100 years ago today, Jonas Salk was born. As the creator of the inactivated polio vaccine, he not only changed the course of human history, he also ushered changed the field of public health forever. We can count the polio vaccines and the elimination of smallpox as probably the two great success of public health.
In its mildest form, polio causes a mild bout of diarrhea. In its worst form, the virus migrates to the spine, impedes development and causes debilitating long term paralysis. My grandfather was struck with the disease and had one of his legs stunted and weakened (though he managed to serve in WWII anyway as a Marine). A carpenter who worked for me a while back died due to long term respiratory complications from a childhood polio infection.
Polio is mostly foreign to anyone born in my generation. We were nearly all vaccinated, and the high levels of vaccination have destroyed opportunities for the virus to persist in the environment, protecting everyone, even those who don’t get the vaccine.
Unfortunately, though Salk’s achievements were great, medical care and attention to polio was hardly equitable and tainted by the racism of the time.
During the 1930s the systematic neglect of Black polio victims had become publicly visible and politically embarrassing. Most conspicuously, the polio rehabilitation center in Warm Springs, Ga, which Roosevelt, himself a polio survivor, had founded, accepted only White patients. This policy, reflecting the ubiquitous norm of race-segregated health facilities, was sustained by a persuasive scientific argument about polio itself. Blacks, medical experts insisted, were not susceptible to this disease, and therefore research and treatment efforts that focused on Black patients were neither medically necessary nor fiscally justified.
It is likely true that African Americans experienced a lower burden of disease than white children. We now know that polio’s worst effect arise from the lack of acquired immunity to the disease. Repeated infections from infancy, most importantly during the first six months, when babies still have maternal antibodies to fight for them. Improvements to sanitation delayed exposure to the virus, so that children were not immune and thus more susceptible to the disease’s worst effects.
In short, polio is a disease of development, not underdevelopment. The horrible racism of the pre-civil rights medical system can’t be denied, but the observed disparities in disease incidence might have not been imagined given the disparities in sanitation and access to clean water.
Presently, we are fighting a battle to insure that all kids in Sub-Saharan Africa are vaccinated. However, there still exist pockets where the medical system so dysfunctional and the politics so chaotic, that vaccination rates are low and disease continues to flourish. In places like Afghanistan and Northern Nigeria, the hope of polio elimination is almost non-existent
1. Rogers N: Race and the Politics of Polio: Warm Springs, Tuskegee, and the March of Dimes. American Journal of Public Health 2007, 97(5):784.
Unfortunately, the Twa are long gone from the island, which is now occupied by Suba and Luo people, though the Suba are quickly being assimilated into the Luo through marriage.
It’s an odd place. They’ve got a small tourism industry, are currently installing new power lines and have recently gotten true ferry service from the mainland, but the roads are still terrible.
We ran into a group of missionaries on the way back. I always feel somewhat violated after talking with missionaries in Africa. What are they doing here? This looked like some polygamous group of Mormons but it turned out they were from Alberta and Kansas.
One of them asked us what we were “lonesome for.” I didn’t know how to respond so we asked them what they were lonesome for, to which they said “Wal Mart.”
While I hate to judge, it was telling that they all introduced themselves to us, but not Victor, an employee of the Kenyan Medical Research Institute who was standing right next to us. I’m convinced that they don’t see the locals as people.
What developmental role do missionaries play? They make no demands on politicians to solve pressing problems of political dysfunction, infrastructural weakness, employment, a lack of access to capital, crippling bureaucracy, corruption, graft, nepotism and terrorism. None of these problems can be solved through missionary activities which emphasize odd moral codes more fitting to white, rural Kansas than complicated and chaotic Kenya.
It’s been an extremely long day.
Nearly 80% of people in this area of Kenya practice open defecation. They don’t use toilets. Of course, fecal matter washes into the lake, which happens to be where they all get their drinking water from. Diarrheal disease is, of course, out of control.
As a public health professional, I’m justifiably annoyed that there are people out there who can’t handle even the simplest sanitation solution: shitting in a single hole. However, it is what it is.
JICA has sponsored the construction of put latrines and the installation of water tanks at several schools in the area. These interventions are dirt cheap, but are way beyond the financial reach of impoverished communities along Lake Victoria. While we would assume that the Kenyan government would be expected to contribute money to help protect their children, the reality is that this area has been politically marginalized since independence. Schools can’t depend on the government to provide even sufficient wages for teachers, let alone sanitation infrastructure. Given the political problems between the current Kikuyu government and the Luo, it’s unlikely that the funds would be provided, even if they were available.
One of the schools we visited is 100% community funded. While it was a rudimentary facility, the locals have to be commended for taking matters into their own hands. I just wish they’d take sanitation more seriously.
Talked to a great bunch of people, listened to some great stories and drank 7 bottles of Coca-Cola. Off to bed.
The thinking, however, isn’t entirely illogical and can, of course, even be traced back to Malthus himself. Malthus believed that helping the poor would only increase their misery through worsening conditions of crowding and starvation. If Malthus had lived in 2013 and were concerned with welfare policy, he’d probably be a card carrying member of the Republican Party.
For the record, I despise Malthus (and his spawn, Paul Ehrlich). I can’t think of a more cynical and heartless thinker. It’s disturbing to me that his ideas continue to permeate today, despite being wrong at best and simply hateful, at worst. More disturbing is how eagerly his ideas are absorbed by even otherwise well meaning people.
“It’s obvious,” I’ve heard people say while implicitly suggesting the some lives (ours) are worth more than others (theirs). As cliched as it may sound, I think that every human has both a right to live and the right to a life that is healthy and meaningful. Not saving kids from malaria compromises the ability to do either.
So far, though, no one really knows whether life saving interventions in developing countries fuel population growth. Does saving a child’s life simply increase the number of mouths to feed, thereby straining resources and insuring misery for everyone? David Roodman, a public policy consultant working on behalf of GiveWell, a group which does analyses on the effectiveness of charity programs, has searched the published literature to find the answer.
I think the best interpretation of the available evidence is that the impact of life-saving interventions on fertility and population growth varies by context, above all with total fertility, and is rarely greater than 1:1. In places where lifetime births/woman has been converging to 2 or lower, family size is largely a conscious choice, made with an ideal family size in mind, and achieved in part by access to modern contraception. In those contexts, saving one child’s life should lead parents to avert a birth they would otherwise have. The impact of mortality drops on fertility will be nearly 1:1, so population growth will hardly change.
He goes through the available data and finds evidence to suggest that averted child deaths are associated with a decrease in the number of births over the lifetime of a woman. This is somewhat non-controversial. It has long been noticed that economic development and increased access to medical care is associated with decreased lifetime fertility.
Where things become controversial is in the case of developing countries, where saving a child’s life might not have the same effect on reducing births overall. This might be true in the short term, and Roodman finds evidence to suggest this. A short term reduction in child mortality might not yield immediate results.
The issue might be more nuanced, however. Merely providing malaria interventions such as insecticide treated nets to prevent disease without increasing access to quality health services might lead to a situation where population increases quite rapidly. I would think that this might explain why some of the most malarious countries in the world are experience the most rapid population growth. Malawi would be an example.
The strategy, then, is incomplete and Roodman’s analysis might suggest that we need to take a holistic approach to include both malaria prevention and reproductive health services.
I would, however, suggest that the problem is more complicated, particularly when reflecting on Kenya, where the most effective method of reducing fertility has probably been the imposition of school fees. The issue then isn’t merely a matter of saving kids and Depo shots, it’s also a matter of finances. If people can’t afford kids, they won’t have them, but the only way to arrive at economic barriers to reproduction is to have an economy, which is exactly what a country like Malawi doesn’t have.
The new OECD “Society at a glance” (paywall) report came out today. It’s part of a series of policy papers assessing the social implications of the economic crisis and its aftermath, and offers a list of policy recommendations on a yearly basis.
The picture is never good.
The financial upheaval of 2007-08 created not just an economic and fiscal crisis but also a social crisis. Countries that experienced the deepest and longest downturns are seeing profound knock-on effects on people’s job prospects, incomes and living arrangements. Some 48 million people in OECD countries are looking for a job – 15 million more than in September 2007 – and millions more are in financial distress. The numbers living in households without any income from work have doubled in Greece, Ireland and Spain. Low-income groups have been hit hardest as have young people and families with children.
The financial crash was one of the most important events that occurred within my lifetime, but still some people don’t seem to get how far reaching its impacts have been. The American Republican Party seemed to mostly bury its collective head in the sand, perfectly willing to sacrifice the welfare of poor people for the sake of a few narrow political goals.
The paper is filled with interesting data and charts, but the are some other gems here. Food security:
While federal food assistance programmes in the United States now support roughly twice as many households as in 2007, the number with inadequate access to food at some time in the year has nonetheless climbed from 13 million (11% of all households) in 2007 to 17.6 million (15%) in 2012. Rates of food insecurity were substantially higher among households with children (20% in 2012) and lone-parent families were particularly affected (35%). Forty-one percent of all food-insecure households received no support through federal food assistance programmes.
As someone who grew up in a food insecure household, I take this quite seriously. Right wingers who have a stocked fridge don’t get what it’s like to have an empty fridge. It’s easy to say that SNAP benefits foster “a culture of dependence” with a bulging stomach. Perhaps they don’t know that in food insecure households, the last people to eat are the kids. Of course, they don’t care.
To “crisis-proof” social policies and to maintain effective support throughout the economic cycle, governments must look beyond the recent downturn. First, they need to find ways to build up savings during upswings to ensure they can meet rising costs during downturns. On the spending side, they should link support more to labour market conditions – for example, by credibly reducing benefit spending during the recovery, and by shifting resources from benefits to active labour market policies. On the revenue side, they should work to broaden tax bases, reduce their reliance on labour taxes and adjust tax systems to account for rising income inequality. Second, governments need to continue the structural reforms of social protection systems begun before the crisis. Indeed, the crisis has accelerated the need for these. In the area of pensions, for example, some future retirees risk greater income insecurity as a result of long periods of joblessness during working age. In health care, structural measures that strip out unnecessary services and score efficiency gains are preferable to untargeted cuts that limit health care access for the most vulnerable.
If GWB 1 is any indication, the Republican Party dislikes savings and when they get a surplus they seem to squander it. There’s no reason to believe that the future will be any better. I’m thinking about the dichotomy of labor taxation versus capital taxation. Republicans have made it quite clear that they dislike capital taxation and prefer labor taxation. But what this does is create a gated community of capital holders, who exert vast political control without having to take responsibility for, well, much at all.
While I do advocate for a national sales tax to pay for transfers to create an income floor for American wage earners, we also need to tax the hell out of inheritances. There’s no reason that Bill Gates’ son (does he have one?) deserves a leg up any higher than he’s already got it. If America wants to foster innovation, it has to start by bolstering it’s labor classes. Forcing them to go without meals and scramble around to meet basic health needs only creates a dog eat dog culture of basic survival, and leaves little room for good ideas.
Alright, happy zombie day.
Here’s a few articles I’ve been reading this morning that I liked.
Intellectual Property Rights, the Pool of Knowledge, and Innovation by Joe Stiglitz (National Bureau of Economic Research)
We began by noting that some observers of innovation have claimed that a more important determinant of the levels of investment in R & D and the pace of
innovation than the intellectual property regime is the “opportunity set,” the knowledge pool from which applied researchers can draw. Knowledge, it is has long been recognized, is a public good—a
common resource from which all can draw (see, e.g., Stiglitz 1987).32 Intellectual property provides a way of appropriating the returns to investments in knowledge, but in doing so, effectively privatizes a public good. But every innovation draws upon prior knowledge, and the boundaries of “new” knowledge are inherently imprecise. Patents inevitably enclose what would otherwise have been in the
public domain. In doing so, not only do they impede the efficient use of knowledge, but because knowledge itself is the most important input into the production of further knowledge (innovations),
they may even impede the flow of innovations.
Democracy does cause growth (National Bureau of Economic Research)
Our baseline results use a linear model for GDP dynamics estimated using either a standard within estimator or various different Generalized Method of Moments estimators, and show that democratizations increase GDP per capita by about 20% in the long run. These results are confirmed when we use a semiparametric propensity score matching estimator to control for GDP dynamics. We also obtain similar results using regional waves of democratizations and reversals to instrument for country democracy. Our results suggest that democracy increases future GDP by encouraging investment, increasing schooling, inducing economic reforms, improving public good provision, and reducing social unrest. We find little support for the view that democracy is a constraint on economic growth for less developed economies.
Abe’s Law: Domestic Dimensions of Japan’s Collective Self-Defense Debate (HERE)
The Edutainment Industrial Complex (Africa is a country)
So this is their strategy? Ask a bunch of relatively wealthy, globally-mobile pop superstars to tell rural youth to not participate in the flashy urban lifestyle they (the artists) usually promote–to stay in the countryside and participate in the resource extraction side of global capitalism? As Sean pointed out to me over email, the video isn’t unlike the type campaign some dictatorship (South Africa’s racist regime was fond of it) might use as a tool of “national development” or to fight crime or build national morale.
Is this a surprise? Western liberals have long romanticized rural poverty and encouraged Africans to simply do nothing about their developmental problems. Sorry, I had to put on my curmudgeon hat for a while.
- The Sustainable Development Goals: Too restrictive? Too wordy? Or simply dadaist?
- Why malaria? Over-researched, over-funded, diminishing returns? Rambling on the need for student mentorship.
- New Publication: “First Report of a Foodborne Providencia alcalifaciens Outbreak in Kenya.”
- Eid in Kwale, Kenya
- Infectious disease transmission dynamics and the ethics of intervention based public health research
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