Aid, paternalism, and skepticism

Bill Easterly, the ex-blogger who just can't stop, writes about a conversation he had with GiveWell, a charity reviewer/giving guide that relies heavily on rigorous evidence to pick programs to invest in. I've been meaning to write about GiveWell's approach -- which I generally think is excellent. Easterly, of course, is an aid skeptic in general and a critic of planned, technocratic solutions in particular. Here's an excerpt from his notes on his conversation with GiveWell:

...a lot of things that people think will benefit poor people (such as improved cookstoves to reduce indoor smoke, deworming drugs, bed nets and water purification tablets) {are things} that poor people are unwilling to buy for even a few pennies. The philanthropy community’s answer to this is “we have to give them away for free because otherwise the take-up rates will drop.” The philosophy behind this is that poor people are irrational. That could be the right answer, but I think that we should do more research on the topic. Another explanation is that the people do know what they’re doing and that they rationally do not want what aid givers are offering. This is a message that people in the aid world are not getting.

Later, in the full transcript, he adds this:

We should try harder to figure out why people don’t buy health goods, instead of jumping to the conclusion that they are irrational.

Also:

It's easy to catch people doing irrational things. But it's remarkable how fast and unconsciously people get things right, solving really complex problems at lightning speed.

I'm with Easterly, up to a point: aid and development institutions need much better feedback loops, but are unlikely to develop them for reasons rooted in their nature and funding. The examples of bad aid he cites are often horrendous. But I think this critique is limited, especially on health, where the RCTs and all other sorts of evidence really do show that we can have massive impact -- reducing suffering and death on an epic scale -- with known interventions. [Also, a caution: the notes above are just notes and may have been worded differently if they were a polished, final product -- but I think they're still revealing.]

Elsewhere Easterly has been more positive about the likelihood of benefits from health aid/programs in particular, so I find it quite curious that his examples above of things that poor people don't always price rationally are all health-related. Instead, in the excerpts above he falls back on that great foundational argument of economists: if people are rational, why have all this top-down institutional interference? Well, I couldn't help contrasting that argument with this quote highlighted by another economist, Tyler Cowen, at Marginal Revolution:

Just half of those given a prescription to prevent heart disease actually adhere to refilling their medications, researchers find in the Journal of American Medicine. That lack of compliance, they estimate, results in 113,00 deaths annually.

Let that sink in for a moment. Residents of a wealthy country, the United States, do something very, very stupid. All of the RCTs show that taking these medicines will make them live longer, but people fail to overcome the barriers at hand to take something that is proven to make them live longer. As a consequence they die by the hundreds of thousands every single year. Humans may make remarkably fast unconscious decisions correctly in some spheres, sure, but it's hard to look at this result and see any way in which it makes much sense.

Now think about inserting Easterly's argument against paternalism (he doesn't specifically call it that here, but has done so elsewhere) in philanthropy here: if people in the US really want to live, why don't they take these medicines? Who are we to say they're irrational? That's one answer, but maybe we don't understand their preferences and should avoid top-down solutions until we have more research.

A reductio ad absurdum? Maybe. On the one hand, we do need more research on many things, including medication up-take in high- and low-income countries. On the other hand, aid skepticism that goes far enough to be against proven health interventions just because people don't always value those interventions rationally seems to line up a good deal with the sort of anti-paternalism-above-all streak in conservatism that opposes government intervention in pretty much every area. Maybe it's a good policy to try out some nudge-y (libertarian paternalism, if you will) policies to encourage people to take their medicine, or require people to have health insurance they would not choose to buy on their own.

Do you want to live longer? I bet you do, and it's safe to assume that people in low-income countries do as well. Do you always do exactly what will help you do so? Of course not: observe the obesity pandemic. Do poor people really want to suffer from worms or have their children die from diarrhea? Again, of course not. While poor people in low-income countries aren't always willing to invest a lot of time or pay a lot of money for things that would clearly help them stay alive for longer, that shouldn't be surprising to us. Why? Because the exact same thing is true of rich people in wealthy countries.

People everywhere -- rich and poor -- make dumb decisions all the time, often because those decisions are easier in the moment due to our many irrational cognitive and behavioral tics. Those seemingly dumb decisions usually reveal the non-optimal decision-making environments in which we live, but you still think we could overcome those things to choose interventions that are very clearly beneficial. But we don't always. The result is that sometimes people in low-income countries might not pay out of pocket for deworming medicine or bednets, and sometimes people in high-income countries don't take their medicine -- these are different sides of the same coin.

Now, to a more general discussion of aid skepticism: I agree with Easterly (in the same post) that aid skeptics are a "feature of the system" that ultimately make it more robust. But it's an iterative process that is often frustrating in the moment for those who are implementing or advocating for specific programs (in my case, health) because we see the skeptics as going too far. I'm probably one of the more skeptical implementers out there -- I think the majority of aid programs probably do more harm than good, and chose to work in health in part because I think that is less true in this sector than in others. I like to think that I apply just the right dose of skepticism to aid skepticism itself, wringing out a bit of cynicism to leave the practical core.

I also think that there are clear wins, supported by the evidence, especially in health, and thus that Easterly goes too far here. Why does he? Because his aid skepticism isn't simply pragmatic, but also rooted in an ideological opposition to all top-down programs. That's a nice way to put it, one that I think he might even agree with. But ultimately that leads to a place where you end up lumping things together that are not the same, and I'll argue that that does some harm. Here are two examples of aid, both more or less from Easterly's post:

  • Giving away medicines or bednets free, because otherwise people don't choose to invest in them; and,
  • A World Bank project in Uganda that "ended up burning down farmers’ homes and crops and driving the farmers off the land."

These are a both, in one sense, paternalistic, top-down programs, because they are based on the assumption that sometimes people don't choose to do what is best for themselves. But are they the same otherwise? I'd argue no. One might argue that they come from the same place, and an institution that funds the first will inevitably mess up and do the latter -- but I don't buy that strong form of aid skepticism. And being able to lump the apparently good program and the obviously bad together is what makes Easterly's rhetorical stance powerful.

If you so desire, you could label these two approaches as weak coercion and strong coercion. They are both coercive in the sense that they reshape the situations in which people live to help achieve an outcome that someone -- a planner, if you will -- has decided is better. All philanthropy and much public policy is coercive in this sense, and those who are ideologically opposed to it have a hard time seeing the difference. But to many of us, it's really only the latter, obvious harm that we dislike, whereas free medicines don't seem all that bad. I think that's why aid skeptics like Easterly group these two together, because they know we'll be repulsed by the strong form. But when they argue that all these policies are ultimately the same because they ignore people's preferences (as demonstrated by their willingness to pay for health goods, for example), the argument doesn't sit right with a broader audience. And then ultimately it gets ignored, because these things only really look the same if you look at them through certain ideological lenses.

That's why I wish Easterly would take a more pragmatic approach to aid skepticism; such a form might harp on the truly coercive aspects without lumping them in with the mildly paternalistic. Condemning the truly bad things is very necessary, and folks "on the inside' of the aid-industrial complex aren't generally well-positioned to make those arguments publicly. However, I think people sometimes need a bit of the latter policies, the mildly paternalistic ones like giving away medicines and nudging people's behavior -- in high- and low-income countries alike. Why? Because we're generally the same everywhere, doing what's easiest in a given situation rather than what we might choose were the circumstances different. Having skeptics on the outside where they can rail against wrongs is incredibly important, but they must also be careful to yell at the right things lest they be ignored altogether by those who don't share their ideological priors.

Busy

In lieu of observations about Ethiopia, notes from my work here, or discussion of recent news/articles/links, here's a picture of the books currently occupying my time at work (fascinating, I know):

Tomorrow I'm off to Mek'ele, the capital of Tigray region in northern Ethiopia, for work for about a week. If you have blog withdrawal in the meantime, I share links to maybe 5-10 articles or blog posts each day on Twitter.

Mimicking success

If you don't know what works, there can be an understandable temptation to try to create a picture that more closely resembles things that work. In some of his presentations on the dire state of student learning around the world, Lant Pritchett invokes the zoological concept of isomorphic mimicry: the adoption of the camouflage of organizational forms that are successful elsewhere to hide their actual dysfunction. (Think, for example, of a harmless snake that has the same size and coloring as a very venomous snake -- potential predators might not be able to tell the difference, and so they assume both have the same deadly qualities.) For our illustrative purposes here, this could mean in practice that some leaders believe that, since good schools in advanced countries have lots of computers, it will follow that, if computers are put into poor schools, they will look more like the good schools. The hope is that, in the process, the poor schools will somehow (magically?) become good, or at least better than they previously were. Such inclinations can nicely complement the "edifice complex" of certain political leaders who wish to leave a lasting, tangible, physical legacy of their benevolent rule. Where this once meant a gleaming monument soaring towards the heavens, in the 21st century this can mean rows of shiny new computers in shiny new computer classrooms.

That's from this EduTech post by Michael Trucano. It's about the recent evaluations showing no impact from the One Laptop per Child (OLPC) program, but I think the broader idea can be applied to health programs as well. For a moment let's apply it to interventions designed to prevent maternal mortality. Maternal mortality is notoriously hard to measure because it is -- in the statistical sense -- quite rare. While many 'rates' (which are often not actual rates, but that's another story) in public health are expressed with denominators of 1,000 (live births, for example), maternal mortality uses a denominator of 100,000 to make the numerators a similar order of magnitude.

That means that you can rarely measure maternal mortality directly -- even with huge sample sizes you get massive confidence intervals that make it difficult to say whether things are getting worse, staying the same, or improving. Instead we typically measure indirect things, like the coverage of interventions that have been shown (in more rigorous studies) to reduce maternal morbidity or mortality. And sometimes we measure health systems things that have been shown to affect coverage of interventions... and so forth. The worry is that at some point you're measuring the sort of things that can be improved -- at least superficially -- without having any real impact.

All that to say: 1) it's important to measure the right thing, 2) determining what that 'right thing' is will always be difficult, and 3) it's good to step back every now and then and think about whether the thing you're funding or promoting or evaluating is really the thing you care about or if you're just measuring "organizational forms" that camouflage the thing you care about.

(Recent blog coverage of the OLPC evaluations here and here.)

Monday Miscellany

Podcast break

Power outages in Addis -- at least in my neighborhood -- are short but still more or less a daily occurrence. At the office we have a generator that kicks in, but at home I like to think of these outages as "podcast breaks." Here are two I listened to recently that are particularly worthwhile, even if your power is on:

  • Planet Money has a nice, non-technical summary of Oregon's randomized Medicaid program. (Previous post on the same subject with more technical details here. Recent NYT coverage here.)
  • Ira Glass spoke in Princeton earlier this year, and he discussed how This American Life has been moving towards more investigative reporting -- they brought down a lousy judge in Georgia, for example. Their latest investigative installation is incredible: What Happened at Dos Erres tells the true story of the long-lost survivor of a massacre in Guatemala that wiped out an entire village. It's a great use of a human narrative to make you care about an important but disturbing story, from the role of the US in that era of Guatemalan history to the role of the investigations in modern Guatemalan politics. The reporting was done in tandem with ProPublica, so there's an excellent prose version you can read here.

(They've also shared some updates on the story here.)

Addis taxi economics

A is in his early 20s, and he's my go-to taxi driver. He speaks good conversational English, which he picked up in part through being befriended by a Canadian couple who lived in Ethiopia for a while. Addis traffic is crazy but a bit more forgiving than some cities I've seen -- there don't seem to be many real traffic rules, but there's more deference to other drivers. "A, you drive like a pro," my friend says. "How long have you been driving?" "Oh, just six months!" (We gulp.) In Addis "taxi" is used to refer to both ancient minibuses that drive set routes throughout the city and to traditional blue-and-white cars -- often ancient-er -- that will take you wherever you want to go. (Google Images of Addis taxis here.) A's car is the latter type, an old model that breaks down often and has one window handle you have to pass around to roll down each window.

Minibuses charge a flat rate on pre-specified routes, usually just a few Birr (ie, less than $0.20 US), but the personal taxis can charge much more. So having a few reliable drivers' cell numbers is helpful because the prospect of your continued business helps ensure that you'll get a better price for each ride.

Regarding taxis more generally: always negotiate a fare before you get in. Depending on the mood of the driver, current traffic and road construction, and the evident wealth, race, or nationality of the prospective passenger, the prices quoted will vary widely. I was once quoted 60 Birr and 150 Birr as starting prices ($3.50 and $8.80 US) by two drivers standing right next to each other!

Almost all of the taxi business seems to come from internationals and upper-class Ethiopians. Thus, taxis often congregate around the neighborhoods, hotels, and restaurants frequented by these groups. You'll also get quoted a higher starting price if you're seen coming out of a nice hotel than if you pick a cab just around the corner.

Starting prices definitely differ by race as well. (Here I cite conversations with Chinese-American and Bengali-American friends living in Addis.) Drivers will generally assume you're from America (if you're Caucasian), China (if you're East Asian), and India (if you're South Asian) and charge accordingly. White people get the highest starting prices, whereas if they assume you're Chinese or Indian the starting price will be about 70% of the white price. This is, of course, entirely anecdotal, so econ PhD students take note: there's some fascinating research to be done on differential pricing of initial and final fares for internationals living in Addis. In economics this differential pricing is called price discrimination (which can actually be good for consumers as it allows producers to provide services to a broader range of people, who often have different preferences and ability to pay).

A doesn't own his taxi, and says that most drivers don't either. Instead, he rents/leases his from a man who owns many taxis. That guy made enough money ("he is rich now!") that he now goes to Dubai to buy other cars to import into Ethiopia. (Dubai is the go-to place for importing many things here.) A pays the owner a flat rate to have the taxi for a 10-day period, with more or less automatic renewals as long as he's doing well enough to keep paying the fee. If he gets sick or wants to take a day off he has to pay that day's rental fee out of earnings from another day, so A gets up at 6 am and drives until after midnight. Seven days a week.

A is only six months into the job, but he's already looking for the next gig. He aspires to work as a tour guide -- better pay and better hours, he says. And, I think, less risk of injury: almost all the taxis in Addis are from an era before airbags and seatbelts became commonplace. I think A would be a great tour guide -- I hope it works out.

Sweet tooth

Turns out this fad isn't limited to New York and DC -- there's a cupcake place a couple blocks from my office: 

(Cupcake Delights, in Addis' Bole neighborhood)

Now if only we can get a Chipotle?

What we will lose

In the language of the Tuvan people, khoj özeeri means not only slaughter but also kindness, humaneness, a ceremony by which a family can kill, skin, and butcher a sheep, salting its hide and preparing its meat and making sausage with the saved blood and cleansed entrails so neatly that the whole thing can be accomplished in two hours (as the Mongushes did this morning) in one's good clothes without spilling a drop of blood.

That's from this National Geographic article, which analogizes lost linguistic diversity to lost biodiversity. Here's the kind of knowledge we might lose:

Smaller languages often retain remnants of number systems that may predate the adoption of the modern world's base-ten counting system. The Pirahã, an Amazonian tribe, appear to have no words for any specific numbers at all but instead get by with relative words such as "few" and "many." The Pirahã's lack of numerical terms suggests that assigning numbers may be an invention of culture rather than an innate part of human cognition. The interpretation of color is similarly varied from language to language. What we think of as the natural spectrum of the rainbow is actually divided up differently in different tongues, with many languages having more or fewer color categories than their neighbors.

For more on the ties between language and color, check out the amazing recent RadioLab podcast, "Color." And FlowingData features a cool map showing the geographic clustering of endangered languages.

Monday Miscellany

  • I thought this essay (PDF) by Chris Blattman was excellent. It's a summary of three recent books (two by scholars, one by a former general) on issues surrounding children and warfare, mixed in with some of Blattman's observations about working in such a charged field.
  • GiveWell on needs in meta-research.  But meta-research isn't everything: see this recent post by Jed Friedman on the "tyranny of the known" and the Copenhagen Consensus.
  • Adam Ozimek and Noah Smith argue that we should have more immigration of high-education workers to the US.
  • What was the environmental impact of the Teenage Mutant Ninja Turtles?

In 1990, some 250,000 turtles were imported into Britain to feed the demand of young Turtles fans who wanted them as pets. For only a few pounds, kids could easily buy a small turtle, not knowing that it would grow to be the size of a dinner plate. When the kids no longer wanted to take care of the animals, they were often dumped in rivers and ponds, where they devastated native ecosystems. The problem became so severe that the European Union banned the sale of the most popular breed, red-eared terrapins, in 1997.

Where are the programs?

An excerpt from Bill Gates' interview with Katherine Boo, author of Behind the Beautiful Forevers (about a slum in Mumbai):

Bill Gates: Your peek into the operations of some non-profits was concerning. Are there non-profits that have been doing work which actually contributes to the improvement of these environments? Katherine Boo: There are many nonprofits doing work that betters lives and prospects in India, from SEWA to Deworm the World, but in the airport slums, the closer I looked at NGOs, the more disheartened I felt. WorldVision, the prominent Christian charity, had made major improvements to sanitation some years back, but mismanagement and petty corruption in the organization's local office had hampered more recent efforts to distribute aid. Other NGOs were supposedly running infant-health programs and schools for child laborers, but that desperately needed aid existed only on paper. Microfinance groups were reconfigured to exploit the very poor. Annawadi residents dying of untreated TB, malaria and dengue fever were nominally served by many charitable organizations, but in reality encountered only a single strain of health advocate—from the polio mop-up campaign. (To Annawadians, the constant appearance of polio teams in slum lanes being eviscerated by other illnesses has  become a local joke.) I tend to be realistic about occasional failures and "leakages" in organizations that do ambitious work in difficult contexts, but the discrepancy between what many NGOs were claiming in fundraising materials and what they were actually doing was significant.

In general, I suspect that the reading public overestimates the penetration of effective NGOs in low-income communities--a misapprehension that we journalists help create. When writing about nonprofits, we tend to focus either on scandals or on thinly reported "success stories" that, en masse, create the impression that most of the world's poor are being guided through life by nigh-heroic charitable assistance. It'd be cool to see that misperception become more of a reality in the lives of low-income families.

Ethiopia bleg

Bleg: n. An entry in a blog requesting information or contributions. (via Wiktionary)

Finals are over, and I just have a few things to finish up before moving to Addis Ababa, Ethiopia on June 1. I'll be there for almost eight months, working as a monitoring and evaluation intern on a large health project; this work will fulfill internship requirements for my MPA and MSPH degrees, and then I'll have just one semester left at Princeton before graduating. After two years of "book-learning" I'm quite excited to apply what I've been learning a bit.

One thing I learned from doing (too many?) short stints abroad is that it's easy to show up with good intentions and get in the way; I'm hopeful that eight months is long enough that I can be a net benefit to the team I'll be working with, rather than a drain as I get up to speed. I plan to get an Amharic tutor after I arrive -- unfortunately I figured out my internship recently enough that I wasn't able to plan ahead and study the language before going.

I'm especially excited to live in Ethiopia. I have not been before -- this will be my first visit to East Africa / the Horn of Africa at all. I'll mostly be in Addis, but should also spend some time in rural areas where the project is being implemented. I've already talked with several friends who briefly lived in Addis to get tips on what to read, what to do, who to meet, and what to pack. That said I'm always open for more suggestions.

So, I'll share what I've already, or definitely plan to read, and let you help fill in the gaps. Do you have book recommendations? Web or blog links? RSS suggestions? What-to-eat (or not eat) tips? Here's what I've dug up so far:

  • Owen Barder has several informative pages on living and working in Ethiopia here.
  • Chris Blattman's post on What to Read About Ethiopia has lots of tips, some of which I draw on below. His advice for working in a developing country is also helpful, along with lists of what to pack (parts one and two), though they're obviously not tailored to life in Addis. Blattman also links to Stefan Dercon's page with extensive readings on Ethiopian agriculture, and helpfully organizes relevant posts under tags, including posts tagged Ethiopia.
  • As for a general history, I've started Harold Marcus' academic History of Ethiopia, and it's good so far.
  • Books that have gotten multiple recommendations from friends -- and thus got bumped to the top of my list -- include The Emperor, Cutting for Stone, Chains of Heaven, and The Sign and the Seal. Other books I've seen mentioned here and there include Sweetness in the Belly, Waugh in Abyssinia, Notes from the Hyena's Belly, Scoop, and A Year in the Death of Africa. If you rave about one of these enough it might move higher up the priority list. But I'm sure there are others worth reading too.
  • For regular information flow I have a Google Alert for Ethiopia, the RSS feed for AllAfrica.com's Ethiopia page, and two blogs found so far:  Addis Journal and Expat in Addis. (Blog recommendations welcome, especially more by Ethiopians.) There's also a Google group called Addis Diplo List.
  • One of my favorite novels is The Beautiful Things That Heaven Bears -- the story of an Ethiopian immigrant in Washington, DC's Logan Circle neighborhood in the 1980s. It's as much about gentrification as it is about the immigrant experience, and I first read it as a new arrival in DC's Petworth neighborhood -- which is in some ways at a similar 'stage' of gentrification to Logan Circle in the 80s.
  • I've started How to Work in Someone Else's Country, which is aimed more at short-term consultants but has been helpful so far.
  • Also not specific to Ethiopia, but I'm finally getting around to reading the much-recommended Anti-Politics Machine, on the development industry in Lesotho, and it seems relevant.

Let me know what I've missed in the comments. And happy 200th blog post to me.

(Note: links to books are Amazon Affiliates links, which means I get a tiny cut of the sales value if you buy something after clicking a link.)

Monday Miscellany

Just one final exam to go. For now, some links:

  • The fascinating emergence of a scholarly citation cartel.
  • The TV show House is coming to a close. If you're a fan, you might check out The Medical Detectives -- many of the plot lines from the first season of House were drawn from it. The main difference is that in The Medical Detectives (and the real world) most good things are accomplished by hard-working teams of doctors and epidemiologists, rather than (mostly) solitary diagnostic genius.
  • More from Ed Yong on replication failures in psychological research. Berk Ozler disagrees.
  • "Straight white male is the lowest difficulty setting there is" -- a way of explaining adversity and discrimination to those innumerate enough to not understand that anecdotes do not disprove averages. For the record,  I was always bad at video games and chose the easiest level.
  • Chemistry blogger Derek Lowe discusses a preventative trial for Alzheimer's.
  • Finally, the authors of Disastrous Passion, the hilarious online novel about aid workers in love, announced they're going to finish it up and release it as an ebook. But they also note "At this point the manuscript is being edited and revised, some chapters overhauled, sub-plot lines cleaned up." I'm a bit worried that my favorite minor character may get cut: he resembles someone I've criticized and is (coincidence?) named Brett...

Our future selves will mock this (I hope)

Smiling people holding hands. Walking on the beach. Inexplicable doves flying through blue skies. Terrible side effects discussed cheerily by a honey-voiced narrator.... That's right, this post is about direct-to-consumer pharmaceutical advertising. Niam Hardimh, writing at Crooked Timber, shares one of the odd things about living in the US -- for those who aren't used to our TV:

One thing that is striking, compared with European TV, is what is advertised and how. In particular,  I don’t think you see ads for prescription medicines in Europe, certainly not in Ireland or the UK. They seem to be all over American TV.

I am particularly struck by the way these ads are made. The visuals  typically show someone having a happy and trouble-free life while using these drugs, overlaid with soothing music and a reassuringly bland voice-over. But clearly the US FDA requires advertisers to include all the small print in their ads as well.

Do you read all the known downsides of the medicines you take? Don’t...

It's easy to become habituated to these since they're everywhere, but it hasn't always been that way, and in most places it still isn't -- the US and New Zealand are the only two countries that allow direct advertising of drugs. Here's an exemplary ad for Vioxx, which was pulled off the market because it caused health problems (which Merck systematically lied about):

Ice skating. A minor celebrity. Inspiring music. They even note that "Vioxx specifically targets the Cox2 enzyme." How many Americans can even define what an enzyme is? I'm sure consumers are more likely to remember that than the mentioned side effects ("bleeding can occur without warning")... Other lovely examples include this other ad for Vioxx, and one for Zocor.

For more examples and some background on how the ads came to be, check out "Sick of pharmaceutical ads: here's why they won't go away" on io9.

Busy

It's a busy time of year: this week I'm prepping for a day-long comprehensive exam that covers the core classes at the Woodrow Wilson School, with sections on politics, economics, statistics, and psychology. Next week I'll be starting my actual final exams. And on June 1st I travel to Addis Ababa, Ethiopia, where I'll be working through January 2013. (More on that soon, once I figure out how much - if at all - I'll be blogging about my internship there.) So expect few new posts, other than a couple that are already queued up. In the meantime, here are two papers that I have not yet read but that should both prompt a lot of discussion amongst health and development folks:

Gabriel Demombynes and Sofia Karina Trommlerova, in the World Bank's Kenya office: "What has driven the decline of infant mortality in Kenya?" And here's a discussion of the paper by Michael Clemens at the CGD blog: "Africa’s Child Health Miracle: The Biggest, Best Story in Development." Clemens and Demombynes previously coauthored some excellent work criticizing the Millennium Development Villages' evaluation efforts.

And speaking of the Millennium Villages, Jeff Sachs writes in the Huffington Post: "Breakthroughs in Health in the Millennium Villages." He's highlighting a new study in the Lancet by Sachs, Paul Pronyk, and a number of other authors with this long title: "The effect of an integrated multisector model for achieving the Millennium Development Goals and improving child survival in rural sub-Saharan Africa: a non-randomised controlled assessment."

No time to read these now, but I imagine they will paint very different pictures of what is going on with child health in Africa, using different methodologies, and offer contrasting solutions -- I'm looking forward to reading them in the weeks to come and seeing if either paper moves my priors.

Stats lingo in econometrics and epidemiology

Last week I came across an article I wish I'd found a year or two ago: "Glossary for econometrics and epidemiology" (PDF from JSTOR, ungated version here) by Gunasekara, Carter, and Blakely. Statistics is to some extent a common language for the social sciences, but there are also big variations in language that can cause problems when students and scholars try to read literature from outside their fields. I first learned epidemiology and biostatistics at a school of public health, and now this year I'm taking econometrics from an economist, as well as other classes that draw heavily on the economics literature.

Friends in my economics-centered program have asked me "what's biostatistics?" Likewise, public health friends have asked "what's econometrics?" (or just commented that it's a silly name). In reality both fields use many of the same techniques with different language and emphases. The Gunasekara, Carter, and Blakely glossary linked above covers the following terms, amongst others:

  • confounding
  • endogeneity and endogenous variables
  • exogenous variables
  • simultaneity, social drift, social selection, and reverse causality
  • instrumental variables
  • intermediate or mediating variables
  • multicollinearity
  • omitted variable bias
  • unobserved heterogeneity

If you've only studied econometrics or biostatistics, chances are at least some of these terms will be new to you, even though most have roughly equivalent forms in the other field.

Outside of differing language, another difference is in the frequency with which techniques are used. For instance, instrumental variables seem (to me) to be under-used in public health / epidemiology applications. I took four terms of biostatistics at Johns Hopkins and don't recall instrumental variables being mentioned even once! On the other hand, economists just recently discovered randomized trials. (Now they're more widely used) .

But even within a given statistical technique there are important differences. You might think that all social scientists doing, say, multiple linear regression to analyze observational data or critiquing the results of randomized controlled trials would use the same language. In my experience they not only use different vocabulary for the same things, they also emphasize different things. About a third to half of my epidemiology coursework involved establishing causal models (often with directed acyclic graphs)  in order to understand which confounding variables to control for in a regression, whereas in econometrics we (very!) briefly discussed how to decide which covariates might cause omitted variable bias. These discussions were basically about the same thing, but they differed in terms of language and in terms of emphasis.

I think an understanding of how and why researchers from different fields talk about things differently helps you to understand the sociology and motivations of each field.  This is all related to what Marc Bellemare calls the ongoing "methodological convergence in the social sciences." As research becomes more interdisciplinary -- and as any applications of research are much more likely to require interdisciplinary knowledge -- understanding how researchers trained in different academic schools think and talk will become increasingly important.

Facebook's brilliantly self-interested organ donation move

How can social media have a big impact on public health? Here's one example: Facebook just introduced a feature that allows users to announce their status as organ donors, and to tell the story of when they decided to sign up as a donor. They're -- rightly, I think -- getting tons of good press from it. Here's NPR for example:

Starting today, the social media giant is letting you add your organ-donation status to your timeline. And, if you'd like to become an organ donor, Facebook will direct you to a registry.

Patients and transplant surgeons are eager for you to try it out.

Nearly 114,000 people in this country are waiting for organs, according to the United Network for Organ Sharing. But there simply aren't enough organs to go around.

It's an awesome idea. Far too few Americans are organ donors, so anything that boosts sign-up rates is welcome. As Ezra Klein notes, organ donation rates would be much higher if we simply had people opt out of donating, rather than opt in, but that's another story. (And another aside: I hope they alerted some smart people beforehand to help them rigorously measure the impact of this shift!)

Call me a cynic, but I think the story of why Facebook chose to do this -- and in the way they did it -- is more interesting.Yes, there's altruism, but Facebook is a business above all. Maybe they're just trying to cultivate that Google ethos of "we sometimes spend lots of money on far-sighted things just to make the world a better place." Facebook will certainly garner lots of public good will from this.

But I think, even more importantly, Facebook gets magnificent cover for introducing new modules on health/wellness. Check out the screenshot from their newsroom post on the new features:

That's right -- in the new Health & Wellness section you can enter not only whether you're an organ donor, but also these categories: "Overcame an Illness," "Quit a Habit," "New Eating Habits," "Weight Loss," "Glasses, Contacts, Others," and "Broken Bone."

All life events some people may want to share, of course. But Facebook makes money off of advertising, and just think of how much money Americans spend on weight loss, or on trying to quit smoking (or more usually, continuing it), or on glasses and contacts. Then think how much more advertisers will pay to show ads to segments of the billions of Facebook users who have shared the fact that they're actively trying to lose weight.

Maybe Facebook has seen this sort of health data as a major growth area for some time, but was wary of introducing such features in the wrong way. On any other news day the introduction of these features would have triggered a new outbreak of the "Facebook feature prompt privacy outcry" and "Why does Facebook need your health data?" stories. Sure, we'll get some of those this time, but I think any backlash will pale in comparison to the initial PR bump.

I don't think there's necessarily anything wrong with the move, and I certainly welcome any boost in organ donor registration. It may just be that this is a case where Facebook's business interests in inducing us to share more of our personal information with them just happens to happily coincide with a badly needed public good. Either way, the execution is brilliant, because so far I've mostly seen news stories talking about how great organ donation is. And I just updated my Facebook status.

Obesity in the US

One of my classmates whose primary interest is not health policy posted this graph on Facebook, saying "This is stunning... so much so in fact that I'm a bit skeptical of its accuracy." The graph compares obesity rates by state in 1994 vs. 2008, and unfortunately it is both terrifying and accurate. (I can't find the original source of this particular infographic, but the data is the same as on this CDC page.)

I think those of who study or work in public health have seen variations on these graphs so many times that they've lost some of their shock value. But this truly is an incredible shift in population health in a frighteningly short period of time. In 1994 every state had an adult population that was less than 20% obese, and many were less than 15% obese. A mere 14 years later, Colorado is the only state under 20%, and quite a few have rates over 30% -- these were completely unheard of before.

I did a quick literature search, trying to understand what causal factors might be responsible for such a rapid shift. It's a huge and challenging question, so maybe it should be unsurprising that I didn't find an article that really stood out as the best. Still, here are three articles that I found helpful:

1. Specifically looking at childhood obesity in the US (which is different from the rates highlighted in the map above, but related): "Childhood Obesity: Trends and Potential Causes" by Anderson and Butcher (JStor PDF, ungated PDF). Their intro:

The increase in childhood obesity over the past several decades, together with the associated health problems and costs, is raising grave concern among health care professionals, policy experts, children's advocates, and parents. Patricia Anderson and Kristin Butcher document trends in children's obesity and examine the possible underlying causes of the obesity epidemic.

They begin by reviewing research on energy intake, energy expenditure, and "energy balance," noting that children who eat more "empty calories" and expend fewer calories through physical activity are more likely to be obese than other children. Next they ask what has changed in children's environment over the past three decades to upset this energy balance equation. In particular, they examine changes in the food market, in the built environment, in schools and child care settings, and in the role of parents-paying attention to the timing of these changes.

Among the changes that affect children'se nergy intake are the increasing availability of energy dense, high-calorie foods and drinkst hroughs chools. Changes in the family, particularly increasing dual-career or single-parent working families, may also have increased demand for food away from home or pre-prepared foods. A host of factors have also contributed to reductions in energy expenditure. In particular, children today seem less likely to walk to school and to be traveling more in cars than they were during the early 1970s, perhaps because of changes in the built environment. Finally, children spend more time viewing television and using computers.

Anderson and Butcher find no one factor that has led to increases in children's obesity. Rather, many complementary changes have simultaneously increased children's energy intake and decreased their energy expenditure. The challenge in formulating policies to address children's obesity is to learn how best to change the environment that affects children's energy balance.

2. On global trends: "The global obesity pandemic: shaped by global drivers and local environments" by Swinburn et al. (Here's the PDF from Science Direct and an ungated PDF for those not at universities.) Summary:

The simultaneous increases in obesity in almost all countries seem to be driven mainly by changes in the global food system, which is producing more processed, affordable, and effectively marketed food than ever before. This passive overconsumption of energy leading to obesity is a predictable outcome of market economies predicated on consumption-based growth. The global food system drivers interact with local environmental factors to create a wide variation in obesity prevalence between populations.

Within populations, the interactions between environmental and individual factors, including genetic makeup, explain variability in body size between individuals. However, even with this individual variation, the epidemic has predictable patterns in subpopulations. In low-income countries, obesity mostly affects middle-aged adults (especially women) from wealthy, urban environments; whereas in high-income countries it affects both sexes and all ages, but is disproportionately greater in disadvantaged groups.

Unlike other major causes of preventable death and disability, such as tobacco use, injuries, and infectious diseases, there are no exemplar populations in which the obesity epidemic has been reversed by public health measures. This absence increases the urgency for evidence-creating policy action, with a priority on reduction of the supply-side drivers.

3. Finally, on methodological differences and where the trends are heading: "Obesity Prevalence in the United States — Up, Down, or Sideways?" (NEJM, ungated PDF). Evidently there's some debate over whether rates are going up or have stabilized in the last few years, because different data sources say different things. Generally the NHANES data (in which people are actually measured, rather than reporting their height and weight) is the best available (and that's what the maps above are made from). An excerpt:

One key reason for discrepancies among the estimates is a simple difference in data-collection methods. The most frequently quoted data sources are the NHANES studies of adults and children, the BRFSS for adults, and the CDC's Youth Risk Behavior Survey (YRBS)4 for high- school students. Although sampling strategies, response rates, age discrepancies, and the wording of survey questions may account for some variability, a major factor is that in calculating the BMI, the BRFSS and YRBS rely on respondents' self-reported heights and weights, whereas the NHANES collects measured (i.e., actual) heights and weights each year, albeit from a considerably smaller sample of the population. Since people often claim to be taller than they are and to weigh less than they actually do, we should not be surprised that obesity prevalence figures based on self-reported heights and weights are considerably lower than those based on measured data.

I would greatly appreciate any suggestions for what to read in the comments, especially links to work that tries to rigorously assess (rather than just hypothesize on) the relative import of various drivers of the increase in adult obesity.

Group vs. individual uses of data

Andrew Gelman notes that, on the subject of value-added assessments of teachers, "a skeptical consensus seems to have arisen..." How did we get here? Value-added assessments grew out of the push for more emphasis on measuring success through standardized tests in education -- simply looking at test scores isn't OK because some teachers are teaching in better schools or are teaching better-prepared students. The solution was to look at how teachers' students improve in comparison to other teachers' students. Wikipedia has a fairly good summary here.

Back in February New York City released (over the opposition of teachers' unions) the value-added scores of some 18,000 teachers. Here's coverage from the Times on the release and reactions.

Gary Rubinstein, an education blogger, has done some analysis of the data contained in the reports and published five posts so far: part 1, part 2, part 3, part 4, and part 5. He writes:

For sure the 'reformers' have won a battle and have unfairly humiliated thousands of teachers who got inaccurate poor ratings. But I am optimistic that this will be be looked at as one of the turning points in this fight. Up until now, independent researchers like me were unable to support all our claims about how crude a tool value-added metrics still are, though they have been around for nearly 20 years. But with the release of the data, I have been able to test many of my suspicions about value-added.

I suggest reading his analysis in full, or at least the first two parts.

For me one early take-away from this -- building off comments from Gelman and others -- is that an assessment might be a useful tool for improving education quality overall, while simultaneously being a very poor metric for individual performance. When you're looking at 18,000 teachers you might be able to learn what factors lead to test score improvement on average, and use that information to improve policies for teacher education, recruitment, training, and retention. But that doesn't mean one can necessarily use the same data to make high-stakes decisions about individual teachers.