An application of survival analysis to the Hunger Games (seriously)

I just finished what is quite possibly the nerdiest thing I've ever written:  "Hunger Games survival analysis." I manage to pull in articles from Matt Yglesias and Erik Kain and discuss tesserae inflation, Prospect Theory, demographics, research by Acemoglu and Robinson and by Michael Clemens, game theory, coordination failures, arguments for open data, and of course the namesake survival analysis. Complete with Kaplan-Meier survival estimator graphs and all:

I posted it as a page rather than a blog post to make some of the formatting easier, so please click through to read the real thing.

Before you get all excited about male birth control

When you're a public health grad student and something related to health hits the news, your friends make sure you see it. Since there's a lot of bad science writing on the internet this can be rather frustrating. In the last few hours I've seen several people post this  to Facebook, and another emailed me with the subject line "Woh" and asked if this was too good to be true.... So what's the story? Techcitement has a breathless article titled "The Best Birth Control In The World Is For Men" by Jon Clinkenbeard, which he followed up with "Could This Male Contraceptive Pill Make a Vas Deferens in the Fight Against HIV?" The first article starts with this hook:

If I were going to describe the perfect contraceptive, it would go something like this: no babies, no latex, no daily pill to remember, no hormones to interfere with mood or sex drive, no negative health effects whatsoever, and 100 percent effectiveness. The funny thing is, something like that currently exists.

Clinkenbeard is describing RISUG, or "Reversible inhibition of sperm under guidance." Wikipedia explains:

RISUG is similar to vasectomy in that a local anesthetic is administered, an incision is made in the scrotum, and the vas deferens is tugged out with a small pair of forceps. Rather than being cut and cauterized, as it is in a vasectomy, the vas deferens is injected with [a] polymer gel and pushed back into the scrotum.

Sounds awesome? Why don't we have it already? Clinkenbeard continues:

The trouble is, most people don’t even know this exists. And if men only need one super-cheap shot every 10 years or more, that’s not something that gets big pharmaceutical companies all fired up, because they’ll make zero money on it (even if it might have the side benefit of, you know, destroying HIV).

Before you go injecting something in your scrotum... not so fast! Yes, in one sense it exists. But on the other hand we don't really know how well it works, and we don't really know how safe it is. Clinkenbeard makes it sound like it's a done deal, and claiming that Big Pharma is standing between you and the cure for babies (not to mention HIV!) certainly helped the article go viral. He then links to a bunch or articles and a few petitions.

While pharmaceutical companies do all sorts of things to manipulate data (start here if you don't believe that), I think they could actually make TONS of money on this if it worked. The price of medicines isn't usually based on how much they cost to manufacture but on how much they can be sold for, and I think there's clearly a market for male contraception: just think how much men would pay for the insurance to both avoid pregnancy and not have to use condoms. A drug company could conceivably make a lot of money off this product by getting it to market first.

Guha's initial studies were very small. A Phase II clinical trial published by Guha et al in 1997 featured a grand total of 12 men (PDF). (It also contains this humorous understatement: "Objective data on posttreatment frequency of intercourse could not be obtained.") In another study 20 men received an injection, but one man's partner still got pregnant.

Before a drug can (or should) go to market, it needs to be tested for both efficacy and safety, and everything needs to be done up to certain standards. Guha's original work wasn't. From a Wired article on RISUG by Bill Gifford, published this time last year:

In its report, the WHO team agreed that the concept of RISUG was intriguing. But they found fault with the homegrown production methods: Guha and his staff made the concoction themselves in his lab, and the WHO delegation found his facilities wanting by modern pharmaceutical manufacturing standards. Furthermore, they found that Guha’s studies did not meet “international regulatory requirements” for new drug approval—certain data was missing. The final recommendation: WHO should pass on RISUG.

These barriers can be overcome, if the researchers can get the investment necessary to make high quality product and run clinical trials. The Wired article describes how they've made progress and are now running clinical trials in India -- but the results are still a few years out. In the same article we get this:

"Pharmaceutical companies are not interested in one-offs," Weiss says. "They’re interested in things they can sell repeatedly, like the birth control pill or Viagra."

But that's not as true as it used to be. These arguments used to explain why pharmaceutical companies didn't invest in developing vaccines, but then they realized they could charge obscene amounts for individual doses -- orders of magnitude higher than what they charged before. They've managed these high prices because 1) there are always new cohorts of kids needing the vaccine (as there would be with men needing RISUG) and 2) because the health benefits are so large that even at the higher prices the vaccines are cost effective.

So are pharma companies just disinterested in male contraception? No. For quick and dirty evidence check ClinicalTrials.gov, where US clinical trials must be registered. I find 436 studies on contraception, of which 84 are specifically about male contraception. There's a disparity there, but it's explained in part by the fact that many of the non-male contraception studies are about delivery methods (like this one involving text message reminders) and you can't even start do this sort of research on male birth control before we have effective methods. Maybe they're under-investing a bit -- drug R&D is risky, as firms spend an average of $1.3 billion on research for every one drug  brought to market -- but it's not being ignored.

In closing, that Wired article from last year has some of the same breathless new-techthusiasm as the new Techcitement piece, but it's a lot better at explaining where things stand today. Clinical trials in India are ongoing, but it will be another year or so before we hear any results. If those are considered high quality and they're successful, it might spur the drug behemoths to up the massive amounts required for clinical trials in the US.

Generally, getting your science news from the coauthor of "The Pirate Treasure of the Himalaya" does't seem like the best idea. Drugs and treatments fail at every stage of the clinical trials pipeline, and that's a good thing because it means consumers will be less likely to spend money on ineffective or unsafe drugs. If everything works out with RISUG, it could be an incredible success story and a great public health tool. There might well be hope on the horizon, but contrary to Clinkenbeard's assertions we don't yet know very well if this works, and we don't yet know if it's safe. For that, we need good ole clinical trials, not petitions.

Up to speed: microfoundations

[Admin note: this is the first of a new series of "Up to speed" posts which will draw together information on a subject that's either new to me or has been getting a lot of play lately in the press or in some corner of the blogosphere. The idea here is that folks who are experts on this particular subject might not find anything new; I'm synthesizing things for those who want to get up to speed.]

Microfoundations (Wikipedia) are quite important in modern macroeconomics. Modern macroeconomics really started with Keynes. His landmark General Theory of Employment, Interest and Money (published in 1936) set the stage for pretty much everything that has come since. Basically everything that came before Keynes couldn't explain the Great Depression -- or worse yet how the world might get out of it -- and Keynes' theories (rightly or wrongly) became popular because they addressed that central failing.

One major criticism was that modern macroeconomic models like Keynes' were top-down, only looking at aggregate totals of measures like output and investment. That may not seem too bad, but when you tried to break things down to the underlying individual behaviors that would add up to those aggregates, wacky stuff happens. At that point microeconomic models were much better fleshed out, and the micro models all started with individual rational actors maximizing their utility, assumptions that macroeconomists just couldn't get from breaking down their aggregate models.

The most influential criticism came from Robert Lucas, in what became known as the Lucas Critique (here's a PDF of his 1976 paper). Lucas basically argued that aggregate models weren't that helpful because they were only looking at surface-level parameters without understanding the underlying mechanisms. If something -- like the policy environment -- changes drastically then the old relationships that were observed in the aggregate data may no longer apply. An example from Wikipedia:

One important application of the critique is its implication that the historical negative correlation between inflation and unemployment, known as the Phillips Curve, could break down if the monetary authorities attempted to exploit it. Permanently raising inflation in hopes that this would permanently lower unemployment would eventually cause firms' inflation forecasts to rise, altering their employment decisions.

Economists responded by developing "micro-founded" macroeconomic models, ones that built up from the sum of microeconomic models. The most commonly used of these models is called, awkwardly, dynamic stochastic general equilibirum (DGSE). Much of my study time this semester involves learning the math behind this. What's the next step forward from DGSE? Are these models better than the old Keynesian models? How do we even define "better"? These are all hot topics in macro at the moment. There's been a recent spat in the economics blogosphere that illustrates this -- what follows are a few highlights.

Back in 2009 Paul Krugman (NYT columnist, Nobel winner, and Woodrow Wilson School professor) wrote an article titled "How Did Economists Get It So Wrong?" that included this paragraph:

As I see it, the economics profession went astray because economists, as a group, mistook beauty, clad in impressive-looking mathematics, for truth. Until the Great Depression, most economists clung to a vision of capitalism as a perfect or nearly perfect system. That vision wasn’t sustainable in the face of mass unemployment, but as memories of the Depression faded, economists fell back in love with the old, idealized vision of an economy in which rational individuals interact in perfect markets, this time gussied up with fancy equations. The renewed romance with the idealized market was, to be sure, partly a response to shifting political winds, partly a response to financial incentives. But while sabbaticals at the Hoover Institution and job opportunities on Wall Street are nothing to sneeze at, the central cause of the profession’s failure was the desire for an all-encompassing, intellectually elegant approach that also gave economists a chance to show off their mathematical prowess.

Last month Stephen Williamson wrote this:

[Because of the financial crisis] There was now a convenient excuse to wage war, but in this case a war on mainstream macroeconomics. But how can this make any sense? The George W era produced a political epiphany for Krugman, but how did that ever translate into a war on macroeconomists? You're right, it does not make any sense. The tools of modern macroeconomics are no more the tools of right-wingers than of left-wingers. These are not Republican tools, Libertarian tools, Democratic tools, or whatever.

A bit of a sidetrack, but this prompted Noah Smith to write a long post (that is generally more technical than I want to get in to here) defending the idea that modern macro models (like DSGE) are in fact ideologically biased, even if that's not their intent. Near the end:

So what this illustrates is that it's really hard to make a DSGE model with even a few sort-of semi-realistic features. As a result, it's really hard to make a DSGE model in which government policy plays a useful role in stabilizing the business cycle. By contrast, it's pretty easy to make a DSGE model in which government plays no useful role, and can only mess things up. So what ends up happening? You guessed it: a macro literature where most papers have only a very limited role for government.

In other words, a macro literature whose policy advice is heavily tilted toward the political preferences of conservatives.

Back on the main track, Simon Wren-Lewis, writing at Mainly Macro, comes to Krugman's defense, sort of, by saying that its conceivable that an aggregate model might actually be more defensible than a micro-founded one in certain circumstances.

This view [Krugman's view that aggregate models may still be useful] appears controversial. If the accepted way of doing macroeconomics in academic journals is to almost always use a ‘fancier optimisation’ model, how can something more ad hoc be more useful? Coupled with remarks like ‘the economics profession went astray because economists, as a group, mistook beauty, clad in impressive-looking mathematics, for truth’ (from the 2009 piece) this has got a lot of others, like Stephen Williamson, upset. [skipping several paragraphs]

But suppose there is in fact more than one valid microfoundation for a particular aggregate model. In other words, there is not just one, but perhaps a variety of particular worlds which would lead to this set of aggregate macro relationships....Furthermore, suppose that more than one of these particular worlds was a reasonable representation of reality... It would seem to me that in this case the aggregate model derived from these different worlds has some utility beyond just one of these microfounded models. It is robust to alternative microfoundations.

Back on the main track, Krugman followed up with an argument for why its OK to use both aggregate and microfounded models.

And here's Noah Smith writing again, "Why bother with microfoundations?"

Using wrong descriptions of how people behave may or may not yield aggregate relationships that really do describe the economy. But the presence of the incorrect microfoundations will not give the aggregate results a leg up over models that simply started with the aggregates....

When I look at the macro models that have been constructed since Lucas first published his critique in the 1970s, I see a whole bunch of microfoundations that would be rejected by any sort of empirical or experimental evidence (on the RBC side as well as the Neo-Keynesian side). In other words, I see a bunch of crappy models of individual human behavior being tossed into macro models. This has basically convinced me that the "microfounded" DSGE models we now use are only occasionally superior to aggregate-only models. Macroeconomists seem to have basically nodded in the direction of the Lucas critique and in the direction of microeconomics as a whole, and then done one of two things: either A) gone right on using aggregate models, while writing down some "microfoundations" to please journal editors, or B) drawn policy recommendations directly from incorrect models of individual behavior.

The most recent is from Krugman, wherein he says (basically) that models that make both small and big predictions should be judged more on the big than the small.

This is just a sampling, and likely a biased one as there are many who dismiss the criticism of microfoundations out of hand and thus aren't writing detailed responses. Either way, the microfoundations models are dominant in the macro literature now, and the macro-for-policy-folks class I'm taking at the moment focuses on micro-founded models (because they're "how modern macro is done").

So what to conclude? My general impression is that microeconomics is more heavily 'evolved' than macroeconomics. (You could say that in macro the generation times are much longer, and the DNA replication bits are dodgier, so evolving from something clearly wrong towards something clearly better is taking longer.)

Around the same time that micro was getting problematized by Kahneman and others who questioned the rational utility-maximizing nature of humans, thus launching behavioral economics revolution -- which tries to complicate micro theory with a bit of reality -- the macroeconomists were just  getting around to incorporating the original microeconomic emphasis on rationality. Just how much micro will change in the next decades in response to the behavioral revolution is unclear, so expecting troglodytesque macro to have already figured this out is unrealistic.

A number of things are unclear to me: just how deep the dissatisfaction with the current models is, how broadly these critiques (vs. others from different directions) are endorsed, and what actually drives change in fields of inquiry. Looking back in another 30-40 years we might see this moment in time as a pivotal shift in the history of the development of macroeconomics -- or it may be a little hiccup that no one remembers at all. It's too soon to tell.

Updates: since writing this I've noticed several more additions to the discussion:

• Simon Wren-Lewis at Mainly Macro: Microfoundations and the speed model development
• Harold Pollack at the Incidental Economist: Micfoundations, it's not just a debate for macroeconomists
• Joseph at Observational Epidemiology: Microfoundations
• Also related: Paul Krugman share a recent speech on "Economics in the Crisis"
• Simon Wren-Lewis again: "What have microfoundations ever done for us?"

The US health care non-system

I spent much of yesterday thinking about the past, present, and future of the American health care system. I've largely chosen classes with an international or methodological focus so this was a bit of a departure from my normal fare. In one day I finished up some readings on health reform, wrote a brief paper speculating on what US healthcare will look like in 2030, attended a talk by Uwe Reinhardt largely based on this paper (PDF), and went to a three hour lecture on US health care (part of a class on the economics of the US welfare state). It's a mammoth subject, and there are many bloggers who write exclusively about domestic health policy -- the guys at the Incidental Economist have smart stuff to say on it every day. There's so much to be said and done even on the somewhat narrowed subject of the Affordable Care Act (ie, "ObamaCare").

But that's not what keeps popping into my head.What keeps getting reinforced is how our system really isn't a system at all, but a weird conglomeration of lots of different approaches for various fragments of our society that emerged for quirky historical and political reasons. I found this description -- from a report comparing various industrialized countries' systems -- humorously understated: "The U.S. does not have a 'health system,' but rather a variety of private and public institutions and programs that regulate, finance, and deliver care." (source)

Paul Starr's classic Social Transformation of American Medicine is a good start for trying to understand how we got to the 'variety' we have today.  The end result is that it doesn't serve very many people well at all. The US is a great place to get the most advanced care if you can afford it, but even then you're going to pay a lot more for it. For the non-wealthy the expenses are amplified and we end up rationing care by ability to pay. By pretty much every standard other than innovation (ie, including the delivery of that innovation to those who really need it, not just those who can pay) the US falls dreadfully short. We get poor life expectancy, magnified inequalities, and spending that's roughly twice as much per person as in any other wealthy country.

Ironically, whether the Affordable Care Act goes into effect in 2014 depends largely on whether Obama gets reelected, and whether Obama gets reelected or not depends largely on what the unemployment rate does between now and November. So the future of the US health system depends in a very real way on fluctuations in the economy over the next eight months, and no one really understand that well at all.

If you're just looking at the trajectory of the American health system the ACA is a major reform, even a fundamental one.  It will do (and has already started to do) a lot of good things, but I'm skeptical that it will do all that much to fix costs or shift our focus to public health ---prevention over treatment. There are a lot of good small fixes in there, but nothing revolutionary when you compare us to other countries.

And this is why I find domestic health policy profoundly depressing. It's why I've chosen to focus more on international health than domestic politics. In international health I think the prospects for witnessing and contributing to massive, heartening, orders-of-magnitude positive change in my professional lifetime are quite real. On US health policy, I'm less optimistic. My friend and classmate Jesse Singal wrote a description of the US health system -- in the context of astonishingly ridiculous remarks by some conservatives on contraception -- that I think about sums it up:  "...our medical system is an octopus riding a donkey riding a skateboard into a sadness quarry."

Rights bleg

bleg: (Internet slang) An entry in a blog requesting information or contributions. (from Wiktionary)

This entry was prompted by an interesting post on religion and human rights by Kate Cronin-Furman over at Wronging Rights. My question here has little to do with the contents of that particular post other than having been prompted by it in my impossibly tangential brain, but I think it's a great post that you should all read regardless. Now on to my question:

I'm not sure I believe in human rights. Don't get me wrong; I'm not a monster, and I'm really more agnostic on them than a certain skeptic. I also happen to value very highly pretty much all the widely-believed human rights and most everything to which the title of a human right has been expanded. I'm not convinced that my personal normative valuation or preference is the same as actually believing in human rights (their existence and universality), or whether the rights framework is the most true or helpful one. The work I want to do overlaps a lot with rights practitioners and language -- again with the valuation of those ends. I've also read quite a few things written by human rights activists, but mostly on the level of "we were trying to document or stop this atrocity" or otherwise using the language of rights towards an end which I support, but usually assuming from the beginning that the reader believed in human rights. It also seems that a lot of things that just seem good to many people, independent of a rights-based framework, are touted in that language because it is simply what is done. I also get the impression that there are a fair number of people working within the 'human rights establishment' who see the construct as more useful than true (or don't distinguish between the two) but I have no way to verify that.

None of these hesitations are final, of course -- this may simply be a shortcoming in my education that I need to rectify. I grew up very religious and went to a very conservative college that only employs professors who belong to a particular conservative evangelical denomination. I missed out on formal coursework or guided readings in secular philosophy or ethics, or at least any presentation of that material by people who actually believed it. Some of what I learned was heavily filtered through that strain of fundamentalist thought that looks at everything that is not itself and decries it as an un-moored, baseless fantasy. (Amongst others, blame Francis Schaeffer -- one his books recounts the truly atrocious evangelistic technique of trying to convince a confused young person that there are only two intellectually honest ways to reconcile hopelessness resulting from the perceived failure of secular philosophy to find meaning; believe in God or commit suicide.)

There were certainly others who were more gentle in approach but the underlying thought was always there, that there can be no absolute statements -- whether about morality or rights -- without theistic belief. However, in college I took a skeptical turn and eventually came to disbelieve my theist roots altogether. My graduate work has been more technically-focused (which is what I wanted), for example considering how to achieve improvements in health rather than deep thinking about the foundational assumption that there is a right to health. Many of my peers who attended liberal arts schools or research universities have obviously focused on the study of human rights to a much greater extent, whereas my education bypassed it altogether. To some extent I want to believe in human rights because it seems to be the dominant framework and language and things would just be simpler if I did. But wanting to believe something because it's helpful is not enough to me. It seems like it would be easier to believe in human rights if one did believe in a higher power, which may be one reason why liberal religious groups seem well-represented in human rights circles.

So finally, my bleg: what should I read? Is there a single primer on or defense of the foundations of human rights that you would recommend to a secular/skeptical person like me? This could be a book, an essay, a journal article --  whatever you think might be the most convincing case. I think this line of thinking deserves more than a simple read of a Wikipedia page; I'm hoping that you can distill the arguments that you've found most useful in thinking about rights into a few recommendations. Likewise, if you're in the doubter camp or think there is a better secular alternative out there I'd be happy to hear counter-suggestions as well.

Values and humility in economics

Greg Mankiw is a Harvard economist, former chairman of President Bush's Council of Economic Advisers, and currently an advisor to the Romney presidential campaign. He teaches a large introductory economics course at Harvard and writes both the widely used Principles of Economics and a blog that displays the same crisp, eminently-readable prose as his textbook. In a show of solidarity with the Occupy Boston movement, some of his students walked out of that class earlier this year. Much has been written about the walkout  (Update: here's the students' open letter and a response that outlines why walking out of this particular class isn't the most informed move.) Still I wanted to highlight Mankiw's column in yesterday's New York Times, titled  "Know what you're protesting." I share some of his reaction:

But my second reaction was sadness at how poorly informed the Harvard protesters seemed to be. As with much of the Occupy movement across the country, their complaints seemed to me to be a grab bag of anti-establishment platitudes without much hard-headed analysis or clear policy prescriptions. Ironically, the topic of the lecture that the protesters chose to boycott was economic inequality, including a discussion of recent trends and their causes.

Fair. But later in the piece Mankiw says something that really rankles (emphasis added):

I don’t claim to be an economist of Paul Samuelson’s stature. (Probably no one alive can.) But like him, I have written a textbook that has introduced millions of students to the mainstream economics of today. If my profession is slanted toward any particular world view, I am as guilty as anyone for perpetuating the problem.

Yet, like most economists, I don’t view the study of economics as laden with ideology. Most of us agree with Keynes, who said: “The theory of economics does not furnish a body of settled conclusions immediately applicable to policy. It is a method rather than a doctrine, an apparatus of the mind, a technique for thinking, which helps the possessor to draw correct conclusions.”

That is not to say that economists understand everything. The recent financial crisis, economic downturn and meager recovery are vivid reminders that we still have much to learn. Widening economic inequality is a real and troubling phenomenon, albeit one without an obvious explanation or easy solution. A prerequisite for being a good economist is an ample dose of humility.

I'll preface my reaction to this with my own dose of humility: my studies at the Woodrow Wilson School this semester are my first exposure to serious economics, and I'm realizing every day that I have ever more to learn. I think it can be helpful to approach a field with fresh eyes so I hope my thoughts here won't be entirely discredited by my fresh arrival to the dismal science.

That said, No! This seems like denial, pure and simple. My impression is that one of the areas where economists have most often failed to display humility is when thinking of and talking about the interaction of their values and methodologies.  Yes, economics has epistemological limitations, but these are equaled or surpassed by its axiological limitations, and may be more consequential because -- unlike with the more readily acknowledged methodological shortcomings -- economists themselves don't always make clear the values implicit in their worldviews. I think economists and those who are impacted by their views (ie, everyone else) would benefit from clearer statements of how values impact economics.

Mankiw's textbook does very briefly address the political philosophies underlying views on income redistribution, from utilitarianism to liberalism to libertarianism (pages 442-3 in the 5th edition). But this is halfway through the text and only in the context of the chapter on "income inequality and poverty." In reality, your views on maximizing utility for all versus (at another extreme) only caring about how policies affect the poorest have an impact on pretty much every piece of welfare economics. Here from what I can tell Mankiw is quite mainstream -- when considering the effects of a particular policy using the tools of welfare economics, the underlying philosophical preferences are almost always assumed. The conclusions of those studies are then touted as positive statements ("Policy X is bad for the economy") when that may or may not be true, depending on whether you share the same fundamental normative roots.

Prof. Mankiw spoke at Princeton on October 20 (you can view the lecture here) and it was a well-presented talk. His remarks were broad and intelligent, though maybe a bit constrained by the fact that he is associated with a presidential campaign and thus can't rock the boat too much (even with a disclaimer that his remarks were his own). In that talk Mankiw similarly began by emphasizing the need for economists to show greater humility in light of recent failures; he then proceeded to discuss a good number of specific policy recommendations with quite a bit of confidence. My biggest question coming out of the lecture was how to square the Mankiw who calls for greater humility from economists with the Mankiw who makes policy prescriptions. If we don't know with certainty what the impacts of particular policies will be or how to do more than tweak the performance or recovery of an economy, why not start with the policies least likely to do harm to the most vulnerable members of society? That would generally be my preference, growing out of my own nascent political philosophy.

In his textbook (5th edition page 35) Mankiw evenly explicitly notes that "Economists give conflicting advice sometimes because they have different values." This is true, and if anything it is under-emphasized. Elsewhere Mankiw has been more direct, contrasting the philosophies of Nozick and Rawls and noting how those might result in very different policy prescriptions on taxation. Mankiw ends up closer to Nozick and so it's no surprise that his policy prescriptions are for lower corporate taxes (re-emphasized in the Princeton talk as one of the things on which he very strongly agrees with Romney).

How is this anything but a heavy dose of ideology being injected into economics? How can we square this with the Mankiw who says he doesn't see the study of economics as "laden with ideology"? Part of the problem is that there are figures such as Mankiw who are concurrently serious researchers on scientific questions within economics and proponents of normative preferences in the political sphere. Can the outside observer tell when an economist is being one and not the other? Can economists realize this in themselves? When you couch these preferences in the language of economics without making the underlying values explicit, it's hard to believe that the field is not laden with ideology. To the extent that he doesn't even recognize how these value statements pervade the field, Mankiw is -- in his own words -- as guilty as anyone for perpetuating the problem.

Timing

This week in one of my classes we were scheduled to discuss humanitarian intervention and the "responsibility to protect" principle. Our case study is on Libya, and especially on the initial decision to intervene. Not coincidentally, one of the professors for the course is Anne-Marie Slaughter (see her NYT editorial in support of action, just days before UN Resolution 1973). The news of Gadhafi's death broke just before class. Then, after a session touching on these topics in the context of broader theories of international relations, I found myself in a computer lab with several of my classmates. We were mostly checking our email or printing assignments, but the conversation turned to Libya. Someone mentioned that a video had been posted of Gadhafi still alive when he was captured (see here), and we started pulling up different videos and trying to piece together what happened. What order, who did what, how we should react, and so forth.

Separate from the implications of Gadhafi's death for the future of Libya, there's a question of how quickly media has changed how we interact with world events, and how participants in those events seek to portray them. A century ago radio brought real-time news, followed a few decades later by TV. The last decade has seen the proliferation of digital video cameras and the rise of sites like YouTube where anyone can disseminate footage to the entire world, at first side-stepping the old media and then being amplified by it.

I don't know how this situation would have played out a few decades ago, but here we were watching videos taken earlier the same day by rebel forces in Libya. Has there ever been faster turnaround between the fall of a despot, the spread of imagery to shape the narrative of what happened? As viewers and discussants we were participating in the immediate struggle to claim responsibility.

Discarding efficacy?

Andrew Grove, former CEO of Intel, writes an editorial in Science:

We might conceptualize an “e-trial” system along similar lines. Drug safety would continue to be ensured by the U.S. Food and Drug Administration. While safety-focused Phase I trials would continue under their jurisdiction, establishing efficacy would no longer be under their purview. Once safety is proven, patients could access the medicine in question through qualified physicians. Patients' responses to a drug would be stored in a database, along with their medical histories. Patient identity would be protected by biometric identifiers, and the database would be open to qualified medical researchers as a “commons.” The response of any patient or group of patients to a drug or treatment would be tracked and compared to those of others in the database who were treated in a different manner or not at all.

Alex Tabarrok of Marginal Revolution (who is a big advocate for FDA reform, running this site) really likes the idea. I hate it. While the current system has some problems, Grove's system would be much, much worse than the current system. The biggest problem is that we would have no good data about whether a drug is truly efficacious, because all of the results in the database would be confounded by selection bias. Getting a large sample size and having subgroups tells you nothing about why someone got the treatment in the first place.

Would physicians pay attention to peer-reviewed articles and reviews identifying the best treatments for specific groups? Or would they just run their own analyses? I think there would be a lot of the latter, which is scary since many clinicians can’t even define selection bias or properly interpret statistical tests. The current system has limitations, but Grove's idea would move us even further from any sort of evidence-based medicine.

Other commenters at Marginal Revolution rightly note that it's difficult to separate safety from efficacy, because recommending a drug is always based on a balance of risks and benefits. Debilitating nausea or strong likelihood of heart attack would never be OK in a drug for mild headaches, but if it cures cancer the standards are (and should be) different.

Derek Lowe, a fellow Arkansan who writes the excellent chemistry blog In The Pipeline, has more extensive (and informed) thoughts here.

Update (1/5/2012): More criticism, summarized by Derek Lowe.

Machine gun roundup: the story gets worse

Machine Gun Preacher opens widely today. I wrote a piece for Foreign Policy that went up last night titled "Machine Gun Menace." It's mostly a summary of what I've written before on Childers (here, here, and here) but with some new material -- including Childers' denial to me of ever having sold arms -- and some further thoughts on the perils of armed humanitarianism. It starts with my favorite quote from Childers' book: "The Lord I serve is the living Lord Jesus. And to show you he's alive, I'm going to send you to meet him right now!" You can read the full article here. Thanks to Joshua Keating at FP for the chance to take the arguments I've made here to a broader audience (and to my friend Jesse for editing help). Dave Gilson brings the story to another audience at Mother Jones and Scott Baldauf at the Christian Science Monitor, who expressed early interest in the story, also writes about it there.

But the biggest new information on Sam Childers comes in this Christianity Today story by Mark Moring (with reporting in South Sudan by Uma Julius and Esther Nakkazi). I've been a bit frustrated by this whole Childers story since I first started writing about it, as I don't have the resources (or time, as a full time grad student) to travel and do the research necessary to address all the doubts raised by Childers' stories. Since I started writing on him I've received several emails from folks who previously or currently work in South Sudan, expressing a range of doubts -- but most of them did not want to be quoted by name for various reasons.

It looks like Moring, Julius, and Nakkazi have done the hard work of asking around to people in the community -- moving beyond the sort of trip where journalists only see what the charity wants them to see. If even half of the allegations they convey are true then this whole series of events is an absolute travesty: dozens if not hundreds of media outlets have interviewed, written about, or featured Childers. It seems that very, very few asked any critical questions or presented his story with much complexity. Some of this may be about resource constraints, but the questions are beginning to be asked now that the movie is coming out, so it's hard to say that's the whole story. I think one lesson for the future is this: when you talk to a supposed humanitarian making outlandish claims, it is not OK to only talk to them. Their actions affect others, and media should be more than megaphone-holding cheerleaders or fundraisers.

Back to the Christianity Today story. It opens:

Witnesses have said that the children at Shekinah Fellowship Children's Village are malnourished, unhealthy, and unhappy. Several locals—including pastors, government officials, and a high-ranking member of the military—tell Christianity Today that Childers has exaggerated or outright lied about his work in the African nation.

Community leaders want his orphanage in Nimule—near the border with Uganda—to be shut down immediately, and for local ministries to take over. In a September 2 letter to Childers, 14 local leaders—including the man who says he gave 40 acres of land to Childers to build the orphanage—wrote that Chiders has "dishonored our agreement" to take care of orphans, and that they demand "immediate closure of the compound." Childers told CT he never received that letter.

So it sounds like Childers may not have the community support you'd expect if he was doing good work. Childers predictably blames the allegations all on a disgruntled former employee. (Careful followers of aid scandals will note the almost exact parallel between that and Greg Mortenson's reaction to allegations against him -- Mortenson at first blamed almost everything on a disgruntled and dishonest former employee). If that was the only source of these accusations there would be plenty of reason to doubt them. But here's more from an American doctor who visited in 2009:

Wilson said no adults—including Childers—were at the orphanage when his team visited in 2009, but that they left medicine and antibiotics with clear instructions how to administer them. But when they returned two days later, none of the medicine had been given to the children.

"I don't know what to do," Wilson said, "but I have to do something." He ended up asking CT to investigate, and several people we spoke with recently confirmed what Wilson and the nurse observed.

They go on to talk about the health problems many of the children were having. Really, read it. There's also a claim that echoes a criticism someone in South Sudan emailed to me, that Childers often stages photographs and acts differently when media are around:

Okumu and others said they witnessed Childers staging photographs of himself fighting against the LRA in order to make his story sound more compelling and to attract more donors to his ministry. Okumu said Childers used guards and children from the orphanage to stage the photos nearby. "He claimed to be rescuing kidnapped children from the LRA," Okumu said. "But it was false. He just took pictures of the children in the bush around the compound here."

Seth Trudeau, who is involved with another orphanage in Nimule, South Sudan, says that Childers' orphanage was shut down by the local government last month. If that's true, it raises the question of why and how Childers is still promoting the movie to raise money for his charity (I haven't read that the orphanage was actually shut down anywhere else). Seth writes this:

Over the course of the last year, Sarah and I knew extended families who were taking their children away from the home, which surprised us. As the LRA's strength had waned in South Sudan, this children's home had broadened its focus from rescued child soldiers to all orphans and vulnerable children - which made it all the more shocking to us that families would be taking their children back: by definition, these children had come to the home because the families were so ill equipped to care for the children in the first place. At CCH, we had families who would lie about their circumstances in order to get their children in, so it struck us as strange that the opposite phenomenon was taking place on the other side of town.

Very strange indeed. If the children had extended families that could take care of them but just lacked the resources, it raises the troubling question of whether an orphanage was an appropriate charity model in the first place. Why not just support the families so they can care of the kids themselves? That -- along with the stories of Childers being absent for long periods of time and the lack of adults on site -- remind me again of criticism of orphanages as an aid model (here and here) at the blog Good Intentions Aren't Enough. Hopefully the attention from the movie and these first critical reports will lead to more questions being asked and answered.

How Sam Childers endangers humanitarians everywhere - reax from the web

(For background see my original long post and this update.) Sam Childers gets back from Somalia (where he's currently scouting for a humanitarian mission??) on August 10th, and I've been asked to contact him. I plan to, as I want to see if he's willing to answer some of the many questions that potential donors deserve answers to -- based on his own prior statements.

In the mean time, several aid/development bloggers have written about the Machine Gun Preacher:

A couple short mentions: Tom Murphy and Ken Opalo both link, while Tom Paulson at Humanosphere calls it all "fascinating and disturbing."

Tales from the Hood is a long-running blog written by "J." While the author is anonymous, many aid / development bloggers have met him (including me) or know who he is and what he does -- which is how we know that he's not just talk: he's a legit humanitarian bad-ass who's worked in countries your high school geography teacher has never heard of. J's work is widely respected and his blog is a watering hole for aid and development workers around the globe. He also has a certain flair for description, as you can see in his piece on Childers:

[Childers] has a custom chopper and a movie deal, and when he’s not out busting caps into LRA, Childers pastors a biker-themed church in rural Pennsylvania (but of course). I think my favorite part is where he states that he is after Joseph Kony. Like, to kill him. Like, good old-fashioned cowboys and Africans.

And nothing says, “I worship the Prince of Peace” quite like vowing to kill someone.

While some commenters on this blog have said that Childers' actions are just "between him and God" -- and thus we shouldn't criticize him -- in reality nobody works in a vacuum. Reckless actions today can make future work via more reasonable approaches impossible. This critique, regarding how what Childers does and says can impact humanitarians everywhere, is very important. Here's J again:

There is already suspicion, in some cases rightly earned, that humanitarian aid workers may not be strictly humanitarian... But thanks to the Machine Gun Preacher, next time I'm stopped and questioned at a checkpoint, it will be even harder for me to make the case that I'm really there (wherever 'there' is) for strictly humanitarian purposes. And so that we're clear, this is true regardless of whether I'm in Killinochi, Erbil, or LAX. His videos and pics (along with those of many others) are up there, out in the open for all to see...

I have colleagues and close personal friends in South Sudan, including exactly the areas where Sam Childers claims to “help where no one else will.” I frequently must make the decision to deploy people who I supervise and for whom I am responsible to places where the ratio of assault rifles to healthy babies in the general population is far higher than it should be.... We very often go into insecure places where our presence and the associated suspicion that we may have ulterior motives puts not only us, but our local colleagues and those we’re trying to help at greater risk, too.

And so every time the inarticulate Machine Gun Preacher packs heat into South Sudan he makes the entire world more dangerous for me and my friends and innumerable real aid worker colleagues. Every time he puts up another video of himself jumping into his white SUV with an AK47 across his lap, he increases the likelihood that I or someone I care about is going to get shot.

Commenter MB adds this:

As someone who spent many years in South Sudan (pre- and post- CPA), who is currently in Iraq (stuck behind T-walls and armored SUVs)… this burns me up!. Any one who portrays us as CIA, military, armed, mercenary, or anything other than trying to help is beyond stupid! And anyone who would do a “reality series” (is that for real??) about them puts all of our lives, the lives of our friend, colleagues and those we are trying to help, in serious danger!...

Later in the thread the same commenter notes:

I think it’s fairly telling that those of us who have worked in South Sudan, over many years and people currently in South Sudan (a friend did an informal poll of people she knows there) knew nothing whatsoever about this guy.

I've heard the same sentiment from others, which is telling. I've also exchanged emails with two people in Sudan who have raised other concerns about Sam, and I'm hoping that they'll decide to share those publicly soon. While there are some supporters who will believe Childers is on a mission from God regardless of what I say (or anyone else for that matter), it's important for anyone who has information or concerns about Childers to share them as the publicity machine for the movie gears up. On that note, it would be great if someone who edits Wikipedia (I won't because I think I'm too close to the issue) could update his ridiculously one-sided Wikipedia page to have a more objective voice.

Another aid worker who blogs, Erin in Juba, adds some thoughts here. She notes this passage from the Machine Gun Preacher blog:

As we neared Nimule we began to relax but we weren’t out of danger yet.  We rounded a corner and hurtled in a tribal clash between the Dinka and Madi tribes.  4,000 fighters, armed with pangas (machetes), rudimentary bows, spears and clubs, stormed back and forth looking for someone to fight.  In amongst the drunks I saw an elderly man poised for battle and a young woman with a bow in her hand and a baby slung across her back.  As the situation escalated we had no choice but to lock and load.  Shots were fired and we drove through the screaming remnants of the volatile mob.  Luckily, no one was killed.

If that strikes you as outlandish, you may appreciate Erin's take:

AGGGGHHHHHH.  Tribal violence in South Sudan is a complicated clusterf[***], to say the least. However, most of the violence is in between the tribes. The traditions of violence and cattle raiding go back generations, and are a tragedy for sure, but because of their specific tribal-focused aims, they tend to not focus on targeting humanitarians.  And then this idiot claims he has “no choice” but to go blazing into the middle of a mob? ...

Right. She also notes:

It’s also ironic that Sam claims to work with the SPLA to free child soldiers since the army had its very own child soldier branch (the Red Army).

For now the feedback is this: some aid workers who work in Sudan and other dangerous environments think Childers' stories should be taken with a grain of salt, and say that what he is doing makes this work more dangerous for everyone. All of the supporting statements seem to be coming from people who are associated with his church and don't seem to question Rev. Childers at all. They shouldn't expect the same free pass as the movie brings him more attention. Childers has simply said a lot of outrageous things, and if he wants people to trust his judgment and give him money he has his work cut out for him.

Another way to help in Somalia

One of the best ways to address the severe acute malnutrition seen during famines -- like the one in Somalia now -- is a Ready-to-Use Therapeutic Food (RUTF). They're basically nutritionally fortified peanut butter manufactured to certain quality standards, and they're incredibly effective. Which brings me to MANA, or Mother-Administered Nutritive Aid (and yes, a Biblical reference). They're on a long list of things I've been meaning to write about, but my memory was jogged by their Somalia email blast. I'm a natural skeptic about start-up nonprofits, but over time they've won me over with their idea. The model is relatively simple: for now they're manufacturing RUTFs in the US and selling them to UNICEF and large NGOs that have established distribution networks. I like that aspect -- they're not trying to be all things to all men by distributing it themselves, as they've recognized that role is better done by others.

But the US manufacturing is just a stop-gap. For one, it's helping them learn the ropes on producing high quality RUTFs  and supplying these badly needed and under-produced goods to organizations with complicated purchasing requirements. Their end goal is to establish a self-sustaining (ie, profitable) manufacturing plant in Rwanda, and they're making progress on it.  A donation now will help them make more RUTFs and help them establish the Rwanda facility until it gets to a point where it no longer requires ongoing help.

One reason I think MANA is the right sort of group to establish such a business in Rwanda is that it's co-founded by Mark Moore, and he's well situated to work on both the problems of small enterprises in east Africa and international politics and supply chains. Like me, Mark is a Harding alum. He's a smart guy who spent ten years in eastern Uganda as a missionary (and started the Kibo Group development org), but he also has a Masters in development studies from Georgetown and served as Mary Landrieu's Africa specialist in the Senate. His work was the sort of evangelical aid I thought of when I read Dave Algo's recent post on how secular aid and development workers should be less hostile to good aid work done by evangelicals. Well, this it: in my opinion it's a smart business model run (an being an aspiring development professional, I'd welcome critical feedback in the comments as well) by people who can provide some necessary help to get things set up, and then step back out of the way. Once the facility is up and running in Rwanda it will mean more of our aid money can actually go into the east African economy as NGOs buy RUTFs from MANA and pay its local workers' wages.

Those who know me well or read this blog know that I have ambivalent feelings about Harding. I went there planning on being a medical missionary, and while I lost my faith I also made many friends, and my experiences there led me to my current interests in global health. So I have good things to say and bad things to say. One of the good things -- that I don't say enough -- is that there are a lot of incredibly sincere, hard-working people who come out of the school and do work that I couldn't find fault with if I tried. This is one of them, and I'm sure they'd appreciate your support.

More on Rev. Sam Childers

Earlier this week I wrote five posts (combined into one here) on a scary character named Sam Childers. He goes by the name "Machine Gun Preacher" (website) and I concluded that he was either a self-aggrandizing liar, dangerous, or both. His enthusiastic supporters and a PR rep have commented and contacted me, and I wanted to related the new information below. The short version is that the needle is swinging farther from liar and closer to dangerous. Regardless of the corrections and additions I've noted here, I think it obviously stands that you shouldn't give Childers your money. Childers has been promoting himself as just the hero the children of South Sudan need, and is finally getting a movie based on his life. For the full list of dubious claims (which were not limited to working with the SPLA) see my prior posts, but it's worth noting again that he's stockpiling arms at his orphanage and has admitted to selling weapons to unnamed armed factions in Sudan, Uganda, and Rwanda. He's apparently fighting with or is friends with the SPLA or some faction of it (details are unclear). His organization doesn't seem up-front enough about what they have done and will continue to do with your donation to deserve it. And now (according to comments here) he may be poised to start raising money for famine relief in Somalia.

If you just want Kony killed, Childers doesn't sound like your best shot -- and it's simply not true that the use of child soldiers in the region will end if you kill Kony, as the SPLA has used them too, after all. For reasons why contributing more arms to the conflict is a bad idea, start here. If you want to give to a charity that helps children in South Sudan but is not associated with Childers' violent tactics, try this organization for starters (rec here) -- and I'm sure there are many, many others.

The new information:

1. Whoever moderates the Machine Gun Preacher Reality Series Facebook page (possibly the directors of an upcoming documentary on Childers?) posted this document: It is dated July 12, 2011, signed by a Lt. Gen Mete, and reads:

This is to certify that Rev. Samuel hee Childers has worked with the SPLA for over 10 year he also RUN an orphanage in Nimule, and travels the out South Sudan he has been granted permission to posses and carry a pistol and rifle for personal security while executing his duties. When seen assist where necessary.

This obviously contradicts the prior press release, apparently from the main SPLA spokesperson denouncing Childers. Assuming this new release is legit, it raises questions about the SPLA's cohesion and communication. That isn't too surprising, as one former South Sudan resident said they thought there was considerable struggle over control between the center and other factions.

2. Maria Sliwa, Childers' (update: former) current publicist, commented on this post noting that she was not yet representing Childers at the time she wrote the article I linked to. Thus, I was in error to say she had failed to disclose that, and I've added corrections to the appropriate posts.

3. I evidently goofed in saying Marc Forster was on Oscar-winning director -- apparently he's only directed films that were nominated for Oscars. I could care less about the Academy Awards so this distinction isn't important to me , but some (including Childers supporters who commented here) evidently think this is a big deal that throws my entire credibility into doubt. Sorry?

While I'm at it, here's a clip of Childers being interviewed by Pat Robertson on the 700 club. In it he says that many US government officials have contacted him, that he's also fought the Janjaweed (funny how that didn't make it into his dramatic report of his trip to Darfur), and that he gets his weapons from the government (presumably of South Sudan?) rather than buying them from "the Russians" as he said elsewhere. Again, I'm not against helping children in South Sudan, but it doesn't seem giving Childers money is the best way to do so.

Who is Sam Childers? (conclusion)

This is part 5 of a longer article on Sam Childers, the “Machine Gun Preacher.” Read part 1, part 2, part 3 and part 4, or view the whole series as one long article. In the April 2011 Times of London profile (not online), Childers said this:

"I tell you this - and I believe the day is coming soon - if I had the money, I could have Joseph Kony's head. I could bring him down. And I will have the money, soon." […]

… Childers insists the film will be a hit: "It's going to do unbelievable well." He hopes it will make him famous, so he can raise more funds for his manhunt and his orphanage.

My hope is that more people will think critically about what the “Machine Gun Preacher” is advocating and doing in Sudan, and choose to give to other organizations instead. There are plenty of reasons to doubt his work:

1. Violence. By his own claims Childers has personally killed people – in the double digits. He is not a man of peace, and it’s hard to see how his claimed tactics bring the situation closer to that. Even if he were the best option for getting Kony (highly doubtful), it doesn’t seem to me that the use of child soldiers in the region would disappear with Kony’s demise. Also, since many of Kony’s troops are themselves soldiers, how does Childers avoid killing them?
2. Weapons. Again by his own claims, Childers has sold weapons to armed groups in Sudan, Rwanda, and the Congo. There are no happy-go-lucky bands of nice Christian warriors in the area; every group I’ve read about has been accused of terrible crimes at some point. Feeding more weapons into the conflict will only make things worse, and end up hurting the children Childers purports to help. His solutions are woefully shortsighted.
3. Lies. Childers claimed to be a “white commander” in the SPLA, but the SPLA has publicly denounced him and called for legal action. This apparent falsehood casts some doubt on whether Childers really does the things he claims – the violence and weapons described above – so we’re left choosing between whether he is dishonest or dangerous. Or both. (Update: see Childers' letter of support from an SPLA general here -- but also note that this isn't the only of his claims that begs skepticism.)
4. Disrespect. Much of what Childers’ trafficks in – weapons aside – is poverty porn of the worst sort. By only emphasizing the worst aspects of any situation Childers may drive up his donations, but he demeans those he seeks to serve. He goes even further in his report on South Darfur, prompting a commenter who worked in the region to call him out.
5. The White Man’s burden. Childers’ story is only the latest in a long history of “Whites in Shining Armour” narratives that emphasize the heroics of white Americans and Europeans while downplaying the agency of the people of Sudan and elsewhere in Africa.
6. It’s a bad model to begin with. Saundra S of the blog Good Intentions Are Not Enough has written extensively on why donors should be wary of orphanages.

What then shall we do?

I realize some people will find these posts and be discouraged because they were moved by stories of suffering in Sudan and just want to give to someone. Don’t respond to the emotion you’re feeling by supporting Sam Childers, as there are – contrary to his claims – many other organizations working in South Sudan that do good work. If you feel compelled to give to a charity in South Sudan you might consider Oxfam. If you only give to Christian groups, consider World Vision. No group is perfect, but these are both reputable charities. My apologies for not being familiar with smaller charities on the ground, and I would appreciate suggestions from those who are more familiar with the area.

Ironically, I think Sam Childers is best summed up by blogger Chris Baron in this review – where Baron obviously believes in Childers. He asks good rhetorical questions, but obviously I think the evidence points to a different conclusion:

There are only two options, he is either an insatiable liar or there is a God in Heaven who has tasked his angels concerning Sam’s work. And how many liars do you know give up everything in order to save children, build orphanages and fight enemies who are not their own? Liars don’t do that. Liars are self serving.

---------------------

Notes on Angels of East Africa’s finances: The organization’s income has increased in recent years from $309,166 in 2006 (tax PDF), $578,992 in 2007, $446,294 in 2008, and $877,755 in 2009. Vanity Fair reported that the orphanage has an “annual budget of about $600,000, raised primarily through Childers’s speaking fees and donations from a global network of evangelicals.”

I’m not a Form 990 tax expert, so I will leave more detailed explorations to others. The travel costs ($233,717 in 2008 and $216,809 in 2009) seem high to me. Childers certainly isn’t taking a huge salary: the first year his salary was listed was 2008, at a mere $38,900. It’s hard to tell what all they’ve spent money on – all orphanage expenses are listed under line items such as “Wires to Africa.” Presumably some of this money went to purchase weapons as well?

Miscellaneous notes: here are some additional semi-relevant links that I could not work into this narrative but you may enjoy:

• The FAA fined Childers $28,000 in 2007 for transporting oil and other hazardous materials by plan.
• A bunch of photos of Sam Childers in Africa.
• A video interview in which Childers says he joined SPLA, features sick, crying Africans and naked children, and describes him as a “a rebel turned savior called the bearded white man.”
• An adaptation of a chapter in Childers’ book.
• It’s not clear to me where the claims in this PDF come from, but they outline some even more grandiose claims supposedly made by Childers – seems less reputable to me.
• This video is a short documentary on Childers (or maybe a preview for one?).
• Childers has a second book titled Living on the Edge coming out in a year or less.
• This long-ish MSNBC story also features Childers. It’s remarkable how uncritical the coverage of him has been by so many media sources. I also find it hard to imagine that they would take his more extraordinary claims seriously if he were an African rather than an American.

Disowned

This is part 4 of a longer article on Sam Childers, the “Machine Gun Preacher.” Read part 1, part 2, and part 3, or view the whole series as one long article. So how do we know that Childers isn’t telling the truth? His SPLA buddies said so. After claiming that he was the only white SPLA commander, that he let them use his house as a radio base, and that he recruited SPLA troops as his own personal child-rescuing mercenary outfit, in October 2010 the SPLA put out a press release (through long-time Sudan hand John Ashworth). It reads:

Sam Childers is not associated with the SPLA

This is to inform all who are concerned that Sam Childers is not associated with the SPLA. Sam is alleged to be busy now collecting money in the USA using the name of the SPLA. He went to the level of alleging that he is “paying  his militia force – a platoon of seasoned fighters recruited from the SPLA – and for his effort, he says, the Government of Southern Sudan has named him an honorary commander, the only white man to achieve that distinction”.

The SPLA does not know Sam Childers. SPLA cannot release its soldiers for militia purposes as that is not allowed by the SPLA Act of 2009. If the allegation is true, then the SPLA is appealing to those who are concerned to take legal measures against Sam for the misusing the name of an organization which is not associated with him.

Thanks. Signed: Lt. Gen. Kuol Deim Kuol, SPLA Spokesman

A rather inconvenient truth. This press release was actually the first I had heard of Childers, as the blogger Roving Bandit (formerly of Sudan) highlighted both Childers’ story and the SPLA’s press release.

Post-press release I believe the most sympathetic possible view of Childers is that he started an orphanage and rescued some children… but maybe he’s prone to exaggerating his feats and the means by which he accomplishes them. Maybe Maria Sliwa got carried away in promoting him writing about him and exaggerated his SPLA claims and violent tactics. But even if those stories originated with her (who can ever know?) (Update: see previous post re: Sliwa’s work as his publicist not beginning at the time of her article) [Now] Childers has now fully claimed them as his own. You can read a few excerpts of his memoir through Google Books. In it he claims:

I had SPLA soldiers with me from the first time I went to Africa. Once they realized I was as committed to helping the people of Sudan as they were, they accepted me as their friend and fellow soldier. When I saw that they didn’t have the equipment and supplied they needed in the field, I started bringing them gifts like binoculars, tents, and sleeping bags.

I started hiring the SPLA for security work, and because we worked so close together, I became an SPLA soldier myself. They saw that my heart was to make a difference in the lives of their people, so they started calling me a commander. I carried truckloads of food, salt, sugar, blankets, and other supplies to the front for soldiers, as well as preaching to them and encouraging them in battle.

In his book Childers also claims to have been present during the negotiation of the CPA (which brought Sudan’s civil war to a close). By his own telling he was the only one at the table concerned with the humanitarian needs of the Sudanese people, which didn’t make people happy: “U.S. secretary of state Colin Powell had some representatives at the talks, and I heard they got upset with me. One of them asked somebody else, ‘Who the hell is this white guy?’”

So who the hell is Sam Childers? He wants you to believe he’s working to resolve South Sudan’s problems, but to me he seems dangerously unstable. Here’s a man with a temper, selling arms to groups he likely doesn’t understand, and promoting himself with dubious claims. I certainly won’t donate. But like it or not, the Machine Gun Preacher movie is coming soon. USA Today has a brief preview, and more is sure to come. In the meantime Childers has been touring the country’s churches in a custom-painted Machine Gun Preacher truck and raising money through the Machine Gun Preacher store.

Those who follow the aid and philanthropy world may find all of this a bit reminiscent of the Greg Mortenson scandal. The Mortenson scandal erupted in part because people who were suspicious about exaggerations in Mortenson’s story kept quiet for much too long. I imagine there are many people who have met Childers throughout the years who feel the same. The United States has thousands of tiny charities – many of them with a religious mission – that never make it big. Mortenson’s claims were finally scrutinized when his books became bestsellers, but by that time his organization had already raised millions of dollars. I’m worried that Sam Childers is about to see the same type of fame: a massive increase in donations driven by his book, and especially by the Machine Gun Preacher movie.

To be fair, I see no indication that Childers has mishandled money as Mortenson apparently did. You can look up the tax records for “Boyers Pond – Shekinah Fellowship – Angels of East Africa Inc” using their tax number, EIN 251841332. (See the note at the end of this series for more on the finances.) But the lack of accountability is troubling. If the organization has a board it’s not listed publicly. The main employees of the charity appear to be Childers, his wife, and their daughter. That may be standard issue for smaller charities, but with revenues approaching $1 million annually – and certain to increase after the movie is released – it should be cause for some concern.

Continue reading part 5 here, or you can read the whole series as one long article.

To be lowly in spirit

This is part 3 of a longer article on Sam Childers, the “Machine Gun Preacher.” Read part 1 and part 2, or read the whole series as one long article. Childers has never been a modest man. More from Urbina's profile of him:

[Childers] compares himself to the biblical figure Ishmael, whose wild spirit, he says, drove women into transports of desire. “It was insane. I would have five girls in a single night. I mean, seriously, I could have had your mother if I had wanted her.” He glares at me, a speck of food stuck in his mustache, as if I don’t believe him. More than the drugs and sex, it was the violence that fed Childers.

That is the image the Reverend Sam chooses to project. He’s a violent man on a mission, and God is on his side. To some that message may be horrifying, but he’s obviously found a niche. Unfortunately there is a strain of American Christianity that eats this up. It’s quite different from the church I grew up in, which was historically pacifist (but has lately strayed towards mainstream Republican militarism). I hope most Christians will recoil in horror when they hear what Childers does in the name of God, but not everyone will. Those groups will latch onto Childers’ violent streak will just pour more money into his work.

The story could end there – with Childers as some bizarre mash-up of Rambo and missionary – except that it gets stranger. Childers claims have grown more grandiose with time, and/or he’s tailored them to fit different audiences to avoid mentioning important parts of his work that might be relevant to donors.

Childers’ organization is now called Angels of East Africa. If you go to their website, www.AngelsofEastAfrica.com, you get redirected to MachineGunPreacher.org. But, if you go to any other page on the website the content is still there, giving you a taste of how the site looked before it got the fancy (and I imagine expensive) Machine Gun Preacher makeover. The original Angels of East Africa “About” page is here. The history page has more. Much of the story is the same, but there are glaring omissions: no mention of being involved with the SPLA. Despite a description of Kony, there’s no indication that Childers was trying to hunt him down. It’s all much simpler — just rescuing orphans and building the orphanage.

Angels of East Africa is also associated with a Christian ministry called Boyers’ Pond / World Missions New Sudan. Their website (www.boyerspond.com) also now redirects to MachineGunPreacher.org. But the original webpages behind the main page are still there, including descriptions of rescue missions January 2007 (including an ambush) and May 2007. Again, there’s no mention of fighting with the SPLA or tracking down Kony. Incredibly, Childers does note in the January 2007 report that as “many times happens, several were not healthy enough to make the trip and we had to leave them behind.”

You shall not swear falsely

All of this made me think: when and where did Childers first claim involvement with the SPLA? As late as 2007 he wasn’t making those claims in material clearly written by him, even in places you’d expect him to do so. After some searching, the earliest instance of his more outrageous claims regarding active involvement in combat and interactions with the SPLA didn’t come from Childers. It came from this 2005 article written by Maria Sliwa (emphasis added):

With a physique like Jean Claude Van Damme, 42-year-old Sam Childers has hunted alligators in the US and has smacked down miscreants in Africa. This titan, who could easily pass for Hulk Hogan’s younger brother, sold hard drugs in the late 70s and early 80s and was a rider with the Outlaws, a motorcycle gang in Florida. He has since put his notorious ways behind him and now uses his muscular prowess to save lives in Sudan and Uganda.

On a recent morning, Sam surveyed the orphanage he built on the 36 acres of bush land he cleared four years ago in Nimule, South Sudan. His orphanage is a safe haven for children who are captured out of, or are lucky enough to escape from the Lord’s Resistance Army (LRA), a rebel paramilitary group operating in Uganda and Sudan, which has been designated a terrorist group by the US State Department. Though Sam’s gut is overstocked with intestinal fortitude, the terror that rages around his orphanage is so frightening that just thinking about it can send a cold shiver of electric sparks up and down his sturdy spine.

Sam is a pastor and is the only white commander in the Sudan Peoples Liberation Army (SPLA), another rebel group, which, like the LRA has troops in Sudan and Uganda.

Maybe Childers has been telling a consistent story all along in private, but this is (as far as I can tell) the first public mention of his work with the SPLA. And this narrative took over the others until it became the hyperbolic Sam we hear from today. So who is Maria Sliwa? Though she didn’t disclose it in writing her article, Sliwa runs a PR firm, and Childers is her client. (Updated Correction: Maria Sliwa left a comment on this post saying that she did not begin representing Childers until 2008. I had assumed so because a) the page that has her contact info appeared to be much older, judging by the web design, and b) it reads more like a PR piece than objective journalism. She later clarified that she does not currently represent Childers.) An old page on the Boyers’ Pond site lists her as his press contact. Her website (and an older version) lists media appearances she’s arranged for clients, and her ability to push a story is quite impressive.

Maria Sliwa’s clients include several people connected to modern-day slavery and Sudan (such as Simon Deng) but also many conservative figures. One is Joseph Farah – founder of World Net Daily and one of the leading proponents of Birtherism (the “birther czar”). Farah is known to play fast and loose with the facts, to say the least, so Sliwa’s work promoting him should not inspire us to have confidence in her devotion to the truth.

Continue reading part 4 here, or you can read the whole series as one long article.

The devil's hunter and his weapons

This is part 2 of a longer article on Sam Childers, the “Machine Gun Preacher.” Part 1 is here, or you can read the whole series as one long article. Crush the wicked where they stand

Some of Childers’ most outrageous claims are his most recent. An April 2010 Vanity Fair profile, “Get Kony” by Ian Urbina – worth reading in full – focused on Childers’ personal quest to kill Joseph Kony. Kony is, of course, a really bad guy. He’s the leader of the Lord’s Resistance Army (LRA), a guerilla group in northern Uganda known for its use of child soldiers. Childers claims to be hunting him. Urbina’s story doesn’t present Childers as particularly good at hunting or much closer to catching Kony than any of the others who are out for his head. But the beginning gives you a taste of Childers’ character:

It’s two a.m., and we’re barreling down a deeply pocked dirt road in Southern Sudan. In the cool of night, the temperature is nearly 100 degrees. Sam Childers, 46, is behind the wheel of a chrome-tinted Mitsubishi truck. Christian rock blares on the speakers. He has a Bible on the dash and a shotgun that he calls his “widow-maker” leaning against his left knee. His top sergeant, Santino Deng, 34, a Dinka tribesman with an anthracite complexion and radiant black eyes, sits in the passenger seat, an AK-47 across his lap.

In time, he liquidated his construction business, sold his pit bulls, auctioned his antique-gun collection, and mortgaged his home to help pay for regular trips to Sudan, where he began spending most of his time. He became obsessed with the fate of the thousands of children who have lost their parents to the fighting. In due course he would set up an orphanage in Sudan. But it was Joseph Kony who grabbed his attention. “I found God in 1992,” Childers says, in what is by now a ritual formulation. “I found Satan in 1998.” He has vowed to track Kony down and, in biblical fashion, to smite him.

From there the story gets more elaborate. According to Vanity Fair, Childers claims to be feeding and supplying the Sudan People’s Liberation Army (SPLA), a southern Sudanese armed group whose political wing has more recently become a major component of independent South Sudan’s government. Childers said that he “made his home in Uganda available to the rebels for a radio-relay station.” He also claims to have been present when the SPLA captured “an L.R.A. soldier believed to be part of Kony’s inner circle. Childers wanted to sedate the man and surgically implant a transmitter so he could be tracked when he returned to the base camp. An S.P.L.A. commander overruled Childers and dealt with the man the old-fashioned way—he executed him.”

No word on whether Childers reported this to anyone before the interview; executing prisoners is a war crime.

God’s RPG stockpile?

The profile continues, describing how a group of soldiers arrive to discuss the hunt for Kony. They ask to see inside his church:

The building, with a high sheet-metal roof and glassless windows, displays no religious markings. Inside, stacked floor to ceiling, sit hundreds of oblong olive-green crates. They contain rocket-propelled grenade launchers, AK-47s, and thousands of rounds of ammunition. The room is dusty, and birds flutter in the rafters. Childers says he supplies mostly the S.P.L.A., and also stores some of its arms. He adds that he has sold weapons to factions in Rwanda and Congo, but declines to specify which ones.

Childers said he gets his weapons from Russians, but only legally. He eventually got frustrated with Urbina’s questions about his arms dealing, but he already admitted a lot. Childers is stockpiling arms, including heavy weapons like RPGs that seem excessive for the needs of an orphanage’s self-protection. He’s storing these weapons in a church at his orphanage (which presumably might make it a target) and he sells weapons to the SPLA, which is not a squeaky clean group. While better than the LRA, the SPLA also has been known to use child soldiers during the period Childers sold them arms. Worse is Childers’ mention of selling weapons to “factions in Rwanda and Congo,” all of which are involved in a convoluted series of conflicts in which all parties have committed terrible crimes. If Childers is truly trying to bring an end to conflict in the region, he should start by recognizing that pumping more small arms into the area isn’t going to help.

In addition to selling arms, Childers claims that his “rescue missions” have also led to his personal engagement in combat. When asked how many LRA members he personally killed, “[Childers] reluctantly admits to ‘more than 10.’” In another long profile – from April 9, 2011 in The Times of London (which I unfortunately can’t find online) Childers appears to say he's only killed in self-defense, though it’s hard to deem armed expeditions to find the LRA “self-defense.” That profile also emphasizes the primacy of Childers’ hunt for Kony. It also describes him showing off the guns he keeps in his bedroom at the orphanage:

He hauls an Uzi machine pistol out of one [plastic crate] and clicks in a 32-round magazine. From another comes a longbarrelled Magnum revolver, and from under his narrow metal-framed bed comes a case containing a Mossberg bolt-action sniper rifle and a pump-action shotgun. Another box beneath the bed is full of hand grenades.

If you’re not convinced already that his tactics are shortsighted and part of the problem, rather than a solution, you might be wondering if – just maybe – Childers knows the local situation so well that he was able to pick the “right” side in the conflict. Other stories indicate that Childers is impatient and interacts poorly with the Sudanese people. Urbina's profile continues (emphasis added):

A little later we pull to the side of the road for firewood to bring back to the orphanage. A woman and her husband stand there with a listless baby who is gravely ill from parasites and malaria. Childers offers to take the woman and child to the hospital in Nimule. The father shyly declines, saying he plans to take her to a different clinic tomorrow. A look of rage flashes in Childers’s eyes. “I ought to beat you right here, you know that?” he yells. “What kind of father are you? You are not serious about your children.” Childers points to a nearby grave, where the family has already buried an infant. “What is wrong with you?” Childers by now is surrounded by several of his soldiers, guns on their shoulders. He steps toward the man. “I should really beat you,” he repeats. Terrified, the father gives in. We take mother and child to the hospital.

The child recovers; Childers almost certainly saved its life. But the bullying lingers in memory long afterward. I remember once asking Childers whether any vil­lagers had ever declined his offer to take their children, or whether he had ever taken any against their will. He erupted angrily: “You know what? I don’t have time to be distracted by this sort of interrogation.”

This is hardly reassuring. While Childers doesn’t answer Urbina’s questions about taking children against their will (or detailed questions about his arms dealing), it’s clear that his own ambitions feed off of media coverage. How else did Urbina come to profile him? Self-aggrandizing is a good word for it. Urbina describes Childers as “droning on about the feature film that he hopes will be made about his life, a proj­ect advanced by a Hollywood agent.” Who does that?

Continue reading part 3 here, or you can read the whole series as one long article.

Who is Sam Childers?

He goes by many names, Reverend Sam and the “Machine Gun Preacher” amongst them. If you haven’t heard much from Sam Childers, you will soon. To date he’s been featured in a few mainstream publications, but most of his exposure has come from forays into Christian media outlets and cross-country speaking tours of churches. In 2009 he published his memoir, Another Man’s War. But Childers is about to become much better known: his life story is being made into a movie titled Machine Gun Preacher. It hits the big screen this September, starring Gerard Butler (300) and directed by Oscar-winner Marc Forster (Monster’s Ball, Quantum of Solace).

Why should you care? If you’re concerned about Africa (especially the newly independent South Sudan), neutrality and humanitarianism, or how small charities sometimes make it big on dubious stories, Childers is a scary character. By his own admission Sam Childers is a Christian and a savior to hundreds of children, as well as a small-time arms-dealer and a killer. And, as far as I can tell, he’s a self-aggrandizing liar who chronically exaggerates his own stories and has been denounced by many, including the rebel group of which he claimed to be a commander.

It’s hard to get to the bottom of much of Childers’ story. I first heard of him months ago and have been scouring the web, but the trail is still pretty thin. On the on hand there’s a ton of copy written about him – but almost all of it originates with Childers’ own storytelling. I think there are a number of good reasons we should be skeptical.

The short version of his coming-to-the-big-screen story is this: Childers used to be a drug-dealing gang member who loved motorcycles almost as much as he craved women, drugs, and violence – especially violence. He fell in love with his wife after they met through a drug deal, and she convinced him to turn his life around. Sam found Jesus, got involved with the church, and went to Africa. There he encountered the Joseph Kony’s Lord’s Resistance Army and it use of child soldiers. He found his calling leading armed rescue missions to free enslaved children in northern Uganda and southern Sudan. Now that his life story is being made into a movie -- a goal Childers has long sought -- his ministry will only grow stronger and save more children.

His website, MachineGunPreacher.org, makes no apologies about his violent tactics. Here’s one of the banners that adorns the front page:

What you see now is a slickly-polished presentation, but it hasn’t always been that way. Childers’ story has grown over time, apparently aided by a PR firm, sympathetic media, and a quest to be ever more sensational. My gut reaction is that he’s making much of it up – and I’ll present evidence that shows at least some of his claims are likely falsehoods. We can choose to believe that Childers’ claims are true, in which case he is dangerous, or that they’re false and he’s untrustworthy. The reality is probably that he’s a bit of both.

This is part 1 of a longer article on Childers. Continue reading part 2 here, or you can read the whole series as one long article.

Football epidemiology

In an attempt to prove Cowen's First Law -- "there is literature on everything" -- I enjoy highlighting unusual epidemiological studies (see tornado epidemiology, for one.) These studies may seem a bit odd until you start thinking like an epidemiologist: measurement is the first step to control. The latest issue of Pediatrics has a new study by Thomas et al. on the "Epidemiology of Sudden Death in Young, Competitive Athletes Due to Blunt Trauma." Some of the methods seem a bit sketchy, but that's kind of the authors' point as they note,

"without a systematic and mandatory reporting system for sudden cardiac deaths in young competitive athletes, the true absolute number of these events that occur in the United States cannot be known."

While this study is mostly concerned with the sudden deaths not caused by cardiac events, the same principle holds true: if anything, the problem is under-reported.

Thomas et al. use 30 years of data from the "US National Registry of Sudden Death in Young Athletes," looking at 1980–2009. Deaths in the database came from a variety of sources including LexisNexis searches, news media accounts assembled by other commercial search services, web searches, reports from the US Consumer Product Safety Commission and the National Center for Catastrophic Sports Injury Research, and direct reports from schools and parents.

Of the total deaths included in the study, about 261 were caused by trauma, or around 9 deaths per year. 57% of the 261 deaths were in a single sport, football. Notably, there were about four times as many deaths due to cardiac causes as to trauma.

In football they find defensive positions have more deaths than offensive positions, "presumably because such players commonly initiate and deliver high-velocity blows while moving toward the point of contact." While the majority of deaths were in defensive players, the single most represented position was running backs.

Why the focus on deaths in young athletes? The authors note by comparison that lightning causes about 50 deaths per year, and motor vehicle injuries case 12,000 deaths per year. (Aside: You can tell the authors don't work in injury prevention since they say "motor vehicle accident" rather than "injury" -- injury prevention researchers prefer the latter terminology because they believe "accidental" deaths sound unavoidable.) The authors explain their own focus by noting that these sudden deaths attract "considerable media attention, with great importance to the physician and lay communities, particularly given the youthful age and apparent good health of the victims."

In related news: "The Ivy League [announced that...] in an effort to minimize head injuries among its football players, it will sharply reduce the number of allowable full-contact practices teams can hold."

The battle for hearts and minds

A major difference between the public health approach and the beliefs and strategies underlying fields such as human rights or medicine is that public health concerns the prioritization of limited resources. There is a limited pie. Even if you believe that pie can be expanded (it can, at times), it cannot be expanded infinitely, and so at some point in the policy process someone has to make a decision about how to prioritize the resources at hand. This traditional public health approach overlaps with and gets blurred into human rights and medicine and politics such that the value judgments underlying different claims aren't always apparent. We have a certain number of interventions that are known to work -- they save lives and reduce suffering -- but we don't have enough resources to do all of those things in every place that needs them. If we choose option A, some people will be saved or helped, and some will die. If we choose option B, a different number of people will be saved or helped, and some other group of people will die. The discussion of who will be saved is often explicit, while the discussion of the opportunity cost, those who will not be saved is almost always lacking. Both groups are abstract, but the opportunity cost group is usually more abstract than the people you're trying to help. These are generalities of course, and in reality there is uncertainty built into the claims about just how many lives could be saved or improved with any one approach.

The problem is this: pretty much everything we do in global health is good. Sure, we can argue specifics and there are glaring examples to the contrary, but for the most part we all want to save lives, prevent suffering, and improve health. No one is seriously against successful interventions when they stand alone: no one thinks people with HIV shouldn't get antiretrovirals, or children with diarrhea shouldn't get oral rehydration therapy. Rather, they may oppose spending money on HIV instead of on childhood diarrhea (or in reality, vice versa). Who is comfortable with making an argument against preventing childhood burns? Being against treating horrific cancers? Any takers? So we all argue for something that is good, and avoid the messy discussions of trade-offs.

Thus, much of the conflict in the global health fields is about spending money on X intervention versus intervention or approach Y. Or, better yet, traditional and known intervention A versus new and sexy and unproven-at-scale approach B. I don't think I'd want to live in a world where all health decisions are made entirely by cost-benefit analysis, nor would I want to live in a world where all decisions on care and policy are made from a rights-based approach -- both approaches result in absurdities when taken to their extremes and to the neglect of each other. My impression is that most professionals in global health draw insight from both poles, so that individuals fall somewhere on a continuum and disagree more with others who are furthest away. The tension exists not just between differing camps but within all of us who feel torn by hard choices.

So the differences between the mostly utilitarian public health old-guard and the more recent crop of rights-driven global health advocates aren't always clear-cut, and they often talk right past each other ... or they just work at different organizations, teach at different schools and attend different conferences so they won't have to talk to each other. To some extent they're fundraising from different audiences, but they also end up advocating that the same resources -- often a slice of the US global health budget -- get spent on their priorities. These tensions usually simmer under the surface or get coated in academic-speak, but sometimes they come out. Which brings me to an anecdote to leaven my generalities:

A few months ago I was having a private conversation with a professor, one who leans a bit towards the cost-benefit side of the continuum with a dose of contrarianism thrown in for good measure. Paul Farmer came up -- I don't remember how. I paraphrase:

Resource allocation is the central dilemma in public health. Period. If people don't get that, they're not public health. Paul Farmer? Fuck Paul Farmer. He just doesn't get it.

You won't hear that in a lecture or in a public speech, but it's there. I've heard similar sentiments from the other side of the spectrum, those who see the number-crunching cost-benefiteers as soulless automatons who block the poor from getting the care they need.

These dilemmas are not going away any time soon. But I think being conscious of them and striving to be explicit about how our own values and biases shape our research and advocacy will help us to collectively reach a balance of heart and mind that makes more sense to everyone.

HIV/AIDS is one of the areas of global health where the raw passion of the heart most conflicts with the terrible dearth of resources we have to fight the demon. Decisions have ugly consequences either way you choose, and, rightly or wrongly, dispassionate research is often anything but. The recent news that pre-exposure prophylaxis (PrEP) can prevent HIV acquisition in sero-discordant heterosexual couples is huge in the news right now. Elizabeth Pisani (epidemiologist and author of The Wisdom of Whores) hits the nail on the head in this recent blog post. She notes that there are voices clamoring for widespread scale-up of PrEP -- treating the HIV negative partner -- but that PrEP prevents infection in 60% of cases while treating the HIV-positive partner cuts infection by 96%. Continuing:

That leaves us with the question: who should get PReP? Right now, there are not enough antiretrovirals to go around to treat all the sick people who need treatment. If we’re going to use them selectively for prevention, we should start with the most effective use, which appears to be early treatment of the infected partner in discordant couples. We could also give them to people who aren’t in a couple but who know that they’re likely to get around a bit and might want to stay safe without using condoms. That’s potentially a lot of people; it will stretch our purses. But more than that, it will stretch our political will.

So who is PReP for? We’ve got a better option for discordant couples. We’re not going to want to give it to randy adolescents. We know it works for gay men, but some of the countries where the trials took place would rather thump or jail gay men than protect their sexual health.[...] But I think we would be unwise to rush around talking about massive roll-out of PReP before we actually figure out who it works for in the real world.

Treating people with HIV is good. Preventing infection via treatment is good. Prevention infection via PrEP is good (assuming it doesn't breed more drug resistant strains and make it harder to treat everyone... but that's another story). But most voices in the debate have an agenda and are pushing for one thing above the rest. One of them -- or a balance of them -- is right, but you have to understand their values before that can be discerned. And I think many people in global health don't even think explicitly about their own values, such as the mix of cost-benefit and rights-based approaches they find most appealing. Rather, we all want to promote whatever we're working on that the moment. After all, it's all good.

Weekend meanderings: rockets, Apollo 13 and development

Outer space and rockets were what first sparked my interested in science. My 4th and 5th grade GT teacher, Wanda Holland, taught a summer model rocketry camp for 5th grade science students in my hometown in Arkansas. I went to the camp, fell in love with rockets, and built so many in the next year that Mrs. Holland invited me back as an "assistant" the next year. I kept assisting, then co-teaching the camp through 9th grade and along the way acquired an immense knowledge of mostly useless trivia about astronomy and rocket science. By the time I reached 9th grade I had a collection of hundreds of rockets -- including multiple stage rockets, gliders, scale models, and onboard cameras. I even remember asking a friend once why he would spend money on clothes when he could buy another rocket kit. Needless to say, I was cool. At some point in high school I discovered interests in travel, in playing guitar, in cars, and in girls. Rocketry slowly fell by the wayside. In 10th grade I was building a greater-than-full-scale model of the AIM-9 Sidewinder missile in the family garage (the real thing is 9 feet tall, mine would have been 14'). I had already done the composite reinforcement on the main airframe body tubes when I calculated out how much the construction supplies, avionics, and solid fuel motors would cost, and I realized it would take much more money than my part-time job as a grocery bagger would provide. Then good fortune struck: I won $500 in a regional grocery bagging competition (seriously) which would have let me complete the rocket and buy the fuel to fly it once. But by that point my priorities had shifted and I chose to use it towards a trip to Ghana. That decision is one of many small steps that led me from wanting to be a rocket scientist or astronaut to an interest in global health. The experiences I had in Ghana, and later in Zambia and South Africa, led me to my current interests, and rockets have been a sideshow ever since.

While rocketry hasn't been my primary interest in years, I still try and keep up with my rocket blog, especially when I get around to flying one of my own projects. The old urge to be an astronaut, still strikes now and then. I was a bit bummed that I didn't make it down to the last ever Space Shuttle launch since I always told myself I'd make it to one of them. So this weekend I indulged myself by re-watching Apollo 13, one of my all-time favorite movies.

Apollo 13 holds up surprisingly well 16 years after its release. The casting, the acting, the writing -- it's all excellent. The special effects hold up well too. The soundtrack fits the movie perfectly, especially the triumphant horn riffs during the launch sequence (which I used to watch over and over for hours when I was in junior high). The movie manages to sneak in a surprising amount of jargon, but it works because it's a compelling human interest story focusing on the astronauts and their families. And director Ron Howard managed to infuse the movie with considerable suspense despite everyone knowing how it ends.

Since this is a blog (mostly) about international health and development, I feel it's my duty to draw a few extremely tenuous connections between space flight, this movie, and my current interests:

• Computers are older than I often think. I mean, they're relatively new in the grand scheme of things, but in my head I often date the importance of the computer to the wide availability of the personal computer. The first Apple home computer I had access to in the early 90s had an operating system contained entirely on a floppy disk, and a separate drive for another floppy disk on which you could load programs and files. Computers have come a long way since then, but even that little Apple was an incredible advance over the computers of the NASA era. Still, they were good enough to take us to the moon in the 1960s. Though you do get the distinct impression that Lovell sure could have used a USB thumb drive to transfer the 'main operating program' from the command module to the LEM at the height of the crisis.
• Organization as technology. Part of my summer reading is Charles Kenny's optimistic take on global development, Getting Better. In an early section describing the history of theories of economic development, Kenny discusses how some economists have argued that institutions are as important for development as any given technology. Example institutions include specialization of labor, "double-entry bookkeeping, just-in-time management systems," etc. There's an early scene in Apollo 13 where Jim Lovell (Tom Hanks) is giving a tour of the massive Vehicle Assembly Building and describes astronauts as only the most visible part of a massive system. Having just read about institutions -- and economists' attempts to predict national growth rates -- I couldn't help but think of the massive specialization of labor that allowed us to go the Moon. One of the delights of being a hobby rocketeer is that you can do it all, at least the fun parts, yourself. But real NASA engineers are part of massive systems that work together to do much more than any individual could. That's one reason that disasters like Columbia and Challenger are almost always ultimately traceable to problems in how those systems of people work together, rather than a single failure in materials or a single mistake by an individual. The question "what caused the Challenger disaster?" can be answered on as many different levels as "what sparked the recession?"
• Why did we win the space race? Relatedly, if economists or engineers had tried to predict who would win the race to the Moon in 1950 or 1960, there would have been any number of reasons to pick the Soviets over the Americans. Both sides had natural resources, large numbers of engineers, and rocket scientists poached from the Germans after World War II. While we got the better German, the Soviets had an early lead in rocket development. Then the 60s were particularly rough for the Soviet rocket program (see the Nedelin catastrophe). Arguments abound as to why the US eventually got to the Moon first, but my impression is that US institutions, and especially the engineering systems (not just the particular technological fixes) developed by the US played a significant role.
• Rubella. Astronaut Ken Mattingly (Gary Sinise) was supposed to be on Apollo 13, but he was exposed to a virus and bumped to the flight lest he become sick on his back to the Moon -- his removal from the flight set the stage for Jack Swigert (Kevin Bacon) to take the third spot just 72 hrs before launch. In the movie they just say "measles," but in reality it was German measles -- a synonym for rubella. The other astronauts had natural immunity because they had had rubella as kids, but Mattingly hadn't, so he got bumped. The rubella vaccine (see graph at right) wasn't introduced until the 1960s, so Mattingly's kids would have gotten the vaccine, but he hadn't. Oops. Rubella is also one of the few vaccines not developed my Maurice Hilleman. OK, that's a slight exaggeration, but Hilleman did invent vaccines for eight diseases: measles, mumps, hepatitis A, hepatitis B, chickenpox, meningitis, pneumonia and Haemophilus influenzae bacteria. Incredible.