"The only thing worse than being a poverty reporter is if no one ever wrote about it at all."

From a Guernica interview with Katherine Boo, author of Behind The Beautiful Forevers, on life in a Mumbai slum:

Guernica: Was it important to you to stay in the vicinity of the community?

Katherine Boo: Quite the contrary. It was important to me, in the course of my reporting in Annawadi, day after day, night after night, to leave and get a sense of the city as a whole. It is a city that until eleven years ago was unknown to me, and is changing all of time, so I really had to explore it, learn about it. I certainly did a lot reporting around the five-star hotels as well as Annawadi. I did my whole anthropology of five-star bathrooms, each one more lavish than the next. (Laughs.)

Even if I were to stay in Annawadi or something like it, it wouldn’t be the same. After Hurricane Katrina, for instance, I did stay in the shelter [when] I did reporting for The New Yorker. But me staying in a shelter is not the same as someone who’s been evacuated to that shelter. This whole thing of, “I’m walking a mile in their shoes by living this certain way.” Well, I’m not living that way. I can turn around and leave. We can do the best we can to get to the core of people’s circumstances, but it’s ludicrous to think that my being in Annawadi all of that time is walking in their shoes. It’s not.

The quote in the title of this post is from a section on the feelings of guilt that haunt Boo when she thinks about how her work exploits people, especially poor people. The interview's a great read. (Found via LongForm.org, a great source for creative nonfiction / narrative journalism.)

Mystification

I read a bunch of articles for my public health coursework, but one that has stuck in my mind and thus been on my things-t0-blog-about list for some time is "Mystification of a simple solution: Oral rehydration therapy in Northeast Brazil" by Marilyn Nations and L.A. Rebhun. Unfortunately I can't find an ungated PDF for it anywhere (aside: how absurd is it that it costs $36 USD to access one article that was published in 1988??) so you can only access it here for free if you have access through a university, etc. The article describes the relatively simple diarrhea treatment, ORT (oral rehydration therapy), as well as how physicians in a rural community in Brazil managed to reclaim this simply procedure and turn it into a highly specialized medical procedure that only they could deliver. One thing I like is that the article has (for an academic piece) a great narrative: you learn how great ORT is ... then about the ridiculous ritualization / mystification of a simple process that keeps it out of reach of those who need it most ... then about the authors' proposed solution ... and finally a twist where you realize the solution has some (though not certainly not all) of the same problems. Here's one of their case studies of how doctors mystified ORT:

Benedita, a 7-month-old girl with explosive, watery diarrhea of 5 days duration, weakness, and marked dehydration, was brought by her mother to a government hospital emergency room. White-garbed nurses and physicians examined the baby and began ORT. They meticulously labeled a sterilized baby bottle with millimeter measurements, weighed the child every lSmin, mixed the chemical packet with clean water, gave the predetermined amount of ORT, and recorded all results on a chart, checking exact times with a wristwatch. The routine continued for over 3 hr, during which little was said to the mother, who waited passively on a wooden bench. Later interviews with the mother revealed that she believed the child’s diarrhea was due to evil eye, and had previously consulted 3 [traditional healers]. Despite her more than 5 hr at the clinic, the mother did not know how to mix the ORT packet herself. When asked if she thought she or a [traditional healer] could mix ORT at home, she replied, “Oh no, we could never do that. It’s so complicated! I don’t even know how to read or write and. I don’t even own a wristwatch!”

They then discuss how they trained a broader group of providers (including the traditional healers) to administer the ORT themselves. But the traditional healers end up ritualizing the treatment as much or more than the physicians did:

... Dona Geralda cradled the leaves carefully so as not to spill their evil content as she carried them to an open window and flung them out. The evil forces causing diarrhea are believed to disappear with the leaves, leaving the child’s body ‘clean’ and disease-free...Turning to the small altar in a comer of the healing room, Dona Geralda offered the ORS 'holy water' to the images of St Francisco and the folk hero Padre Cicero there.

There's more to both sides of the ritualization in the body of the article, and the similarities are striking. I'm not sure the authors intended to make it this way (and this likely speaks more to my own priors or prejudices), but the traditional healers' ritualization sounds quite suspicious to me, full of superstition and empty of understanding of how ORT works, while at the same time the physicians' ritualization, as unnecessary as it is, is comfortingly scientific. The crucial difference though is that the physicians' ritualization seriously impedes access to care, while the healers' process does not -- in fact, it even makes care more accessible:

Clearly, our program did not de-ritualize ORTdelivery; the TH’s administration methods are highly ritualized. The ceremony with the leaves, the prayer,the offering of the ORS-tea to the saints, are all medically unnecessary to ensure the efficacy of ORT.They neither add to nor detract from its technologial effectiveness. But in this case, the ritualization, insteadof discouraging the mother from using ORT and mystifying her about its ease of preparation andadministration, encourages her to participate actively in her child’s cure.

Neat.

Monday miscellany

Another kind of "game" theory

Alan Greenspan wooed his first wife by inviting her to his apartment so that he could read her an article he had written on monopolies:

We had been discussing monopolies at dinner, and I was trying to keep her engaged. So I invited her back to my apartment to read an article I wrote in the mid-1960s. I was raising serious questions about the whole basis of the Sherman Antitrust Act of 1890, and I actually went through considerable detail as to what I thought was wrong about it. Nothing I’ve seen in reality has changed it. I’m not denying that monopolies are terrible things, but I am denying that it is readily easy to resolve them through legislation of that nature. But we were in conversation of some form or another which related to this. So I was terribly curious to see how she’d respond.

Also:

I’ve frankly forgotten how she responded.

Life among the Econ

"Life among the Econ" (ungated PDF) is a classic essay by Axel Leijonhufvud that's worth revisiting -- here's the intro:

The Econ tribe occupies a vast territory in the far North. Their land appears bleak and dismal to the outsider, and travelling through it makes for rough sledding; but the Econ, through a long period of adaptation, have learned to wrest a living of sorts from it. They are not without some genuine and sometimes even fierce attachment to their ancestral grounds, and their young are brought up to feel contempt for the softer living in the warmer lands of their neighbours such as the Polscis and the Sociogs. Despite a common genetical heritage, relations with these tribes are strained-the distrust and contempt that the average Econ feels for these neighbours being heartily reciprocated by the latter-and social intercourse with them is inhibited by numerous taboos. The extreme clannishness, not to say xenophobia, of the Econ makes life among them difficult and perhaps even somewhat dangerous for the outsider. This probably accounts for the fact that the Econ have so far-not been systematically studied....

Monday miscellany

  • Edward Carr writes on "monitoring, evaluation, and conflicts of interest," examining the tension between the advantages of having evaluations done by the implementing organization, vs. the disadvantages of some perverse incentives along the way. Highly recommended, as is the follow-up post on making sure we can learn from M&E.
  • Tara Smith of the blog Aetiology reviews Spillover, a new book on zoonotic diseases, that just moved to the top tier of my reading list; I've long been fascinated by zoonotic diseases and even wrote my senior biology thesis on the (much-debated) origins of Ebola outbreaks.
  • Oops -- we don't really know whether sunscreen (or at least the types most people have been using) protect against skin cancer.
  • Aaron Carroll on the real (though often denied) American physician shortage.
  • 3iE, i.e., the International Initiative for Impact Evaluation, which advocates for and funds randomized trials and other rigorous study designs, just published the results of a randomized trial on the effectiveness of policy briefs.
  • A Q&A on trying to raise bonobos in a human language environment for multiple generations.
  • Writing at The Economist, Matt Steinglass argues that the U.S. is unlikely to implement policies that would have any great impact on obesity.
  • Finally, here's a report of a new, AIDS-like disease (though not thought to be contagious) in Thailand and Taiwan. via @EpiDoctor

Weekend reading: race in America

Ta-Nehisi Coates is one of my favorite writers -- I highly recommend his memoir, The Beautiful Struggle, about growing up in Baltimore. His writing has a riveting flow even on the most innocuous subjects, so when he writes about something serious it really kills. He has a long and excellent cover story in The Atlantic this month on Barack Obama: "Fear of a Black President". It's the best thing I've read this month:

What black people are experiencing right now is a kind of privilege previously withheld—seeing our most sacred cultural practices and tropes validated in the world’s highest office. Throughout the whole of American history, this kind of cultural power was wielded solely by whites, and with such ubiquity that it was not even commented upon. The expansion of this cultural power beyond the private province of whites has been a tremendous advance for black America. Conversely, for those who’ve long treasured white exclusivity, the existence of a President Barack Obama is discombobulating, even terrifying. For as surely as the iconic picture of the young black boy reaching out to touch the president’s curly hair sends one message to black America, it sends another to those who have enjoyed the power of whiteness.

Read it.

mHealth resources

MHealth (ie, mobile health) is all the rage in some public health circles; using mobile technology like phones to collect data, to send reminders for antenatal appointments, etc. I'll be honest that I didn't invest a ton of energy in reading about various mhealth initiatives the last two years while taking classes because a) some of it seems overhyped and b) being a young, tech-savvy health professional I was mildly worried about getting pigeonholed into that work and chose to concentrate more on general methodology and tools. But now that my work involves mhealth (somewhat peripherally for now) I'm paying more attention. Here are two good resources that came across my radar recently:

  • William Philbrick of mHealth Alliance has put together a useful report called "mHealth and MNCH: State of the Evidence" (PDF). It summarizes what the research to date on mobile health technology says about maternal, newborn, and child health. Most helpfully, I think, it outlines a few areas where there's not much need for further duplicative research, and other areas where there has been little or no research at all. This is good reading even if you're not particularly interested in mHealth, as the study notes that the mHealth community is fairly close and doesn't always do the best job of disseminating results to the broader global health industry.
  • I first saw the link above via my friend and Hopkins classmate Nadi, who sent it out to the mHealth Student Group on Google Groups. Lots of other good links and discussion on that group, so join up!

The longevity transition

Now, the United States and many other countries are experiencing a new kind of demographic transition. Instead of additional years of life being realized early in the lifecycle, they are now being realized late in life. At the beginning of the twentieth century, in the United States and other countries at comparable stages of development, most of the additional years of life were realized in youth and working ages; and less than 20 percent was realized after age 65. Now, more than 75 percent of the gains in life expectancy are realized after 65—and that share is approaching 100 percent asymptotically.... The new demographic transition is a longevity transition: How will individuals and societies respond to mortality decline when almost all of the decline will occur late in life?...

That's from "The New Demographic Transition: Most Gains in Life Expectancy Now Realized Late in Life," (PDF) by Karen Eggleston and Victor Fuchs. Via @KarenGrepin.

Monday miscellany

In general, we think the strongest cases use multiple forms of evidence, some addressing the weaknesses of others. For example, immunization campaigns are associated with both strong “micro” evidence (which shows that intensive, well-executed immunization programs can save lives) and “macro” evidence (which shows, less rigorously, that real-world immunization programs have led to drops in infant mortality and the elimination of various diseases).

  • Here's an interview with the author of a book arguing that the Obama administration's stimulus was a huge success. Includes this quote:

Unemployment actually topped 8 percent the month the stimulus passed, which obviously wasn’t the fault of the stimulus. Recoveries after financial cataclysms are always ugly. But when you spend $800 billion on an economic recovery package, and the recovery stinks, people don’t tend to look past that.... That said, the national media should have tried to look past that, but it didn’t, because the national media sucks at covering public policy.

Think of a good experimental design: randomised control variables, holding everything else constant, etc. Now think of the worst possible experimental design. Imagine something that engineers or psychologists might dream up over beers for a laugh, or to illustrate what not to do. That's what economists face. It's as if our lab assistants (the fiscal and monetary authorities) were deliberately trying to make our (economists') lives as hard as possible. They do this, of course, not to spite us, but to try to make everyone else's lives as easy as possible. To get a good experimental design for economists, both the fiscal and monetary authorities would need to be malevolent.

When randomization is strategic

Here's a quote from Tom Yates on his blog Sick Populations about a speech he heard by Rachel Glennerster of J-PAL:

Glennerster pointed out that the evaluation of PROGRESA, a conditional cash transfer programme in Mexico and perhaps the most famous example of randomised evaluation in social policy, was instigated by a Government who knew they were going to lose the next election. It was a way to safeguard their programme. They knew the next Government would find it hard to stop the trial once it was started and were confident the evaluation would show benefit, again making it hard for the next Government to drop the programme. Randomisation can be politically advantageous.

I think I read this about Progresa / Oportunidades before but had forgotten it, and thus it's worth re-sharing. The way in which Progresa was randomized (different areas were stepped into the program, so there was a cohort of folks who got it later than others, but all the high need areas got it within a few years) made this more politically feasible as well. I think this situation, in which a government institutes a study of a program to keep it alive through subsequent changes of government, will probably be a less common tactic than its opposite, in which a government designs an evaluation of a popular program that a) it thinks doesn't work, b) it wants to cut, and c) the public otherwise likes, just to prove that it should be cut -- but only time will tell.

A misuse of life expectancy

Jared Diamond is going back and forth with Acemoglu and Robinson over his review of their new book, Why Nations Fail. The exchange is interesting in and of itself, but I wanted to highlight one passage from Diamond's response:

The first point of their four-point letter is that tropical medicine and agricultural science aren’t major factors shaping national differences in prosperity. But the reasons why those are indeed major factors are obvious and well known. Tropical diseases cause a skilled worker, who completes professional training by age thirty, to look forward to, on the average, just ten years of economic productivity in Zambia before dying at an average life span of around forty, but to be economically productive for thirty-five years until retiring at age sixty-five in the US, Europe, and Japan (average life span around eighty). Even while they are still alive, workers in the tropics are often sick and unable to work. Women in the tropics face big obstacles in entering the workforce, because of having to care for their sick babies, or being pregnant with or nursing babies to replace previous babies likely to die or already dead. That’s why economists other than Acemoglu and Robinson do find a significant effect of geographic factors on prosperity today, after properly controlling for the effect of institutions.

I've added the bolding to highlight an interpretation of what life expectancy means that is wrong, but all too common.

It's analagous to something you may have heard about ancient Rome: since life expectancy was somewhere in the 30s, the Romans who lived to be 40 or 50 or 60 were incredibly rare and extraordinary. The problem is that life expectancy -- by which we typically mean life expectancy at birth -- is heavily skewed by infant mortality, or deaths under one year of age. Once you get to age five you're generally out of the woods -- compared to the super-high mortality rates common for infants (less than one year old) and children (less than five years old). While it's true that there were fewer old folks in ancient Roman society, or -- to use Diamond's example -- modern Zambian society, the difference isn't nearly as pronounced as you might think given the differences in life expectancy.

Does this matter? And if so, why? One area where it's clearly important is Diamond's usage in the passage above: examining the impact of changes in life expectancy on economic productivity. Despite the life expectancy at birth of 38 years, a Zambian male who reaches the age of thirty does not just have eight years of life expectancy left -- it's actually 23 years!

Here it's helpful to look at life tables, which show mortality and life expectancy at different intervals throughout the lifespan. This WHO paper by Alan Lopez et al. (PDF) examining mortality between 1990-9 in 191 countries provides some nice data: page 253 is a life table for Zambia in 1999. We see that males have a life expectancy at birth of just 38.01 years, versus 38.96 for females (this was one of the lowest in the world at that time). If you look at that single number you might conclude, like Diamond, that a 30-year old worker only has ~10 years of life left. But the life expectancy for those males remaining alive at age 30 (64.2% of the original birth cohort remains alive at this age) is actually 22.65 years. Similarly, the 18% of Zambians who reach age 65, retirement age in the US, can expect to live an additional 11.8 years, despite already having lived 27 years past the life expectancy at birth.

These numbers are still, of course, dreadful -- there's room for decreasing mortality at all stages of the lifespan. Diamond's correct in the sense that low life expectancy results in a much smaller economically active population. But he's incorrect when he estimates much more drastic reductions in the economically productive years that workers can expect once they reach their economically productive 20s, 30s, and 40s.

----

[Some notes: 1. The figures might be different if you limit it to "skilled workers" who aren't fully trained until age 30, as Diamond does; 2. I'm also assumed that Diamond is working from general life expectancy, which was similar to 40 years total, rather than a particular study that showed 10 years of life expectancy at age 30 for some subset of skilled workers, possibly due to high HIV prevalence -- that seems possible but unlikely; 3. In these Zambia estimates, about 10% of males die before reaching one year of age, or over 17% before reaching five years of age. By contrast, between the ages of 15-20 only 0.6% of surviving males die, and you don't see mortality rates higher than the under-5 ones until above age 85!; and 4. Zambia is an unusual case because much of the poor life expectancy there is due to very high HIV/AIDS prevalence and mortality -- which actually does affect adult mortality rates and not just infant and child mortality rates. Despite this caveat, it's still true that Diamond's interpretation is off. ]

Monday miscellany

  • This week's must-read article is Atul Gawande on "Big Medicine," comparing it to, of all things, the Cheesecake Factory. The sections on quality control and efficiency at the restaurant chain are incredible, and the description of the ICU command center will make you think it's science fiction (though of course it's not). For some follow-up, here are responses by Karen Grepin, Austin Frakt, and more Austin Frakt. (Update: here's an interesting, critical take on the subject.)
  • Practice Fusion has taken a a big (HIPAA-friendly) dataset from their work with health insurance records and claims in the US and made it available for a data analysis contest: Analyze This! Also, here's an interesting post from them on syndromic surveillance.
  • Mainly Macro on how a memo by Greg Mankiw and John Taylor for the Romney campaign is giving economics a bad name.
  • Indolaysia on "Policy analysis without causal identification: gun ownership and state terror" in two parts: part 1 and part 2. Includes .do file to replicate his analysis.
  • Worth re-reading given recent events: Ryan Lizza's profile of Paul Ryan.
  • Simply Statistics wonders what your CV would look like if you included all the things you failed to do.
  • And a bit off topic but still fun: the history of rock & roll, the world's biggest wave, and Where the Hell is Matt (2012).

Friday photos

Friday photos may be a new recurring feature on this blog -- while I won't post reviews of every place I go on weekends (or during the week for work), it's hard to resist sharing some highlights of Ethiopia. A beautiful and fascinating country: Medhane Alem, the largest monolithic church in the world, is just one of a dozen churches at Lalibela carved from solid rock in the 14th century AD:

Medhane Alem at Lalibela

Swimming at the "Queen of Sheba's Bath", in Aksum, northern Ethiopia:

Queen of Sheba's Bath, Aksum

More photos of travel around Ethiopia can be found here.

The great quant race

My Monday link round-up included this Big Think piece asking eight young economists about the future of their field. But, I wanted to highlight the response from Justin Wolfers:

Economics is in the midst of a massive and radical change.  It used to be that we had little data, and no computing power, so the role of economic theory was to “fill in” for where facts were missing.  Today, every interaction we have in our lives leaves behind a trail of data.  Whatever question you are interested in answering, the data to analyze it exists on someone’s hard drive, somewhere.  This background informs how I think about the future of economics.

Specifically, the tools of economics will continue to evolve and become more empirical.  Economic theory will become a tool we use to structure our investigation of the data.  Equally, economics is not the only social science engaged in this race: our friends in political science and sociology use similar tools; computer scientists are grappling with “big data” and machine learning; and statisticians are developing new tools.  Whichever field adapts best will win.  I think it will be economics.  And so economists will continue to broaden the substantive areas we study.  Since Gary Becker, we have been comfortable looking beyond the purely pecuniary domain, and I expect this trend towards cross-disciplinary work to continue.

I think it's broadly true that economics will become more empirical, and that this is a good thing, but I'm not convinced economics will "win" the race. This tracks somewhat with the thoughts from Marc Bellemare that I've linked to before: his post on "Methodological convergence in the social sciences" is about the rise of mathematical formalism in social sciences other than economics. This complements the rise of empirical methods, in the sense that while they are different developments, both are only possible because of the increasing mathematical, statistical, and coding competency of researchers in many fields. And I think the language of convergence is more likely to represent what will happen (and what is already happening), rather than the language of a "race."

We've already seen an increase in RCTs (developed in medicine and epidemiology) in economics and political science, and the decades ahead will (hopefully) see more routine serious analysis of observational data in epidemiology and other fields (in the sense that the analysis is more careful about causal inference), and  advanced statistical techniques and machine learning methodologies will become commonplace across all fields as researchers deal with massive, complex longitudinal datasets gleaned not just from surveys but increasingly from everyday collection.

Economists have a head start in that their starting pool of talent is generally more mathematically competent than other social sciences' incoming PhD classes. But, switching back to the "race" terminology, economics will only "win" if -- as Wolfers speculates will happen -- it can leverage theory as a tool for structuring investigation. My rough impression is that economic theory does play this role, sometimes, but it has also held empirical investigation in economics back at times, perhaps through publication bias (see on minimum wage) against empirical results that don't fit the theory, and possibly more broadly through a general closure of routes of investigation that would not occur to someone already trained in economic theory.

Regardless, I get the impression that if you want to be a cutting-edge researcher in any social science you should be beefing up not only your mathematical and statistical training, but also your coding practice.

Update: Stevenson and Wolfers expand their thoughts in this excellent Bloomberg piece. And more at Freakonomics here.

Sentimental narratives

In his contribution to the book Humanitarianism and Suffering, historian Thomas Laqueur charts the birth of “the sentimental narrative” and its role in changing hearts and inspiring action. “In the late eighteenth century,” he writes, “the ethical subject was democratized; more and more people came to believe it was their obligation to ameliorate and prevent wrongdoing to others.” The sentimental narrative Lacquer identifies is a sneaky one. Superficially, it seems humane, a good-hearted response to the impoverished and their plight. But it also objectifies the sufferers it nominally empowers—people with pain to ameliorate, against whom wrongdoings are to be prevented, on whose behalf this compassion is to be invested. However many noble or real or useful things that investment may bring, it also flatters us, by affirming our own righteousness.

That's from Jina Moore's essay in the Boston Review on telling stories about Africa as a foreigner. It's definitely worth a read, as is her follow-up blog post, "Good News from Africa," (in the sense that the news is well-done, not that the news is always "good") which highlights several examples of the extraordinary writing she'd like to see more of. And follow @itsjina on Twitter.

Monday miscellany

  • Three-Toed Sloth discusses what makes a statistician vs. a data scientist, a debate you're likely to encounter if your work intersects with quantitative work in any way.
  • Eight (relatively) young economists on the future of their field, via pretty much everyone. I'd love to see what similarly junior economists in the 1970s would have guessed would befall economics over the last 40 years; I could see at least some of them getting the broad sweep right, but I'd also bet they would overestimate how much progress a couple academic generations can make. Call me a pessimist.
  • This post by Lee Crawfurd points to Esther Duflo's Tanner lecture on paternalism in development economics, which restates some of the themes from Poor Economics. I highly recommend the lecture based on what I've read; though my read was quick I found it both fascinating and dense (in the sense that it is idea- and information-rich, not dull) and realized I will need to revisit it, maybe more than once. I also liked this quote from Lee's post:

Back in England, I can't imagine anything worse than having to meet all of my neighbours after work to figure out how we are going to run the rubbish collection or fix the potholes in the road. That stuff just gets done. Services get delivered without me having to think about it at all. All I need is a mechanism to complain if things don't work, but don't ask me to help you plan how to fix it.

  • A dose of pop culture remix: what would 2001 have looked like had it been made in 2012? This trailer answers that question (which I'm sure you've wondered, right?).
  • This looks interesting: the "Public Health Twitter Journal Club" is currently picking its next article for discussion from a selection of smoking-related papers.
  • Finally, a non-link observation: watching the Olympics abroad (specifically, on ArabSat) makes me realize how much the coverage I've watched during previous Olympiads is shaped by being in the US. Not only has (for better or worse) the coverage focused on the actual events, rather than endless interviews and inspirational backstories, I've been impressed by the difference in the quantity of Americans on display. While the US does have one of the largest Olympic teams, many events I've watched haven't had American competitors at all, or only had one who didn't medal, whereas coverage in the US is always biased towards events in which Americans are traditionally strong. I guess it's blindingly obvious in a sense, but a good reminder: often you only see what you're looking for.