management practices from the Sloan School of Management with medical social activism. More on that here.

Global Health Equity From MIT World

Paul Farmer speaks about public entities being enabled to confer rights while at the same time speaking about the need for business practices like supply chains to create comprehensive healthcare and medical delivery systems for the world's poor. This is a concerted effort to address the challenges raised by Best Intentions Unintended Consequences

MIT World » : Global Health Equity

• ABOUT THE LECTURE:
  Don't foolishly advise Paul Farmer that his bold projects can't succeed. For the past 20 years, Farmer's been toppling orthodoxies concerning the delivery of health care to people of developing nations, and to our country's inner city poor. In a talk full of insights and anecdotes, Farmer brings his audience up to date on his groundbreaking work and methods.
• Farmer has written extensively about health and human rights, and about the role of social inequalities in the distribution and outcome of infectious diseases. He is the author of Pathologies of Power (University of California Press, 2003); Infections and Inequalities (University of California Press, 1998); The Uses of Haiti (Common Courage Press, 1994); and AIDS and Accusation (University of California Press, 1992). In addition, he is co-editor of Women, Poverty, and AIDS, (Common Courage Press, 1996) and of The Global Impact of Drug-Resistant Tuberculosis (Harvard Medical School and Open Society Institute, 1999).
• Farmer is the recipient of the Duke University Humanitarian Award, the Margaret Mead Award from the American Anthropological Association, the American Medical Association's Outstanding International Physician (Nathan Davis) Award, and the Heinz Humanitarian Award. In 1993, he was awarded a John D. and Catherine T. MacArthur Foundation "genius award" in recognition of his work.

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Best Intentions Unintended Consequences

The Los Angeles Times had an article that called into question whether the Gates Foundation was having a net positive impact on healthcare in Africa.

Unintended victims of Gates Foundation generosity - Los Angeles Times

The Gates Foundation, endowed by the personal fortunes of the Microsoft Corp. chairman, his wife and Berkshire Hathaway Inc. Chairman Warren E. Buffett, has given $650 million to the Global Fund. But the oxygen valve fell outside the priorities of the fund's grants to Lesotho. Every day, nurses say, one or two babies at the hospital die as Mankuebe did -- bypassed in a place where AIDS overshadows other concerns.

Mixed effects

The Gates Foundation has targeted AIDS, TB and malaria because of their devastating health and economic effects in sub-Saharan Africa. But a Times investigation has found that programs the foundation has funded, including those of the Global Fund and the GAVI Alliance, which finances vaccines, have had mixed influences on key measures of societal health:

* By pouring most contributions into the fight against such high-profile killers as AIDS, Gates grantees have increased the demand for specially trained, higher-paid clinicians, diverting staff from basic care. The resulting staff shortages have abandoned many children of AIDS survivors to more common killers: birth sepsis, diarrhea and asphyxia.

The article provided the impetus to go back and look again at the Vivian Hoffman paper. The paper raised questions about the real impact of social-entrepreneurs, such as the Acumen Fund, had on helping the poor. The post links to a Marginal Revolution post and from there to a New York Times article that questioned whether direct distribution of the nets of the nets was best or were social entrepreneurial programs. Similar questions of effectiveness arose from the the Fast Company article regarding Grameen Phone Company.

The Bill & Melinda Gates Foundation supported Global Fund seems to see this either as a public relations problem, if we want to be cynical, or as a problem of self-definition, they can't be all things to all people or perhaps something in the middle. There does seem to be some truth to the later proposition that they can't be all things to all people but it is arguably a matter of balance. Because it's Bill Gates cynicism seems far easier than it might otherwise.

The LA Times did do a follow up report on the Global Funds dispute with their article. The Global Fund not only has their own piece criticizing the LA Times article, they also have a letter from the National Aids Control Commission of Rwanda.

I have an issue with attempts to find fault to create a story, which the LA Times article and the Fast Company article seem to lean too much towards in my view. The New York Times article and Vivian Hoffman paper though seemed different. My second reading of the Hoffman paper did provide a better understanding and impressed upon me again the uncomfortable perspective that going in with a decidedly social-entrepreneurial slant as the best intentions to provide assistance without fully understanding the culture could have unintended but detrimental consequences. What I don't know is what course of action, if any, have been taken by the social-entrepreneurs to address these issues. This is not, of course, the same as arguing that traditional government centered policies are automatically better.

Within the LA Times article they make a statement which is apparently in conflict with what I got from the Hoffman article.

According to UNICEF, malaria kills relatively few children. Birth-related problems, pneumonia and diarrhea are the top causes of child mortality. All are treatable but occur at high rates, in part because resources are concentrated on AIDS, TB and malaria, The Times reported.

This is in contrast to the Vivian Hoffman paper,

Malaria kills over one million people annually, 90 percent of them children under the age of five (World Health Organization, 2004).

What I found at the WHO website, which provided more insight, is that the key health dangers for children are:

• From one month to five years of age, the main causes of death are pneumonia, diarrhoea, malaria, measles and HIV. Malnutrition contributes to more than half of deaths.

• Pneumonia is the prime cause of death in children under five years of age. Nearly three-quarters of all cases occur in just 15 countries. Addressing the major risk factors – including malnutrition and air pollution – is essential to preventing pneumonia, as is vaccination. Antibiotics and oxygen are vital tools for effectively managing the illness.

• Diarrhoeal diseases are a leading cause of sickness and death among children in developing countries. Treatment with Oral Rehydration Salts (ORS) combined with zinc supplements is safe, cost-effective, and saves lives.

• One African child dies every 30 seconds from malaria. Insecticide-treated nets prevent transmission and increase child survival.

• Over 90% of children with HIV are infected through mother-to-child transmission, which can be prevented with antiretrovirals, as well as safer delivery and feeding practices.

• About 20 million children under five worldwide are severely malnourished, which leaves them more vulnerable to illness and early death.

  About two-thirds of child deaths are preventable through practical, low-cost interventions. WHO is improving child health by helping countries to deliver integrated, effective care in a continuum - starting with a healthy pregnancy for the mother, through birth and care up to five years of age. Investing in strong health systems is key to delivering this preventive care.

This does argue for taking a more comprehensive approach to children's healthcare in developing countries but it does not argue that it is being caused by “in part because resources are concentrated on AIDS, TB and malaria, The Times reported.” Amy Smith of MIT, who is recognized for finding low tech solutions for global problems informed us that smoke from indoor cooking was the number one killer of young children.

Meanwhile, Acumen Fund has been recognized by Fast Company as one of its top 45 Social Capitalists: Acumen Fund.

The increasing gap between rich and poor is one of the greatest challenges of our generation. Half the world lives on less than three dollars a day while 250 individuals hold more wealth than the bottom two billion. Creating a sustainable world means reducing that gap.

Aid alone will not end poverty. Traditional charity often meets immediate needs but is not designed to enable people to solve problems over the long term. Poor people seek dignity, not dependence.

Acumen Fund identifies and supports enterprises that provide health, water, housing and energy to the poor. We bring capital, knowledge and talent to accelerate markets for the poor, having seen their power as customers who are willing to pay for affordable, quality services that can change their lives. We have seen this working with our portfolio enterprise in South Asia and Eastern Africa.

While Iqbal Quadir has become the head of the Legatum Center for Development and Entrepreneurship at MIT.

Acumen's founder Jacqueline Novogratz, Iqbal Quadir and others working in this field have also been topics of contemplation in this weblog and have been included within the Pearls of Paradigm Processing Social and Economic Paradigms.

No final conclusion, just an ever increasing realization of the complexity of the issues. As Emily Oster, the University of Chicago economist, pointed out we need to look for root causes in not only understanding poverty and poor health care -- but also other issues such as the price of coffee, and the routes of long-haul truckers.

“In short, there is a lot we don't know; and our assumptions about what we do know may keep us from finding the best way to stop the disease.”

Breaking Through The Paradigms With Science

Human Genetic Variation: 2007 Breakthrough of the Year video.

With the December issue of Science Magazine - the science oriented interest of this weblog hit the jackpot.

According to an article in Science Magazine Human Genetic Variation:is the 2007 Breakthrough of the Year.

On 21 December 2007, Science unveiled its Breakthrough of the Year for 2007 -- the realization that DNA differs from person to person much more than researchers had suspected. That conceptual advance, driven by results from several fields, may transform medicine, but could also threaten personal privacy.

In this video presentation, featuring Science news writer Liz Pennisi, Francis Collins of the National Institutes of Health, and David Altshuler of the Harvard/MIT Broad Institute, we offer a look at the past year's discoveries in human genetic variation and their implications.

For a basic understanding of modern biology, a good place to start is the MIT Introduction to Biology course co-taught by Professor Eric Lander, one of the founders of the Harvard/MIT Broad Institute.

Another past post of possible interest is This Software builds its Own Hardware.

Interesting Papers, Articles and Web Sites from Science Magazine
Human Genetic Variation: An NIH Curriculum Supplement
A creative, inquiry-based instruction program, designed to promote active learning and stimulate student interest in medical topics.

International HapMap Project
A multi-country effort to identify and catalog genetic similarities and differences in human beings.

Database of Genotype and Phenotype (dbGaP)
Developed to archive and distribute the results of studies that have investigated the interaction of genotype and phenotype, including genome-wide association studies, medical sequencing, and molecular diagnostic assays.

Genetic Association Information Network (GAIN)
A public-private partnership that aims to understand the genetic factors influencing risk for complex diseases.

ENCODE (Encyclopedia of DNA Elements)
Project launched by the National Human Genome Research Institute (NHGRI) that aims to identify all functional elements in the human genome sequence.

SNPs: A Science Primer
An introduction to single nucleotide polymorphisms, provided by the National Center for Biotechnology Information.

SNPedia
A web site for sharing information about the effects of DNA variations on traits and disease.

The Human Genome: Your Genes, Your Health, Your Future
A comprehensive resource on the human genome, its role in health and medicine, and the broader social impact of unravelling its mysteries; produced by the Wellcome Trust.

A Question of Nets Malaria and Social Aid 2

My latest post on the malaria net issue on Marginal Revolution received a response from Greg Laden who has an interesting scientifically based blog Evolution not just a theory any more. Gregg is, according to his blog, an independent scholar affiliated with the University of Minnesota (Graduate faculty of Quaternary Paleoecology, Anthropology, and some other departments, occasional instructor, and administrator). He has the credentials and is doing something that this weblog sees as very worthwhile - utilizing other disciplines such as anthropology to get new perspectives by disciplines such as economics on current world challenges. However, that works both ways, anthropology could use some new perspectives from economics. While he does provide food for thought, I do have disagreements or at least alternative viewpoints from his line of thinking. My response follows.

Greg,

First off thanks for the response. Also checked out your blog and was impressed. You would seem to be working at a technical level a number of levels deeper than my college anthropology class. My own view is that is is very beneficial for us to have those with technical knowledge in other fields to provide input to the discussion in other realms. Second you may be being too cynical but perhaps not that skeptical. A few points for consideration - my own included with the caveat that I might be being too optimistic. I would agree with your assessment if we limit the scope of the analysis to one large governmental bureaucratic institution interacting with another. As you point out, one criticism often laid upon these efforts is that this aid helps corrupt governments and little gets to the people who need it. Here is another source of information which addresses both your point that the foreign aid a country receives lands in the pockets of corrupt officials. and the position I wish to put forward . http://mitworld.mit.edu/video/395/ (I can't seem to make links in these posts perhaps because I am using a freebie blogger) This is where I am perhaps being too optimistic but arguably this does not apply to organizations like Acumen Fund which emphasizes sustainable bottom-up solutions over traditional top-down aid. If the nets are actually made in Africa there is less need to my mind for "parental" oversight by outside agencies. I fully agree with you that one of the great fallacies of the "market" distribution method is the assumption that a good will not generate a price unless a government official or economist puts a price on it. There is, however, still an allocation of resources in terms of cost and a value. I am not arguing that the recipients should pay either the cost or any profit value but a system of sustainable distribution should recognize these factors. This approach does more than take a band-aid (albeit a really big and important band-aid) approach helping the sick and poor become just poor. I do have to admit though that this approach does arguably have its limitations in being able to achieve "market penetration" to the degree required because the enterprise can only grow or produce so fast which may not be fast enough for the health need.. Assuming the mind set of a "change agent" with the best of intentions, one needs to manufacture the nets, if not in the country of need then transport the nets, and distribute the nets. I can use a lump sum charity donation in the form of foreign aid but then you have the issue of the bureaucracy tied to the money. Golden Rule - He who has the gold makes the rules. Even if I use your distribution system of showing up in Kinshasa with a barge full of mosquito nets, left unguarded for a month, one still has to consider the first two steps. You don't really get to do "regardless of how they get there". Furthermore, I have to wonder if there wouldn't be the equivalent of the mosquito net scalper arising out of all of this. There is no perfect system and much (most) of what goes on could be a hell of a lot better but hopefully things can get better through new technology and new thinking. Brian

A Question of Nets Malaria and Social Aid

Marginal Revolution had a post regarding the economics of malaria net distribution which is based upon a New York Times article Distribution of Nets Splits Malaria Fighters. The article is not as "full" a review as is claimed in the post as it does a meager job in looking at the other side and it is hard to evaluate the unilateral positions taken. One of the claims made is that

"There has been a paradigm shift," Dr. Olumese said. "We need to use the momentum we have right now." But is that actually the case or is it business as usual with the same old paradigms.

The immediacy of the issue would argue for direct action without complications of entrepreneurial marketing and distribution but is it that simple or is there a place for the social marketing approach and the goal of empowerment? Providing another perspective is Jacqueline Novogratz who has implemented on the ground solutions. The first video is from 2005, the second is from 2007. The first video is misnamed, it goes beyond Africa. The issue of nets is covered more fully under confluence of health and enterprise in the second video.
TED Talks Jacqueline Novogratz: Investing in Africa's own solutions
TED Talks Jacqueline Novogratz: Tackling poverty with "patient capital"