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

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

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

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

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

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

Weekend reading: race in America

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

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

Read it.

Sentimental narratives

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

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

On food deserts

Gina Kolata, writing for the New York Times, has sparked some debate with this article: "Studies Question the Pairing of Food Deserts and Obesity". In general I often wish that science reporting focused more on how the new studies fit in with the old, rather than just the (exciting) new ones. On first reading I noticed that one study is described as having explored the association of "the type of food within a mile and a half of their homes" with what people eat. This raised a little question mark in my mind, as I know that prior studies have often looked at distances much shorter than 1.5 miles, but it was mostly a vague hesitation. And if you didn't know that before reading the article, then you've missed a major difference between the old and new results (and one that could have been easily explained). Also, describing something as "an article of faith" when it's arguably something more like "the broad conclusion draw from most most prior research"... that certainly established an editorial tone from the beginning.

Intrigued, I sent the piece to a friend (and former public health classmate) who has work on food deserts, to get a more informed reaction. I'm sharing her thoughts here (with permission) because this is an area of research that I don't follow as closely, and her reactions helped me to situate this story in the broader literature:

1. This quote from the article is so good!

"It is always easy to advocate for more grocery stores,” said Kelly D. Brownell, director of Yale University’s Rudd Center for Food Policy and Obesity, who was not involved in the studies. “But if you are looking for what you hope will change obesity, healthy food access is probably just wishful thinking.”

The "unhealthy food environment" has a much bigger impact on diet than the "healthy food environment", but it's politically more viable to work from an advocacy standpoint than a regulatory standpoint. (On that point, you still have to worry about what food is available - you can't just take out small businesses in impoverished neighborhoods and not replace it with anything.)

2. The article is too eager to dismiss the health-food access relationship. There's good research out there, but there's constant difficulty with tightening methods/definitions and deciding what to control for. The thing that I think is really powerful about the "food desert" discourse is that it opens doors to talk about race, poverty, community, culture, and more. At the end of the day, grocery stores are good for low-income areas because they bring in money and raise property values. If the literature isn't perfect on health effects, I'm still willing to advocate for them.

3. I want to know more about the geography of the study that found that low-income areas had more grocery stores than high-income areas. Were they a mix of urban, peri-urban, and rural areas? Because that's a whole other bear. (Non-shocker shocker: rural areas have food deserts... rural poverty is still a problem!)

4. The article does a good job of pointing to how difficult it is to study this. Hopkins (and the Baltimore Food Czar) are doing some work with healthy food access scores for neighborhoods. This would take into account how many healthy food options there are (supermarkets, farmers' markets, arabers, tiendas) and how many unhealthy food options there are (fast food, carry out, corner stores).

5. The studies they cite are with kids, but the relationship between food insecurity (which is different, but related to food access) and obesity is only well-established among women. (This, itself, is not talked about enough.) The thinking is that kids are often "shielded" from the effects of food insecurity by their mothers, who eat a yo-yo diet depending on the amount of food in the house.

My friend also suggested the following articles for additional reading:

Before you get all excited about male birth control

When you're a public health grad student and something related to health hits the news, your friends make sure you see it. Since there's a lot of bad science writing on the internet this can be rather frustrating. In the last few hours I've seen several people post this  to Facebook, and another emailed me with the subject line "Woh" and asked if this was too good to be true.... So what's the story? Techcitement has a breathless article titled "The Best Birth Control In The World Is For Men" by Jon Clinkenbeard, which he followed up with "Could This Male Contraceptive Pill Make a Vas Deferens in the Fight Against HIV?" The first article starts with this hook:

If I were going to describe the perfect contraceptive, it would go something like this: no babies, no latex, no daily pill to remember, no hormones to interfere with mood or sex drive, no negative health effects whatsoever, and 100 percent effectiveness. The funny thing is, something like that currently exists.

Clinkenbeard is describing RISUG, or "Reversible inhibition of sperm under guidance." Wikipedia explains:

RISUG is similar to vasectomy in that a local anesthetic is administered, an incision is made in the scrotum, and the vas deferens is tugged out with a small pair of forceps. Rather than being cut and cauterized, as it is in a vasectomy, the vas deferens is injected with [a] polymer gel and pushed back into the scrotum.

Sounds awesome? Why don't we have it already? Clinkenbeard continues:

The trouble is, most people don’t even know this exists. And if men only need one super-cheap shot every 10 years or more, that’s not something that gets big pharmaceutical companies all fired up, because they’ll make zero money on it (even if it might have the side benefit of, you know, destroying HIV).

Before you go injecting something in your scrotum... not so fast! Yes, in one sense it exists. But on the other hand we don't really know how well it works, and we don't really know how safe it is. Clinkenbeard makes it sound like it's a done deal, and claiming that Big Pharma is standing between you and the cure for babies (not to mention HIV!) certainly helped the article go viral. He then links to a bunch or articles and a few petitions.

While pharmaceutical companies do all sorts of things to manipulate data (start here if you don't believe that), I think they could actually make TONS of money on this if it worked. The price of medicines isn't usually based on how much they cost to manufacture but on how much they can be sold for, and I think there's clearly a market for male contraception: just think how much men would pay for the insurance to both avoid pregnancy and not have to use condoms. A drug company could conceivably make a lot of money off this product by getting it to market first.

Guha's initial studies were very small. A Phase II clinical trial published by Guha et al in 1997 featured a grand total of 12 men (PDF). (It also contains this humorous understatement: "Objective data on posttreatment frequency of intercourse could not be obtained.") In another study 20 men received an injection, but one man's partner still got pregnant.

Before a drug can (or should) go to market, it needs to be tested for both efficacy and safety, and everything needs to be done up to certain standards. Guha's original work wasn't. From a Wired article on RISUG by Bill Gifford, published this time last year:

In its report, the WHO team agreed that the concept of RISUG was intriguing. But they found fault with the homegrown production methods: Guha and his staff made the concoction themselves in his lab, and the WHO delegation found his facilities wanting by modern pharmaceutical manufacturing standards. Furthermore, they found that Guha’s studies did not meet “international regulatory requirements” for new drug approval—certain data was missing. The final recommendation: WHO should pass on RISUG.

These barriers can be overcome, if the researchers can get the investment necessary to make high quality product and run clinical trials. The Wired article describes how they've made progress and are now running clinical trials in India -- but the results are still a few years out. In the same article we get this:

"Pharmaceutical companies are not interested in one-offs," Weiss says. "They’re interested in things they can sell repeatedly, like the birth control pill or Viagra."

But that's not as true as it used to be. These arguments used to explain why pharmaceutical companies didn't invest in developing vaccines, but then they realized they could charge obscene amounts for individual doses -- orders of magnitude higher than what they charged before. They've managed these high prices because 1) there are always new cohorts of kids needing the vaccine (as there would be with men needing RISUG) and 2) because the health benefits are so large that even at the higher prices the vaccines are cost effective.

So are pharma companies just disinterested in male contraception? No. For quick and dirty evidence check ClinicalTrials.gov, where US clinical trials must be registered. I find 436 studies on contraception, of which 84 are specifically about male contraception. There's a disparity there, but it's explained in part by the fact that many of the non-male contraception studies are about delivery methods (like this one involving text message reminders) and you can't even start do this sort of research on male birth control before we have effective methods. Maybe they're under-investing a bit -- drug R&D is risky, as firms spend an average of $1.3 billion on research for every one drug  brought to market -- but it's not being ignored.

In closing, that Wired article from last year has some of the same breathless new-techthusiasm as the new Techcitement piece, but it's a lot better at explaining where things stand today. Clinical trials in India are ongoing, but it will be another year or so before we hear any results. If those are considered high quality and they're successful, it might spur the drug behemoths to up the massive amounts required for clinical trials in the US.

Generally, getting your science news from the coauthor of "The Pirate Treasure of the Himalaya" does't seem like the best idea. Drugs and treatments fail at every stage of the clinical trials pipeline, and that's a good thing because it means consumers will be less likely to spend money on ineffective or unsafe drugs. If everything works out with RISUG, it could be an incredible success story and a great public health tool. There might well be hope on the horizon, but contrary to Clinkenbeard's assertions we don't yet know very well if this works, and we don't yet know if it's safe. For that, we need good ole clinical trials, not petitions.

Timing

This week in one of my classes we were scheduled to discuss humanitarian intervention and the "responsibility to protect" principle. Our case study is on Libya, and especially on the initial decision to intervene. Not coincidentally, one of the professors for the course is Anne-Marie Slaughter (see her NYT editorial in support of action, just days before UN Resolution 1973). The news of Gadhafi's death broke just before class. Then, after a session touching on these topics in the context of broader theories of international relations, I found myself in a computer lab with several of my classmates. We were mostly checking our email or printing assignments, but the conversation turned to Libya. Someone mentioned that a video had been posted of Gadhafi still alive when he was captured (see here), and we started pulling up different videos and trying to piece together what happened. What order, who did what, how we should react, and so forth.

Separate from the implications of Gadhafi's death for the future of Libya, there's a question of how quickly media has changed how we interact with world events, and how participants in those events seek to portray them. A century ago radio brought real-time news, followed a few decades later by TV. The last decade has seen the proliferation of digital video cameras and the rise of sites like YouTube where anyone can disseminate footage to the entire world, at first side-stepping the old media and then being amplified by it.

I don't know how this situation would have played out a few decades ago, but here we were watching videos taken earlier the same day by rebel forces in Libya. Has there ever been faster turnaround between the fall of a despot, the spread of imagery to shape the narrative of what happened? As viewers and discussants we were participating in the immediate struggle to claim responsibility.

The Tea Test

If you haven't been following it, there's currently a lot of controversy swirling around Greg Mortenson, co-author of Three Cups of Tea and co-founder of the Central Asia Institute. On Sunday 60 minutes aired accusations that Mortenson fabricated the 'creation myth' of the organization, a story about being kidnapped by the Taliban, and more. The blog Good Intentions Are Not Enough is compiling posts related to the emerging scandal, and the list is growing fast. If you haven't read it already, Jon Krakauer's mini-book, Three Cups of Deceit: How Greg Mortenson, Humanitarian Hero, Lost His Way, is really worth the read. Completely engrossing. It's a free download at byliner.com until April 20. It's about 90 pages, and Krakauer has obviously been researching it for a while -- in fact, my guess is that Krakauer turned 60 Minutes onto the story, rather than vice versa, which would help explain why he was featured so heavily in their piece. In the TV interview Krakauer quotes several former employees saying quite unflattering things about how CAI is run, so it's good to see that he gets many of those people on record in his ebook.

A few disclaimers: I think it's worth pointing out that a) as a one-time supporter and donor to CAI, Krakauer arguably has an axe to grind, b) several of Krakauer's previous books (Into Thin Air, Into the Wild, and Under the Banner of Heaven) have had sections disputed factually, though to me Into the Wild is the only case where he seems to have actually gotten things wrong, and c) I'm a big fan of him as a writer and thus am possibly a bit predisposed to believe him. Admitting by biases up front like good epidemiologist.

That said, it sounds like CAI has been very poorly led. Krakauer's book levels many damning claims about Mortenson and CIA's financial management that, while less emotionally shocking than the exaggerations about the 'creation myth,' should be much more troubling. CAI and Mortenson's responses to the accusations so far on 60 Minutes have seemed superficial, and I think it's safe to say that they will not come out of this looking squeaky clean.

I believe this episode raises two broader questions for the nonprofit community.

First, Krakauer chronicles a string of board members, employees, and consultants who came in, were shocked by how things were done and/or discovered discrepancies, and ended up leaving or resigning in protest. This section (pages 50-51) jumped out at me:

After Mortenson refused to comply with CFO Debbie Raynor's repeated requests to provide documentation for overseas programs, Raynor contacted Ghulam Parvi (the Pakistan program manager) directly, instructing him to provide her with documentation. For two or three months Parvi complied - until Mortenson found out what was going on and ordered Parvi to stop. Raynor resigned.

In 2007, Mortenson hired an accomplished consultant to periodically fly to Central Asia to supervise projects. When he discovered irregularities and shared them with Mortenson, Mortenson took no action to rectify the misconduct. In 2010, the consultant quit in frustration.

In September 2007, CAI hired a highly motivated, uncommonly capable woman to manage its international programs. Quickly, she demonstrated initiative and other leadership skills the Institute sorely needed. She had exceptional rapport with Pakistani women and girls. In 2008, she unearthed serious issues in Baltistan that contradicted what Mortenson had been reporting. After she told Mortenson about these problems, she assumed he would want her to address them. Instead, as she prepared to return to Pakistan in 2009, Mortenson ordered her to stay away from Baltistan. Disillusioned, she resigned in June 2010.

Seriously -- ff this has been going on for so long, how on earth is it just coming out now? Evidently a nationally known organization can have nearly its entire board resign and multiple employees quit, and it doesn't make the news until years later? Some of this (I'm speculating here) likely results from a hesitance on the part of those former employees to speak ill of CAI, whether because they still believed in its mission or because they were worried about being the sour grape person. Were they speaking out and nobody listened, or is there simply no good way to raise red flags about a nonprofit organization?

Second, while most organizations aren't guilty of fraud -- we hope -- there's at least one other take-away here. Another excerpt that jumped out at me:

On June 13, 2010, Parvi convened a meeting in Skardu to discuss Three Cups of Tea. Some thirty community leaders from throughout Baltistan participated, and most of them were outraged by the excerpts Parvi translated for them. Sheikh Muhammad Raza—chairman of the education committee at a refugee camp in Gultori village, where CAI has built a primary school for girls—angrily proposed charging Mortenson with the crime of fomenting sectarian unrest, and urged the District Administration to ban Mortenson and his books from Baltistan.

Based on Krakauer's footnotes, Parvi may be one of his less reliable sources, but this idea -- that the people portrayed in the book were outraged when it was translated to them because of how misleading it is -- comes up several times. Yes, fabricating stories is really bad. But how many other things do nonprofits say in their advertising that would be uncomfortable or downright offensive if you translated it for (and/or showed the accompanying pictures to) the recipients or beneficiaries or their services?

I propose a simple way to check this impulse -- to write about people as if they are victims or powerless -- and in honor of Three Cups of Tea, I call it the "Tea Test":

Step One: read the website content, blog posts, or email appeal you just got from your charity of choice. Or, if you work for a nonprofit organization, read your own stuff.

Step Two: imagine arriving in the recipient city or village, with a translated copy of that text. Would you be uncomfortable reading that website or blog or email to the people you met? Would it require tortured explanations, or would it instantly make sense and leave them feeling dignified?

That's it: if Step Two didn't make you cringe, then you passed the Tea Test. If it made you uncomfortable, made them feel ashamed, or got you attacked -- re-draft your copy and try again. Or find another organization to support.

I think there are many organizations that pass the Tea Test, but probably many more that fail. These organizations don't necessarily share all the faults of CAI as laid out by Krakauer and others, but they wouldn't fare much better in this situation, because they say something for one audience that was never intended to get back to the others.

I hope the idea of the Tea Test -- reading a translated copy of that material to the people it's describing -- will be helpful for donors and nonprofiteers alike. As a former online fundraiser I know I've broken this rule, and as a donor I've found things appealing that I probably should have reacted strongly against. I'm going to try to do better.

Update: I've posted a slightly revised (and I hope easier to remember) version of the Tea Test on a permanent page here.

Modelling Stillbirth

William Easterly and Laura Freschi go after "Inception Statistics" in the latest post on AidWatch. They criticize -- in typically hyperbolic style, with bonus points for the pun in the title -- both the estimates of stillbirth and their coverage in the news media. I left a comment on their blog outlining my thoughts but thought I'd re-post them here with a little more explanation. Here's what I said:

Thanks for this post (it’s always helpful to look at quality of estimates critically) but I think the direction of your criticism needs to be clarified. Which of the following are you upset about (choose all that apply)?

a) the fact that the researchers used models at all? I don’t know the researchers personally, but I would imagine that they are concerned with data quality in general and would much preferred to have had reliable data from all the countries they work with. But in the absence of that data (and while working towards it) isn’t it helpful to have the best possible estimates on which to set global health policy, while acknowledging their limitations? Based on the available data, is there a better way to estimate these, or do you think we’d be better off without them (in which case stillbirth might be getting even less attention)? b) a misrepresentation of their data as something other than a model? If so, could you please specify where you think that mistake occurred — to me it seems like they present it in the literature as what it is and nothing more. c) the coverage of these data in the media? On that I basically agree. It’s helpful to have critical viewpoints on articles where there is legitimate disagreement.

I get the impression your main beef is with (c), in which case I agree that press reports should be more skeptical. But I think calling the data “made up” goes too far too. Yes, it’d be nice to have pristine data for everything, but in the meantime we should try for the best possible estimates because we need something on which to base policy decisions. Along those lines, I think this commentary by Neff Walker (full disclosure: my advisor) in the same issue is worthwhile. Walker asks these five questions – noting areas where the estimates need improvement: - “Do the estimates include time trends, and are they geographically specific?” (because these allow you to crosscheck numbers for credibility) - “Are modelled results compared with previous estimates and differences explained?” - “Is there a logical and causal relation between the predictor and outcome variables in the model?” - “Do the reported measures of uncertainty around modelled estimates show the amount and quality of available data?” - “How different are the settings from which the datasets used to develop the model were drawn from those to which the model is applied?” (here Walker says further work is needed)

I'll admit to being in over my head in evaluating these particular models. As Easterly and Freschi note, "the number of people who actually understand these statistical techniques well enough to judge whether a certain model has produced a good estimate or a bunch of garbage is very, very small." Very true. But in the absence of better data, we need models on which to base decisions -- if not we're basing our decisions on uninformed guesswork, rather than informed guesswork.

I think the criticism of media coverage is valid. Even if these models are the best ever they should still be reported as good estimates at best. But when Easterly calls the data "made up" I think the hyperbole is counterproductive. There's an incredibly wide spectrum of data quality, from completely pulled-out-of-the-navel to comprehensive data from a perfectly-functioning vital registration system. We should recognize that the data we work with aren't perfect. And there probably is a cut-off point at which estimates are based on so many models-within-models that they are hurtful rather than helpful in making informed decisions. But are these particular estimates at that point? I would need to see a much more robust criticism than AidWatch has provided so far to be convinced that these estimates aren't helpful in setting priorities.

Michael Lewis retrospective

I've been a fan of Michael Lewis' writing ever since Ashby Monk (author of the best niche blog on sovereign wealth funds) pointed me towards Liar's Poker. Some recent and not so recent fare:

Lewis’s article in Manhattan, Inc. magazine is a terrific yarn and a remarkable artifact–mainly because of how wrong Lewis turned out to be.... The imaginary scenario Lewis crafts, of a massive Tokyo earthquake crushing the global economy, reflects a time when Japan was an ascendant economic force widely believed on the cusp of ending U.S. pre-eminence. In that world, Lewis’s imagined chain of events goes something like this: Large swaths of Tokyo will be destroyed by a magnitude 7.9 earthquake. Stock markets collapse, in part as Japanese companies and investors sell foreign assets, including U.S. Treasury bonds and commodities, to finance the country’s rebuilding. Japanese banks and companies pull money and halt their loans outside the country, sapping  a big source of the fuel for economic growth world-wide. Global interest rates soar to 5%, meaning Americans can’t afford loans to buy cars or homes. The U.S. economy skids to a halt, though Japan manages just fine....

Not always right, but always interesting.

Gates and Media Funding

You may or may not have heard of this controversy: the Gates Foundation -- a huge funding source in global health -- has been paying various media sources to ramp up their coverage of global health and development issues. It seems to me that various voices in global health have tended to respond to this as you might expect them to, based on their more general reactions to the Gates Foundation. If you like most of Gates does, you probably see this as a boon, since global health and development (especially if you exclude disaster/aid stories) aren't the hottest issues in the media landscape. If you're skeptical of the typical Gates Foundation solutions (technological fixes, for example) then you might think this is more problematic.

I started off writing some lengthy thoughts on this, and realized Tom Paulson at Humanosphere has already said some of what I want to say. So I'll quote from him a bit, and then finish with a few more of my own thoughts. First, here is an interview Paulson did with Kate James, head of communications at the Gates Foundation. An excerpt:

Q Why does the Gates Foundation fund media?

Kate James: It’s driven by our recognition of the changing media landscape. We’ve seen this big drop-off in the amount of coverage of global health and development issues. Even before that, there was a problem with a lack of quality, in-depth reporting on many of these issues so we don’t see this as being internally driven by any agenda on our part. We’re responding to a need.

Q Isn’t there a risk that by paying media to do these stories the Gates Foundation’s agenda will be favored, drowning out the dissenting voices and critics of your agenda?

KJ: When we establish these partnerships, everyone is very clear that there is total editorial independence. How these organizations choose to cover issues is completely up to them.

The most recent wave of controversy seems to stem from Gates funding going to an ABC documentary on global health that featured clips of Bill and Melinda Gates, among other things. Paulson writes about that as well. Reacting to a segment on Guatemala, Paulson writes:

For example, many would argue that part of the reason for Guatemala’s problem with malnutrition and poverty stems from a long history of inequitable international trade policies and American political interference (as well as corporate influence) in Central America.

The Gates Foundation steers clear of such hot-button political issues and we’ll see if ABC News does as well. Another example of a potential “blind spot” is the Seattle philanthropy’s tendency to favor technological solutions — such as vaccines or fortified foods — as opposed to messier issues involving governance, industry and economics.

A few additional thoughts:

Would this fly in another industry? Can you imagine a Citibank-financed investigative series on the financial industry? That's probably a bad example for several reasons, including the Citibank-Gates comparison and the fact that the financial industry is not underreported. I'm having a hard time thinking of a comparable example: an industry that doesn't get much news coverage, where a big actor funded the media -- if you can think of an example, please let me know.

Obviously this induces a bias in the coverage. To say otherwise is pretty much indefensible to me. Think of it this way: if Noam Chomsky had a multi-billion dollar foundation that gave grants to the media to increase news coverage of international development, but did not have specific editorial control, would that not still bias the resulting coverage? Would an organization a) get those grants if it were not already likely to do the cover the subject with at last a gentle, overall bias towards Chomsky's point of view, or b) continue to get grants for new projects if they widely ridiculed Chomsky's approach? It doesn't have to be Chomsky -- take your pick of someone with clearly identifiable positions on international issues, and you get the same picture. Do the communications staffers at the Gates Foundation need to personally review the story lines for this sort of bias to creep in? Of course not.

Which matters more: the bias or the increased coverage? For now I lean towards increased coverage, but this is up for debate. It's really important that the funding be disclosed (as I understand it has been). It would also be nice if there was enough public demand for coverage of international development that the media covered it in all its complexity and difficulty and nuance without needing support from a foundation, but that's not the world we live in for now. And maybe the funded coverage will ultimately result in more discussion of the structural and systemic roots of international inequality, rather than just "quick fixes."

[Other thoughts on Gates and media funding by Paul Fortner, the Chronicle of Philanthropy, and (older) LA Times.]

Peace on Earth

The START treaty is one step closer to ratification in Russia. Of course, it probably doesn't affect the probability that we'll all die in a nuclear war in any significant way, but I still generally think a world with fewer nuclear warheads sitting around is a good thing. The story I linked to is still missing something: a broader analysis of why the leadership of both countries is so firmly behind nuclear reduction. I understand that it's expensive to maintain the weapons, and that both sides likely see the reduction as having little effect on their deterrent capabilities, but there's a third reason. I've read -- I can't remember where, and would love to be pointed to links in the comments -- that the worldwide use of nuclear full for power generation outpaces worldwide mining of fissionable materials and that continued destruction of old warheads is thus necessary to keep nuclear power cheap. If that's true, it's a pretty key fact that's being left out of coverage. Wouldn't the story be different if it was framed as "there's a shortage of nuclear fuel and if the elites can't figure out a way to keep disarmament going, it will affect energy prices in the long term"?

I think this underscores a shortcoming of traditional journalism. By focusing on key individuals doing key things and making public statements, broader historical, social, and economic trends can get missed, or downplayed. We end up with a "Great Men" first draft of history rather than a more complete and true picture.

Anyway, Merry Christmas.

Randomizing in the USA, ctd

[Update: There's quite a bit of new material on this controversy if you're interested. Here's a PDF of Seth Diamond's testimony in support of (and extensive description of) the evaluation at a recent hearing, along with letters of support from a number of social scientists and public health researchers. Also, here's a separate article on the City Council hearing at which Diamond testified, and an NPR story that basically rehashes the Times one. Michael Gechter argues that the testing is wrong because there isn't doubt about whether the program works, but, as noted in the comments there, doesn't note that denial-of-service was already part of the program because it was underfunded.] A couple weeks ago I posted a link to this NYTimes article on a program of assistance for the homeless that's currently being evaluated by a randomized trial. The Poverty Action Lab blog had some discussion on the subject that you should check out too.

The short version is that New York City has a housing assistance program that is supposed to keep people from becoming homeless, but they never gave it a truly rigorous evaluation. It would have been better to evaluate it up front (before the full program was rolled out) but they didn't do that, and now they are.  The policy isn't proven to work, and they don't have resources to give it to everyone anyway, so instead of using a waiting list (arguably a fair system) they're randomizing people into receiving the assistance or not, and then tracking whether they end up homeless. If that makes you a little uncomfortable, that's probably a good thing -- it's a sticky issue, and one that might wrongly be easier to brush aside when working in a different culture. But I think on balance it's still a good idea to evaluate programs when we don't know if they actually do what they're supposed to do.

The thing I want to highlight for now is the impact that the tone and presentation of the article impacts your reactions to the issue being discussed. There's obviously an effect, but I thought this would be a good example because I noticed that the Times article contains both valid criticisms of the program and a good defense of why it makes sense to test it.

I reworked the article by rearranging the presentation of those sections. Mostly I just shifted paragraphs, but in a few cases I rearranged some clauses as well. I changed the headline, but otherwise I didn't change a single word, other than clarifying some names when they were introduced in a different order than in the original. And by leading with the rationale for the policy instead of with the emotional appeal against it, I think the article gives a much different impression. Let me know what you think:

City Department Innovates to Test Policy Solutions

By CARA BUCKLEY with some unauthorized edits by BRETT KELLER

It has long been the standard practice in medical testing: Give drug treatment to one group while another, the control group, goes without.

Now, New York City is applying the same methodology to assess one of its programs to prevent homelessness. Half of the test subjects — people who are behind on rent and in danger of being evicted — are being denied assistance from the program for two years, with researchers tracking them to see if they end up homeless.

New York City is among a number of governments, philanthropies and research groups turning to so-called randomized controlled trials to evaluate social welfare programs.

The federal Department of Housing and Urban Development recently started an 18-month study in 10 cities and counties to track up to 3,000 families who land in homeless shelters. Families will be randomly assigned to programs that put them in homes, give them housing subsidies or allow them to stay in shelters. The goal, a HUD spokesman, Brian Sullivan, said, is to find out which approach most effectively ushered people into permanent homes.

The New York study involves monitoring 400 households that sought Homebase help between June and August. Two hundred were given the program’s services, and 200 were not. Those denied help by Homebase were given the names of other agencies — among them H.R.A. Job CentersHousing Court Answers and Eviction Intervention Services — from which they could seek assistance.

The city’s Department of Homeless Services said the study was necessary to determine whether the $23 million program, called Homebase, helped the people for whom it was intended. Homebase, begun in 2004, offers job training, counseling services and emergency money to help people stay in their homes.

The department, added commissioner Seth Diamond, had to cut $20 million from its budget in November, and federal stimulus money for Homebase will end in July 2012.

Such trials, while not new, are becoming especially popular in developing countries. In India, for example, researchers using a controlled trial found that installing cameras in classrooms reduced teacher absenteeism at rural schools. Children given deworming treatment in Kenya ended up having better attendance at school and growing taller.

“It’s a very effective way to find out what works and what doesn’t,” said Esther Duflo, an economist at the Massachusetts Institute of Technology who has advanced the testing of social programs in the third world. “Everybody, every country, has a limited budget and wants to find out what programs are effective.”

The department is paying $577,000 for the study, which is being administered by the City University of New York along with the research firm Abt Associates, based in Cambridge, Mass. The firm’s institutional review board concluded that the study was ethical for several reasons, said Mary Maguire, a spokeswoman for Abt: because it was not an entitlement, meaning it was not available to everyone; because it could not serve all of the people who applied for it; and because the control group had access to other services.

The firm also believed, she said, that such tests offered the “most compelling evidence” about how well a program worked.

Dennis P. Culhane, a professor of social welfare policy at the University of Pennsylvania, said the New York test was particularly valuable because there was widespread doubt about whether eviction-prevention programs really worked.

Professor Culhane, who is working as a consultant on both the New York and HUD studies, added that people were routinely denied Homebase help anyway, and that the study was merely reorganizing who ended up in that pool. According to the city, 5,500 households receive full Homebase help each year, and an additional 1,500 are denied case management and rental assistance because money runs out.

But some public officials and legal aid groups have denounced the study as unethical and cruel, and have called on the city to stop the study and to grant help to all the test subjects who had been denied assistance.

“They should immediately stop this experiment,” said the Manhattan borough president, Scott M. Stringer. “The city shouldn’t be making guinea pigs out of its most vulnerable.”

But, as controversial as the experiment has become, Mr. Diamond said that just because 90 percent of the families helped by Homebase stayed out of shelters did not mean it was Homebase that kept families in their homes. People who sought out Homebase might be resourceful to begin with, he said, and adept at patching together various means of housing help.

Advocates for the homeless said they were puzzled about why the trial was necessary, since the city proclaimed the Homebase program as “highly successful” in the September 2010 Mayor’s Management Report, saying that over 90 percent of families that received help from Homebase did not end up in homeless shelters. One critic of the trial, Councilwoman Annabel Palma, is holding a General Welfare Committee hearing about the program on Thursday.

“I don’t think homeless people in our time, or in any time, should be treated like lab rats,” Ms. Palma said.

“This is about putting emotions aside,” [Mr. Diamond] said. “When you’re making decisions about millions of dollars and thousands of people’s lives, you have to do this on data, and that is what this is about.”

Still, legal aid lawyers in New York said that apart from their opposition to the study’s ethics, its timing was troubling because nowadays, there were fewer resources to go around.

Ian Davie, a lawyer with Legal Services NYC in the Bronx, said Homebase was often a family’s last resort before eviction. One of his clients, Angie Almodovar, 27, a single mother who is pregnant with her third child, ended up in the study group denied Homebase assistance. “I wanted to cry, honestly speaking,” Ms. Almodovar said. “Homebase at the time was my only hope.”

Ms. Almodovar said she was told when she sought help from Homebase that in order to apply, she had to enter a lottery that could result in her being denied assistance. She said she signed a letter indicating she understood. Five minutes after a caseworker typed her information into a computer, she learned she would not receive assistance from the program.

With Mr. Davie’s help, she cobbled together money from the Coalition for the Homeless and a public-assistance grant to stay in her apartment. But Mr. Davie wondered what would become of those less able to navigate the system. “She was the person who didn’t fall through the cracks,” Mr. Davie said of Ms. Almodovar. “It’s the people who don’t have assistance that are the ones we really worry about.”

Professor Culhane said, “There’s no doubt you can find poor people in need, but there’s no evidence that people who get this program’s help would end up homeless without it.”

Aid Workers vs. Journalists?

UPDATE: I mistakenly assumed the commenter name "ansel" was a pseudonym, so my comments on anonymity in the final paragraph may not be as applicable. Updates in brackets. Interesting debate going on at Tales From the Hood: First, J (the anonymous aid worker blogger behind Tales), wrote "Dear Journalists: What to look for in aid programs," which includes suggestions like "Understand that you cannot evaluate a project, program or organization during one-day visit....Ask about learning.... Ask about outcomes....Use logic... Understand ambiguity...[and] Understand that things are almost never the way they seem." The summary sounds pretty basic, but the details aren't necessarily as simple.

Which prompted a lengthy comment from someone named ansel [Ansel Herz of MediaHacker]: "Dear aid groups, Do not invite us on one-day tours of your programs and expect them to be useful to us in any way.... We need to be able to come out to where you’re working unannounced and talk with you – your people in the field....Do not send out press releases over and over simply listing off the sheer numbers of stuff you’ve distributed or have stocked in warehouses as if it indicates how much you’ve accomplished. Quality of life is not measured by those (nearly impossible to verify independently) numbers." Etc.

J responded at length with a follow-up post (that probably stand alone if you're only going to read one link). There are several points of agreement -- on NGOs needing to be more open, for example -- but the main disagreement is over "supply and demand" of lousy, feel-good information. Do NGOs give it to journalists because the journalists demand it, or do journalists take it from NGOs because it's all they can get? (I know, a bit simplified -- so check out the links.)

Of course, some of the debate  was prompted by J and [Ansel]'s tone, which is unfortunate. While I understand the necessity of anonymous blogging, I think this debate is one where the tones would have been slightly different -- and more productive -- had both writers been commenting under their own names. Still, seeing the [partially] anonymous back-and-forth gives you an idea of the animus that can exist between the different actors.

Tuskegee in Guatemala

The news that a US government study in the 1940s involved injecting Guatemalans with syphilis has been circulating, and it makes my stomach turn. Susan Reverby -- the Wellesley historian who uncovered the fiasco -- has made the draft paper available on her website: "'Normal Exposure' and Inoculation Syphilis: A PHS 'Tuskegee' Doctor in Guatemala, 1946-48," which will be published in the Journal of Policy History in January.

From the introduction:

Policy is often made based on historical understandings of particular events, and the story of the “Tuskegee” Syphilis Study (the Study) has, more than any other medical research experiment, shaped policy surrounding human subjects. The forty-year study of “untreated syphilis in the male Negro” sparked outrage in 1972 after it became widely known, and inspired requirements for informed consent, the protection of vulnerable subjects, and oversight by institutional review boards.

When the story of the Study circulates, however, it often becomes mythical. In truth the United States Public Health Service (PHS) doctors who ran the Study observed the course of the already acquired and untreated late latent disease in hundreds of African American men in Macon County, Alabama. They provided a little treatment in the first few months in 1932 and then neither extensive heavy metals treatment nor penicillin after it proved a cure for the late latent stage of the disease in the 1950s. Yet much folklore asserts that the doctors went beyond this neglect, and that they secretly infected the men by injecting them with the bacteria that causes syphilis. This virally spread belief about the PHS’s intentional infecting appears almost daily in books, articles, talks, letters, websites, tweets, news broadcasts, political rhetoric, and above all in whispers and conversations. It is reinforced when photographs of the Study’s blood draws circulate, especially when they are cropped to show prominently a black arm and a white hand on a syringe that could, to an unknowing eye, be seen as an injection.

Historians of the Study have spent decades now trying to correct the misunderstandings in the public and the academy, and to make the facts as knowable as possible. The story is horrific enough, it is argued, without perpetuating misunderstanding over what really did happen and how many knew about it. What if, however, the PHS did conduct a somewhat secret study whose subjects were infected with syphilis by one of the PHS doctors who also worked in “Tuskegee?” How should this be acknowledged and affect how we discuss historical understandings that drive the need for human subject protection?

(Emphasis added.) And later:

Ironically, though, the mythic version of the “Tuskegee” Study may offer a better picture of mid-century PHS ethics than the seemingly more informed accounts. For Public Health Service researchers did, in fact, deliberately infect poor and vulnerable men and women with syphilis in order to study the disease. The mistake of the myth is to set that story in Alabama, when it took place further south, in Guatemala.

Interestingly, the episode happened during a period of hope in Guatemalan history -- one of elections and land reforms, before decades of civil war that followed our overthrow of the democratically elected government:

The United Fruit Company owned and controlled much of Guatemala, the quintessential “banana republic,” in the first half of the 20th century. When the PHS looked to Guatemala for its research in the immediate post-World War II years, it came into the country during the period known for its relative freedoms; between 1944 and the U.S. led CIA coup of the elected government in 1954, there were efforts made at labor protection laws, land reform, and democratic elections. The PHS was part of the effort to use Guatemala for scientific research as they presumed to transfer laboratory materials, skills, and knowledge to Guatemalan public health elite.

And one last tidbit:

In reporting to Cutler after he returned to the States, he explained that he had brought Surgeon General Thomas Parran up to date and that with a “merry twinkle [that] came into his eye…[he] said ‘You know, we couldn’t do such an experiment in this country.’”60

Read the whole thing.

Confronting ourselves

The Independent's Johann Hari interviews Gideon Levy, a controversial Israeli critic of Israel's actions in the Occupied Territories. An excerpt:

He reported that day on a killing, another of the hundreds he has documented over the years. As twenty little children pulled up in their school bus at the Indira Gandhi kindergarten, their 20 year-old teacher, Najawa Khalif, waved to them – and an Israel shell hit her and she was blasted to pieces in front of them. He arrived a day later, to find the shaking children drawing pictures of the chunks of her corpse. The children were "astonished to see a Jew without weapons. All they had ever seen were soldiers and settlers."

And another:

Levy uses a simple technique. He asks his fellow Israelis: how would we feel, if this was done to us by a vastly superior military power? Once, in Jenin, his car was stuck behind an ambulance at a checkpoint for an hour. He saw there was a sick woman in the back and asked the driver what was going on, and he was told the ambulances were always made to wait this long. Furious, he asked the Israeli soldiers how they would feel if it was their mother in the ambulance – and they looked bemused at first, then angry, pointing their guns at him and telling him to shut up.

"I am amazed again and again at how little Israelis know of what's going on fifteen minutes away from their homes," he says. "The brainwashing machinery is so efficient that trying [to undo it is] almost like trying to turn an omelette back to an egg. It makes people so full of ignorance and cruelty." He gives an example. During Operation Cast Lead, the Israel bombing of blockaded Gaza in 2008-9, "a dog – an Israeli dog – was killed by a Qassam rocket and it on the front page of the most popular newspaper in Israel. On the very same day, there were tens of Palestinians killed, they were on page 16, in two lines."

I'm trying to imagine how the American public would react if the front pages always carried news of the latest Afghan "collateral damage" -- not just the numbers, but real, humanizing stories. For that matter, if we saw graphic coverage of the damage done to US soldiers and contractors, might things change?

Certainly one reason the American polity has been able to happily go about its business while we've waged devastating wars in two countries is that, by and large, Americans don't hear about the damage we inflict. Yes, we see a bit of political analysis ("How will this affect the election?") and occasional stories about US casualties ("Three soldiers killed in a helicopter crash"), but we're not forced to confront the hundreds of civilian casualties from stray bombs and bullets and germs in any serious, compelling way. That complete lack of confrontation, more than any bias in the stories that do get coverage, allows the tragedy of our foreign adventures to continue.

On war journalism, truth-telling, and independence

I read a few things recently that I thought were worth highlighting. The first is a bit of historical background on the brutality of war: an Atlantic article from 1989 on World War II and how its reality differed from its presentation to civilians in propaganda back home. I wonder to what extent movies like Saving Private Ryan have changed this perception. I read it a few days ago, and was reminded of it when I read a letter to Andrew Sullivan from a combat vet:

"You see what you're sending us to do? You see who is dying because you support a war in a part of the world you know nothing about?" The ignorance of the population is so vast that when I was deploying to Iraq and (thankfully) coming back, as I passed through Atlanta-Hartfield, people would congratulate me and my fellow servicemembers, shake our hands, say thanks, etc., and all I wanted to do was scream at them, "Get educated you ignoramus! This isn't a great thing; it's futile!"

In tangentially related news, Pro Publica has a new report showing that contractor deaths are exceed military deaths in Iraq and Afghanistan. In other words, the number of casualties haven't necessary dropped because more of the jobs that would have traditionally been done by soldiers are now being done by contractors / mercenaries.

And even more tangentially, some historical context for how intertwined our media and military / intelligence establishments can be: more than 400 American journalists have carried out assignments for the CIA in the last 25 years. This sort of line-blurring is understandably problematic for both journalistic integrity and issues of access, somewhat analogous to how militaries co-opt the independence of humanitarian and public health workers in war zones.