Archive - January, 2009

Prevention vs. Treatment

Christine Gorman at the Global Health Report blog asked several bloggers who write about global health to take on the subject of treatment vs. prevention. I write about health as a layperson from personal  experience and public policy. Other bloggers writing today on the subject offer professional expertise and a variety of viewpoints.

The news that the malaria parasite has developed resistance to the best new drug formulated to treat it is cause for significant concern. According to reports, malaria along the Cambodia Thailand border shows signs of resisting artemisinin, an extraction from a plant used in traditional medicine.

One of the greatest fears in the malaria community is the resurgence of the disease, something veterans have witnessed before in the not-so-distant past. Malaria was significantly reduced globally in the 1950s only to come back aggressively and with greater resistance when abatement efforts slowed. The failure to contain it through consistent, on-going effort led to an even more virulent and widespread global outbreak.

We are at a key moment in the fight against this disease. It could be the first warning of a drug resistant strain that has the potential to explode into an even greater threat to world health. How will political and  health leaders respond?

They face a key issue, one that has been discussed and debated for a number of years–prevention vs. treatment. The debate isn’t only about malaria, of course, it cuts across the spectrum of health concerns. It’s about an underlying philosophy of funds allocation. Should time, talent and resources be channeled to research, prevention or direct service?

I became involved in the debate more than thirty years ago around another set of issues. The issue I confronted (as a citizen member of a board of directors for a genetic research program) was to support a policy to put more funds into preventive research which, if enacted, would have the effect of redirecting funds away from direct treatment for children with genetic conditions.

It was an agonizing forced choice, one that I’ve since come to believe is short-sighted and even morally indefensible. It posits that funding research, treatment and prevention is not possible.

It’s based on the morally repugnant premise that health care can be reduced to an economic argument. Obviously, research for prevention must be funded. Prevention in the form of immunizations, innoculations, education for lifestyle changes and medications must be funded, and so, too, must treatment. It’s short-sighted to juxtapose these as if they are competitive, or worse, to act as if funding them is a zero sum game. It isn’t.

It’s also worth noting that the drug resistant parasite in Asia can migrate to other regions, and the mosquito carrying it is no respecter of nationality. Thus, threats in one part of the world threaten people across the world.

A few years ago, I wrote of the proposal by Gary Gunderson and Larry Pray to  focus on the leading causes of life. They make the point that focusing on deficits frames the discussion so that it leads to competition for finite resources when we could see the whole constellation of health in a holistic and positive view. Calling this a search for the “leading causes of life,” Gunderson and Pray write we must move forward on all fronts and not try to capture our piece of the pie for one area of work.

The debate about treatment vs. prevention is the wrong debate. The larger issue is about funding those efforts that lead to a healthy, productive future globally, or choosing other paths.

The United States chose the path of profligate spending on war that destroys human life and leaves us less secure in virtually every way–emotionally, financially and physically.

The same politicians who are resisting health care funding are the ones who drove us into the economic ditch that is collapsing on us now. They went along with an off-budget war that will cost 3 trillion dollars while cutting taxes to pay for it and now tell us we can’t devote our precious limited resources to constructive uses. Bob Herbert asks why anyone is listening to them today. Indeed, why?

To debate treatment vs. prevention is to become diverted from the crucial issue–how shall we move forward humanitarian, progressive policies and programs that contribute to global well-being?

Through global partnerships we can carry out research to prevent and treat malaria, and do much more to combat other diseases and health concerns as well. But this will require sustained support for a change in priorities, a change that has begun but will need continuing reinforcement and updating.

With regard to malaria, it’s urgent to continue preventive measures including bednets, training, environmental cleanup, water management and indoor spraying in addition to sustained spending on research and treatment.

Prevention vs. treatment? That’s the wrong debate.

BBC & Sky Refuse Gaza Appeal

The BBC and Sky television refuse to broadcast a two-minute appeal for humanitarian aid for the children of Gaza, contending that to do so would risk the impartiality of news coverage.

A coalition of thirteen humanitarian agencies is participating in the Disasters Emergency Committee to provide emergency assistance to the people of Gaza.

Dr. John Sentamu, Archbishop of York, had the most concise criticism saying, “This is not a row about impartiality but rather about humanity.”

Media and Development

The agreement between the African Medical and Research Foundation (AMREF) and the Guardian, the London-based daily newspaper, to document a development program in Kitane, Uganda is leading to interesting and valuable insights into the relationship between the non-profit development organization and the journalists covering the effort.

The interaction between development and journalism has long fascinated and frustrated me. It’s fascinating because the expectations raised by the presence of a journalist in an on-the-ground development program are remarkably diverse, and often so divergent as to be fantastic.

People in the local community often have unrealistically high expectations that the telling of their story will have immediate positive results. It’s as if their lives will change overnight for the better. The development staff are likely to be very skeptical and less-than-transparent for fear the telling of the slightest screw-up or failure will put the whole enterprise at risk. Or, they expect the journalists to be an extension of their public relations efforts, or, even better, to become a de facto fundraiser for the project.

The journalist may also face conflicting choices in reporting. If committed to the idealistic goals of the project–to improve the harsh conditions under which people live–how much of the unsuccessful venture should be reported? On the other hand, it’s neither fair nor accurate to fail to report on it.

This leads to a careful dance and many ethical decisions that all concerned must weigh. And this brief list is only a starting point. Drill deeper and you’ll find much more beyond these simple illustrations.

It’s frustrating because development does not reduce well to simplistic stories of good deeds nor well-intended charity yet it is often framed in precisely this way.

Humanitarian aid does not exist in a vacuum. Aid agencies and journalists operate in an environment of living, breathing, ever-changing cultural, social and political interactions. And these introduce competition, conflict and ambiguity as well as cooperation, community-building and civic responsibility. And, of course, there are power relationships, sometimes so obvious they are blinding and sometimes so opaque it’s impossible to discern who’s on first, on or top.

The conversation on the Kitane blogs is revealing. These different expectations well up and create new learnings and present the ethical dilemmas in striking relief.

Among the most interesting conversations is about transparency. As I read the comments I recalled that covering development isn’t as simple nor as benign as sometimes assumed.

Development isn’t normally a front page story. It’s a slow, unfolding progression of steps unlike the cataclysm of war, famine or other shattering events. As a result, development gets short shrift. The drama of development is measured in small increments and the whole story can only be told after years of effort pay off in a functioning community with a sound economic base. These aren’t the ingredients of front-page drama.

The discussion on the Kitane blogs probes these issues with greater depth and with considerably more insight than we’re likely to see anywhere outside of scholarly journals or internal reports of development agencies.

For that reason, the Kitane project is a great contribution to both development journalism and development practice.

Carry the Constitution With You

I carry a copy of the U.S. Constitution in mini-booklet form with me when I travel. That, and a pocketbook-size scripture, plus miscellaneous reading material. I refer to the Constitution, sometimes out of idle curiosity and sometimes because I need to be reminded of its content and promise. Just as with scripture.

The two point to the highest ideals to which we can aspire. Normally I wouldn’t blog about spam but this Friday before Martin Luther King Day and the Inauguration of President-elect Barack Obama a promotional email for a pocket-size edition of the U.S. Constitution got my attention. This weekend it seems a more appropriate item than it might on other days.

Writing as Healing is not Blogging for Publication

A guest blogger on the Lifehack blog caught my attention with a short piece on writing as a form of self-healing. So did an article by Stephen Drachler on blogging by United Methodists. Blogging is personal writing published for the world to see, if you want it to be so. And therein lies the dilemma.

The Lifehack writer makes the point that writing for personal healing is significantly different from writing for publication. Drachler’s article points to the tensions. One blogger asked him to not use her name because she is still unidentified in her blog. And another ticked off a bishop when a blog post expressed something the bishop didn’t agree with.

When I started this blog some questioned my wisdom even if I was not writing about my professional responsibilities in the church. As it turns out, these do creep in. Others felt it was a waste of time because they said the audiences we serve don’t use blogs for information. As the leader of a communications agency, I had my own reservations.

But the communications problem of mainline church leaders is not that they’ve been outspoken in the public conversation, it’s that they’ve been, for the most part, absent. They are unable to garner the media coverage they deserve, or they avoid it.

This blog has not set the world afire, but I’m often amazed and surprised when I get a note from someone halfway around the world commenting on something I’ve written about a global issue. And I get touching personal notes that I don’t put into the comments because they weren’t written for publication. While the comments are paltry in number, I’m also surprised when I speak somewhere and someone comes up and engages me in conversation about something they’ve read here.

I don’t write this blog for self-healing, but I suspect getting something off my chest sometimes has that effect. At the same time, I impose constraints on myself, as we all should when we write for the Internet and don’t want to be fired or lose a job fifteen years from now for writing something carelessly.

I haven’t blasted away with the full emotional force I’ve felt about some controversial issues despite the fact that I’ve found plenty of reasons to do so in the past eight years and occasionally I probably wrote more forcefully than was “safe.”

But the most difficult challenge of blogging for me is finding a voice. Writing for the web is different from other kinds of writing, and it’s an area I’ve not trained for. Moreover, it goes against the grain of much of what I’ve been taught and practiced over the years.

After having my knuckles figuratively rapped by a journalism professor for not being objective, or for putting personal judgment into a piece when it didn’t belong, I began to write with such objectivity my stories were bland. So I had to reassess.

Now, bloggers must write not only for readers but for search engines. The old inverted pyramid is still the best tool for many stories, especially news, but putting as many key words as possible into the lead is still a challenge. And if I were a headline writer I’d starve because my headlines are so neutral and objective I’d be out the door in no time.

And, as you can see if you’ve gotten this far, brevity isn’t my strong suit. I admire those bloggers who are really good at getting key ideas into a few words. At this stage I’m not one of them.

But I keep trying.

Will Media Coverage Derail Health Care Reform?

In a provocative blog post on the Health Beat Blog Niko Karvounis discusses how media coverage of health care could derail health care reform. Karvounis offers an insightful review of health care coverage in mainstream media and says the challenge will be to make sure titillation doesn’t trump the issues.

The potential for this to happen is obvious. We see it in political coverage regularly. The tendency to cover personality clashes and political spats can take the place of reporting on less colorful but more important matters of policy that will ultimately shape the system.

The risk, says Karvounis, is that the insubstantial will detract from the substantial policy decisions that must be made. We will witness more “horse race” reporting and lose perspective about what’s important.

There are plenty of substantial gaps in health reporting already. Karvounis points to Kaiser Family Foundation research that reveals health care policy comprised less than one percent of news stories and just 27.4% of health-focused stories between January 2007 and June 2008.

In fact, the Foundation reports that news about health and health care comprised barely 4% of all news reported in that time period. Health policy comprised a scant 0.9%.

Karvounis quotes Mark Rushefsky and Kant Patel, authors of Politics, Power, and Policymaking: The Case of Health Care Reform in the 1990s, who say “mass media may not tell us what to think, but they are very successful in telling us what to think about.”

While it’s true the media may, to a significant degree, still focus our attention, Karvounis does not give attention to the availability of new media to mobilize and inform. While his assessment is on the mark, the use of these new media–cell phones, blogs, social networking, email–was not a factor in the most recent attempts at health care reform led by Hillary Clinton. These tools have matured and are more pervasive than ever before. So, while the challenge Karvounis issues to the media is valid, it may not be the only definitive challenge that needs to be heard.

The challenge to utilize other media to inform and mobilize is much more relevant today and could be a powerful way to build a grassroots movement for reform. We haven’t tested this yet, but the time is at hand. The model was pretty well tested during the political campaign and, by all accounts, found to be effective.

While I take Karvounis’ analysis seriously, I find myself saying, “Yes, but.” The “but” is that those citizen-based advocacy groups already at work on health care should give attention to creating a nationwide grassroots advocacy network for health care reform and for addressing the diseases of poverty globally using media available to them right now.

What concerns me about Karvounis’ analysis is not that it’s wrong, but that health care reform and public policy affecting global health are too important to leave to the media, politicians or the health care industry. Grassroots advocacy groups discussing strategy right now must expand beyond traditional approaches such as influencing Washington policy-makers one-by-one (as important this is), build communications networks and use digital media to mobilize the grassroots.

Doing so could potentially keep the focus of the mainstream media on the policy issues and keep the attention of the policymakers on what matters. Obviously, another significant challenge is to achieve consensus about policies and reforms. This is no less difficult today than it has been in the past. It’s more than a communications challenge, of course. It’s a matter of managing conflicting claims and competing solutions, and achieving an acceptable compromise that we can all live with. All the more reason to kick a communications network into gear and keep the focus of the national conversation on policy. If we don’t, this is where we will founder.

And if we do, it may be one way to assure that media coverage doesn’t derail health care reform.

Exploited Children

When Nicholas Kristof wrote of his experience with a young woman sold into prostitution in Phnom Penh he reminded me how little distance we’ve covered the past three decades in protecting children from exploitation.

Years ago I was sitting in a Land Cruiser waiting for a ferry in Cambodia when I saw the barrel of a missile launcher bob past the back window. As the weapon carrier came alongside me I saw a boy no more than eleven or twelve, considerably shorter than the missile strapped to his back. This was my first observation of child soldiers. But not the last.

Some years later I was in Mozambique where children were forcibly conscripted into an armed rebel movement known as Renamo. I visited a place where many of these children were being given safe haven because they were unable to return to their families. The families and their home villages were afraid of them. They had been trained to wreak terror, and they succeeded. Now, at the end of the fighting, they were unacceptable and unwanted.

Those who cared for them called them “traumatized children.” And that they were. Some were obviously depressed and withdrawn. Others would fight at the drop of a hat. Still others were so manic they could not sit in a classroom and learn.

Kristof’s story is about trafficking children for sex slavery. Unfortunately, horrific as this is, it’s but one of the ways children are exploited. Forced labor, conscription into militias, fake adoptions into indebted servitude, and children abandoned to exist on the streets are all among the list of horrors to which children around the world are subjected.

My friend Linda Robbins wrote in her Christmas letter, ” I am also persuaded that a pack of Montana wolves is more committed to rearing, training, and protecting their young than most human communities.

It may have ‘taken a village’ in the not so distant past, but today that euphemism is falling short all over the world.  Last weekend, a 24-year-old mother in my neighborhood felt inspired to trek down the street despite a sub-zero blizzard to get cigarettes.  She left her year-old toddler at home alone, to wander out an unlatched door into the alley in the snow, clad only in his diaper.  Wolves would not do this.

CNN today had yet another story of a prominent public figure accused of utilizing the internet to stalk children.  The international traffic in children for their bodies—or parts thereof—is a horror only humans could conceive.  A herd of elephants will quickly form a circle of protection around their young at the sound of an approaching Land Cruiser.  I’ve been there, I’ve seen it, and can’t help wondering:  where is the circle of safety for children today?”

Where, indeed? Here are a few places.

Human Trafficking and Sexual Exploitation

General Board of Church and Society

Children’s Defense Fund

Nothing But Nets

Publishing, Journalism, Music and New Digital Media

A postscript.

After writing this I discovered a couple of blog posts with different perspectives. Blogger Kelby Carr writes that newspapers are heading in the wrong direction by cutting content and paring down long form journalism.

Erin Kotecki Vest wrote about the journalistic results of the adaptation to brevity, short attention span and unwavering objectivity.

As a result of the proliferation of digital media, the restructuring of nearly every industry that deals with information–publishing, radio, television, journalism, advertising–is breath-taking.

Add to this the effects of digital distribution in the music industry and the arrival of new venues for information and entertainment that have never been a factor in the competition for mind space and it becomes clear just how fundamental is this change.

This isn’t a new thought, of course, but it’s a recurring theme in recent days. What brought it to mind was the move to the web by the Christian Science Monitor and staff reductions and the cancellation of two programs recently by NPR. These reductions also made it clear that the changes we’re living through affect non-profit as well as for-profit ventures. And the pressures are not only economic. They may include the need to reach a more diverse demographic, respond to globalization, find a more direct and efficient way to interact with an audience, provide a multimedia experience and offer new products.

The old models of producing and distributing information, and generating revenue if you’re in a for-profit corporation, are breaking down and new models are yet to be developed. (Did anyone really anticipate ring tones at the start of the cellphone revolution?)

Our non-profit organization recently announced a reduction of seven positions. We did everything within our capacity to assist these colleagues and most have already found new employment. That doesn’t mean the change is less wrenching or worrisome, nor that the issues we face are lessened. The problems aren’t resolved by cutting back. We still need to add skills in digital media.

It’s paradoxical that the strengths of the old models don’t count for much. For example, NPR is enjoying near-record audiences.  The Pew Center for People and the Press reports as newspaper readership declines, online readership is increasing. More revenue streams are available in the music industry but there’s still no clear pathway to viable business plans for content creators.

Digital production is not necessarily less expensive than print. In fact, it can be more expensive, and digital products are not necessarily more profitable.

Demand for information in multiple formats adds to the challenge. Audiences are not only fragmenting, media usage is expanding across a wider spectrum of media as costs rise and income stabilizes or decreases. If reach and audience size don’t matter as they once did, then clearly, the metrics of the old operating models don’t apply right now and perhaps they will never work the same again.

When the Detroit Free Press went to three-day home delivery the managing editor was emphatic that seven-day home delivery would not be restored. The move is not a temporary adaptation, it’s permanent.

Four days later the Free Press announced reductions and redeployment of staff, a plan for digital media distribution and more multimedia content. It’s a microcosm of the publishing industry today.

Each of these industries faces unique problems but, in general, as demand grows for information across various media, new staff skills are required to create and maintain expanded infrastructure, producers are needed to package and manage information, different information is called for as content weaves through and drives users to various media, and new products must be developed and marketed.

The trends identified in the State of the Media 2008 report by the Project on Excellence in Journalism point toward a profound shift in the expectations of readers, how they use information and the fluid nature of news as an ongoing narrative, not a fixed product.

The report also reinforces a trend identified in many other places, namely, the shift from delivering a product to delivering service and empowering the user. A shift marketers identified a few years ago in other arenas has now come to journalism.

Audiences today cross borders and interact in ways not possible before. The dialogue that is the strength of the Internet is now global. Language, once a barrier, is likely to become less so as new transliteration tools are developed.

A key issue for information providers who desire to reach global audiences is how to communicate with them in the language they prefer and that is, therefore, most likely to communicate effectively and with relevance, and to invite them into a two-way conversation.

Adapting to and responding to this landscape is the challenge. And despite the obvious need to manage resources responsibly, the challenge is not resolved by reducing and paring down alone. Nor will increased funding assure success. Paring back less useful skills and shepherding resources may make a difference, but at its core the challenge is bigger than money.

The efforts by the music industry to halt illegal downloading and protect revenue through lawsuits has moderated such behavior at the cost of alienating music fans. Music sales and concert revenues continue to slip. It’s common to read references to this effort in many places as an example of how not to deal with digital piracy with your customer base.

Money is an important part of the problem, but the greater challenge is about creativity, innovation and risk. Adapting and surviving requires a willingness to innovate, the courage to risk and the capacity to fail and get back up and try again. It’s essential to maintain a relationship with end users, listening to what they want, and how they want it delivered. And even then the answers may be confusing or unclear. It’s an ever-changing, fast-moving landscape.

A good supply of antacid helps.