Measles is big this year

The CDC just put out a Health Advisory describing measles' big comeback. Though endemic transmission is the US has been interrupted, but importations keep happening when the unvaccinated population travels or come into contact with travelers:

The United States is experiencing a high number of reported measles cases in 2011, many of which were acquired during international travel. From January 1 through June 17 this year, 156 confirmed cases of measles were reported to CDC. This is the highest reported number since 1996. Most cases (136) were associated with importations from measles-endemic countries or countries where large outbreaks are occurring. The imported cases involved unvaccinated U.S. residents who recently traveled abroad, unvaccinated visitors to the United States, and people linked to these imported cases. To date, 12 outbreaks (3 or more linked cases) have occurred, accounting for 47% of the 156 cases. Of the total case-patients, 133 (85%) were unvaccinated or had undocumented vaccination status. Of the 139 case-patients who were U.S. residents, 86 (62%) were unvaccinated, 30 (22%) had undocumented vaccination status, 11 (8%) had received 1 dose of measles-mumps-rubella (MMR) vaccine, 11 (8%) had received 2 doses, and 1 (1%) had received 3 (documented) doses.

Measles was declared eliminated in the United States in 2000 due to our high 2-dose measles vaccine coverage, but it is still endemic or large outbreaks are occurring in countries in Europe (including France, the United Kingdom, Spain, and Switzerland), Africa, and Asia (including India). The increase in measles cases and outbreaks in the United States this year underscores the ongoing risk of importations, the need for high measles vaccine coverage, and the importance of prompt and appropriate public health response to measles cases and outbreaks.

Measles is a highly contagious, acute viral illness that is transmitted by contact with an infected person through coughing and sneezing. After an infected person leaves a location, the virus remains contagious for up to 2 hours on surfaces and in the air. Measles can cause severe health complications, including pneumonia, encephalitis, and death.

The message is simple: parents should vaccinate their children because not doing so has serious health effects not only on those children, but also on those who are unable to be vaccinated because they are either too young or have medical contraindications. If everyone who believed (wrongly) that vaccines are unsafe would move to one country (let's call it Unvaccinstan) then the choice would have fewer ethical pitfalls: you make a bad choice, and your kids might get sick. But as it is there are many people who simply can't get vaccinated -- kids with cancer for example, or kids in the window between when your maternal antibodies aren't that effective against measles but still interfere with the vaccine -- so the choice has much broader societal impact. I imagine that many of the parents who choose not to vaccinate -- who are often of higher educational status and more liberal politics -- view themselves  as virtuous; the reality is sadly the opposite.

Monday Miscellany: NYC edition

Two weeks ago I moved to New York City for the summer, so today's links from around the interwebs are focused on the Big Apple:

Lead poisoning in China

It's a huge problem -- the Times calls it a Hidden Scourge:

Here, Chinese leaders have acknowledged that lead contamination is a grave issue and have raised the priority of reducing heavy-metal pollution in the government’s latest five-year plan, presented in March. But despite efforts to step up enforcement, including suspending production last month at a number of battery factories, the government’s response remains faltering.

At a meeting last month of China’s State Council, after yet another disclosure of mass poisoning, Prime Minister Wen Jiabao scolded Environmental Minister Zhou Shengxian for the lack of progress, according to an individual with high-level government ties who spoke on the condition of anonymity.

The government has not ordered a nationwide survey of children’s blood lead levels, so the number of children who are at risk is purely a matter of guesswork. Mass poisonings like that at the Haijiu factory typically come to light only after suspicious parents seek hospital tests, then alert neighbors or co-workers to the alarming results.

And relevant to my current work, which I hope to write about more soon.

Tornado epidemiology

The news out of Joplin, Missouri is heartbreaking, and it comes so quickly on the heels of the tornadoes that hit Tuscaloosa, Alabama. Central Arkansas, where I grew up, gets hit by tornadoes every spring, so I have plenty of memories of taking shelter in response to warnings. College nights with social plans ruined when we had to hunker down in an interior hallways. Dark, roiling clouds circling and the spooky calm when the rain and hail stop but the winds stay strong. Racing home from work to get to my house and its basement -- a rarity in the South -- before a particularly ominous storm hit. Neighboring communities were sometimes hit more directly by storms, and Harding students often participated in clean-up an recovering efforts, but my town was spared direct hits by the heaviest tornadoes. So what does epidemiology have to say about tornadoes? Their paths aren't exactly random, in the sense that some areas are more prone to storms that produce tornadoes. Growing up I knew where to take shelter: interior hallways away from windows if your house didn't have a basement or a dedicated storm shelter. I also knew that mobile homes were a particularly bad place to be, and that the carnage was always worst when a tornado happened to hit a mobile home lot.

But there is some interesting research out there that tells us more than you might think. Obviously and thankfully you can't do a randomized trial assigning some communities to get storms and others not, so the evidence of how to prevent tornado-related injury and death is mostly observational. What do we know? I'm not an expert on this but I did a quick, non-systematic scan and here's what I found:

First, the annual tornado mortality rate has actually gone down quite a lot over the last few decades. That says nothing about the frequency and intensity of tornadoes themselves, which is a matter for meteorologists to research. The actual number deaths resulting from tornadoes would probably be a function of the number of people in the US, where they live and whether those areas are prone to tornadoes, the frequency and intensity of the tornadoes, and risk factors for people in the affected area once the tornado hits.

This NOAA site has the following graph of tornado mortality where the vertical axis is tornado deaths per million people in the US (on a log scale) and the horizontal axis covers 1875 - 2008.

Second, many of the risk factors for tornado injury and death are intuitive and suggest possible interventions to minimize risk in tornado-prone areas. Following tornadoes in North and South Carolina in 1984, Eidson et al. surveyed people hospitalized and family members of people who were killed, along with uninjured persons who were present when the surveyed individuals were hurt. The main types of injury were deep cuts, concussions, unconsciousness and broken bones. Risk factors included living in mobile homes, "advanced age (60+ years), no physical protection (not having been covered with a blanket or other object), having been struck by broken window glass or other falling objects, home lifted off its foundation, collapsed ceiling or floor, or walls blown away." Some of those patterns might indicate potential tornado education interventions -- better shelters for mobile home residents, targeting alerts to older residents, covering with a blanket, and staying in interior hallways, to say nothing of building codes to make more survivable structures.

Third, some things are less clear, like whether it's safe to be in a car during a tornado. Daley et al. did a case-control study of tornado injuries and deaths in the aftermath of tornadoes in Oklahoma in 1999. They found higher risk of tornado death for those in mobile homes (odds ratio of 35.3, 95% CI 7.8 - 175.6) or outdoors (odds ratio of 141.2, 95% CI 15.9 - a whopping 6,379.8) compared to other houses. They found no difference in risk of death, severe injury, or minor injury among people in cars vs. those in houses. And they found that risk of death, severe injury, or minor injury was actually lower among those "fleeing their homes in motor vehicles than among those remaining." That's surprising to me, and contrary to much of the tornado-related safety warnings I heard from meteorologists and family growing up. I wonder if this particular study goes against the majority of findings, or whether there is a consensus based in data at all.

Fourth, our knowledge of tornadoes can be messy. One demographic approach to tornado risk factors (Donner 2007) is to look for correlations between tornado fatalities and injuries with rural population, population density, household size, racial minorities, deprivation/poverty, tornado watches and warnings, and mobile homes. Donner noted that "Findings suggest a strong relationship between the size of a tornado path and both fatalities and injuries, whereas other measures related to technology, population, and organization produce significant yet mixed results."

That's just a sampling of the literature on tornado epidemiology. The studies are interesting but relatively rare, at least from initial perusal. That's probably because tornado deaths and injuries are relatively rare in the US. Still, the storms themselves are terrifying and they often wreak havoc on a single community and thus generate more sympathy and news coverage than a more frequent -- and thus less extraordinary -- problem like car crashes.

Update: NYT has an interesting article about tornado preparedness, including some speculation on why the Joplin tornado was so bad.

This is all very meta

One of the best things about XKCD is that the mouse-over text (simply rendered using the title attribute in the <img> HTML tag) will almost always give you a second laugh or an interesting thought. This comic isn't his best, but it has this great mouse-over text:

Wikipedia trivia: if you take any article, click on the first link in the article text not in parentheses or italics, and then repeat, you will eventually end up at "Philosophy."

Naturally, I went to Wikipedia and clicked Random Article, which gave me the Bradford-Union Street Historic District in Plymouth, Massachusetts. The links followed in order were:

  1. Bradford-Union Street Historic District
  2. Plymouth, Massachusetts
  3. Plymouth County, Massachusetts
  4. County (United States)
  5. U.S. state
  6. Federated state
  7. Constitution
  8. State (polity)
  9. Institution
  10. Social structure
  11. Social sciences
  12. List of academic disciplines
  13. Academia
  14. Organism
  15. Community
  16. Interaction
  17. Causality
  18. Event
  19. Observable
  20. Physics
  21. Natural science
  22. Science
  23. Knowledge
  24. Fact
  25. Information
  26. Sequence
  27. Mathematics
  28. Quantity
  29. Property (philosophy)
  30. Modern philosophy
  31. Philosophy

According to the Wikipedia page on the phenomenon (of course there's one, which also of course already referenced the XKCD mention) the longest known link chain is just 35 links back to philosophy, so my random find is way up there.

It's interesting to observe how the selections work back from entries on specific, literal things to broader categories.  The selections go from place to categories of place to knowledge to a meta-description of what knowledge. I imagine that if you grouped Wikipedia entries by category you'd see similar chains leading back to philosophy. For instance, I think all place names should follow a similar trajectory to my example.

I also wonder what the distribution would look like if you took a list of all entries on Wikipedia and graphed them by this philosophy index number. I think all articles listed together would be messy, but a list of articles weighted by web traffic would yield a a logarithmic distribution with the bulk of the entries being people, places, or things that are far from philosophy but eventually link there. Also, the distribution of any single category (places in the United States, for example) should be more similar to a normal distribution, and the narrower the category is the more true that would be. Now if someone will just build a computer program to test my hypothesis.

Best practices of ranking aid best practices

Aid Watch has a post up by Claudia Williamson (a post-doc at DRI) about the "Best and Worst of Official Aid 2011". As Claudia summarizes, their paper looks at "five dimensions of agency ‘best practices’: aid transparency, minimal overhead costs, aid specialization, delivery to more effective channels, and selectivity of recipient countries based on poverty and good government" and calculates an overall agency score. Williamson notes that the "scores only reflect the above practices; they are NOT a measure of whether the agency’s aid is effective at achieving good results." Very true -- but I think this can be easily overlooked. In their paper Easterly and Williamson say:

We acknowledge that there is no direct evidence that our indirect measures necessarily map into improved impact of aid on the intended beneficiaries. We will also point out specific occasions where the relationship between our measures and desirable outcomes could be non-monotonic or ambiguous.

But still, grouping these things together into a single index may obscure more than it enlightens. Transparency seems more of an unambiguous good, whereas overhead percentages are less so. Some other criticisms from the comments section that I'd like to highlight include one from someone named Bula:

DfID scores high and USAID scores low because they have fundamentally different missions. I doubt anyone at USAID or State would attempt to say with a straight face that AID is anything other than a public diplomacy tool. DfID as a stand alone ministry has made a serious effort in all of the areas you’ve measured because it’s mission aligns more closely to ‘doing development’ and less with ‘public diplomacy’. Seems to be common sense.

And a comment from Tom that starts with a quote from the Aid Watch post:

“These scores only reflect the above practices; they are NOT a measure of whether the agency’s aid is effective at achieving good results.”

Seriously? How can you possibly give an aid agency a grade based solely on criteria that have no necessary relationship with aid effectiveness? It is your HYPOTHESIS that transparency, overhead, etc, significantly affect the quality of aid, but without looking at actual effeciveness that hypothesis is completely unproven. An A or an F means absolutely nothing in this context. Without looking at what the agency does with the aid (i.e. is it effective), why should we care whether an aid agency has low or high overhead? To take another example, an aid agency could be the least transparent but achieve the best results; which matters more, your ideological view of how an agency “should” function, or that they achieve results? In my mind it’s the ends that matter, and we should then determine what the best means are to achieve that result. You approach it with an a priori belief that those factors are the most important, and therefore risk having ideology overrule effectiveness. Isn’t that criticism the foundation of this blog and Dr. Easterly’s work more generally?

Terence at Waylaid Dialectic has three specific criticisms worth reading and then ends with this:

I can see the appeal, and utility of such indices, and the longitudinal data in this one are interesting, but still think the limitations outweigh the merits, at least in the way they’re used here. It’s an interesting paper but ultimately more about heat than light."

I'm not convinced the limitations outweigh the merits, but there are certainly problems. One is that the results quickly get condensed to "Britain, Japan and Germany do pretty well and the U.S. doesn’t."

Another problem is that without having some measure of aid effectiveness, it seems that this combined metric may be misleading -- analogous to a process indicator in a program evaluation. In that analogy, Program A might procure twice as many bednets as Program B, but that doesn't mean it's necessarily better, and for that you'd need to look at the impact on health outcomes. Maybe more nets is better. Or maybe the program that procures fewer bednets distributes them more intelligently and has a stronger impact. In the absence of data on health outcomes, is the process indicator useful or misleading? Well, it depends. If there's a strong correlation (or even a good reason to believe) that the process and impact indicators go together, then it's probably better than nothing. But if some of the aid best practices lead to better aid effectiveness, and some don't, then it's at best not very useful, and at worst will prompt agencies to move in the wrong direction.

As Easterly and Williamson note in their paper, they're merely looking at whether aid agencies do what aid agencies say should be their best practices. However, without a better idea of the correlation between those aid practices and outcomes for the people who are supposed to benefit from the programs, it's really hard to say whether this metric is (using Terence's words) "more heat than light."

It's a Catch-22: without information on the correlation between best aid practices and real aid effectiveness it's hard to say whether the best aid practices "process indicator" is enlightening or obfuscating, but if we had that data on actual aid effectiveness we would be looking at that rather than best practices in the first place.

Miscellany: Epidemic City and life expectancy

In 8 days I'll be done with my first year of graduate studies and will have a chance to write a bit more. I've been keeping notes all year on things to write about when I have more time, so I should have no shortage of material! In the meantime, two links to share: 1) Just in time for my summer working with the New York City Department of Health comes Epidemic City: The Politics of Public Health in New York. The Amazon / publisher's blurb:

The first permanent Board of Health in the United States was created in response to a cholera outbreak in New York City in 1866. By the mid-twentieth century, thanks to landmark achievements in vaccinations, medical data collection, and community health, the NYC Department of Health had become the nation's gold standard for public health. However, as the city's population grew in number and diversity, new epidemics emerged, and the department struggled to balance its efforts between the treatment of diseases such as AIDS, multi-drug resistant tuberculosis, and West Nile Virus and the prevention of illness-causing factors like lead paint, heroin addiction, homelessness, smoking, and unhealthy foods. In Epidemic City, historian of public health James Colgrove chronicles the challenges faced by the health department in the four decades following New York City's mid-twentieth-century peak in public health provision.

This insightful volume draws on archival research and oral histories to examine how the provision of public health has adapted to the competing demands of diverse public needs, public perceptions, and political pressure.

Epidemic City delves beyond a simple narrative of the NYC Department of Health's decline and rebirth to analyze the perspectives and efforts of the people responsible for the city's public health from the 1960s to the present. The second half of the twentieth century brought new challenges, such as budget and staffing shortages, and new threats like bioterrorism. Faced with controversies such as needle exchange programs and AIDS reporting, the health department struggled to maintain a delicate balance between its primary focus on illness prevention and the need to ensure public and political support for its activities.

In the past decade, after the 9/11 attacks and bioterrorism scares partially diverted public health efforts from illness prevention to threat response, Mayor Michael Bloomberg and Department of Health Commissioner Thomas Frieden were still able to work together to pass New York's Clean Indoor Air Act restricting smoking and significant regulations on trans-fats used by restaurants. Because of Bloomberg's willingness to exert his political clout, both laws passed despite opposition from business owners fearing reduced revenues and activist groups who decried the laws' infringement upon personal freedoms. This legislation preventative in nature much like the 1960s lead paint laws and the department's original sanitary code reflects a return to the 19th century roots of public health, when public health measures were often overtly paternalistic. The assertive laws conceived by Frieden and executed by Bloomberg demonstrate how far the mandate of public health can extend when backed by committed government officials.

Epidemic City provides a compelling historical analysis of the individuals and groups tasked with negotiating the fine line between public health and political considerations during the latter half of the twentieth century. By examining the department's successes and failures during the ambitious social programs of the 1960s, the fiscal crisis of the 1970s, the struggles with poverty and homelessness in the 1980s and 1990s, and in the post-9/11 era, Epidemic City shows how the NYC Department of Health has defined the role and scope of public health services, not only in New York, but for the entire nation.

2) Aaron Carroll at the Incidental Economist writes about the subtleties of life expectancy. His main point is that infant mortality skews life expectancy figures so much that if you're talking about end-of-life expectations for adults who have already passed those (historically) most perilous times as a youngster, you really need to look at different data altogether.

The blue points on the graph below show life expectancy for all races in the US at birth, while the red line shows life expectancy amongst those who have reached the age of 65. Ie, if you're a 65-year-old who wants to know your chances of dying (on average!) in a certain period of time, it's best to consult a more complete life table rather than life expectancy at birth, because you've already dodged the bullet for 65 years.

(from the Incidental Economist)

The Tea Test

If you haven't been following it, there's currently a lot of controversy swirling around Greg Mortenson, co-author of Three Cups of Tea and co-founder of the Central Asia Institute. On Sunday 60 minutes aired accusations that Mortenson fabricated the 'creation myth' of the organization, a story about being kidnapped by the Taliban, and more. The blog Good Intentions Are Not Enough is compiling posts related to the emerging scandal, and the list is growing fast. If you haven't read it already, Jon Krakauer's mini-book, Three Cups of Deceit: How Greg Mortenson, Humanitarian Hero, Lost His Way, is really worth the read. Completely engrossing. It's a free download at byliner.com until April 20. It's about 90 pages, and Krakauer has obviously been researching it for a while -- in fact, my guess is that Krakauer turned 60 Minutes onto the story, rather than vice versa, which would help explain why he was featured so heavily in their piece. In the TV interview Krakauer quotes several former employees saying quite unflattering things about how CAI is run, so it's good to see that he gets many of those people on record in his ebook.

A few disclaimers: I think it's worth pointing out that a) as a one-time supporter and donor to CAI, Krakauer arguably has an axe to grind, b) several of Krakauer's previous books (Into Thin Air, Into the Wild, and Under the Banner of Heaven) have had sections disputed factually, though to me Into the Wild is the only case where he seems to have actually gotten things wrong, and c) I'm a big fan of him as a writer and thus am possibly a bit predisposed to believe him. Admitting by biases up front like good epidemiologist.

That said, it sounds like CAI has been very poorly led. Krakauer's book levels many damning claims about Mortenson and CIA's financial management that, while less emotionally shocking than the exaggerations about the 'creation myth,' should be much more troubling. CAI and Mortenson's responses to the accusations so far on 60 Minutes have seemed superficial, and I think it's safe to say that they will not come out of this looking squeaky clean.

I believe this episode raises two broader questions for the nonprofit community.

First, Krakauer chronicles a string of board members, employees, and consultants who came in, were shocked by how things were done and/or discovered discrepancies, and ended up leaving or resigning in protest. This section (pages 50-51) jumped out at me:

After Mortenson refused to comply with CFO Debbie Raynor's repeated requests to provide documentation for overseas programs, Raynor contacted Ghulam Parvi (the Pakistan program manager) directly, instructing him to provide her with documentation. For two or three months Parvi complied - until Mortenson found out what was going on and ordered Parvi to stop. Raynor resigned.

In 2007, Mortenson hired an accomplished consultant to periodically fly to Central Asia to supervise projects. When he discovered irregularities and shared them with Mortenson, Mortenson took no action to rectify the misconduct. In 2010, the consultant quit in frustration.

In September 2007, CAI hired a highly motivated, uncommonly capable woman to manage its international programs. Quickly, she demonstrated initiative and other leadership skills the Institute sorely needed. She had exceptional rapport with Pakistani women and girls. In 2008, she unearthed serious issues in Baltistan that contradicted what Mortenson had been reporting. After she told Mortenson about these problems, she assumed he would want her to address them. Instead, as she prepared to return to Pakistan in 2009, Mortenson ordered her to stay away from Baltistan. Disillusioned, she resigned in June 2010.

Seriously -- ff this has been going on for so long, how on earth is it just coming out now? Evidently a nationally known organization can have nearly its entire board resign and multiple employees quit, and it doesn't make the news until years later? Some of this (I'm speculating here) likely results from a hesitance on the part of those former employees to speak ill of CAI, whether because they still believed in its mission or because they were worried about being the sour grape person. Were they speaking out and nobody listened, or is there simply no good way to raise red flags about a nonprofit organization?

Second, while most organizations aren't guilty of fraud -- we hope -- there's at least one other take-away here. Another excerpt that jumped out at me:

On June 13, 2010, Parvi convened a meeting in Skardu to discuss Three Cups of Tea. Some thirty community leaders from throughout Baltistan participated, and most of them were outraged by the excerpts Parvi translated for them. Sheikh Muhammad Raza—chairman of the education committee at a refugee camp in Gultori village, where CAI has built a primary school for girls—angrily proposed charging Mortenson with the crime of fomenting sectarian unrest, and urged the District Administration to ban Mortenson and his books from Baltistan.

Based on Krakauer's footnotes, Parvi may be one of his less reliable sources, but this idea -- that the people portrayed in the book were outraged when it was translated to them because of how misleading it is -- comes up several times. Yes, fabricating stories is really bad. But how many other things do nonprofits say in their advertising that would be uncomfortable or downright offensive if you translated it for (and/or showed the accompanying pictures to) the recipients or beneficiaries or their services?

I propose a simple way to check this impulse -- to write about people as if they are victims or powerless -- and in honor of Three Cups of Tea, I call it the "Tea Test":

Step One: read the website content, blog posts, or email appeal you just got from your charity of choice. Or, if you work for a nonprofit organization, read your own stuff.

Step Two: imagine arriving in the recipient city or village, with a translated copy of that text. Would you be uncomfortable reading that website or blog or email to the people you met? Would it require tortured explanations, or would it instantly make sense and leave them feeling dignified?

That's it: if Step Two didn't make you cringe, then you passed the Tea Test. If it made you uncomfortable, made them feel ashamed, or got you attacked -- re-draft your copy and try again. Or find another organization to support.

I think there are many organizations that pass the Tea Test, but probably many more that fail. These organizations don't necessarily share all the faults of CAI as laid out by Krakauer and others, but they wouldn't fare much better in this situation, because they say something for one audience that was never intended to get back to the others.

I hope the idea of the Tea Test -- reading a translated copy of that material to the people it's describing -- will be helpful for donors and nonprofiteers alike. As a former online fundraiser I know I've broken this rule, and as a donor I've found things appealing that I probably should have reacted strongly against. I'm going to try to do better.

Update: I've posted a slightly revised (and I hope easier to remember) version of the Tea Test on a permanent page here.

Modelling Stillbirth

William Easterly and Laura Freschi go after "Inception Statistics" in the latest post on AidWatch. They criticize -- in typically hyperbolic style, with bonus points for the pun in the title -- both the estimates of stillbirth and their coverage in the news media. I left a comment on their blog outlining my thoughts but thought I'd re-post them here with a little more explanation. Here's what I said:

Thanks for this post (it’s always helpful to look at quality of estimates critically) but I think the direction of your criticism needs to be clarified. Which of the following are you upset about (choose all that apply)?

a) the fact that the researchers used models at all? I don’t know the researchers personally, but I would imagine that they are concerned with data quality in general and would much preferred to have had reliable data from all the countries they work with. But in the absence of that data (and while working towards it) isn’t it helpful to have the best possible estimates on which to set global health policy, while acknowledging their limitations? Based on the available data, is there a better way to estimate these, or do you think we’d be better off without them (in which case stillbirth might be getting even less attention)? b) a misrepresentation of their data as something other than a model? If so, could you please specify where you think that mistake occurred — to me it seems like they present it in the literature as what it is and nothing more. c) the coverage of these data in the media? On that I basically agree. It’s helpful to have critical viewpoints on articles where there is legitimate disagreement.

I get the impression your main beef is with (c), in which case I agree that press reports should be more skeptical. But I think calling the data “made up” goes too far too. Yes, it’d be nice to have pristine data for everything, but in the meantime we should try for the best possible estimates because we need something on which to base policy decisions. Along those lines, I think this commentary by Neff Walker (full disclosure: my advisor) in the same issue is worthwhile. Walker asks these five questions – noting areas where the estimates need improvement: - “Do the estimates include time trends, and are they geographically specific?” (because these allow you to crosscheck numbers for credibility) - “Are modelled results compared with previous estimates and differences explained?” - “Is there a logical and causal relation between the predictor and outcome variables in the model?” - “Do the reported measures of uncertainty around modelled estimates show the amount and quality of available data?” - “How different are the settings from which the datasets used to develop the model were drawn from those to which the model is applied?” (here Walker says further work is needed)

I'll admit to being in over my head in evaluating these particular models. As Easterly and Freschi note, "the number of people who actually understand these statistical techniques well enough to judge whether a certain model has produced a good estimate or a bunch of garbage is very, very small." Very true. But in the absence of better data, we need models on which to base decisions -- if not we're basing our decisions on uninformed guesswork, rather than informed guesswork.

I think the criticism of media coverage is valid. Even if these models are the best ever they should still be reported as good estimates at best. But when Easterly calls the data "made up" I think the hyperbole is counterproductive. There's an incredibly wide spectrum of data quality, from completely pulled-out-of-the-navel to comprehensive data from a perfectly-functioning vital registration system. We should recognize that the data we work with aren't perfect. And there probably is a cut-off point at which estimates are based on so many models-within-models that they are hurtful rather than helpful in making informed decisions. But are these particular estimates at that point? I would need to see a much more robust criticism than AidWatch has provided so far to be convinced that these estimates aren't helpful in setting priorities.

from Baltimore to Central America via David Simon's imagination

David Simon, creator of The Wire and newly minted MacArthur Fellow, is interviewed by Bill Moyers in Guernica. It's one of the best things I've read in quite a while.

David Simon: You talk honestly with some of the veteran and smarter detectives in Baltimore, the guys who have given their career to the drug war, including, for example, Ed Burns, who was a drug warrior for twenty years, and they’ll tell you, this war’s lost. This is all over but the shouting and the tragedy and the waste. And yet there isn’t a political leader with the stomach to really assess it for what it is.

Bill Moyers: So whose lives are less and less necessary in America today?

David Simon: Certainly the underclass. There’s a reason they are the underclass. We’re in an era when you don’t need as much mass labor; we are not a manufacturing base. People who built stuff, their lives had some meaning and value because the factories were open. You don’t need them anymore.

When I first moved to Baltimore I avoided watching The Wire for several months because I didn't want it to color my first impressions, and I've still only had time to watch the first season. But based on that alone, The Wire was a work of art, and one that was always risky in terms of commercial success because of the length of its story arcs.

A while back Kottke highlighted Simon's original pitch for the series (emphasis added):

But more than an exercise is realism for its own sake, the verisimilitude of The Wire exists to serve something larger. In the first story-arc, the episodes begin what would seem to be the straight-forward, albeit protracted, pursuit of a violent drug crew that controls a high-rise housing project. But within a brief span of time, the officers who undertake the pursuit are forced to acknowledge truths about their department, their role, the drug war and the city as a whole. In the end, the cost to all sides begins to suggest not so much the dogged police pursuit of the bad guys, but rather a Greek tragedy. At the end of thirteen episodes, the reward for the viewer -- who has been lured all this way by a well-constructed police show -- is not the simple gratification of hearing handcuffs click. Instead, the conclusion is something that Euripides or O'Neill might recognize: an America, at every level at war with itself.

And not just with itself. The Guernica interview I quoted from above resonated with me because I had just finished this Economist article on "Central America: the tormented isthmus" which outlines the many ways in which America's appetites and means result in our internal war being continuously foisted upon other countries.

Nearly all the world’s cocaine is produced in Colombia, Peru and Bolivia. The biggest consumer is the United States, where the wholesale price of a kilo of the stuff, even full of impurities, starts at $12,500. The route to market used to run from Colombia to the tip of Florida, across the Caribbean. But the United States Coast Guard shut down that corridor by the early 1990s, and shipments switched to the Pacific coast of Mexico. Now Mexico, too, has increased the pressure on the traffickers, just as Colombia has done in the south.

Ever supple, the drugs business has sought new premises. Somewhere between 250 and 350 tonnes of cocaine—or almost the whole amount heading for the United States—now pass through Guatemala each year, according to American officials...

The impact has been lethal. Guatemala’s murder rate has doubled in the past decade. In both Guatemala and El Salvador, the rate of killing is higher now than during their civil wars.

The comments on that article led me to this BBC article from April 7, on the drug-fueled violence in Mexico.

This view [that the violence is the result of fighting between rival criminal gangs, a sign of progress in the drug war] was echoed by the head of the US Drug Enforcement Administration, Michele Leonhart, at an international conference in the Mexican City of Cancun on Wednesday.

"It may seem contradictory, but the unfortunate level of violence is a sign of success in the fight against drugs," the DEA chief said.

And that must also mean that the increasing violence in Central America due to shifts in drug trafficking patterns is truly a sign that we're winning the future. If this is success, maybe we'd all be better of with failure.

Summer plans

My first (and only) full year of coursework for my masters program is drawing to a close. Finals are in mid-May, and comprehensive exams are in early June. Then it's off to New York City! On June 8 I will be joining the 5th class of the Epi Scholars program with the New York City Department of Health and Mental Hygiene. Each scholar (read: grad student in epidemiology) is paired with a staff mentor and given a specific project to work on throughout the summer. The research work is augmented by training on SAS and GIS, educational sessions on health disparities and other topics that touch on the work of the Department. The project I will be working on involves characterizing children with severe lead poisoning in New York to help clinicians better screen for them. I've only heard amazing things about this program from the Hopkins students and alumni who have gone before, so I'm quite excited.

In the fall I will move to an as-yet-undisclosed location and spend the majority of my second year doing 'field work' in global health. One of the reasons I chose this program is that it gives me the chance to get a substantial chunk (6-12 months) of work experience abroad in one place before I complete my degree, and I plan to take full advantage of that. More on where I'll be once things are finalized.

Stuff wannabe aid workers like

The blog Stuff Expat Aid Workers Like is really tearing it up lately. Their latest post is#45 - Blogging to Display Their Superior Thinking. An excerpt:

Microlending?  Oversold uncritically as a silver bullet and only your Kiva-donating grandma still thinks this is a cure-all.  Girl Effect? Undoes its own message with its objectionable messaging.  Advocacy? You mean, “badvocacy?” Perilously reductionist and, anyway, spearheaded by way too many celebrities, neo-hippies and naive idealists for it to do any real good.  In-kind donations?  Logistical nightmare and destroyer of local markets.  Popular journalists on the developing country beat (and Nicolas Kristof in particular)?  Dangerously oversimplify complex global issues that only the real EAW bloggers truly understand.

The secret and deep hope of the EAW blogger is to get the blessing of the aid blog patriarch, Bill Easterly, and any of his disciples, and get a shout out or, better yet, featured on his blogroll.

Ouch. Of course, none of this applies to me yet because I am not a real expat aid worker, but rather a grad student intending to be one. But hopefully this fall I will be able to start fulfilling this post (which I think is their best yet): #44 - Blogging for the Folks Back Home.

Update/clarification: the "wannabe" in the title is a reference to me. Thought that was clear, but maybe it wasn't.

Fact for the day

Astonishingly, a third of the wealthiest 20% of Indian children are malnourished, too, and they are neither poor nor excluded.

That's from the Economist last Thursday.

Wonder what it says about India, but also what it says about our measures of wealth and malnutrition.

GlobalHealthLearning.org

USAID evidently offers a number of short online courses on global health, including quite a few related to PEPFAR. I just registered but haven't tried these out yet -- if you have, please let me know what you think in the comments. They're available at www.globalhealthlearning.org. From an email:

We are pleased to announce the launch of six new eLearning courses on the U.S. Agency for International Development’s Global Health eLearning Center (www.globalhealthlearning.org):

  • Healthy Businesses: Familiarizes learners with strategies to design and deliver activities to ensure that commercial for-profit health care providers have the business, operational, and financial capacity to sustainably provide essential health services.
  • Male Circumcision: Policy and Programming: Provides learners with an overview of scientific evidence of male circumcision’s (MC's) protective effect against HIV transmission, the acceptability and safety of MC, challenges to MC program implementation, and policy and program guidance.

PEPFAR-related eLearning courses:

  • Data Use for Program Managers: Provides learners with a systematic approach to planning for the use of data, specifically within the field of HIV/AIDS.
  • Economic Evaluation Basics: Gives learners a basic understanding of the common methods used to conduct an economic evaluation and the role of economic evaluations in policy and program decision-making in the field of international public health.
  • Geographic Approaches to Global Health: Acquaints learners with spatial data and the use of such data to enhance the decision-making process for health program implementation in limited resource settings.
  • PEPFAR Next Generation Indicators Guidance: Allows learners to gain a better understanding about the newest version of the NGI Reference Guide and how the information contained in the guide can be used to report progress of PEPFAR programs within national monitoring and evaluation frameworks.

Thank you very much for your interest in and support of the Global Health eLearning Center!

h/t Kriti

Everyday science

David Brooks highlights a discussion "on what scientific concepts everyone’s cognitive toolbox should hold" on Edge.org. Brooks' first highlight is this:

Clay Shirkey nominates the Pareto Principle. We have the idea in our heads that most distributions fall along a bell curve (most people are in the middle). But this is not how the world is organized in sphere after sphere. The top 1 percent of the population control 35 percent of the wealth. The top two percent of Twitter users send 60 percent of the messages. The top 20 percent of workers in any company will produce a disproportionate share of the value. Shirkey points out that these distributions are regarded as anomalies. They are not.

The full Edge.org symposium is here. I'm not sure these individual insights are science or even scientific concepts, as much as "insights on thinking that some scientists have found useful" -- but still interesting. Here's Richard Dawkins on the Double-Blind Control Experiment (emphasis added):

....Why do half of all Americans believe in ghosts, three quarters believe in angels, a third believe in astrology, three quarters believe in Hell? Why do a quarter of all Americans and believe that the President of the United States was born outside the country and is therefore ineligible to be President? Why do more than 40 percent of Americans think the universe began after the domestication of the dog?

Let's not give the defeatist answer and blame it all on stupidity. That's probably part of the story, but let's be optimistic and concentrate on something remediable: lack of training in how to think critically, and how to discount personal opinion, prejudice and anecdote, in favour of evidence. I believe that the double-blind control experiment does double duty. It is more than just an excellent research tool. It also has educational, didactic value in teaching people how to think critically. My thesis is that you needn't actually do double-blind control experiments in order to experience an improvement in your cognitive toolkit. You only need to understand the principle, grasp why it is necessary, and revel in its elegance.

If all schools taught their pupils how to do a double-blind control experiment, our cognitive toolkits would be improved in the following ways:

1. We would learn not to generalise from anecdotes.

2. We would learn how to assess the likelihood that an apparently important effect might have happened by chance alone. 3. We would learn how extremely difficult it is to eliminate subjective bias, and that subjective bias does not imply dishonesty or venality of any kind. This lesson goes deeper. It has the salutary effect of undermining respect for authority, and respect for personal opinion....

"The Most Important Medical Discovery of the 20th Century"

Just a reminder -- it wasn't open heart surgery or sequencing the human genome:

A massive cholera outbreak in refugee camps on the border of India and Bangladesh in the 1970s exposed the limitations of intravenous treatment and paved the way for a radically different approach to treating dehydration.

In 1971, the war for independence in what is now Bangladesh prompted 10 million refugees to %ee to the border of West Bengal, India. !e unsanitary conditions in the overcrowded refugee camps fueled a deadly cholera outbreak characterized by fatality rates approaching 30 percent.' Health officials from the Indian and West Bengal governments and relief agencies faced a daunting task: Conditions were squalid and chaotic, intravenous fluid was in scarce supply, treatment facilities and transportation were inadequate, and trained personnel were limited.' Mass treatment with intravenous therapy alone would not halt the impending crisis.

Dr. Dilip Mahalanabis, a cholera expert at the Johns Hopkins Centre for Medical Research and Training in Calcutta and head of a health center at one of the refugee camps, proposed an alternative to the intravenous treatment. He suggested the camp use a new method of oral replacement of fluid, known as oral rehydration therapy, that had been developed in the 1960s in Bangladesh and Calcutta.

The science was as ingenious as it was simple: A solution of water, salt, and sugar was found to be as effective in halting dehydration as intravenous therapy. Dr. Mahalanabis’ team recognized the many advantages of oral therapy over the intravenous rehydration: It is immensely cheaper, at just a few cents per dose; safer and easier to administer; and more practical for mass treatment. ORT, however, had still not been tested in an uncontrolled setting, and skeptical health specialists cautioned that only health professionals and doctors should administer the new therapy.)

Mahalanabis’ team moved quickly to introduce the treatment to the 350,000 residents of the camp. Packets of table salt, baking soda, and glucose were prepared in Calcutta at the diminutive cost of one penny per liter of fluid.' The solution was widely distributed, with instructions about how to dissolve it in water. Despite the shortage of trained health personnel, large numbers of patients were treated, with mothers, friends, and patients themselves administering the solution.

The results were extraordinary: At the height of the outbreak, cholera fatalities in the camp using ORT dropped to less than 4 percent, compared with 20 percent to 30 percent in camps treated with intravenous therapy.

From Millions Saved, case study 8: diarrhea in Egypt. Just re-reading it for a class.

Michael Lewis retrospective

I've been a fan of Michael Lewis' writing ever since Ashby Monk (author of the best niche blog on sovereign wealth funds) pointed me towards Liar's Poker. Some recent and not so recent fare:

Lewis’s article in Manhattan, Inc. magazine is a terrific yarn and a remarkable artifact–mainly because of how wrong Lewis turned out to be.... The imaginary scenario Lewis crafts, of a massive Tokyo earthquake crushing the global economy, reflects a time when Japan was an ascendant economic force widely believed on the cusp of ending U.S. pre-eminence. In that world, Lewis’s imagined chain of events goes something like this: Large swaths of Tokyo will be destroyed by a magnitude 7.9 earthquake. Stock markets collapse, in part as Japanese companies and investors sell foreign assets, including U.S. Treasury bonds and commodities, to finance the country’s rebuilding. Japanese banks and companies pull money and halt their loans outside the country, sapping  a big source of the fuel for economic growth world-wide. Global interest rates soar to 5%, meaning Americans can’t afford loans to buy cars or homes. The U.S. economy skids to a halt, though Japan manages just fine....

Not always right, but always interesting.

Progress on Polio in Africa?

From the latest CDC Morbidity and Mortality Weekly Report: "Progress Toward Interrupting Wild Poliovirus Circulation in Countries with Reestablished Transmission -- Africa, 2009-2010" There are only four countries where polio is still "endemic" -- Afghanistan, Pakistan, India, and Nigeria. Combined the four endemic countries have about 23% of the world's population, though to be fair polio is only endemic in some portion of each country.

But the actual definition of "endemic" may not match with lay assumptions about that term. For polio, endemic countries are defined as those where transmission has never been broken. So a country where polio has been reintroduced -- and is now spreading on its own, without the need for additional introductions -- is by definition still not endemic. Thus, there's essentially a three-tiered system: a) endemic countries, b) countries with reestablished transmission, and c) countries without established transmission, which may have sporadic outbreaks from imported cases or from vaccine-derived polio.

The CDC report linked above provides an overview of polio in African countries. Between 2002 and 2009 several dozen previously polio-free countries had outbreaks of polio from strains imported from India or Nigeria. (The strain of polio in each outbreak is genetically typed, which means we can determine which known strain the new one is closest too, and thus from whence the outbreak came.) Of those countries, four--Angola, Chad, Democratic Republic of the Congo (DRC), and Sudan--had persistent transmission (more than one year) after re-importation of polio that occurred before 2009. One of the milestone of the Global Polio Eradication Initiative (GPEI) was that polio transmission would be interrupted in those four countries by the end of 2010. The conclusion of the MMWR report is that it has been stopped in Sudan, but not Angola, Chad, or DRC.