Twitter and Global Health

I finally gave in and created a Twitter account back on November 4 so I could participate in the #votereport project. It reminded me somewhat of the way mobile phone or SMS texting has shaped elections in Africa, starting with the 2000 election in Ghana and continuing on to the more recent 2008 election in Zimbabwe. It also got me thinking about how such democracy-movement techniques could be adapted to global health. Perhaps to introduce some much-needed transparency in pharmaceutical supply chains?

Votereport was a volunteer-led project that called on U.S. voters to characterize their election experience by providing three major pieces of information: where they voted, how long they waited to vote and whether the experience was a good one or a bad one. If yours was a bad experience, then you were supposed to give a brief description why, e.g. mismatch of your name compared to driver’s license records caused an official to doubt your right to vote.

From a technical point of view, we’re talking about structured-data.

I messed up my first attempt at tweeting my own vote but fortunately someone named ZekeSaysSo showed me how to do it: “#votereport. #10019 #good #wait:40 at 6 AM. longest lines I have ever seen at this polling place at this hour.”

Each specific piece of information was preceded by a # sign or hashtag, also known as a pound sign, to make the information more easily sortable by computer.

People like Adrian Holovaty have convinced a lot of us reporters that one major path to a future for journalism lies through structured data. As Holovaty defined it in 2006, structured data is “the type of information that can be sliced-and-diced, in an automated fashion, by computers.”

Holovaty’s breakthrough example in 2005: using the structured data from Chicago crime statistics mashed up with Google maps to automatically generate geographical pictures of a neighborhood’s character. You can see the latest iteration of his efforts at Everyblock.com

The new wrinkle about Votereport, the Ghanian and Zimabwean elections is that “we the people” provided the structured data—in real time with tangible results. Mobile texting plus radio coverage stopped voting irregularities in Ghana in 2000 and prevented Robert Mugabe from being able to fudge electoral results in Zimbabwe earlier this year—although it didn’t stop him from hanging on to power.

Nothing quite so impressive in the U.S. but Votereport did help a number of individuals cast regular ballots instead of provisional ballots after minor misspellings of their name threatened their franchise rights. Because anyone who tweeted #bad and provided information as to why they couldn’t vote was automatically put into contact with an election protection lawyer. In many cases, simple misunderstandings were resolved before the voting booths closed.

See also Ethan Zuckerman’s thoughtful look at the pros and cons of twittering vs. texting elections.

Seems like you could adapt this type of technology to other uses. I’m thinking specifically about the government’s drug-supply chain in Malawi.

Many, many people I talked to complained about how they can’t get the drugs they need for hospitals and clinics from the Malawi government’s Central Medical Stores. Even the taxi drivers in Lilongwe know that a lot of the pharmaceuticals get diverted from the public sector to the private sector—despite periodic purges of the employees involved.

What if every hospital administrator, clinical officer and nurse used their mobile phone to text every encounter they had with Malawi’s CMS, giving information about the number and kind of drugs that were missing? And you compared that to the number and kind of drugs they started off with—many made available through international agreements?

How long would it take before CMS employees retaliated? Could you get enough people to participate so that no one individual would be targeted for retribution?

Just wondering. What do you think?

See also this Slideshare presentation on Twitter for Health by PF Anderson at the University of Michigan.

Can There Be Too Much Training?

There are many moments from my three-month Malawi trip that I just had to store away for later reflection. I recognized a ring of truth even if I did not quite understand what it meant or how it fit into the larger picture. What a number of people said to me about the role of training—which theoretically seems like a good thing—was just one of these moments that set my head spinning.

A number of managers I interviewed griped that excessive training sessions were distorting the health care system in Malawi. Too many nurses in a country with precious few nurses in the first place were out of their clinic or hospital for various two-week training sessions, often every other month. Several health care workers—particularly in government hospitals—said they depended on the extra pay they got from those training sessions. A couple of Malawians I met who did trainings admitted they could not get anyone to come unless they offered financial incentives.

Now I learn these were not just a few isolated cases. Training and sustainability have turned into perverse incentives in numerous HIV programs in Malawi, according to a new study by Ann Swidler (UC Berkeley) and Susan Cotts Watkins (UPenn and UCLA). I am trying to get a hold of the full paper but this excerpt, provided by Bill Savedoff at the Center for Global Development, is electrifying:

Swidler and Watkins follow the logic of the “sustainability” mantra [Savedoff writes] to show how incentives at every level – from the international donors to the national elites, interstitial elites and local population – make funding for training (and training of trainers) the dysfunctional outcome of an otherwise well-meaning effort. The donors can claim they are “teaching the population to fish,” the national elites get income and status from managing and negotiating the programs, the interstitial elites (usually young high-school-educated volunteers) get contacts and opportunities to rise socially and economically, and the local population gets .. well, relatively little.

[snip]

Swidler and Watkins make the case for what is really needed quite clearly in their final remarks:

"It is hard to say precisely what constructive recommendations follow from the perspective we have offered here, but we do have several suggestions. First, the ideal of sustainability is a convenient self-delusion for funders and they would do much better if they could systematically and rigorously determine what projects are effective and then sustain them by paying local workers to actually do good—provide health care, sell discounted seeds and fertilizers, treat STIs, provide ARVs, supply children with books and school uniforms, or care for the ill and elderly (Kremer & Miguel, 2007).

Second, since few of the approaches to AIDS prevention currently in vogue have shown any measurable effect (Potts et al, 2008), we encourage funding that responds to Malawians’ desire to take care of the vulnerable in their communities, provide for their children’s futures, and build economic security, independent of the issue of HIV and AIDS. Indeed, reading the proposals that Malawian villagers submitted in their usually vain attempts to gain access to AIDS funding convinces us that villagers do know what they want, but little of it is training in how to prevent, mitigate, or treat AIDS. The first two they already know how to do as well as the experts who try to advise them (Watkins, 2004), and treating AIDS has to be done through the health-care system.

"Finally, we suggest that donors consider the “hidden curriculum” their procedures teach. Requirements for elaborate proposals, bank accounts, and monitoring and evaluation might better be replaced by simple procedures that would funnel more resources to villagers and less to monitors. Such resources would create continuing projects that both villagers and employees (perhaps the brighter, more successful of the villagers’ children) might rely upon. Rather than projecting a social imaginary that they find morally gratifying, donors and NGOs might provide opportunities that could sustain the realistic aspirations of those they claim to help."

Hat-tips to Alanna Shaikh and Bill Savedoff for the study.

Links: Varmus, Rape, Methadone

A few worthwhile links on U.S. policy, rape, to start off the workweek.

Harold Varmus speaks on the U.S. commitment to global health on on Tuesday, Dec. 16, 2008 at 11:30 AM Eastern time (U.S.). Videocast will be available at videocast.nih.gov (NIH)

Update: Read the report on global health priorities from the Institute of Medicine on which Varmus bases his recommendations.

Journalist Pushpa Jamieson reports that even asking general questions about rape in a Malawi police station is stigmatizing. (The Chronicle)

Methadone project in Ukraine faces tough sell with public. (Global Voices Online)

Vaccines: Careful What You Pay For

Paying poor countries to vaccinate kids sounds like a good idea—as long as no one games the system. A new study from the Institute for Health Metrics Evaluation in Seattle shows that dozens of countries exaggerated their vaccination statistics in order to benefit from financial incentives. As the Seattle Times points out, the Gates Foundation paid for both the vaccine incentive program and the study that criticized it.

The larger issue: what role should financial incentives play in health care? The IHME study, which was published in the Lancet, is not the final word on this debate.

The idea that financial incentives can backfire is nothing new—look at the U.S. tax code for multiple examples. Or the Israeli day-care study by Gneezy and Rustichini (instituting a fine on parents who were late in picking up their kids at daycare resulted in an increase, not a decrease, of late arrivals). You have to pay close attention to how these deals are set up. See the cash transfer programs Julio Frenk championed in Mexico for examples of how to do things right.

Here’s a question for anyone who wants to dig deeper into the IHME study: the program was aimed at kids who wouldn't otherwise have gotten vaccinated. So, did more kids get vaccinated, despite the exaggeration, than would have otherwise? Did their health improve? And if so, is it okay to tolerate a little distortion? How much distortion--5 percentage points or 10, or in this case 16 (74% actual rate vs. 90% reported rate)? On the other hand, if you can't trust the numbers . . .

Update: See Ruth Levine's post at Global Health Policy for a more in-depth analysis of the IHME study.

Spotted Fever Caused Death in Brazil

Whew. It wasn't arenavirus after all. ProMed-Mail has the followup.

Related post: Mystery killer in Brazil.

Daulaire and Gayle for Obama Administration?

Catching up to the news. Helene Gayle, currently leading CARE, is being rumored as a possible pick to head up USAID, according to Al Kamen at the Washington Post. Nils Daulaire may be tapped for HIV/AIDS coordinator, displacing Mark Dybul. If true, I wonder where Dybul will go?

Repeating rumors is precarious business. The way the game is played in Washington, you can't help but feel you're being used by someone--you just never know by whom. (See Valerie Plame.) Maybe it's a trial balloon. Maybe it's wishful thinking. We'll know soon enough.

Related Post: US Food Policy Needs to Change (Editorial)

Update (Jan. 13, 2009) Looks like Dybul is staying on at Pepfar for now. Wonder how he gets along with Hillary Clinton, who as Secretary of State, would presumably be his boss?

Sharing and Global Health Blogging

How can we get more coverage of global health news when old media doesn’t seem to want to do it without outside support and new media (blogs, texting, sharedmedia) still seems a scattershot affair?

This is the fourth post in a series that began with “Rethinking Why I Blog.” The others are “What Plumpy’Nut Taught Me” and “Authentic Sharing vs. Selfish Sharing.”

One of my goals for my Nieman fellowship year was to develop a business plan for a web-based global health news service. I know, I know, “news service” is such a quaint phrase, reminiscent of teletype, telegraphs and Morse code. But it is descriptive. If it’s too old-fashioned for you, think “content platform.”

The idea was to aggregate posts from around the globe as well as to provide funding for original reporting. I further focused the goal by targeting transparency issues in global health funding by eight major organizations. I developed the plan as part of a class on non-profits that I took at the Kennedy School and pitched it to the Open Society and Ashoka folks. Both decided to pass.

Nowadays, though, I’m wondering if maybe I was just trying too hard or too soon? After all, I keep seeing efforts by individuals to write about what they find interesting or newsworthy in global health. The ones I find most interesting are not promotional or advocacy-oriented but rather add context and highlight overlooked news.

In addition to established blogs from academics in the field, e.g. Effect Measure, The Pump Handle, Aetiology, there are a few more student blogs, like these efforts from Karen Grepin at Harvard, GlobeMed at Northwestern University and Unacceptable from Brigham Young University. See others on my blogroll at right.

(Mostly US-generated, I know. Send me your recommendations for global health blogs from other countries using the comment section below!! I haven't been bowled over by what I have read in the health section of Global Voices Online. )

The development community is farther along in self-publishing. See especially blogs from organizations like DFID and the Center for Global Development as well as DFID-funded Scidev.net. While trolling Twitter, I found “Blood and Milk,” a clear-eyed view by Alanna Shaikh of just how ethically challenged anti-poverty work can be despite good intentions.

Now that the Gates Foundation is investing in mainstream news organizations so they can cover global health news, you might say we don’t need individual efforts at reporting and commenting any more. Who needs amateurs, who post between bouts of norovirus or grant applications, when you can hire professionals [irony alert]?

And yet they write.

Update: PharmD+'s list of 100 global health blogs--three of mine are included, one of which is no longer active. But others on the list haven't been updated for quite a while either, e.g. BrownforGlobalHealth (last post Sept. 2007) and Don Burke's Global Health Blog (last post Jan. 2008).

Mystery Killer in Brazil

Note to self: watch ProMed-mail for results of blood tests of South African man who fell ill and died in Brazil last week. Early reports suggested it might have been highly contagious arenavirus--and linked to earlier case in Johannesburg clinic. Two days later, health authorities from South Africa said that scenario was unlikely. The blood tests should say for sure. Unclear if results will be out this week.

Another reason to control rat populations in cities: arenaviruses are closely associated with rodents.

Update: Word from Brazil is that it's spotted fever, not arenavirus.

Story-Telling Makes Sense

Making the obvious difficult. We tell stories to deal with information overload (http://is.gd/af7f) and understand complexity (http://is.gd/af7j).

New Gates Grant for Global Health News

An announcement is due later today from The NewsHour with Jim Lehrer that the Bill & Melinda Gates Foundation is giving WETA, co-producer of The NewsHour, a $3.5 million grant over the next three years to cover global health issues. Foundation-funding of publicly funded news programs like The NewsHour is becoming more and more important as other sources of money, like corporate-funding, dry up.

Other recent investments in global health news coverage by the Gates Foundation include:

1. A nearly $1 million, three-year grant for National Public Radio in 2006.

2. A $5 million, three-year grant for Public Radio International in 2007.

This latest move suggests the Gates Foundation has made a strategic decision to fund news-coverage directly, as opposed to, say, training for journalists in global health issues. In 2007, the Gates Foundation gave the Knight Foundation $1.7 million over three years for health fellowships for journalists in sub-Saharan Africa. Earlier this year, however, the Gates Foundation chose not to renew its three-year grant to the Nieman Foundation for Journalism at Harvard.

The Nieman Foundation is continuing its global health program—although it will award two fellowships next year instead of three.

I’m very interested to see how the Gates-funded NewsHour navigates the challenge of reporting on global health programs that are funded by the Gates Foundation and of interviewing experts who are also receiving funding from the Gates Foundation.

Full disclosure: I received a 2008 Nieman Fellowship for Global Health Reporting. The Gates Foundation had no say in the choice of my field project. And I dealt with even the potential appearance of a conflict-of-interest issue by focusing on the nursing brain drain in Malawi—an issue that, as far as I can tell, has received no Gates funding.

Updated to add Knight Foundation information.