Microfinance Miscellany

I had a conversation yesterday with a PhD student friend (also in international health) about the evaluation of microcredit programs. I was trying to summarize -- off the top of my head, never a good idea! -- recent findings, and wasn't able to communicate much. But I did note that like many aid and development programs, you get a pretty rosy picture when you're using case studies or cherry-picked before-and-after evaluations without comparison groups. So I was trying to describe what it looks like to do rigorous impact evaluations that account for the selection biases you get if you're just comparing people who self-select for taking out loans versus controls. After that discussion, I was quite happy to come across this new resource on David Roodman's blog: yesterday DFID released a literature review of microfinance impacts in Africa.

On a related note, Innovations for Poverty Action hosted a conference on microfinance evaluation last October, and many of the presentations and papers presented are available here. The "What Are We Learning About Impacts?" sections includes presentations given by Abhijit Banerjee (PDF) and Dean Karlan (PDF) of Yale. Worth reading.

Hangman for Stata

Yes, you can load a .do file and play Hangman in Stata. But only true stats nerds are allowed to play.

And on a related note, have you ever wondered how a game as morbid as hangman became so popular? Can you imagine if you visited another culture and they had a word game that everyone -- adults and children -- knew how to play, and it was based on the electric chair or decapitation, would you judge them? Wikipedia tells me its origins are obscure...

Monday Miscellany

This week's links worth sharing:

• NYU's Development Research Institute is hosting a free one-day conference on Friday, March 4th called "New Directions in Development," including talks by William Easterly and Chris Blattman. After realizing (almost immediately) that the title is not a pun on the main show choir featured on Glee, I decided to go. If you read my blog and plan to attend let me know so we can meet up!
• What the strange persistence of rockets can tell us about innovation.
• Cosma Shalizi, of the blog Three Toed Sloth, is posting lecture notes from his course on "Advanced Data Analysis from an Elementary Point of View".
• Nancy Birdsall of the Center for Global Development thinks USAID's new evaluation policy is really good, but isn't getting enough attention. Sounds like a good policy (if it gets implemented, of course) and I'm especially likely to agree, since it tracks pretty closely with the 'policy proposal' I included with a recent grad school joint degree application.
• Mead Over, also at CGD, writes about PEPFAR's new scientific advisory board: "PEPFAR's overriding objective is  "[T]ransition from emergency response to sustainable country-led programs." Despite good intentions, AIDS programs cannot be "sustainable" in poor or even in middle-income countries unless they meet one or both of two criteria: new infections should be rare and high quality AIDS treatment should be much less costly than it is now. PEPFAR seems to realize that it does not currently know how to do this. They hope to gather evidence in order to have a better idea, and our job on the committee is to advise PEPFAR how best to proceed in gathering and analyzing this new information."
• Obama thinks US intelligence agencies should have done more to predict recent events in Tunisia and Egypt. Maybe Obama should read some more Timur Kuran (PDF)?
• What other dictators does the US support?
• Stephen Colbert calls vaccines a waste of money because his kids didn't get sick.
• Andrew Sullivan shares this video of a college student in Iowa talking about how he's not that different from anyone else, even though he has two moms. Powerful:

"The Modern Development Enterprise"

USAID Administrator Raj Shah recently spoke at the Center for Global Development:

h/t to the Interpreter for the video clip -- I hadn't seen it before. But the full text of the speech, which is worth reviewing for those interested in the future direction of USAID, is available here on USAID's website. Check out how many times "evaluation" is mentioned.

Review: "The Panic Virus"

Review of The Panic Virus, by Seth Mnookin. Simon & Schuster Jan 2011 (Available at Amazon) [Disclosure: I got a free copy of the Panic Virus from a friend who has a friend that works at the publisher -- I wasn't given the copy specifically to write a review, but it's still probably better to disclose I didn't pay for the book.]

Seth Mnookin's The Panic Virus starts and ends with two stories of parents whose seemingly normal children come down with a serious illness. He describes their children before the episodes, and then their dread as they go downhill, are hospitalized, and fight for their lives. These stories intentionally parallel the narrative of the vaccines-cause-autism movement -- "our child was normal, then he got the vaccine, and then he got autism, so it must have been the vaccine." However, Mnookin's carefully chosen stories don't support the anti-vaccine movement; they do just the opposite and make you feel heartsick for the children affected by vaccine-preventable diseases.

Mnookin knows how to tug on heart strings, and how to get his readers riled up, so it's a good thing that he comes down strongly pro-vaccine. His case studies are selected for emotional value, and they illustrate how a thoughtfully written narrative can humanize statistics about disease outbreaks and the danger of the anti-vaccine movement. But I approve of Mnookin's tactics ultimately because his stories are true -- vaccines save lives, and much harm has been done by the spread of unfounded fear.

That said, Mnookin's book isn't at all a fearmongering tale of what will happen if you don't vaccinate your child -- the bookend stories are just that, and he could probably have included a few more narratives throughout without stretching it. For the most part his book is a sober narrative of a social movement that goes back to the earliest vaccines, but has only come to nationwide fruition with the rise of the Internet.

Mnookin chronicles the development of early vaccines, and, to his credit, spends a good deal of time on what was done badly by the scientists and advocates. The Cutter Incident is there,  along with the 1976 swine flu vaccine. Mnookin doesn't mince words in describing injuries that have been caused by vaccines, and at many times I found myself cringing and thinking "why weren't better systems in place earlier?" and "they really should have done more".

This willingness to confront unpleasant truths is a strong point for the Panic Virus, and it also gives Mnookin an opportunity to introduce the safety innovations that stemmed from each incident, all while setting the stage for the anti-vaccine movement. Another strength is that The Panic Virus also offers compelling humanizations of many of the parents of autistic children who have been involved in the anti-vaccine movement. Their despair at seeing their children suffer, their ostracization in a society where autism is not accepted, their occasionally callous treatment by physicians who have no easy answers to offer -- all of this makes it impossible not to sympathize with them.

For the most part, Mnookin doesn't present parents as the villains of his story. That role is reserved for shoddy physicians, scientists and pseuodoscientists, and most of all for journalists. Andrew Wakefield, Mark and David Geier, and journalist/author David Kirby all come in for harsh reckonings, along with many other "expert witnesses" for anti-vaccine lawsuits. This book left me quite depressed regarding the role of journalists and TV personalities in the whole fiasco. There has been so much bad reporting, and so little good.

While reading The Panic Virus, I kept thinking that its major shortcoming is a lingering uncertainty about its target audience. Is Mnookin writing for the uninitiated who want an introduction to where the anti-vaccine movement? Or is he writing a broadside for those already staunchly in the pro-vaccine community? There are sections where the rhetoric made me think it was the latter, while the majority of the book seems to be for those with little outside knowledge of vaccine science. Since Mnookin cautions so much against being led astray by charlatans who peddle fear with a thin veneer of scientific-sounding verbiage, I wish he had done a bit more to explain the science done in recent years on vaccine safety, thiomersal, MMR, and autism. I understand why an author writing a popular narrative would avoid trying to describe these subjects: they are incredibly complicated and divert the reader from the narrative. [Note that I haven't read Paul Offit's Autism's False Prophets, which I understand might have a bit more of that.] And it's not like good science writing is entirely missing from The Panic Virus. Some things are explained well, but overall there's just a bit too much deference to the authority of  science and scientists for my tastes, especially for a book intended for lay audiences. It's a good book, but not a great book.

I also wish Mnookin had provided a better counter-narrative in the second half of the book. Broadly speaking, the first half follows the development of vaccines and early vaccine injury scares (founded and unfounded), and the second half explores the rise of the anti-vaccine social movement. The second half is missing strong pro-vaccine characters, such as one or two scientists or policymakers who have been working to combat the anti-vaccine crowd. A lot of good research has been done to disprove fallacious claims, and to look for policy solutions aimed at decreasing opt-out rates on a state level, but none of that is here.

To date the anti-vaccine crowd has really won the narrative war: their message is simpler, and scarier, and has the added perk of being anti-establishment in appealing ways. The Panic Virus didn't give me much hope that that would change soon -- although the book itself is mostly a step in the right direction, combining a pro-science view with a few emotional narratives about vaccine-preventable diseases.

Our best hope is that eventually our scientific explanations of autism etiology will solidify a bit more, and coupled with much more demonstrably effective treatments, the snake oil appeal of the "cures" sold by the anti-vaccine movement will lose their charm. One theme of the Panic Virus is that the anti-vaccine movement arose because parents of autistic children weren't getting the sympathy, explanations, and help they needed. Many factors including a lack of understanding by doctors and communities, isolation, weak scientific explanations, and a lack of viable treatments all created a situation like a field of dry grass. When a powerful idea -- "vaccines cause autism" -- arose and was amplified by the echo chambers of Internet communities, it ripped through the dry field like a wildfire, sowing panic and fear. And the fire still hasn't been put out.

Monday Miscellany

• What are the chances of this "remarkable piece of epidemiological luck" in studying PTSD? Researchers were looking for risk factors that might predispose someone to experience PTSD after a traumatic event, but obviously they couldn't assign people to groups to receive a traumatic stimulus or a placebo. Then, 51 police officers helped recover 73 bodies after an oil rig disaster with responsibilities including "the stripping, washing, and photographing of recovered bodies." But just before the disaster, someone had "assessed many of the officers in an occupational health study using standardized measures: the Hospital Anxiety and Depression (HAD) scale and the Eyesneck Personality Questionnaire (EPQ)." They even had data on officers not involved in the recovery efforts which they used as matched controls. That and much more in "Post-Traumatic Stress Disorder: A Persistent Diagnostic Challenge" (PDF) by Hamid Tavakoli.
• Timur Kuran's "Now Out of Never: The Element of Surprise in the East European Revolution of 1989" (PDF)
• "We don't know how to solve global poverty, and that's a good thing": London School of Economics lecture by Bill Easterly available as a podcast. Basically, a lot of bad things have happened in the past when we were certain we knew the solution to global poverty and implemented drastic solutions with authoritarian tactics.
• The LA Times has a Q&A with Paul Farmer and Ophelia Dahl on Haiti, Baby Doc, cholera vaccine, and more. Here's the last bit:

Q: Will the return of Jean-Claude “Baby Doc” Duvalier have any impact on the work you do and the reconstruction?

Farmer: I have no idea. It just seems to add more turmoil. I can’t see anything good that would come out of it unless there’s accounting for crimes.

Dahl: It doesn’t take a lot to mess with a fragile system. Finding ways to support democracy would be the most useful thing anybody can do. He doesn’t have a history of wanting to support democracy or not sabotage it.

I keep thinking about that famous photograph of Baby Doc, him and Michele Bennett driving out in that car, speeding out of Port Au Prince and she’s smoking like she’s going to a hair appointment. And that was so huge for Haiti. And I just didn’t think I would ...

Farmer: Live to see it?

Dahl: No, I didn’t.

Q: How can a person living in Los Angeles without contacts in Haiti help?

Dahl: Doing a little bit of research into the organizations you’re giving your resources to. Don’t go down and dig pit latrines -- Haitians need those jobs.

Farmer: Some of these camps, in Parc Jean-Marie Vincent, which is about 51,000 people in one little tiny space, they have 286 latrines. Plus, it’s dangerous for women to go to them at night. In Port Au Prince. The numbers are pretty scary. Like with vaccine production, can’t there be a much more ambitious endeavor? We keep talking about Depression-era interventions -- WPA, Civilian Conservation Corps -- that engaged millions of people otherwise idle in public good. Even if half the aid pledge gets in, imagine if that money could go towards creating jobs for people. ... We’re all for moving capital back to Haiti -- the way it’s done is what’s important. If you had to choose between conventional aid programs with a lot of use of contractors, lots of overhead, dumb trainings. If you had to choose between that and lots of money going into creating jobs for Haitians, we obviously vote for the latter. If you want to support good work in a place that’s troubled, you have to do some homework.

Academic vs. Applied... Everything

When I posted on Academic vs. Applied Epi I included the following chart:

Then I realized that this breakdown likely works pretty well for other fields too. I sent a link to an economist friend, who responded: "No doubt this is similar with econ. The theoreticians live in a world of (wrong) assumptions, while the practitioners are facing the tough policy challenges. And there are quite a few similarities with the below...such as urgency etc."

You can replace "physicians" with "economists" or many other professions and the chart holds up. Contrasting academic economics researchers with policymakers, the fields for Timeline, Data quality, Scientific values, Outputs, and Competencies needed all hold up pretty well.

Many positions that are basically epidemiological in nature are filled by physicians with clinical training but very little formal public health and epidemiology training, which is strongly paralleled in the policy realm. Some sort of graduate training is generally necessary for many jobs, so those aiming for the applied track tend to get multipurpose 'public policy' degrees often viewed as weak by the more purist academics, while those studying public policy deride the inapplicability of the theoretical work done by academics. And the orientation of many academic fields towards a set of skills primarily useful in pursuits that aren't highly valued by the more applied practitioners may go a long way in explaining animosity between the two camps.

Unanticipated Revolutions

From the Wikipedia page on Timur Kuran:

The fall of East European communism in 1989 came as a massive surprise. Iran’s Islamic Revolution of 1978-79 stunned the CIA, the KGB, the Shah of Iran that it toppled, and even the Ayatollah Khomeini, whom it catapulted to power. The Russian Revolution of 1917 stunned Lenin, the deposed Romanovs, and foreign diplomats stationed in St. Petersburg. No one foresaw the French Revolution of 1789, not even the rioters who brought it about. In each of these cases, a massive shift in political power occurred when long-submerged sentiments burst to the surface, with public opposition to the incumbent regime feeding on itself. Preference falsification explains why the incumbent regime appeared stable almost until the eve of its collapse. People ready to oppose it publicly kept their opposition private until a coincidence of factors gave them the motivation and the courage to bring their discontents out in the open. In switching sides, they encouraged other hidden opponents to join the opposition themselves. Through the resulting bandwagon process, fear changed sides. No longer did opponents of the old regime feel that they would be punished for being sincere; genuine supporters of the old regime started falsifying their preferences, pretending that the turn of events met their approval.

Timur Kuran first identified this mechanism in a April 1989 article entitled “Sparks and Prairie Fires: A Theory of Unanticipated Political Revolutions,” which offered the cases of 1789, 1917, and 1978-79 as examples of revolutions that stunned the world. A few months later, the pattern was repeated in Eastern Europe. Kuran proceeded to explain why seasoned experts of the communist bloc were caught off guard in “Now Out of Never: The Element of Surprise in the East European Revolution of 1989,” published in 1991. These two papers, like related chapters of Private Truths, Public Lies, suggest that political revolutions and shifts in political opinion in general will catch the world by surprise again and again, because of people’s readiness to conceal their political proclivities under perceived social pressures.^[5]

Asked in an interview whether he thinks that revolutions or counter-revolutions are imminent in the Islamic Middle East, he responded that although most Middle Eastern regimes are unstable due to lack of genuine legitimacy, the required shifts in Middle Eastern public opinion are unpredictable. If Middle Eastern regimes do collapse like a house of cards, he adds, most observers will be stunned, though there will be no shortage of commentators who will say “I told you so.” ^[6]

h/t @tylercowen

Academic vs. Applied Epi

Third term courses (January through mid March) started back up on Monday. It's amazing how quickly my schedule filled back up with classes, readings, seminars, meetings with students about internship opportunities, TA work, and Student Assembly work. But today I have good news and bad news. The good news: no class because it's a snow day after Baltimore got 5-6" of snow last night. The bad news: my power got knocked out (by the snow or the lightning, hard to tell which) so now I'm stuck staying with friends until I get heat, electricity, and wireless back. Oh well. I have some more substantive posts in the works including two book reviews (The Panic Virus and The Emperor of All Maladies) but here's something short for now.

In my first two terms at Hopkins I took Epidemiologic Methods I and II, the first two of a four-part series on methodology for epidemiology investigators. The methods taught were mostly related to large-scale, long-term studies on the etiology of noninfectious diseases. It's important and challenging stuff because the reality of so many diseases is very complicated, but the emphasis is also quite different from what I envision myself focusing on after grad school.

This term I'm in a brand new class called Professional Epidemiology Methods, the first of a two-part series that emphasizes how epidemiology is generally used in public health practice. To get an idea of the differences between these approaches, Dr. Carlos Castillo-Salgado of PAHO (who, with an MD, JD, MPH, and DrPH, gets the coveted unofficial award for "most degrees of faculty at JHSPH," which is quite an accomplishment given the degree proliferation in public health!) used the following table (click for larger version):

It seems that most graduate training epidemiology related more strongly to the right column -- academic epidemiology. That's vital research of course, but I'm glad to get some additional training oriented at the more applied aspects of epidemiology that I imagine I'll use more often while working on projects.

How Not to Collaborate With a Biostatistician

h/t MDW

Blog update - Resources section

I just updated the Resources page here on my blog with a bunch of links to useful things around the interwebs: career advice, global health job listings, international development job listings, and miscellaneous links. Please let me know in the comments if you think of other resources I might include!

Life expectancy: what really mattered

National Geographic has a great series up on global population growth. We'll hit 7 billion people in 2011 - quite a milestone. One thing to quibble about from the article:

Moreover in 1798, the same year that Malthus published his dyspeptic tract, his compatriot Edward Jenner described a vaccine for smallpox—the first and most important in a series of vaccines and antibiotics that, along with better nutrition and sanitation, would double life expectancy in the industrializing countries, from 35 years to 77 today. It would take a cranky person to see that trend as gloomy: “The development of medical science was the straw that broke the camel’s back,” wrote Stanford population biologist Paul Ehrlich in 1968.

I've read statements like this - about increasing life expectancy and its reasons - many times, and it's almost always done in a certain order. Here, life expectancy increases result from "a series of vaccines and antibiotics that, along with better nutrition and sanitation..." It's hardly the most egregious wording I've seen. Often I'll read that "modern medicine" led to increases in life expectancy, so it's nice that the article specifically mentions vaccines, a preventive measure, instead of only the curative parts of modern Western medicine that we're more familiar with as adults.

But the even the formulation "vaccines and antibiotics along with better nutrition and sanitation" still seems problematic. Why is nutrition and sanitation always an afterthought? I don't have a citation handy, but my impression is that the vast majority of the increase in life expectancy stemmed from advances in sanitation and nutrition, while curative medicine (including antibiotics) played a much more minor role. (I would love to read a good paper outlining the relative contribution of changes in nutrition, sanitation, vaccination, antibiotics to life expectancy improvements - if you know of one, please post it in the comments.)

I think this bias stems in part from a larger bias toward seeing advances in public health as medical advances, rather than societal, economic, or political ones. Many (too many?) people working in the public health field have medical backgrounds. Modern medicine is shiny and fancy and dramatic, and (credit where it's due) has made some incredible advances.

Imagine you're given a Rawlsian choice between being born into:

• World A, with the nutrition, sanitation and vaccination of modern Europe but with all of the doctors and drugs mysteriously raptured in a giant Hippocratic tribulation, or
• World B, with the nutrition, sanitation and vaccination of ancient Rome but with Atul Gawande on standby with the latest treatments once you get sick

I'd definitely choose World A. (Though I'm glad we don't have to choose!)

To correct this bias, I think it would helpful if every time we mentioned the dramatic shift in life expectancy over the past few centuries, we emphasized that most of those gains are from reductions in child mortality, and that nutrition and sanitation deserve the lion's share of credit for those improvements. At the least, let's mention them first and then say "along with later, less important developments such as antibiotics."

Mapping Race in Baltimore

The New York Times has a new interactive feature up, called Mapping America: Every City, Every Block. It uses "local data from the Census Bureau's American Community Survey, based on samples from 2005 to 2009." The data includes income and education levels by census tract, which is interesting but not that visually stimulating, and the more striking data on race by household in each census tract. Areas with higher population density are typically easier to work with -- try New York City for starters. My current home, Baltimore, makes a great test case. On these maps, each circle represents 50 households. (As you zoom further out, you start seeing counties instead of census tracks, and each dot represents many more households.)  A screenshot:

By race, blue = black, green = white, red = Asian, yellow = Hispanic.

For those unfamiliar with Baltimore, that's the Inner Harbor at the bottom. As you can see, the neighborhoods just southwest (Federal Hill) and north (Canton, Fells Point) of the harbor are predominantly white. The relatively sparsely populated section in the center is the more commercial downtown. East and West Baltimore are predominantly black. The green (ie, white) strip in the center is Mt. Vernon, whereas the area at the center top with more green (white) and red (Asian) includes the Charles Village neighborhood, where Hopkins' Homewood undergraduate campus is located.

The Johns Hopkins medical campus, including the School of Public Health where I'm a student, is in the predominantly blue (black) area on the middle right of the map above.

One thing that struck me as odd at first is that there are a bunch of green dots (ie, white households) in the middle of Patterson Park, the big green space included in this zoomed in map:

On further thought, I think the maps are showing averages of the data from the entire census tract. The tract that includes Patterson Park also includes some surrounding blocks, which are predominantly white. The distribution of differently colored dots on the map represents the race breakdown within that tract, but the location  of the dots within the tract on this map is completely random. If you play with the tool, you'll find that tracts are highlighted when you mouseover them, and that the spacing of dots within the tract is uniform -- this also accounts for the sudden changes in density you see in some places at the edges between tracts.

Finally, below is a closeup of the area I live in. At the top center of this map is Charles Village (including the Hopkins undergraduate campus). I live near 25th street, which bisects this map horizontally, in the transition between the predominantly white and Asian area in Charles Village and the mostly black neighborhoods in between Mt. Vernon and Charles Village:

h/t @edwardcarr

Haiti: Constancy and Change

A friend of mine recently moved to Haiti to work for a local organization. I've never been to Haiti, and as with many places to which I have yet to travel, it's difficult for me to picture the reality on the ground, especially when I know how much the places I've traveled to have differed from media reports and books I've read. While my friend and I were talking about Haiti, I mentioned that it would be interesting if I could email some questions and post the answers here on my blog. While I don't think any of the sentiments below are that controversial, I hope this will be a continuing series where I can ask questions and get frank answers (and share them with my readers), so we decided to keep it anonymous. I'll call my friend "F" here. Please let me know (in the comments or by email) if you have any questions you'd like me to relay to F for follow-up posts.

Brett: Can you tell me a little about how long you've been in Haiti, how long you lived there in the past, and what you're doing now (in a vague sense)?

F: I spent a nearly a year in Haiti in 2005-06. I always knew I'd be back some time, and after the earthquake on January 12th, 2010, I regretted that I hadn't returned sooner. I finally arrived back a few weeks ago, to take up a new position with the same organization I worked for five years ago.

Brett: How have things changed since the last time you were there? Did you have a lot of expectations about how things would be post-earthquake, and if so, how does the reality compare to what you were expecting?

F: Of course it's very sad to see so many landmarks in Port-au-Prince reduced to rubble, and what used to be great public spaces packed full of thousands and thousands of people living under tents and blue tarpaulins. Walking around the city is a little creepy: I'll wander down streets I know well, and find that a house or church I used to pass every day is gone.

But I've also been surprised by how much hasn't changed. The same fruit vendor I used to buy from five years ago still sits on the same street corner with her basket of oranges - even though the grocery store behind her has completely vanished. From my first morning back in the office, catching up with old friends and co-workers, it was as if I'd never left. Knowing how Haiti had switched from being a developing country to being (in international NGO terms) a humanitarian emergency, I think I was expecting to see some kind of fundamental change in the way things happen here. In reality, while the problems are perhaps more urgent now, the way of life is just the same as before.

Brett: What's the latest on cholera? Is everyone incredibly concerned, or is it just one crisis among many?

F: I think people see cholera as yet another disaster in a terrible year for the country. It's very sad that cholera seems most probably to have been brought here by the UN "assistance" force (which was already almost-universally reviled among Haitian people). However, I have to say I've been genuinely impressed with the speed and effectiveness of the response by the government and NGOs. I'm as cynical as anyone else about how little there is to show for years and years of public health efforts by international NGOs in Haiti: but this time, they seem to have got it more or less right. I arrived only two weeks after the outbreak started, and already by then everybody I met knew exactly what the steps for prevention were. I see people living in even the most basic conditions being meticulously careful about washing their hands and chlorinating their water.

Last week I was visiting a rural community, and I met a woman who was using water from an irrigation channel to wash her pots and pans. My colleagues, and also the local woman who was showing us around, were furious, telling her in no uncertain terms that her children will die of cholera if she continues doing that. But three months ago, it would have been completely normal.

Brett: What do you think I'm missing about Haiti from reading the news and the occasional blog?

F: Wow, where to start? I don't think that the journalistic staples of tent cities, cholera, rock-throwing demonstrators, and heroic Americans battling against poverty gives you much idea of what life in Haiti is really like. Perhaps what would most surprise an outsider is just how normal life here is most of the time. For example, Haiti was again in the international headlines with post-election protests in December. It's true that most people stayed at home for a couple of days while the situation was tense. But on the third day things started quietening down - and by the fourth day, the merchants were back on the streets, children were again hurrying to school in their little checkered uniforms, and the morning traffic jams were as bad as ever. Haitian people have seen a lot of political upheaval and many natural disasters over the years, they've seen international attention come and go, and life has carried on throughout.

There's a fascinating story waiting to be told about the social and economic effects of the 2010 earthquake. Almost every newspaper article I read about Haiti starts by describing it as the poorest country in the western hemisphere. That's true - but the situation is far more complex than that. This country has a lot of very poor people, but also quite a number of reasonably wealthy people too, and some super-rich. (Port-au-Prince has long had a Porsche dealership, believe it or not.) Before the earthquake, the level of inequality in Haiti was even higher than Brazil. Of course the earthquake was indiscriminate: it hit rich and poor alike, destroying the National Palace and the Montana Hotel as well as tens of thousands of single-room block-and-tin-roof houses. But this destruction of houses (combined with an enormous influx of foreigners, who all need a place to stay) has meant a huge increase in the price of accommodation, and a boom for landlords whose property was not damaged. My landlady is frantically adding extensions to our apartment building: that means she's employing a dozen or so construction workers, which is great. Some jobs are being created, but at the same time inflation is soaring. Then there's the complication of the massive internal migrations caused by the earthquake. I don't think anyone really knows what all this means for the long term, but it would be great to see some informed analysis.

Most of all, while there's a lot that's going wrong in Haiti, I wish the media would sometimes mention some of the great things about the country: the lively kompa music which surrounds you constantly in the street, the colorful, expressive language, the way Haitian people are so scrupulously polite and courteous (even among the urban youth, or more so than you'd expect), and the way they have such a strong sense of identity and of their proud history. Coming back has also made me realise how I had missed the Haitian sense of humor. When I get on a bus in the city and ask the people next to me how they're doing, I sometimes get a response of "lamizè ap kraze nou": "we're crushed by misery" - that seems to be the sort of thing people expect foreigners want to hear. But then more often than not, before we've gone a hundred yards down the road, my neighbors are laughing and joking with me - often teasing me about my terrible Creole. People here are certainly resilient: even after all the troubles and tragedy of the last 12 months, they are still able to find reasons to be cheerful.

Circumcision to the Rescue?

The Atlantic's Shaun Raviv has a long article on the scale-up of male circumcision for HIV prevention in Swaziland online here. According to the article (and other sources I've read) circumcision is in demand in Swaziland, but that demand isn't necessarily driven by accurate information:

Many Swazi men want to get circumcised, “but most of them for the wrong reason,” says Bheki Vilane, the national director of Marie Stopes Swazi­land, a non-governmental organization performing circumcisions. He’s voicing the main concern about circumcision as an HIV-prevention strategy: will it make Swazi men even more sexually reckless than they are already? “Some of the men have the misconception that they’ll be 100 percent safe.” To dispel this myth, NGOs are ensuring that every patient goes through counseling before and after the procedure. Each man is told to use condoms, and also given the option to be tested for HIV, which about 85 percent agree to do.

This massive scale-up is of course based on three randomized controlled trials:

[In 2005] a randomized controlled trial in South Africa (later confirmed by studies in Uganda and Kenya) found that circumcised men are as much as 60 percent less likely to contract HIV through heterosexual sex.

What is often not mentioned is the difference between the intervention that was tested in those trials and the intervention that's being scaled up. I would summarize what the randomized trials intervention as "male circumcision with very intensive counseling on the risk of MC (many visits) in an environment where fewer of the participants had the expectation of it completely eliminating risk" vs. the counseling alone. They showed a strong and surprisingly consistent effect across the three studies.

But I would describe the intervention that's being scaled up as "male circumcision with much less intensive counseling (one visit) in an environment where many of the participants have unrealistically high expectations of risk reduction."

I'm worried that the behavioral dis-inhibition from circumcision will more than make up for the risk reduction from the procedure itself. Thus, I'm interested in seeing more data from evaluations of these programs, as well as population-level data that includes the less-well-supervised circumcision operations that are likely to spring up in response to demand.

The article quotes Dr. Vusi Magaula, chair of Swaziland's male circumcision task force, as saying, "With the highest prevalence of HIV in a population ever recorded, we have got to do something to intervene.” But does the urge to do something justify the programs being implemented, especially if there's a very real risk of harm?Unfortunately I don't think we really know the answer to that question, and only the data will tell.

Monday Miscellany

Happy 2011! My first posting of the new decade (yes, they start in 2001, 2011, etc) will be a bit about my blog's new look, and then some links. I tend to only highlight a few links in blog postings like these, often when I have something short I want to say but not enough to flesh out into a full-length post. If you like the links I share, you can follow my Google Reader feed at this URL, and/or let me know if you have a public feed as well. Some of the most interesting reading material I come across is from shared feeds through Reader -- it's a great way to manage your information flow. Now the miscellany:

• First, my blog's new look: For those interested in the technical how-to, most of the changes result from a change in Wordpress themes to Carrington. I was inspired by the formatting of Chris Blattman's blog, which also uses Carrington -- especially the ability to include a blog roll and shared items feed from Google Reader in the sidebars, while still keeping a very clean, readable look to the main column. The new header image is a skyline of Baltimore, where I currently live, manipulated in GIMP (freeware Photoshop, more or less). I used an Emboss filter first (which makes everything grey-scale and highlights the image's lines and textures), then used the bucket fill tool (with varying thresholds) to selectively fill in contiguous areas in the embossed photo with black, white, and an orange-ish red that matches the link color in the Carrington theme.

• I'm back to Twittering, occasionally, at @brettkeller, though I'm still not sure how this will (or should) fit in with other ways of sharing information for me. I stopped for quite a while after leaving my last job as an online organizer, where I think I got a bit burnt out on it. I'm finding the occasional usage refreshing, especially after reconfiguring who I'm following to match more with my current interests. Political news and online fundraising are out and the global health and international development twitterati are in.

• We're getting closer to being able to build space elevators... but don't hold your breath. I've been fascinated with t his idea ever since reading Kim Stanley Robinson's Mars Trilogy, in which space elevators (and terrorist/freedom fighter attacks against them) feature prominently on both the Martian colony and its possessive mother planet Earth. I recently found a used copy of Arthur C Clarke's The Fountains of Paradise, a Hugo and Nebula award winning novel that is (as far as I know) the first science fiction work to focus on space elevators.

• Jina Moore on "Why we should be worried about genocide in Cote d'Ivoire." I really want this to turn out OK, and am worried about the broader consequences for future conflicts if Gbagbo gets to stay, or the situation ends with more violence. In that sense, there's a lot more at stake here than just the current standoff, which even alone would be something to care about.

• "Academic economists to consider an ethics code." It's kind of amazing that they don't have one already. Take this sentiment: "Mr. Lucas added: 'What disciplines economics, like any science, is whether your work can be replicated. It either stands up or it doesn’t. Your motivations and whatnot are secondary.'" You'd think that economists, of all people, would recognize how research and (more importantly in the context of the article) policy recommendations, can be shaped by outside incentives. Making big money from firms that might benefit from your policy recommendations if a huge incentive to consciously or unconsciously tweak your suggestions.

• Tyler Cowen's "The Inequality That Matters." There's a lot that makes this worthwhile, so I'll just say you should read it, and share one quote:

In short, there is an unholy dynamic of short-term trading and investing, backed up by bailouts and risk reduction from the government and the Federal Reserve. This is not good. “Going short on volatility” is a dangerous strategy from a social point of view. For one thing, in so-called normal times, the finance sector attracts a big chunk of the smartest, most hard-working and most talented individuals. That represents a huge human capital opportunity cost to society and the economy at large. But more immediate and more important, it means that banks take far too many risks and go way out on a limb, often in correlated fashion. When their bets turn sour, as they did in 2007–09, everyone else pays the price.

Gates and Media Funding

You may or may not have heard of this controversy: the Gates Foundation -- a huge funding source in global health -- has been paying various media sources to ramp up their coverage of global health and development issues. It seems to me that various voices in global health have tended to respond to this as you might expect them to, based on their more general reactions to the Gates Foundation. If you like most of Gates does, you probably see this as a boon, since global health and development (especially if you exclude disaster/aid stories) aren't the hottest issues in the media landscape. If you're skeptical of the typical Gates Foundation solutions (technological fixes, for example) then you might think this is more problematic.

I started off writing some lengthy thoughts on this, and realized Tom Paulson at Humanosphere has already said some of what I want to say. So I'll quote from him a bit, and then finish with a few more of my own thoughts. First, here is an interview Paulson did with Kate James, head of communications at the Gates Foundation. An excerpt:

Q Why does the Gates Foundation fund media?

Kate James: It’s driven by our recognition of the changing media landscape. We’ve seen this big drop-off in the amount of coverage of global health and development issues. Even before that, there was a problem with a lack of quality, in-depth reporting on many of these issues so we don’t see this as being internally driven by any agenda on our part. We’re responding to a need.

Q Isn’t there a risk that by paying media to do these stories the Gates Foundation’s agenda will be favored, drowning out the dissenting voices and critics of your agenda?

KJ: When we establish these partnerships, everyone is very clear that there is total editorial independence. How these organizations choose to cover issues is completely up to them.

The most recent wave of controversy seems to stem from Gates funding going to an ABC documentary on global health that featured clips of Bill and Melinda Gates, among other things. Paulson writes about that as well. Reacting to a segment on Guatemala, Paulson writes:

For example, many would argue that part of the reason for Guatemala’s problem with malnutrition and poverty stems from a long history of inequitable international trade policies and American political interference (as well as corporate influence) in Central America.

The Gates Foundation steers clear of such hot-button political issues and we’ll see if ABC News does as well. Another example of a potential “blind spot” is the Seattle philanthropy’s tendency to favor technological solutions — such as vaccines or fortified foods — as opposed to messier issues involving governance, industry and economics.

A few additional thoughts:

Would this fly in another industry? Can you imagine a Citibank-financed investigative series on the financial industry? That's probably a bad example for several reasons, including the Citibank-Gates comparison and the fact that the financial industry is not underreported. I'm having a hard time thinking of a comparable example: an industry that doesn't get much news coverage, where a big actor funded the media -- if you can think of an example, please let me know.

Obviously this induces a bias in the coverage. To say otherwise is pretty much indefensible to me. Think of it this way: if Noam Chomsky had a multi-billion dollar foundation that gave grants to the media to increase news coverage of international development, but did not have specific editorial control, would that not still bias the resulting coverage? Would an organization a) get those grants if it were not already likely to do the cover the subject with at last a gentle, overall bias towards Chomsky's point of view, or b) continue to get grants for new projects if they widely ridiculed Chomsky's approach? It doesn't have to be Chomsky -- take your pick of someone with clearly identifiable positions on international issues, and you get the same picture. Do the communications staffers at the Gates Foundation need to personally review the story lines for this sort of bias to creep in? Of course not.

Which matters more: the bias or the increased coverage? For now I lean towards increased coverage, but this is up for debate. It's really important that the funding be disclosed (as I understand it has been). It would also be nice if there was enough public demand for coverage of international development that the media covered it in all its complexity and difficulty and nuance without needing support from a foundation, but that's not the world we live in for now. And maybe the funded coverage will ultimately result in more discussion of the structural and systemic roots of international inequality, rather than just "quick fixes."

[Other thoughts on Gates and media funding by Paul Fortner, the Chronicle of Philanthropy, and (older) LA Times.]

Grad School Buffet

My program only requires one full academic year of coursework. The second year is a mix of a field practicum, work on a masters paper, and additional courses for those who choose to take some (and many do). But most students complete the core requirements for the degree in the first academic year, which is composed of four quarters. So far I've completed the first two quarters, which included 10 classes and 3 additional seminars for a total of 43 credits. Now I have to decide which classes to take in the 3rd and 4th quarters (January through May), when I have fewer required classes and more electives are offered. Fellow Hopkins GDEC (global disease epidemiology and control) student Kriti at EpiTales describes the selection of public health courses at Hopkins as a buffet. Quite true. I've been trying to narrow down my courses for the 3rd and 4th terms and have come up with a preliminary list, excluding many classes that are redundant, don't fit my interests, or have prerequisites that I haven't taken. After narrowing it down a bit, I'm down a list of a mere 42 courses, or which I'll be able to take 10-11 at most:

Armed Conflict and Health Assessing Epidemiologic Impact of Human Rights Violations Clinical and Epidemiologic Aspects of Tropical Diseases* Clinical Vaccine Trials and Good Clinical Practice* Comparative Evaluation for Health Policy in International Health Current Issues In Public Health Data Management Methods in Health Research Studies Demographic Estimation for Developing Countries Demographic Methods for Public Health Design and Conduct of Community Trials* Econometric Methods for Evaluation of Health Programs Emerging Infections Epidemiologic Inference in Outbreak Investigations Ethics of Public Health Practice in Developing Countries Ethnographic Fieldwork Fundamentals of Budgeting and Financial Management* Fundamentals of Program Evaluation GDEC seminar (required) Global Disease Control Programs and Policies (required) Global Sustainability and Health Seminar Global Tobacco Control History of International Health and Development History of Public Health Infectious Diseases and Child Survival* Intro to SAS Statistical Package Introduction to Urban Health Large-scale Effectiveness Evaluations of Health Programs Nutrition in Disease Treatment and Prevention Pandemics of the 20th Century Poverty, Economic Development, and Heath Professional Epi Methods I Professional Epi Methods II Project Development for Primary Health Care in Developing Countries Public Health Practice* Scientific Grant Writing Spatial Analysis and GIS I Statistical Methods for Sample Surveys Statistical Methods in Public Health III (required) Statistical Methods in Public Health IV (required) Systematic Reviews and Meta-Analysis Vaccine Policy Issues

*Classes noted in bold are required, while those in italics meet some other requirements (I have to choose one from a cluster of courses on a subject area -- it's a bit too complicated to explain here).

Obviously I'll have to narrow it down a bit more. While I would probably enjoy most everything on the list, my strategy is to concentrate on coursework in epidemiology, biostatistics, and statistical software (we use Stata in the required biostatistics series, and I would also like to be familiar with SAS and ArcGIS). Then I'll prioritize courses that provide additional skills in program evaluation and trial design and execution. If I have time left in my schedule I'll get to take the other things -- but it looks like I would need to go back for a second plate at the buffet to be able to take even half of these.

(If you're a prospective student and want to browse for yourself, the JHSPH course search feature is here).

Peace on Earth

The START treaty is one step closer to ratification in Russia. Of course, it probably doesn't affect the probability that we'll all die in a nuclear war in any significant way, but I still generally think a world with fewer nuclear warheads sitting around is a good thing. The story I linked to is still missing something: a broader analysis of why the leadership of both countries is so firmly behind nuclear reduction. I understand that it's expensive to maintain the weapons, and that both sides likely see the reduction as having little effect on their deterrent capabilities, but there's a third reason. I've read -- I can't remember where, and would love to be pointed to links in the comments -- that the worldwide use of nuclear full for power generation outpaces worldwide mining of fissionable materials and that continued destruction of old warheads is thus necessary to keep nuclear power cheap. If that's true, it's a pretty key fact that's being left out of coverage. Wouldn't the story be different if it was framed as "there's a shortage of nuclear fuel and if the elites can't figure out a way to keep disarmament going, it will affect energy prices in the long term"?

I think this underscores a shortcoming of traditional journalism. By focusing on key individuals doing key things and making public statements, broader historical, social, and economic trends can get missed, or downplayed. We end up with a "Great Men" first draft of history rather than a more complete and true picture.

Anyway, Merry Christmas.

Randomizing in the USA, ctd

[Update: There's quite a bit of new material on this controversy if you're interested. Here's a PDF of Seth Diamond's testimony in support of (and extensive description of) the evaluation at a recent hearing, along with letters of support from a number of social scientists and public health researchers. Also, here's a separate article on the City Council hearing at which Diamond testified, and an NPR story that basically rehashes the Times one. Michael Gechter argues that the testing is wrong because there isn't doubt about whether the program works, but, as noted in the comments there, doesn't note that denial-of-service was already part of the program because it was underfunded.] A couple weeks ago I posted a link to this NYTimes article on a program of assistance for the homeless that's currently being evaluated by a randomized trial. The Poverty Action Lab blog had some discussion on the subject that you should check out too.

The short version is that New York City has a housing assistance program that is supposed to keep people from becoming homeless, but they never gave it a truly rigorous evaluation. It would have been better to evaluate it up front (before the full program was rolled out) but they didn't do that, and now they are.  The policy isn't proven to work, and they don't have resources to give it to everyone anyway, so instead of using a waiting list (arguably a fair system) they're randomizing people into receiving the assistance or not, and then tracking whether they end up homeless. If that makes you a little uncomfortable, that's probably a good thing -- it's a sticky issue, and one that might wrongly be easier to brush aside when working in a different culture. But I think on balance it's still a good idea to evaluate programs when we don't know if they actually do what they're supposed to do.

The thing I want to highlight for now is the impact that the tone and presentation of the article impacts your reactions to the issue being discussed. There's obviously an effect, but I thought this would be a good example because I noticed that the Times article contains both valid criticisms of the program and a good defense of why it makes sense to test it.

I reworked the article by rearranging the presentation of those sections. Mostly I just shifted paragraphs, but in a few cases I rearranged some clauses as well. I changed the headline, but otherwise I didn't change a single word, other than clarifying some names when they were introduced in a different order than in the original. And by leading with the rationale for the policy instead of with the emotional appeal against it, I think the article gives a much different impression. Let me know what you think:

City Department Innovates to Test Policy Solutions

By CARA BUCKLEY with some unauthorized edits by BRETT KELLER

It has long been the standard practice in medical testing: Give drug treatment to one group while another, the control group, goes without.

Now, New York City is applying the same methodology to assess one of its programs to prevent homelessness. Half of the test subjects — people who are behind on rent and in danger of being evicted — are being denied assistance from the program for two years, with researchers tracking them to see if they end up homeless.

New York City is among a number of governments, philanthropies and research groups turning to so-called randomized controlled trials to evaluate social welfare programs.

The federal Department of Housing and Urban Development recently started an 18-month study in 10 cities and counties to track up to 3,000 families who land in homeless shelters. Families will be randomly assigned to programs that put them in homes, give them housing subsidies or allow them to stay in shelters. The goal, a HUD spokesman, Brian Sullivan, said, is to find out which approach most effectively ushered people into permanent homes.

The New York study involves monitoring 400 households that sought Homebase help between June and August. Two hundred were given the program’s services, and 200 were not. Those denied help by Homebase were given the names of other agencies — among them H.R.A. Job Centers, Housing Court Answers and Eviction Intervention Services — from which they could seek assistance.

The city’s Department of Homeless Services said the study was necessary to determine whether the $23 million program, called Homebase, helped the people for whom it was intended. Homebase, begun in 2004, offers job training, counseling services and emergency money to help people stay in their homes.

The department, added commissioner Seth Diamond, had to cut $20 million from its budget in November, and federal stimulus money for Homebase will end in July 2012.

Such trials, while not new, are becoming especially popular in developing countries. In India, for example, researchers using a controlled trial found that installing cameras in classrooms reduced teacher absenteeism at rural schools. Children given deworming treatment in Kenya ended up having better attendance at school and growing taller.

“It’s a very effective way to find out what works and what doesn’t,” said Esther Duflo, an economist at the Massachusetts Institute of Technology who has advanced the testing of social programs in the third world. “Everybody, every country, has a limited budget and wants to find out what programs are effective.”

The department is paying $577,000 for the study, which is being administered by the City University of New York along with the research firm Abt Associates, based in Cambridge, Mass. The firm’s institutional review board concluded that the study was ethical for several reasons, said Mary Maguire, a spokeswoman for Abt: because it was not an entitlement, meaning it was not available to everyone; because it could not serve all of the people who applied for it; and because the control group had access to other services.

The firm also believed, she said, that such tests offered the “most compelling evidence” about how well a program worked.

Dennis P. Culhane, a professor of social welfare policy at the University of Pennsylvania, said the New York test was particularly valuable because there was widespread doubt about whether eviction-prevention programs really worked.

Professor Culhane, who is working as a consultant on both the New York and HUD studies, added that people were routinely denied Homebase help anyway, and that the study was merely reorganizing who ended up in that pool. According to the city, 5,500 households receive full Homebase help each year, and an additional 1,500 are denied case management and rental assistance because money runs out.

But some public officials and legal aid groups have denounced the study as unethical and cruel, and have called on the city to stop the study and to grant help to all the test subjects who had been denied assistance.

“They should immediately stop this experiment,” said the Manhattan borough president, Scott M. Stringer. “The city shouldn’t be making guinea pigs out of its most vulnerable.”

But, as controversial as the experiment has become, Mr. Diamond said that just because 90 percent of the families helped by Homebase stayed out of shelters did not mean it was Homebase that kept families in their homes. People who sought out Homebase might be resourceful to begin with, he said, and adept at patching together various means of housing help.

Advocates for the homeless said they were puzzled about why the trial was necessary, since the city proclaimed the Homebase program as “highly successful” in the September 2010 Mayor’s Management Report, saying that over 90 percent of families that received help from Homebase did not end up in homeless shelters. One critic of the trial, Councilwoman Annabel Palma, is holding a General Welfare Committee hearing about the program on Thursday.

“I don’t think homeless people in our time, or in any time, should be treated like lab rats,” Ms. Palma said.

“This is about putting emotions aside,” [Mr. Diamond] said. “When you’re making decisions about millions of dollars and thousands of people’s lives, you have to do this on data, and that is what this is about.”

Still, legal aid lawyers in New York said that apart from their opposition to the study’s ethics, its timing was troubling because nowadays, there were fewer resources to go around.

Ian Davie, a lawyer with Legal Services NYC in the Bronx, said Homebase was often a family’s last resort before eviction. One of his clients, Angie Almodovar, 27, a single mother who is pregnant with her third child, ended up in the study group denied Homebase assistance. “I wanted to cry, honestly speaking,” Ms. Almodovar said. “Homebase at the time was my only hope.”

Ms. Almodovar said she was told when she sought help from Homebase that in order to apply, she had to enter a lottery that could result in her being denied assistance. She said she signed a letter indicating she understood. Five minutes after a caseworker typed her information into a computer, she learned she would not receive assistance from the program.

With Mr. Davie’s help, she cobbled together money from the Coalition for the Homeless and a public-assistance grant to stay in her apartment. But Mr. Davie wondered what would become of those less able to navigate the system. “She was the person who didn’t fall through the cracks,” Mr. Davie said of Ms. Almodovar. “It’s the people who don’t have assistance that are the ones we really worry about.”

Professor Culhane said, “There’s no doubt you can find poor people in need, but there’s no evidence that people who get this program’s help would end up homeless without it.”