Plumpy'Nut: Tabatchnick Takes On Nutriset

The debate over Plumpy'Nut and whether it should have been patented in the first place continues.

Now US food company Tabatchncik Fine Foods is talking about creating its own peanut-based therapeutic food to feed severely malnourished youngsters, according to IRIN. And Tabatchnick is considering making its product open-source so anyone can copy their recipe.

From the IRIN piece, as aggregated by Reuters:

"Ben Tabatchnick, head of the family business, said his product was still in the development phase, but the patent would be "open-source", which would allow other producers to replicate his recipe.

His company "was trying to take the fear out of other producers from producing RUTF and keeping up with demand; no one producer can supply (even with licensed franchises) the world demand for RUTF and RUSF [ready-to-use supplementary foods]", he commented. "By allowing others free access (with proper oversight by UNICEF and MSF), this can and will be accomplished." "

For a quick introduction to the patent, see "What Plumpy'Nut Taught Me"

To see all my past posts and links on Plumpy'Nut, click here:

Nurses and the Web: Text For My Talk

Here is the prepared text for the talk I gave yesterday at the American Journal of Nurses conference in Chicago. The slides to go with it are available here and here.

Nurses and the Web: Staking Out Your Territory as an Expert in Health Care
Christine Gorman
Oct. 6, 2009
American Journal of Nursing conference
Chicago, Illinois

[Title slide] Thank you very much for inviting me to Chicago and to share some ideas and experiences about staking your claim on the web.

[next slide: Web Sites] Here is a list of the places you will most easily find me on the Web. I have also posted the PowerPoints on slideshare.net so that if you are following the talk via the audiocast or you just want to refer to it later, you can do so. I will also post a write-up of what I say on my blog at globalhealthreport.com.

There are basically two main points I would like you to take away from today’s talk.

[Next slide: Platform shift] The first is summed up in this slide.

The world of media—all the ways that we get information, that we are entertained, that we interact with and respond to others at a distance—is going through a major shift in platform. The delivery system if you will. We are transitioning from a broadcast platform to a network platform. The often satirized “Voice of God” message that gets delivered to the masses is being replaced by what you might call “the Big Hum” — the constant murmur of many conversations amongst many much smaller groups.

[Next slide: Implicit to Explicit] And the second major point I want to make has to do with the soaring value of taking what you know implicitly and making it explicit.

Providing context has always been important. But its value increases dramatically in a world where we get bombarded by information and voices and opinions all vying for our attention with very few built-in filters to help us separate what is real from what is fantasy.

Now you might expect a lot of how-to guidance and cool technology tips from a talk about how nurses can stake their claim on the Internet. Something like Christine’s top five tips for getting other people to listen to you. Or 7 ways to profit from the social media revolution. Lists are so easy to grasp that they are a popular way to boost your circle of influence on the web—whatever the topic.

And the truth is, you can find many good introductory how-to instructions about lists and other attention-getting devices on the Internet after a couple of searches or by asking questions in various forums.

But I think it is important to have a theoretical framework to understand these issues so that you can adapt them to your own situation. Otherwise, you spend most of your time boosting somebody else’s influence and credibility without building up your own. A little theory makes it easier to evaluate which shiny new tool on the Web you should be paying a lot of attention to—or even helping to build. And which you can avoid wasting your time on.

So the first part of my talk is going to give a fair amount of background. And then we will get into some guidelines and rules of thumb for staking your claim on the Web. Finally, there will be time for questions at the end.

[Next slide: Influences] A lot of the ideas in this talk are inspired by my own experiences on the web and in journalism. But I have also been helped a great deal in my thinking and understanding by the work of a number of Internet thinkers and practitioners. Here are a few of the key ones who have influenced me.

• Yochai Benkler – Berkman Center at Harvard
• Mindy McAdams – University of Florida
• Persephone Miel – Internews
• Clay Shirky – NYU
• Matt Thompson –University of Missouri
• Michael Wesch – Kansas State University
• Ethan Zuckerman – Berkman Center

[Next slide: Literary Heroes] I’ll also admit taking inspiration for this talk from some American literary giants as well, particularly Mark Twain and Upton Sinclair. Mark Twain for his wry insights into the world as it is and how we might like it to be. And Upton Sinclair for his righteous anger and passion for addressing injustice.

Any mistakes, however, are my own.

[Next slide: Platform shift] So back to this platform shift, which starts off as a technical shift—“How are news, entertainment and information created and delivered?” This technical shift has also become a cultural shift, a change in the way we organize our thoughts and ourselves.

Most of us, myself included, grew up in a world where broadcast media dominated. Whether you’re old enough to remember Walter Cronkite or Woodward and Bernstein or you get most of your news from Jon Stewart, you didn’t think much about the fact that this was a one-way conversation. One message to millions of people—hence the “Voice of God” tone.

Listeners, viewers and readers absorb the message, maybe even talk about it with their friends, but what they have to say won’t have much of an impact on the newscaster --unless of course they are already a powerful figure – like a President, a talk show host, a CEO or a celebrity.

This mostly one-way conversation has its advantages and disadvantages but the point I want to make here is that it was not set in stone somewhere. It is actually a function of the enormous costs of production and distribution. Costs which weren’t necessarily there at the beginning but that grew over time.

If you look at the early days of radio, you find a lot of amateurs, enthusiasts, small community groups –like churches – and even lectures by the U.S. Public Health Service on the airwaves. Broadcasters transmitted from low-power stations over a very limited range.

There is a finite amount of electromagnetic spectrum over which you can transmit radio waves, however. Two radio stations trying to transmit over the same frequency from nearby locations would end up interfering with each other’s signals. Eventually the U.S. government started assigning different spots on the spectrum through various licensing arrangements.

Scarcity and regulation favored more powerful transmitters. The amateurs and small groups were priced out of the market. The escalating lawyers’ fees and the cost of building and maintaining powerful transmitting stations eventually meant that, with notable exceptions here and there, only large commercial interests could afford to be in the radio business.

Similarly for newspapers and magazines, the capital required to reach a large metropolitan audience – not to mention a national one – meant tremendous expenditures for presses, distribution trucks and mailing costs – and all the people to keep the process flowing.

But once these initial startup and distribution expenses were met, the cost of adding each additional customer was rather small in comparison. So you could create and deliver huge audiences. And those big audiences were exactly the sorts of people that advertisers wanted to attract.

From an advertiser’s point of view, it wasn’t a terribly efficient system. You never had a sense of how effective any particular advertisement was at bringing in new customers. But broadcast distribution to a mass audience—over the airwaves, via print--was the only game in town and so advertisers played along and were handsomely rewarded.

[Next slide: Advertising inefficiency.] Here’s where it gets interesting—where we can see that inefficiency isn’t always a bad thing. For you see, advertising inefficiency allowed news organizations of the 20th century to invest in professional journalists who spent years covering the same beats, building up an expertise. That inefficiency allowed them to pursue months-long, even years-long investigations. When you think of the great icons of investigative journalism – Watergate and the Pentagon Papers – or more recently the neglect of Iraqi veterans at Walter Reed Army Medical Center or the massive foul ups that occurred both prior to and after Hurricane Katrina – you also have to think about the Ivory Soap and used car ads that made them possible.

Of course, when one person—or a small group of people—has the only megaphone, you have to get that person’s attention unless, of course, you own a megaphone yourself.

It makes sense, you have to pay attention to the biggest voice in the room—even if there are a lot of softer voices around. And if everyone with a message is trying to get the ear of the person with the biggest voice, then that biggest voice grows even more powerful.

The Internet has changed all that and is still changing all that.

[Next slide: Internet map]
This is a map of the Internet and was put together by the folks at Lumeta Corporation and ATT. They kindly gave me permission to use it in this talk. Actually, it’s a map of the Internet as it was at a given point in time in August 2007. And it’s not even a map of the whole Internet. It’s a map of the backbone—the basic skeleton as it were of the major pipes that make up the Internet. It’s not even a complete map of the backbone. If it were, it would be so thick you wouldn’t be able to make any sense of it.

As the creators note, quote “Each line depicts the shortest outgoing route from a test computer to each of more than 320,000 network nodes around the world. The map does not represent the physical or geographic location of servers, but rather is a topological representation of the various networks that combine to form the Internet.” unquote

Now how on earth do you get a one-to-many conversation going in here? Where do you find a Walter Cronkite or a Bob Woodward or an Oprah Winfrey in here? It’s much harder to dominate the conversation. That doesn’t mean it’s impossible—and you could introduce chokeholds and gateways into the Net that would make it easier to control the pathways. But for now, this is more or less the shape of the Internet.

So besides being rather beautiful in a geeky kind of way, this map makes the point very graphically that the Internet is a network. There is no central transmitter broadcasting to everyone else. There may be some conversations that dominate large sections of the Net. But the potential for many, many conversations among smaller groups of people that can go as deep as the group wants to go is suddenly enormous.

This is the network that allowed Craig’s list and web-based ads to shorten the distance between a willing seller and a willing buyer. This is network that cut out quite a lot of the inefficiency out of advertising. This is the network that drove the production and distribution costs of news and information to near zero.

Now a lot of energy and words have been devoted to what this means in terms of maintaining a viable news industry both as an economic issue as well as a larger societal issue.

A free press is every bit as important to democracy now as it was in Benjamin Franklin’s day. And that’s something in which all citizens of the United States –whether they realize it or not – are deeply invested. The economic reality, however, is that we just can’t pay for a free press the same way we have since about the 1920s.

But while others are hard at work trying to figure out a viable business model for the news industry, there is a different part of this story that I want to highlight today.

I believe that most people are still using and thinking about the Internet as a broadcast medium. They are still mesmerized by the idea of being THE BIGGEST VOICE in the room. They want the most page hits, the highest page rank, the most followers on Twitter or friends on Facebook. They are still stuck in the broadcast mindset where the predominant communication is a one-to-many conversation.

We still haven’t grasped what is possible when there are lots of conversations among small groups happening in parallel. We assume it’s chaotic but I think that’s only because we don’t have a lot of experience with it yet.

And because so many of us are still oriented towards using the Internet as a broadcast medium—like the ones we grew up with—we miss the Internet’s extraordinary potential for organizing people. The real Internet revolution is not its broadcast abilities, but the various ways that, as Clay Shirky of NYU puts it, the Internet makes the formation of groups ridiculously easy.

You don’t have to be in the same geographic area, belong to the same clubs or have gone to the same schools. People with the same interests or passions find each other via text, list-servs, blogs and virtual communities.

And with the ubiquity of easy messaging, they can create temporary groups that form and melt away in order to do everything from the very silly to the very serious.

[Next slide: photo of Toronto pillowfight]

This is a flash mob that got together in response to a group of text messages that were forwarded and reforwarded to produce a seemingly spontaneous pillow fight in downtown Toronto.

[Next slide Iran 2009 election protects; Milad Avazbeigi]

Here we have demonstrators protesting apparent election fraud in Iran. The organizers’ were so adept at using social media to focus people’s anger that the government had to shut down the cell phone networks across the country in addition to resorting to violence to put down the protests.

There’s just something about our broadcast upbringing that makes us focus first on the largest groups – the greatest number of connections – but I’d like to argue today that we still have not seen the revolution that can come from the increased formation and connection of small groups and small networks.

I have written a lot of stories over the past 20-plus years. I am particularly proud of the articles I helped to shape at TIME Magazine during the early days of the AIDS epidemic in the U.S. –

[Next slide: AIDS wordle]

The 1980s were a time when tremendous stigma still attached to the disease and to the people who struggled with it. I believe those early stories – by myself and others – eventually helped to change the national conversation.

Those stories could have just as easily NOT been published. I remember lots of fights in the early days within TIME magazine about whether to cover the topic at all – and how to frame the subject. One editor said he wanted to see only stories about “innocent victims” in the opening paragraphs – by which he meant babies who had been infected in utero or hemophiliacs who had been infected due to contaminated blood products. In his thinking – and that of many people at the time – gay men, IV drug users and poverty-stricken Haitians were all suspect, all guilty, all deserving of what befell them.

This was my first real-world education about the potential benefits as well as the limitations of journalism. About how much time and energy are required to make sure that certain stories get told and told well – the stories about people who do not travel the corridors of power.

And it is a lesson that has stayed with me through the years. It certainly was not true all the time but for so many stories, the size of the audience trumped the merit of a story. Size or the power of the constituency. Since there was only a finite resource, a limited amount of space in which to put the news, size and power mattered.

Just as important, however, was the lesson of how the gay community – a community that was fragmented and did not even always think of itself as a community – could come together to tell its own story and to get the public at large – including mainstream media and the powers that be – to pay attention to that story.

The success of AIDS activists in getting more attention and funding to focus on a hitherto obscure and highly stigmatized disease did not, of course, go unnoticed. Most notably, those in the breast cancer advocacy community started adopting some of the strategies and techniques they saw in the AIDS community to great success in order to raise money and awareness.

Indeed, single-disease advocacy has become so successful that some folks are starting to see it as the elephant in the room. The mammoth that is helping to keep us from looking at larger health systems – another one of the siloes that keeps us from looking at bigger but ultimately, perhaps greater payoffs in primary care, and chronic care and the social determinants of health.

But those are all subjects for a different talk.

What I want to get back to is this idea of a community taking ownership of its own story and its own destiny.

Communities have always been important. And under extraordinary circumstances they can do extraordinary things.

But the Internet makes it easier for communities to come together under ordinary circumstances to do both ordinary and extraordinary things.

I’m not talking about orchestrating mass movements – that is still, to my mind, a broadcast way of thinking. I’m talking about bringing together smaller groups that may or may not later grow in numerical size.

The truly revolutionary use of the Internet is not for broadcasting messages but for organizing people.

This is the part that speaks most specifically to where nurses are today.

Over the past two decades and especially in the past two years, as I have spent more and more time with nurses in the U.S. and overseas, I keep hearing some familiar laments.

[Next slide: familiar laments]

The nursing community is fragmented. Nurses are nearly 3 million strong in the US and the largest health care workforce. Only 6% of nurses in the US belong to a professional organization – any professional organization – compared to the United Kingdom where nearly every RN is a member of the Royal College of Nursing.

Nurses have lots of responsibility but no power. They save and protect life and limb but have relatively little power at either at their own institutions, clinics or society at large.

Nurses are not utilized to their maximum potential. I actually found an article about nursing I wrote 20 years ago that made this very point. Things still have not changed. As we move forward with health care reform, will we finally start to address this issue?

Few people in the general public understand what nurses do. Despite the fact that the general public trusts nurses a great deal – as seen in Gallup poll after Gallup poll.

Mostly I have heard these laments in my role as a member of the mainstream press. And it’s absolutely true – nurses are not covered or quoted in the mainstream press to the extent that their role in providing effective, high quality health care would merit.

But the landscape, as I have tried to demonstrate this afternoon, is changing.

And if you keep trying to get the broadcast media to pay attention to your message, your mission and your values, you are going to find yourselves chasing an increasingly diminishing target. Now more than ever, the message is in your hands to deliver.

So let’s start looking a little deeper at the ins and outs of making the network work for you.

For such a supposedly free-wheeling place, you still hear a lot of shoulds on the Web:

[Next slide: various social media brands on the Internet]

You should be on Twitter, Facebook, Posterous or other social media sites. You should contribute entries to Wikipedia, share photos on Flickr, share book marks on Delicious or Digg. You should develop your own social network on the web through Ning or LinkedIn. You should be in the Document Cloud, riding the Google Wave. You absolutely must participate in your professional list-servs. You should share your reviews on Amazon or Netflix. You should. Should. Should. Should. Should.

It’s enough to overwhelm anyone. Especially when you consider you can put a lot of time and energy into something that could just as well disappear tomorrow – the way MySpace is doing.

In fact, sometimes when I look at all these social media innovations, I can’t help but think of Tom Sawyer and that white picket fence.

[Next slide: Tom Sawyer stamp] Here’s a Normal Rockwell illustration of the story. Aunt Polly has told Tom to whitewash the picket fence—it’s his punishment for getting into trouble yet again. But Tom cleverly tricks his friends into doing the work for him by making it seem like something that not everyone can do. Soon they are competing for the honor of whitewashing the fence. And there’s Tom supervising to make sure they do it right.

What was true in 19th century Missouri is true for the 21st century Internet as well. If you’re not careful, you will wind up doing someone else’s work for them – helping them build a new platform – and all for free.

There are only so many hours in the day – only so much time you have available. So your first priority when staking a claim on the web is to figure out what will be most beneficial to you – whether on the job, or as part of your continuing education or advocacy work or to help you in your personal life.

[Next slide: Basics]

Once you’ve decided that something is potentially beneficial, you need to answer a few more basic questions.

Are my friends or people I admire here, too? What good is being on Facebook if all your friends are on Orkut, which is apparently the most popular social platform in Brazil?

Is it easy? – The easier it is to do, the more that people you WANT to hear from will get involved.

Is it fun? – Naturally it can’t JUST be fun if you want to get any work done. But a little bit of fun keeps people going.

The next part is still something of a work-in-progress for me – but here are the guideposts I am now using to help me to decide what is important and where to invest my time. I have arranged them under three areas: organizing people, organizing information and the benefits of sharing.

[Next slide: Organizing people]
Here are five points that I find myself coming back to over and over again when thinking about organizing folks on the web.

Groups are easy to set up – It is also easy to join and leave groups

The collaboration itself still takes lots of time and energy

Who you know is just as important as it ever was – maybe more so

Diversity diminishes groupthink. You need rules and practices to keep a few loudmouths and extroverts from dominating the conversation

Watch out for spammers, viruses, worms, porn pushers, hateniks. We’re not going to find utopia on the Internet. You need to keep a step ahead of the destructive elements.

A lot of this will be familiar to you from your work on teams in the health care setting. So translating this to the Web – what groups are you a part of – keeping in mind that they don’t have to be permanent ones? To what extent are you breaking through silos? Breaking outside your professional limits? What percentage of the folks you engage with online are other nurses? Do you talk online about health care issues with health professionals other than nurses as well as folks outside the health professions?

I would like to give you two examples from my own experience –

My first example has to do with patent issues and a product called Plumpy’Nut.

While I was doing a Nieman fellowship at Harvard, I discovered a weird cross-section of patent law and hunger relief. I learned about a product called Plumpy’Nut – which is basically ultra-fortified peanut butter that is shelf-stable for two years and so doesn’t require a source of clean water. Plumpy’Nut has done wonders to save very young children’s lives in famine settings. In essence, it does for severe acute malnutrition, what oral rehydration therapy did for diarrhea. It doesn’t cure the larger public health problem -- but it dramatically decreases the need for intravenous solutions and the skilled people who provide them – thereby saving many more lives.

The recipe for Plumpy’Nut is also very simple. You can use locally grown peanuts and a modest-sized industrial mixer. The fortified milk powder usually has to be imported but it’s also ubiquitous. As with ORT, the recipe is simple – but somebody had to do the research to figure out the right ingredients and prove it works.

Unlike ORT, however, Plumpy’Nut is protected by a patent – which was sought by its manufacturer Nutriset at the urging of the French government. I learned that Nutriset had issued a cease-and-desist order to a humanitarian group that used the very basic recipe to make its own versions of Plumpy’Nut.

I thought, what a great topic for a group blog. We could get patent lawyers and public health experts and peanut farmers and local communities around the world involved. Naturally some of the big name foundations that have been fighting to bring essential medicines to the poorest countries would want to comment – given similarities with access to AIDS medicines.

And you know what? While I got the blog set up very easily, an interactive group of contributors never materialized. Let me be clear, I discovered several lawyers and health experts and activists who were very willing to talk to me about the issue. But they would rather I wrote about what they said than to write it themselves. Or they didn’t want to be quoted by name. Or – to be brutally honest – they really didn’t see what was in it for them to participate. My original motivation – isn’t this a fascinating case study about how intellectual property concerns are shaping development – wasn’t enough for them.

In other words, the technology was easy to set up but the collaboration proved much more difficult.

On the other hand, I shared all my notes, the summaries of various conversations – in person, online and via email. And once the search engines picked up the posts and others referred to them, people started sending me more bits of pieces of information.

A year after the Peanut Butter and Patents blog first went online, I got an email from Martin Enserink of Science magazine who decided to write up a sidebar on the patent issue for a story he was writing on Plumpy’Nut. A US peanut manufacturers’ association emailed me that they were hiring a lobbyist and using some of the material I had gathered to see whether overturning the patent would lead to greater use of peanuts. More recently, as the issues of whether or not to use Plumpy’Nut has heated up in India, I have heard from a number of journalists there.

So the original idea of a more cohesive group didn’t take shape – but a series of ad-hoc groups did form. Each of these temporary groups contributed a little more information – and then disbanded.

I no longer maintain a separate blog on Plumpy’Nut. If I learn anything new I include it in my regular sporadic blog on global health. And yet, even today, if someone puts the words “Plumpy’Nut” and “patent” into the Google search engine, the first four items that are returned are all written by me and will take you to a collection of material I have pulled together – or curated, which is the term of art now favored by a lot of journalists.

By the way, if you want an example of a group blog for public health that I think works particularly well, check out The Pump Handle. Just put the phrase “the pump handle” in quotes into the Google or Bing or Yahoo search engines and you’ll find it. Good stuff.

My second example has to do with “What to call swine flu?”

Just last spring we all learned about the new swine flu that was then wreaking havoc in Mexico and parts of Texas and California. Several health journalists, myself included were pressed into action to cover the story for various outlets. As it happens, one of the top flu journalists in the world, Helen Branswell of the Canadian Press, was just starting to make her debut on Twitter. She and Maryn McKenna of CIDRAP (which is the Center for Infectious Disease Research and Policy) and Dick Knox of National Public Radio, Jon Cohen of Science, Nancy Shute at USAToday and I quickly found each other on Twitter. Mind you – we are all journalists with competing affiliations but we respect and admire each other’s work.

In the midst of all this, a conversation developed amongst us over Twitter about what to call this new flu. I wish I had the actual Tweetstream to show you but Twitter doesn’t archive old posts and so I cannot now recreate what happened exactly.

The early press reports, of course, were about swine flu. Then the pork producers started complaining that folks would get the wrong impression and worry they could catch the flu virus from eating pork.

The public health authorities who were having their own internal debates about exactly what to call the new flu strains themselves – settled on H1N1 flu for the general public.

The group of journalists I interact with on Twitter, thought that name – H1N1—was too confusing because there was already a seasonal H1N1.

I remember proposing California flu since that’s where the new H1N1 strain was actually first identified. But that seemed much too hard to explain to editors – why we would go with a phrase no one had heard of before.

So each of us made our own decisions but the general consensus was to go with “swine flu” or the “new swine flu” because we weren’t in the business of protecting the pork industry from mistaken concerns.

It was quick, it was easy. No votes were involved. But it was a great chance to take the temperature of what other journalists were doing – not all journalists, mind you – but the journalists that I respect and admire on this topic. And anyone could listen in on and participate in the conversation if they wanted to—if they acted quickly.

Because that conversation happened very quickly. It didn’t need to last long to fit our purposes. As an extra benefit, it also didn’t allow enough time for spammers to break in.

So that’s a little bit about organizing people. And let me reiterate, I think this is the easiest part to overlook about the Web. The true revolution and value of the Web isn’t so much about organizing INFORMATION as it is about organizing PEOPLE.

Nevertheless, organizing information plays a big role and there are four areas that I see coming up again and again here --

[Next slide: Organizing Information]

Out of this group, I want to focus on providing context, which I believe is one of the greatest values that anyone can offer on the Web today. But before I do that let me just say a little about the other three items on this slide:

Crowd-sourcing—is a great way to organize people AND information. In crowd-sourcing, you recruit a lot of people to provide very specific pieces of information. Crowd-sourcing has produced some incredible results, particularly when it comes to monitoring elections. But we are starting to see its use in health care as well.

Some of the best and earliest examples of crowd-sourcing come from sub-Saharan Africa. Citizens in Ghana in 2000 started texting the JoyFM radio station with reports about voters being turned away from polling booths. The radio reports then forced election officials to rectify the situation in real-time, before the voting booths closed.

Nine years later, the use of short but very specific messages has been adapted to help health care personnel penetrate the very murky world of pharmaceutical stockouts in Malawi and Zambia.

Here in the US, Josh Micah Marshall and the folks at Talking Points Memo blog used crowd-sourcing to bring to light a pattern of firings for political purposes in the US Justice Department, which is supposed to be a partisan-free zone. Talking Points Memo won a Polk Award for investigative journalism as a result.

The next item is Structured data. Learning your way around a database is providing more and more insights as large data sets becomes ever more transparent and accessible. And it’s important we keep them open and compatible with each other. More folks are paying attention to Nursing Home Compare, for example, as they make choices about long-term care—despite some glitches in the software.

This massive amount of data is fueling the need for better ways to find and visualize patterns in the numbers. The Dartmouth Atlas folks have been pioneers in showing us these patterns in distributions of health care, staff and variations in costs. Hans Rosling of Sweden has done some great work showing how public health measures change over time—and he makes it fun, too.

But none of this –the crowd-sourcing, the structured data, the visualizing of complex patterns—makes sense without context—without a story that gives greater meaning to all the pieces.

In a world that is just exploding with information, being able to provide the context by which alls those bits and pieces of data make sense has never been more important. It is also, I think, the surest way to stake your claim on the web.

[Slide: implicit to explicit]
So how do you take what is implicit and make it explicit? How do you take what you know implicitly from your professional education and experience and share that with the rest of the world? How do you provide context?

First, talk about what you know. What you are already expert in – the ins and outs of keeping people alive, preventing complications, limiting pain and maximizing quality of life. Name the elephant in the room. Talk about how much time you spend on paperwork versus caring for patients. Tel us about the move to restrict the use of Tylenol and what it will mean to your practices. Just because it’s obvious to you doesn’t mean it’s obvious to anyone else.

Clearly, you don’t want to break HIPAA rules on patient privacy and if you’re going to take on your employer, you’d better make sure you’re part of a big group. [pause]

It’s also imperative to be a part of the important conversations of the day. And of course, what bigger conversation can there be in the public realm these days besides health care reform? Despite what President Obama said when he addressed Congress on Sept. 9, we all know that health care reform is going to be with us for many years to come –even if some kind of health care financing law passes later this year.

IF you want nurses to play more of a role in deciding what health care looks like, make sure that health care – the way it is designed, the way it is delivered, how it could be improved – is part of the ordinary conversations you are having on the Web.

Context does not have to be long and complicated. I am not asking you to write review articles worthy of publication in your spare time. You’d be amazed the amount of context you can pack into 140 characters on Twitter, for example. Listen to Ramsey Baghdadi of the Regulation Policy Market Report, who was live-tweeting the markup of the Senate Financing committee’s bill on health care reform on Sept. 23, 2009:

Baghdadi tweeted: “Two hours into Day 2 of Finance Committee Death March and still not a single vote on 1 of close to 600 amendments. Bring it.”

Right away you get a sense of the complexity, the politics and the timing of it all.

Someone who is particularly good at providing this sort of context at a slightly longer length is Ethan Zuckerman at Harvard’s Berkman Center for Internet and Society.

Back in February when the streets of Madagascar erupted into violence – I’m sure you all remember that right? – there were a handful of reports in the New York Times. Each did a good job of identifying the protagonists and the events of the day but Zuckerman decided to do them one better. He tried to understand what major themes – besides vainglorious politicians – might be underlying the unrest.

After a few phone calls to friends with ties in Madagascar, he quickly outlined the real underlying tension. There was, Zuckerman writes, quote “an unprecedented agreement to lease 3.2 million acres of arable land from Madagascar at $12 an acre.” unquote

This land was being leased to the Korean conglomerate Daewoo. And, as Zuckerman made clear, the reason that is important is because quote: “That swath of land represents half the arable land in the country – it’s an area half the size of the nation of Belgium. Daewoo plans to put most of the land under corn for export to Korea and the remainder under oil palms, hoping to export the oil on the bio-fuels market.” unquote

No wonder everyone was upset.

This little bit of context provided better understanding of what was going on half a world away – it made my reading in the New York Times that much more informative. But as Zuckerman says about his own experience, until he learned the context, quote “the news [about Madagascar] largely floated over me, despite the fact that I have an interest in Madagascar through my Malagasy friends.” unquote

In other words, the context made him more receptive to taking in and searching out even more news on the topic.

Over and over again, we are seeing both in mainstream media and online, providing the right context can drive the conversation. The better you are at providing the context, the more likely people are to listen not only to what you have to say but what others are saying that reinforces what you have to say.

Another person who does this so well is Jeb Sharp, a journalist with Public Radio International. Her series on “How We Got Here” provides a brilliant little history lesson behind the headlines of the day.

Now stories about Plumpy’Nut and Madagascar may seem obscure and even a little tangential. But doesn’t that also describe where nurses find themselves today—often outside the conversation, clamoring for a seat at the table, a chance to influence the decisions?

The point is to get from here to where you want to be by harnessing the tools of communication and organizing people that the Web offers.

Remember, you want your circle of influence to include folks who aren’t nurses. That means forgoing a lot of the nurse-speak that is second nature to so many RNs. For a whole treatise on how to do this, I recommend a book you may already know about: “From Silence to Voice” by Suzanne Gordon and Bernice Buresh.

Also, let me emphasize, this is a conversation – not a broadcast – there has to be give and take. Ask questions, admit mistakes. By all means share what you know but also share what you don’t know.

Which brings me to my last point – about the benefits of sharing in a networked world.

[Next slide: share what you learn}

When people talk about sharing and collaboration on the Web, they can start to sound very utopian and even magical. I’ll just say that being more forthcoming with what I share on the Web has helped me often enough that I keep doing it.

For example,

When I tweeted the other day about some outdated projections about the nursing workforce from the Bureau of Labor Statistics, someone sent me a paper with more up-to-date figures within five minutes.

When I traveled to Malawi last year, I spent three months interviewing nurses throughout the country about their working conditions, the health care system, their challenges and their successes. I posted most of my notes whenever I could get an Internet connection and was in turn contacted by several young people who were looking for logistical information for their own trips to Malawi. That is perhaps not so surprising.

But what did surprise me was that a nursing professor in England reached out to me for advice on a graduate clinical program they wanted to create with a school in Malawi—one of the very ones I had visited. I was able to reassure the professor of the school’s good reputation locally. And I provided constructive criticism on aspects of the UK plan that seemed destined to promote rather than deter the brain drain of nurses out of Malawi.

There is no doubt that sharing and collaboration provide tremendous benefits. But there are still only 24 hours in a day. When thinking about social networks you are designing, have been asked to join or are asking others to join, think about the different motives people have for sharing. What cost – in terms of time and attention are you asking them to bear? What level of commitment do you seriously think you can achieve?

These are extraordinary times. Everyone is out there staking a claim on the Web, trying to get heard. You can improve your chances of success by remembering

ONE: that this is not a broadcast contest – small groups are more powerful than ever before. Don’t get bullied into thinking you have to keep up with Oprah or CNN.

and TWO: your greatest value often lies in providing the context with which to make sense of all the other information floating around out there.

[last slide]
Thank You.

Nurses and the Web: Slides for My Talk

Here are the slides for the talk I am giving on Tuesday (Oct. 6, 2009) at the American Journal of Nursing conference in Chicago. They probably don't make a lot of sense without the text that accompanies them. Still tweaking the narrative (and practicing my delivery). Will post the words next week.

Nurses and the Web

View more presentations from Christine Gorman.

More on Cipla, Plumpy'Nut and India

Stephanie Nolan, the South Asia Correspondent for Canada's Globe and Mail, and I have been corresponding on Twitter about the goings on in India with respect to Plumpy'Nut, RUTFs and official government policy. As part of an article she wrote about the Plumpy'Nut controversy in India, she says, she tried to find out exactly what the Cipla product is and whether it's equivalent to Plumpy'Nut and got ten different answers.

Today she writes that "further invstigation shows Cipla product, whatever is, not WHO-approved & not officially RUTF. Delhi-based Compact closest 2 making."

Related post: India, Plumpy'Nut and Cipla
Related posts on Plumpy'Nut patent issues under intellectual property tag.

India, Plumpy'Nut and Cipla

More on the Plumpy'Nut controversy in India. Cipla, a company more famous for its generic versions of AIDS drugs, makes pre-packaged food supplements for export to Africa, according to Sumana Narayanan in the India environment magazine Down to Earth.

Cipla also told Narayanan that there is no market for such so-called ready-to-use claims no market in India. I find this hard to believe and hope Narayanan follows up on that idea. (She pointed me to her article in a comment to yesterday's post.)

Not sure if this is still true but from what I've heard about India regulation of AIDS drugs in the past, the government's own rules actually probibit the sale of the inexpensive AIDS generics made by Cipla and others locally in India. Makes you wonder if a similar "only for export" rule applies to RUTF as well?

For an update on Cipla, see "More on Cipla, Plumpy'Nut and India."

Click on "intellectual property" tag for previous posts on Plumpy'Nut patent issue:

India Blocks Use of Plumpy'Nut

The Indian government has told Unicef to stop using Plumpy'Nut for the treatment of severe acute malnutrition in that country over concerns about importing and becoming dependent on "foreign food." This is a separate issue from the patent controversy that I have blogged about in the past.

The Indian government questions whether RUTFs (ready-to-use therapeutic food) are better than hot-cooked food, as reported by the Times of India.

On that score, the government's concerns about efficacy seem overblown. Plumpy'Nut is a fortified peanut paste that has a good track record as a ready-to-use therapeutic food in several African countries. And hot cooked meals aren't going to provide the concentrated calorie and nutrient power needed in an emergency situation.

But the larger issue--of having to depend on commercial food imports should not be dismissed lightly. Yes, there's a strong whiff of protectionism but that's understandable in light of the growing crisis in the world's supply of staples. (See Lester Brown's article in Scientific American, or for an even more provocative view, this piece by Deborah Fahy Bryceson in the Monthly Review.)

The solution to the Indian impasse, as reported in the Times Online, may be to use locally produced RUTF. Two Indian companies are starting to get into the business of doing just that.

Planning is Key to Good Multimedia

Multimedia is not easy--takes much, much longer to create than pure text--and requires more thought, cooperation and collaboration.

At each stage of creating the Malawi video that is up on CNN's website--pre-production, production, post-production and distribution--I kept realizing how many different pieces there were. I'll admit there were times when I felt pretty low as each stage seemed to take longer than I anticipated. But I think the result is worth it.

Several multimedia journalists I respect keep emphasizing that you need to do a good job matching up various aspects of the story to the medium. Text--at whatever length (even captions) is particularly good for facts and analysis. Images for action or "slice of life." Audio for emotion.

So, even before I went to Malawi to report on its severe nurses shortage, I knew that I wanted the video to complement the text--not be the whole story. I wanted the video to give a sense of a couple of individual nurses and what they face in a real-world way that is much harder (although not impossible) do to with text.

And then the text could focus on context and analysis. For example, look at these three sentences from my CNN article:

"By the late 1990s, however, Malawi was reeling from the AIDS epidemic. As if that weren't bad enough, the government also had to cut spending on health care and education as a condition for getting help from the U.S. and other countries to liberalize its trade and economy. The publicly funded health system, on which more than 95 percent of Malawians still depend for treatment, quickly started to fall apart. "

Very quickly, I was able to provide the necessary context: the twin ravages of the AIDS epidemic and structural adjustment programs that crippled the Malawian health care system.

The photo essay was the least well-developed part of the CNN package--it really happened almost as an afterthought, when the CNN producer asked me if I had any still photos. But I was able to throw it together in a couple of hours (maybe 20 minutes to pick the photos and longer to export and email them to the producer) because I have organized all the photos Eileen Hohmuth-Lemonick took for the Malawi project as well as caption information in Lightroom, a terrific photo management/database program from Adobe. (And no, nobody paid me to mention Lightroom.)

Once again I wanted to touch on themes of showing nurses in a wide range of activities both inside and outside the hospital/clinic. Given how many negative images of poverty and despair we see from Africa, I specifically chose photos that show success--or at least active engagement. That's something I have thought about a lot over the years and so was able to act quickly.

FYI, I produced one other video based on the Malawi trip, called "Telling Stories, Saving Lives." You can see it in either Flash or Quicktime. I chose to upload it to blip.tv because of the Creative Commons license.

"Telling Stories" is more of a self-contained piece -- but could probably also be paired with a good text story (on women's rights or domestic violence or the arts and health). Why not all three articles connected to that same video. Ahh, my next project!

Related Post:
My Malawi Nurses Video Featured on CNN

My Malawi Nurses Video Featured on CNN

I'm happy to report that my story and video of the crippling shortage of nurses in Malawi has now been published in CNN's new health section "Vital Signs."



I actually shot two videos from my trip to Malawi. You can see the other one on blip.tv. It's called "Telling Stories, Saving Lives."

The videos, as many of you know, were months in the making. Who knew there were so many parts to putting moving images together?

And I have to question the idea that anyone truly is ever alone in producing video.

Many thanks to Nieman Fellow classmates (Ayelet, Joan, Walter, Simon and Stuart) who, along with Jeb Sharp and Joe Neel, gave me guerilla lessons in shooting video, Katherine Bates (who helped ferry all the equipment), Eileen Hohmuth-Lemonick (who took the still photos) Ed Robbins (who edited the videos and wrote the script), Stefanie Friedhoff (who believed in the project and provided the funding) and, of course, the great people at Embangweni Mission Hospital itself.

The two institutions to thank are, of course, the Nieman Foundation for Journalism, which awarded me the fellowship on global health reporting--and the Bill and Melinda Gates Foundation, which supported the Nieman Foundation.*

I haven't even won an award or anything and I'm just gushing with all the people to thank--but perhaps I'll stop there.

*I believe there is no conflict on interest posed by the Gates funding since I was free to chose my project and did my reporting without editorial input from the Gates Foundation.

Anyway, just wanted to share the joy.

Related Post:
Planning is Key to Good Multimedia

Plumpy'Nut: WBAI Radio Interview

Just finished talking with Diana Mason and Barbara Glickstein about patent issues and Plumpy'Nut on WBAI. Intriguingly, the conversation broadened out to food and water issues generally. Here's a list of previous posts about Plumpy'Nut that Diana referred to in her questions.

Unintended irony about cost-effectiveness

Some thoughts on the unspoken history in an article from the Wall Street Journal about cost-effectiveness in global health.

I have been spending more time these past several weeks on Twitter, the short-form micro-blogging platform, rather than on the blog. (I'm @cgorman.) There are obvious limitations to Twitter's 140 character limit. But I find it's a great way to quickly pass along time-sensitive information, as well as get a kind of "temperature reading" of what some of the big issues are thought to be.

It's also exactly the right format to quickly point folks to news articles--like the one that Amy Dockser Marcus of the Wall Street Journal wrote in an intriguing piece titled, "To Fix Health Care, Some Study Developing World."

But it's hard to fit into 140 characters what I thought was missing in Marcus's article. It's a perfectly fine piece of journalism, a good introduction. But there is a lot more to this story.

You get a hint of it in Marcus's praise of the Prevention and Access to Care and Treatment (PACT) Project in Boston. That program was started by Partners in Health in 1995.

The main thrust of Marcus's article is about international programs that provide better health for less money. In other words, the benefits of cost-effectiveness--as seen in poor countries.

Regarding cost-effectiveness: PIH leaders like Paul Farmer and Joia Mukherjee will tell you over and over again that too many in global health are slaves to the idol of cost-effectiveness. (Note, these are their friends they are talking about--the folks who believe in global health.) Farmer and Mukherjee see an unthinking allegiance to cost-effectiveness as a sledge hammer that is often used to deny access to health care for the poor and marginalized.

Regarding health care in poor countries. Mukherjee recently had an op-ed in the Boston Globe slamming the IMF for cutting public sector spending in health and education amongst poor countries as a condition of receiving loans in the 1980s. Part of the reason so many countries were open to working with PIH to develop the sorts of programs praised by the WSJ was because their original government health plans were destroyed by budget cuts demanded by "structural adjustment programs."

The irony, as Mukherjee and her co-author wrote, is astounding. "Today, market-based, financial-sector strategies have failed so miserably that nothing but massive public spending can rescue even the wealthiest economies. The United States itself has used trillions of dollars of public monies to stimulate the economy and secure private institutions. Yet expansionary public spending will not be possible in poor countries if the IMF is given free reign to restrict public expenditures."

So, Twitter for short bursts of information (like headlines). Blogs for looking a little deeper. All of it is a process that sometimes even produces good products.

Related Posts:
Do We Get Our Money's Worth in Global Health?
How I Use Twitter Without Being Overwhelmed

Do We Get Our Money's Worth in Global Health?

Two carefully researched reports in the Lancet argue that the world is not getting its money's worth in global health.

The first, from the World Health Organization, says that a focus on making improvements in individual diseases--like AIDS--has come at the expense of comprehensive programs that offer treatment for all the most pressing health problems.

The other, from Institute for Health Metrics and Evaluation in Seattle, documents a quadrupling of funds for global health since 1990 but shows that some of the poorest countries with the highest disease burdens have actually received less help than somewhat healthier and wealthier countries. In addition, the IHME paper documents the shift in power and influence from government and public agencies to private foundations--like the Gates Foundation, which funded the study--and individuals.

Both research articles--and the accompanying comments and editorials--are well worth reading at length and at leisure (which I plan to do this weekend). I do not know if these articles will spur any changes in direction or action on the ground but I have a feeling we will be hearing about these pieces for some time to come.

Several of the blog posts I have read so far about these studies are rehashes of the press releases that accompanied them. Given the nuances of the arguments and the complexity of the data, it may take a while for more thoughtful reviews to appear.

Maria Cheng's article for the Associated Press is a good, if basic, introduction to the papers. Kaiser Health News says they will post an aggregation soon--and here it is.

Health-Eight Meet in Seattle

Sandi Doughton of the Seattle Times lifts the lid a bit on one of the more exclusive clubs in global health--the Health-8 or H8--meeting this week in Seattle.

Her report documents one more step in the ongoing privatization of global health as power and influence drain away from public groups--like the World Health Organization--to private foundations and non-profit organizations.

Given the reactions in Doughton's article, folks don't seem too concerned about the lack of transparency. After all, it's not like Hilary Clinton having secret talks about health care during her husband's administration or Dick Cheney chatting about energy policy with petroleum execs--right?

Related Post:
Who are the Health 8 (or H8)?

Malawi Project Featured in American Journal of Nursing

I am happy to report that a photo-essay about my Malawi project is the cover story for the June issue of the American Journal of Nursing. That great cover photo of Mphatso Nguluwe was taken by my friend Eileen Hohmuth-Lemonick who joined me on my three-month Malawi trip last year.

Mphatso is a great story-teller, who likes to tell her fellow Christians that she is the mother of nine children by eight different fathers. It's a great teachable moment that I wrote about last July.

My project focused on the nursing shortage in Malawi as a kind of a kind of window into how health systems function in poorer parts of the world. Malawi is in the midst of a six-year program to address its nursing shortage by paying nurses more and supporting more nursing education and training.

Part of what I learned in Malawi is how fragmented and overly narrow most efforts at improving health turn out to be. We think that having more drugs or more nurses and doctors will automatically improve conditions without considering the need for better roads, clean running water or functioning secondary schools to make sure those efforts succeed.

Because it's easier to raise money for a single issue--like AIDS or polio vaccines or girls' education, we continue to maintain (and tell stories about) siloed efforts that don't intentionally contribute to broader, more long-term needs like primary care. There was a study about that from the Institute of Tropical Medicine in Antwerp just yesterday in the Public Library of Science.

I don't understand why--if it took me only three months to figure this out--the professionals who do this for a living still can't seem to adjust their efforts accordingly. As the PLOS study suggests, they must already know this. But then, as the saying goes, "It is difficult to get a man to understand something when his salary depends on his not understanding it."

I tried to get at some of these themes with the photos and captions that are part of the AJN essay as well as the supplemental material that is available online. When I suggested to Diana Mason, the outgoing editor-in-chief, that both be made available for free to non-subscribers as well since they reflect on health in the developing world, she readily agreed. Well, as another saying goes (two aphorisms in one post--that probably exceeds the limit), "it is better to strike even a tiny light than to curse the darkness."

Related posts:
Hiding Broken Practices Behind New Catchphrases
At Work with Malawi's Nurses

Update: Related 10-minute podcast with Christine Gorman on the AJN site

Hiding Broken Practices Behind New Catchphrases

Here is another example of why we need more independent reporting on global health and development. A study from the Public Library of Science found that many global health initiatives are still effectively siloed efforts that focus on single diseases or institutions and do not, despite claims to the contrary, support overall health systems.

And yet, as I have seen in my own travels through Malawi, Lesotho, South Africa and Zambia, improving health systems is precisely what is needed in many poor countries and impoverished areas. "Health system strengthening" has become the new catchphrase but, according to the PLOS report and the lived experience of many in the global health field, there has been no real change in action to support this goal.

One positive trend: the researchers note that while their funding came from the Institute of Tropical Medicine, Antwerp, "the funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript." This slightly more detailed conflict-of-interest statement should be adopted more widely when reporting or writing about global health.

Related post:
Who Pays for Global Health News and Why?

Who Pays for Global Health News and Why?

To maintain credibility, news coverage of global health and development issues must be independent because who pays and why dramatically influences the process of what gets told. This is a sleeper issue that does not get enough attention. As a health journalist, I know we have been down this road before—with respect to misleading consumer news coverage of medications and research studies—and it’s not pretty. In the end, it actually hurts people and wastes money.

It hit me last night why I am so passionate about this topic. I went to a presentation about how to improve health care news coverage in the U.S., which was mostly about how many health news reports don’t cover basic issues like costs, availability or provide even a hint of context about whether something is truly broadly beneficial. The event was sponsored by the New York City chapter of the Association of Health Care Journalists, of which I am a member.

One of the presenters, Gary Schwitzer, a former CNN journalist and current journalism professor who founded HealthNewsReview.org, jokingly suggested that I might throw spitballs at him while he was at the podium. (The other presenter was Harry DeMonaco, who helps Boston's Massachusetts General Hospital decide what treatments are both beneficial and cost-effective.) Instead, Schwitzer provided me with an aha! moment.

For more than 20 years, I have worked in an environment where pharmaceutical and medical device companies have a huge vested interested in getting their products covered by the mainstream media in the best possible light.

As Gary Schwitzer and Harry DeMonaco noted, the economic incentives are so great that the influence extends even to what appears in medical journals. Drugs are often compared against placebo instead of current effective treatments, for example, because the results are more dramatic that way. No one can take a chance on a new medication being scientifically shown to be just as good or only marginally better than a less-expensive one.

Add to that human nature—it is very hard to be objective about something to which you have dedicated lots of your time and energy. So naturally, someone who is a principal investigator on a study is going to be enthusiastic about the work and its potential for alleviating human suffering.

I know that—as do many of my colleagues in the health journalism field. And I hope that I have taken account of those sorts of positive psychological and economic biases in my reporting by looking for more outsides sources, bringing a respectful-but-still skeptical attitude to most research studies.

Just as importantly, I benefited from the structural divide that was set up within TIME Magazine that kept the advertising side separate from the editorial side precisely so that I could be as independent as possible in doing my job.

So here I am, trying to get more news coverage—both online and offline—of important issues in global health and development and I find the same built-in biases that make health-reporting trickier than you might at first think.

There is a built-in bias in almost any story about non-government organizations against considering what governments are doing in health. Every story about a specific disease has a built-in bias against discussing primary care systems or the non-medical interventions (like better schools or roads or robust legal and civil rights for women) that could conceivably have an even greater impact.

The consequences are very real. To give just one example, I will never again be able to read another laudatory story about the “generous donation of medical supplies” without thinking about the amount of donated material that I saw in Malawi last year that had either passed its expiration date or was actually useless—and needed to be discarded, all at the expense of the receiver. This is the sort of problem that missionaries 50 years ago dubbed “junk for Jesus.” It makes the folks back home feel virtuous but it is a burden for the supposed beneficiaries.

Given the costs and the way things are going these days in journalism, there is bound to be money coming from interested parties whether in the form of grants, advertising or even accepting a ride in an aid convoy, to cover global health issues. That’s all the more reason to set up rigorous firewalls so that funders and advocacy groups don’t get editorial approval over the final product. News organizations also need to make those policies public so that the larger community can judge for itself how well they are doing.

Budding global health news organizations—or content providers—also need to be more creative about who they tap as funders/advertisers. Maybe recruit the folks who like to fund transparency projects, for example, instead of going after global health or single-issue advocacy money.

There may also be ways of crowd-funding global health news coverage that we haven’t explored.

But I know we need to be paying as much attention to managing these conflicts within the coverage of global health news as we are to “monetizing content,” to use the current buzz-phrase. And it's just as much an issue for citizen journalists/participatory media as for legacy or professional journalists.

Related posts (updated on May 20,2009)
Click #ghnews label for other posts on covering global health
See also "Pro-Publica and Conflicts of Interest"
Read Ivan Oransky's live tweets from Monday night's AHCJ event with Schwitzer and DeMonaco.

Barbara Hogan, Paul Farmer, Eric Goosby and More

And now for a little global health gossip--in between reading dispatches from the World Health Assembly, which is meeting in Geneva this week . . .

Barbara Hogan is out as South Africa's Health Minister--just a few days after being named one of Time Magazine's 100 Most Influential People in the World. Was she too outspoken about the need for greater transparency and accountability for South Africa's AIDS treatment programs? Too critical about the government's refusal to issue a visa to the Dalai Lama? Is the ANC government that petty? Or is this just normal shuffling of cabinet positions? South Africa watchers are taking a watch-and-see approach--especially since the new Health Minister, who comes from Limpopo, is not widely known.

Paul Farmer has told colleagues he is contemplating a possible position with the U.S. government.

And in other news,

Eric Goosby, who has been tapped by President Obama to replace Mark Dybul as U.S. Global AIDS Coordinator (head of PEPFAR), will be speaking at the Global Business Coalition on AIDS annual conference June 23-24 in Washington, DC. Dybul will be there as well in his new role as co-director, with Larry Gostin, of the Global Health Law Center at Georgetown University. (Dybul joined Georgetown in February).

Thomas Frieden, New York City's health commissioner, is Obama's pick to head up the Centers for Disease Control. Revere, in his unique way, highlights some of the challenges Frieden will face.

And if you're in Washington, D.C. for the Global Health Coalition annual conference, don't miss Katrin Verclas on Wednesday morning, May 27. She organized the excellent barcamp conference on Mobile Tech For Social Change that I attended in New York City back in February and is a crackerjack organizer and advocate for what mobile phones can do for health, finance, accessing the Internet, changing the world.

Oh, and this just in. . . the London School of Hygiene and Tropical Medicine, just won the $1 million Gates Award for Global Health, given out each year at the Global Health Coalition meeting.

Afghanistan: First Acid, Now Gas Attacks Against Girls

Reuters reports that three girls' schools in Afghanistan have now been the targets of improvised gas attacks. Five girls fell into comas for a short while after the most recent attack, which occurred on Tuesday, while 100 others were hospitalized. Apparently, throwing acid at some girls, wasn't enough to convince many of their sisters to stop their education.

The news of the attacks has kept hundreds of girls from showing up at school, according to the Associated Press.

Still unclear: what kind of gas was used. Blood samples have been sent for testing. There is also a chance that a gas leak--as opposed to a premeditated attack was involved at the third school.

Also disturbing, the attacks are happening in Kapisa province, a region east of Kabul that has been relatively open and supportive of girls' education.

Related news:
Katie Couric had a piece on the CBS News about the assassination of a women's rights activist in Afghanistan and the passage of a new law that (may be changed) that would allow marriage as a defense against rape.

Crisis-Mapping the Sri Lankan Fighting

Is there a way to combine human and technological intelligence to figure out what is going on in a tiny section of Sri Lanka, which suffered heavy bombardment this past weekend? Can you, dear reader, help collect that information?

The American Association for the Advancement of Science has published satellite imagery which suggests heavy shelling and mass movement of people. (hat tip @mwmcelroy who works at the AAAS.)

According to the Associated Press (as quoted in the New York Times), "a government doctor said at least 378 civilians — and perhaps as many as 1,000 — had been killed and more than 1,100 wounded on Saturday and Sunday during intensive shelling of the combat zone on Sri Lanka’s northeastern coast, a boggy sliver of beachfront where Sri Lankan troops have surrounded Tamil separatist fighters." (Click here for the full AP report, which details three rounds of shelling on the hospital.)

Journalists report not being allowed into the area to report on what is going on.

This seems like quite a test case for folks who promote the benefits of crisis-mapping.

Crisis-mapping is an emerging technology that uses SMS or mobile texting plus other crowd-sourced pieces of information to map a crisis, while it is happening. The idea is to give folks on the ground as well as those far away some idea of what is going on and which areas are particularly dangerous in real-time. Click here for a video introduction to crisis-mapping from Patrick Meier, whose dissertation features a lot about crisis-mapping and who has been traveling the globe recently introducing folks to it.

I am asking my larger Twitter and blogging community for help in gathering resources. Will share the results here.

Human Health Effects of DDT

Several folks, after reading my last post on DDT, have asked me about DDT's health effects on people. Their point: while DDT may prevent some people from dying of malaria isn't there a cost to their long-term health?

Once again, context is key. The major negative effects of DDT have been on animals--particularly birds and fish. This is very important and not something the environment can sustain, especially since DDT accumulates in any animal's fat tissue (including people's).

As far as we know, DDT's health effects on people are minimal compared to that on fish and birds--something that was straightforwardly acknowledged last year on the website of the World Resources Institute, where Al Gore serves on the board of directors.

More recently there has been some research to indicate that DDT may act as a hormone disrupter and affect fertility as well as promote premature delivery. Animal studies have also suggested a possible cancer risk--but once again that would presumably be at very high dose.

So, if you are just going to look at health effects in people, the scales tip toward using DDT in those parts of sub-Saharan Africa in particular where it would be most helpful.

This is the same kind of cost-benefit ratio that is seen with giving polio vaccines that also sometimes cause the disease itself.

The cost to the environment is the more worrying issue--and something that needs to be addressed whenever DDT is used as part of an anti-malaria program. Fortunately, the amount of DDT that is needed for residential spraying is small. South Africa has shown the spraying can be done with minimal impact on the environment--by training sprayers and making sure no DDT is diverted to agricultural use.

It's a fascinating topic--and hard to find experts who are truly impartial. In my experience of reporting on the topic, people from both the left and right use DDT to score political points without regard to what facts are like on the ground.

Makes me think I should look more closely at the latest report that the World Health Organization has decided to work towards the total elimination of DDT, perhaps even in malarial zones.

Related posts:
Back and Forth on DDT Again
Can Malaria Be Eradicated?

Back and Forth on DDT Again

What's missing from the latest news about the World Health Organization, DDT and malaria? Context! Context! Context! Namely, if DDT had been used from the time of its invention only for public health purposes--for indoor residential spraying against mosquitoes in areas hard-hit by malaria--it would probably never have developed its toxic reputation.

The fact that agricultural interests--particularly cotton farmers--adopted wholesale DDT spraying is what killed birds and poisoned entire ecological systems.

There is a special case to be made for judicious, environmentally-protective DDT spraying of residential homes--particularly in hard-hit African countries. South Africa has shown how to do this and still protect the environment. (I wrote about this in TIME Magazine five years ago. Please also note, it was the combination of DDT and treatment with an anti-malarial drug that turned the tide.)

The World Health Organization seemed to have acknowledged that point back in 2006.

Now comes word that they hope once again to achieve a total ban on DDT, thanks to pilot programs that have used other anti-mosquito pesticides and means in Mexico and Central America. Please note: malaria is much worse, much more prevalent in central and southern Africa so what works in Mexico may have little effect in malarial zones of Africa.

As for increased resistance of mosquitoes to DDT, the point is actually not to kill the mosquitoes but to keep them from biting. And DDT is actually a better mosquito repellent than anything else--exactly what you want, according to a 2007 study in Nature Medicine.

I suppose all public health programs have an element of politics but I find it very frustrating to read news reports that pretend that all decisions with respect to DDT are made solely on a scientific basis.

Related posts:
Can Malaria Be Eradicated?
Human Health Effects of DDT

How I Use Twitter Without Being Overwhelmed

Twitter does not have to be yet another echo chamber—provided you are selective about who you follow. By treating Twitter as a filtering device and NOT a broadcast medium, I think I have a better shot at getting at the story behind the story.

For my purposes, Twitter does three things very well: organizing people, collecting data and doing a quick temperature check.

ORGANIZING PEOPLE

The 20th century still has such a hold on many of us that we find it hard to give up certain broadcast assumptions—that your goals should be to reach as many people as possible and to drive the conversation.

So, most stories about organizing people with Twitter focus on large numbers—10,000 protesters showing up in a square in Moldova, even if later reports question just how much of a role Twitter or SMS texting or even the government itself played in the demonstration.

My goal is not as revolutionary, nor does it require as many people. I want to develop an independent editorial voice to shine more light on global health and development—both as issues and as industries.

Given the tumult in the news business these days, there is a lot we still do not understand about how to make such an enterprise sustainable. But I suspect there are enough people out there who are interested—and who have some good ideas and experience on how to get things done—that we might be able to figure it out eventually.

In the meantime, I am trying to develop a kind of network for global health news through Twitter, my email contact list and the people on my own and other global health blogs.

COLLECTING DATA

We have only begun to explore what is possible with structured data. I predict this area will explode with possibilities once it no longer takes a lot of computer programming skill and expertise to do this right.

For now, most of what I am collecting on Twitter are links—still very 20th century.

Often these are bits of information that do not necessarily relate to each other. Typically I look for links that deal with new models for delivering and sustaining news, that get beyond advocacy in global health and that grapple with some of the ethical dilemmas of how we tell stories, while trying to make money, working against deadlines and across cultures.

One of the most practical uses of Twitter for non-programmers is to figure out whether they should jump to another session at a conference. Check the twitterstream for a conference #hashtag to see which panel discussion looks most interesting and jump ship if yours isn’t meeting your needs. Likewise, let others know if the panel you’re listening to is really interesting.

Notice with conference #hashtags, we’re often talking about small groups with very concrete pieces of information. Indeed, the short messages often can only be understood by those who are already on site. Further, deeper reflection comes later—and is probably based on more research, phone calls, better data.

One of the best examples of collecting concrete data from lots of people is the #votereport project.

#Votereport was a Twitter project in which US voters were encouraged to tweet their voting experience last November 4. Because the predictions were of massive voter turnout, the goal was to see where the lines might be long and where newly registered voters might be encountering problems. Voters were asked to provide three pieces of information: their zip code, the length of the line and whether they had a good or bad experience. If bad (meaning they were turned away), then they gave more details about why.

The brilliant thing was that organizers then were able to put those folks who were turned away in touch with election protection lawyers in real time to see if their legal-electoral issues could be resolved before the voting booths closed.

The big picture issue was maintaining the integrity of the voting process. But the structured data that folks were asked to provide was easy to give and the connection with the larger point was easy to understand.

Eventually I think we will see more projects like #votereport adapted to global health.

But input from large numbers of people will not always be required.

Check out Frontline SMS for one example of what’s possible when you adapt text messaging tools for humanitarian work. I have also wondered if it would be possible to adapt something similar for ensuring the integrity of a country’s supply chain of medicine?

DOING A QUICK TEMPERATURE CHECK

There’s a concept in biology called proprioception. That’s the body’s own awareness of itself in the environment. Because it goes on in the background, we don’t have to give conscious thought to keeping our balance when we decide to run for the bus.

I use Twitter as a kind of proprioception tool for health journalism. Another way to think about it is to use the phrase “situational awareness,” as developed by military strategists and later appropriated by folks in business.

To give just one example, when I tweeted about grappling with what to call the new human swine flu in my own news articles, I learned that several other health journalists I respect were dealing with similar issues. And indeed, that struggle later became the subject of official pronouncements from the Centers for Disease Control and the World Health Organization, as well as long-form news articles by others who are not in my Tweetstream but who I read on the Internet and in hardcopy.

There are only so many hours in the day and only so many minutes I want to devote to Twitter. So my Twitter philosophy is to keep the number of tweets low and to follow only those who also keep their tweets low. If you pick the people you follow right, you will get a much more manageable stream.

I aggressively unfollow people who tweet too much. No matter how good they are, they drown out the others. And messages from high-volume tweeters still get into my tweetstream if the people I follow find them particularly important.

I unfollow people who retweet links without checking them out first.

I don’t mind following someone for a while and then unfollowing them only to refollow them later as my needs change.

If you find you have to follow someone who tweets a lot, follow them through an RSS feed or one of the programs (Tweetdeck, Twhirl, etc) that allow you to segregate their stream from your low-volume crowd. For now, I still access Twitter through the web because I am trying to keep the volume low, not increase it.

I often do not follow my friends if they tweet a lot because we are already on Facebook, I read their blog or we are in constant email contact.

I do not read every tweet. I do not reply to every @message. If you adopt a "river of news" approach to Twitter (similar to the one many of us have had to use with RSS feeds), the stream is much more manageable.

In essence, I think of the people I follow as my filter, a way of getting a sense of important ideas but NOT as a way of getting first-hand information. We are already flooded with facts (not to mention half-truths and outright lies). What we need are better filters.

As in so much of life, you have to take active steps if you really want to understand what is going on as opposed to just being distracted.

If you want to follow me on Twitter, I'm @cgorman.

Related Posts:
Wanted: A Social Network for Global Health News
Sharing and Global Health Blogging

Swine Flu: Stocking Up On Soup, Just In Case

There are still a lot of unanswered questions about the new human swine flu that everyone has been talking—and sometimes obsessing—about. US government officials keep telling us to “hope for the best and prepare for the worst.” Here’s how I am taking that advice. At this point in time, I think it’s reasonable to stock up on canned soup, soap, hand sanitizer and Kleenex—which I have done. I plan to take a train this weekend. If I had to travel further, I would not hesitate to take an airplane. That could change tomorrow or next week. But for me, that’s reasonable for today.

Just finished talking with Lisa Mullins of PRI/WGBH/BBC’s The World. The other guest was Peter Sandman, a risk communications consultant who has been talking about preparing for pandemic flu for several years now. You can hear our segment on the radio at 3 PM on WNYCAM, which is 820 AM in New York. Here's the link to the podcast of the program.

I keep hoping, perhaps vainly, that adults ought to be able to sort through contradictory pieces of information at the same time. Yes, there is reason to be concerned about the new human swine flu. Even if it fizzles out in the next few days to weeks, there is still reason to be concerned. It’s not a bad idea to check your pantry and stock up on a few things that might have gotten low—in case you need to shelter in place. As anyone who has ever been in a hurricane knows, the time to buy extra diapers is not when the National Oceanic and Atmospheric Administration says the storm is going to hit your area in 24 hours. No, it does not make sense to close down the border between Mexico and the US.

Having extra food around the house or gas in the car are easy precautions to take now. There is not enough space in my tiny apartment for a two-week supply of stuff but we have seven days worth to cover my partner and myself. I’m also collecting a few phone numbers from my neighbors and have posted New York City’s flu hotline number (1-800-808-1987) in my kitchen. I have also noticed that I am not shaking people’s hands as much.

It helps to keep a sense of humor. I bought a box of crackers—one of my favorite things to eat whether sick or not—and marked it “IN CASE OF FLU.” I have a tendency to go overboard on crackers and don’t need the extra calories—unless I really am sick.

And after that, it’s kind of a waiting game—to see what will develop.

People who know me well say that I sometimes try too hard to fix things. Curiously, with reports of the new human swine flu, I have adopted a more fatalistic approach. No, I’m not throwing my hands up and doing nothing. I AM taking some precautions (outlined above). I may change my actions in the future. But I do NOT believe that I can 100% guarantee that I or my loved ones won’t get sick if a severe pandemic emerges. Flu is much too contagious for that.

The die is already cast as to whether this particular flu strain goes pandemic and how much illness and death it might cause. We will know soon enough.

For more information on preparing for a possible pandemic, you can go through the checklists at pandemicflu.gov.

Related post: Swine Flu: Getting the Facts Right