Wanted: A Better Metaphor for "Health Systems"

Finding the right metaphor to describe a complex issue is often one of the hardest--and most creative--tasks facing any journalist. Say the words "brain drain" and you feel like you already have an idea of what the issues are--rich countries poaching nurses and doctors from poor countries.* But say the words "health system" and most of us draw a blank about what the phrase means or why it's important.

I know that's the case for me. I started my Malawi project thinking it was about the "brain drain" of nurses. But interviews with Michael Clemens, Fitzhugh Mullan and others convinced me that was only a piece of the puzzle. I needed to widen my focus from what rich countries were doing to lure nurses away to conditions within Malawi that pushed them to leave.

It's about more than just money. You have to look at the state of the entire health system--from conditions in the hospital to how long it takes patients to travel to a clinic (or for a health worker to come to them) to medical opportunities for professional development to individual workers' own hopes and dreams for their children's future.

Ruth Levine of the Center for Global Development suggests the metaphor of the human body to describe a "health system" and likens the physical infrastructure to the bones, the workforce to the muscles, the supply chain to the circulatory system, etc.

Bill Hsiao of Harvard told the Nieman global health fellows his working metaphor is a car. It needs to have enough money (gas in the tank) to run but your basic Tata Nano can get you from point A to B in India for a lot less than a Rolls Royce.

Following up on the automotive metaphors, others have likened health systems to the network of highways that crisscross any major developed country. Imagine trying to move a truck full of lettuce from California to North Dakota on dirt roads vs. six-lane highways and you get the picture. In one case, the produce spoils before reaching its destination. In the other, it seems perfectly unremarkable that you can mix a salad year round.

Don't think we have hit on the right metaphor yet. (Metaphors that need a lot of explanation kind of defeat the purpose.) But more and more of us are working on it.

If you have any suggestions for metaphors to describe health systems, please post them in the comments below.


* More recently, folks like William Easterly have pointed to another view--health workers emigrating to make their lives better and maybe send some cash home in the bargain.

Share What You Know

It has worked wonders for my Malawi project. Last week I received an email from a PhD student in England who is writing a thesis on the experiences of Malawian nurses in the UK, South Africa and Malawi. Talk about an exact match! We've already started comparing notes. She found me because I posted my field project proposal on the web and have been blogging about this trip for the past several months.

And that is just the point. I've spent the past year unlearning some (not all) of my training as journalist. The idea that you have to hoard all the information you have until publication date is not only old-fashioned, it actually keeps you from finding important new contacts. Or should I say, it keeps them from finding you?

Note this probably doesn't work if you are on a tight deadline or are trying to expose wrongdoing at the Walter Reed Medical Center. And all the old rules of contacting known experts and sources, conducting literature and databases searches and following up, double-checking and verifying still apply.

What this means is that we're breaking the "tyranny of the now" that has gripped news-gathering for decades. No longer do stories appear just once and then quickly get displaced by some other news-breaking event. (That's a weakness of traditional news gathering that has been exploited by spin doctors who release bad news on Friday afternoons after the markets close when fewer people are paying attention.)

We're going to have to change some of our ideas about news hooks and exclusivity. People will read/view/use the final product because it provides an overarching framework by which to make sense of complicated issues and all the twists and turns in the report-as-you-learn it model.

In the long run, I think we will see that collaborative story-telling and news-gathering is better than traditional methods at keeping tabs on issues that unfold over longer periods of time, such as global climate disruption or the migration of health workers. But as anyone who has ever served on a committee knows, collaboration takes a lot of effort to work.

Related posts:
At Work With Malawi's Nurses
What Do Patents and Peanut Butter Have To Do With Each Other?

Nine Days to Malawi

Still no sight of the free-standing mosquito net I ordered more than two weeks ago. Travmed, the mail-order company I used, says the manufacturer of the Indoor Travel Tent is going out of business. (In that case, you would think Travmed would take the item off their web site, which they haven't as of this morning.) In any case, I've ordered a replacement.

I get my second hepatitis B shot later this week. Now I'm sorting through the clothes, toiletries, notebooks and rechargeable batteries to figure how much I can lug.

I've organized the Malawi trip a little like a long-distance hike with resupply from friends and fellow travellers who will be coming from the U.S. at various intervals. But also hope to help the Malawian economy by buying local whenever I can. Can't wait.

Two Weeks Until Malawi

My to-do lists have to-do lists. The shotgun microphone for recording interviews has arrived but not the mosquito net. Worst comes to worst, I suppose I can buy one in Lilongwe.

Two things I want to remember from a conversation I had with Pauline Peters earlier this month. The first has to do with the growing chasm between the very poor and every one else. The second has to do with the stress caused by too many visitors.

Peters is an anthropologist who teaches at Harvard’s Kennedy School. She has been following a group of 200 families in the Zomba region of southern Malawi for more than 20 years. None of the families is rich—even by Malawian standards.

When she began, the families at the top 25% of the economic ladder had three times more income than those in the bottom 25%. Ten years later, the gap had widened to an 11-fold difference. Today, she says, the gap is about 10-fold.

The gap between rich and poor is thousands of years old and is found all around the world. But the relative difference has remained fairly steady over all those generations. What has changed in our lifetimes is this extraordinary widening of the gap into a chasm—not just in Malawi but around the world.

And it’s not just economics. There’s a chasm opening up between the healthy and the unhealthy as well. There are huge differences in lifespan of folks who make it to adulthood. I suppose if you looked, you’d find that the gap between educated and uneducated groups is widening as well.

The other thing Peters talked about is how now that Malawi has been “discovered,” everyone seems to be going there. Even presumably beneficial offers of help can prove overwhelming. Government officials get mobbed by visitors. Program directors spend so much time dealing with the needs of visitors (who often have money), they have less time to spend on the program everyone supposedly cares so much about.

I took that as a word of warning—although I’m not sure Peters directed it specifically at me. I have wondered about that myself and will be mindful of my hosts while traveling in Malawi. Even though I believe reporting on the nursing crisis there will ultimately prove beneficial, I know I’m just part of the daily juggle.

Related posts:
At Work with Malawi's Nurses
How Big a Problem is the Brain Drain?

Where are the Global Health Blogs?

Tara Smith updates us from Mongolia on the new outbreak of hand-foot-and-mouth disease that has just been reported there. Tara is both an honest-to-goodness scientist and a blogger--although she hasn't been blogging as much on Aetiology this month. Her specialty is pathogens that jump to humans from other animals.

Other public health blogs by academics that I particularly like to read include Effect Measure (always provocative) and The Pump Handle (with a focus on occupational health).

But for the most part, the number of global health professionals in the blogosphere are few and far between. I am keeping an eye on Global Health Delivery, a kind of blog aborning, to see what develops there. Otherwise, the slack is being taken up by the passionate (H5N1 and THDblog) and a few journalists here and there.

Post a comment if you there are others you know and trust.

Final Prep for Malawi

Less than a month to go before I head for Malawi. Hard to know what to make from this distance about reports of a possible attempted coup.

As for the things that are somewhat under my control, I got most of my shots last week (hepatitis B, meningitis, TdaP for tetanus, diptheria and whooping cough). My typhoid and hepatitis A vaccinations from a few years ago are still good. No need for yellow fever since Malawi is not in a yellow fever zone. Filled my prescription for malarone against malaria. Ordered a mosquito net.

The CDC recommends a pre-exposure rabies vaccine as a precaution but the travel doctor I consulted here in Cambridge says there's a shortage of vaccine in the U.S. and so it's being restricted only to folks who have actually been bitten by a bat or a dog or cat, etc.

In other words, I have taken the recommended medical precautions and will hope for the best.

Considering I'll be in Malawi in their winter, the biggest threat is probably from traffic accidents.

Related posts:
At Work with Malawi's Nurses

Job Posting: Deputy Director at SciDev.net

Help wanted: SciDev.net is looking for a deputy director in London. Deadline is May 31, 2008.

I can't vouch for what it would be like to work for them, but over the past several years, I've come to rely on Scidevnet's news feeds for great, up-to-the minute science and technology reporting from an international perpsective. Their items frequently turn up in my list of shared reading material on global health.

Editorial: US Food Aid Policy Needs to Change

My friend and fellow Nieman David Kohn has an op-ed in the Baltimore Sun on how official U.S. policy makes the food crisis worse. He argues that the U.S. could help more people for the SAME AMOUNT of money it is spending now on food aid by buying food locally instead of shipping it from the U.S. as now required by law.

In fact, U.S. generosity is being undermined by its insistence on using only food produced and shipped from America. Kohn reports that "the U.S. Government Accountability Office found that between 2001 and 2006, the average amount of food sent abroad declined by more than half" due to rising fuel costs.

Even worse, as Kohn says, U.S. policy has subverted the humanitarian mission of non-governmental organizations like Save the Children and Catholic Relief Services:

. . . The government donates much of the food it buys to such groups, which then sell it in developing countries. The transactions yield millions in profits for aid groups, which in turn use the money to pay for other aid work.

It's a perverse system: In essence, aid groups become grain and soybean brokers, making money by selling food in developing countries - and then using the profits to help the poor in those same countries. Most experts say it would be far more efficient to provide direct funding to these groups, rather than giving them food to sell. And because the food is sold to brokers in the target countries, who sell it at market prices, there's no guarantee that the neediest can even afford it. . . .

That's why CARE, which is run by Helene Gayle (who used to be at the Gates Foundation and before that at the U.S. Centers for Disease Control), is opting out of the government food donation system.

I remember thinking that was the right thing to do when I read about CARE's decision last year. Until David's editorial, however, I hadn't understood that standing up for that principle was going to cost CARE $45 million in real dollars, not just in donated food. Read David's whole editorial--it will open your eyes on food aid.

Demand for Plumpy'Nut Outstrips Supply

Dissatisfaction about the availability of Plumpy'nut keeps brewing under the surface but still not much of it is out in the open.

This from an e-mail by Jeff Johnson at Birdgsong-Peanuts (used with his permission):

. . . Demand for Plumpy Nut is many times what Nutriset and their licensees can supply, yet Nutriset won't expand production. We have asked a number of times and they refuse to grant a license outside of the countries where Plumpy Nut is used. I like using local production but the problem is demand is many times what Nutriset and the local licencees can supply. . . .

Related post:
What do patents and peanut butter have to do with starving kids?

Job: Public Health Editor for Global Voices

Global Voices, which aggregates blogs from around the world, is seeking to hire a Public Health Editor. Their preference is for candidates who are outside the U.S. or Europe. The position is part-time and they say right up front that compensation is modest. Deadline is May 24, 2008.