The pie in the sky

It's not clear that if we all beg for bigger slices, we'll just get more pie.

Alanna Shaikh rightly points out that, despite the incredible important of funding HIV/AIDS programmes, there are many health problems that are losing out in the fundraising arms race.

But here’s what I have figured out in the last decade: we can have more pie. Differently put, global health is not a zero-sum game. We can increase the funding that goes to it. In the last ten years, we have. The Global Fund and the Gates Foundation have radically increased the resources available to global health. The private sector has started funding global health, and government donors have increased their commitments.

There is nothing wrong with so much attention going to AIDS. HIV gets exactly as much attention as it deserved. It’s the second most terrifying pandemic of our time. (I really think first place belongs to MDR TB). About two million people a year die from AIDS, and there are about 33 million people currently infected with HIV. It is devastating to communities, families, and nations. It is worthy of every red ribbon, activist, and dollar of funding it receives.

What is wrong is that other health problems don’t get as much attention. And that’s not a problem we solve by ignoring HIV. It’s a problem we solve by bringing more attention to the rest of the world’s serious health problems. We should learn from the publicity for HIV, not complain about it. What we need is to get that kind of attention for everything that deserves it.

I am a little skeptical that the answer lies with more or better publicity for neglected health problems. I think it is unlikely that we are capable of increasing the volume of campaigning on some worthy causes while somehow avoiding crowding out others by increasing the overall pie. Owen Barder does a good job of dissecting some of the issues here.

For one, the more causes that potential donors get bombarded with, the less effective any of them will be. I should demonstrate this with some resounding empirical work, but I think this video of Robert Stack fending off a bunch of activists at LAX says it all:

So increasing overall noise by amplifying fragmented messages might not increase global giving and might even fatigue the entire process.

What about crowding out? We need to be more honest about how many messages we can take on board at once – our collective time thinking about global problems is rather limited. If someone tells me I should be thinking about neglected tropical diseases, that’s less time I’ll spend thinking about HIV/AIDS or education or conditional cash transfers or international trade.

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Perverse incentives in fundraising

On Wednesday, Kim Kardashian is going to die a little. So is her sister, Khloé, not to mention Lady Gaga, David LaChapelle, Justin Timberlake, Usher, Serena Williams and Elijah Wood.

That day is World AIDS Day, and each of these people (as well as a host of others — the list keeps growing) will sacrifice his or her own digital life. By which these celebrities mean they will stop communicating via Twitter and Facebook. They will not be resuscitated, they say, until their fans donate $1 million.

More here. I can think of a few more tweeters that I think should join in. And isn’t $1,000,000 a little low? How about $500,000,000?

The dangers of hot issues

How would we at aidthoughts link HIV/AIDS and climate change in six degrees or less? HIV/AIDS is a major health crisis in Malawi. Ranil and Matt used to work in Malawi. Ranil and Matt both share a love for awful b-movies. Kevin bacon once starred in a film called Temors, about worm-like monsters called graboids which attack people from underground. Tremors is, of course, an allegory for climate change.

How would we more plausibly link HIV/AIDS and climate change in six degrees or less? HIV/AIDS is a major health crisis in Malawi. Ranil and Matt used to work in Malawi. Ranil and Matt both share a love for awful b-movies. Kevin Bacon once starred in the awful b-movie "Temors", about worm-like monsters called graboids which attack people from underground. Tremors is of course a rather deep allegory for climate change.

In an unabashed attempt to cash in on two advocacy areas at the same time, UNFPA has just released a report linking climate change to HIV/AIDS. Whenever the global development agenda is dominated by “hot” issues, agencies and think-tanks have a direct incentive to play six-degrees-of-Kevin-Bacon and tie their work in directly with one of those issues. Why? It provides justification for the work, and hopefully diverts resources to their given cause. What was the hot issue of the past eight years? HIV/AIDS. What’s the new hot issue? Climate change!

This isn’t the only reason why advocacy centred around hot topics is a bad idea: when single-button issues dominate the discourse, we’re much more likely to misallocate resources. When we should be talking about improving health and education systems, we end up parceling up these complex problems into impressive soundbites – HIV/AIDS, malaria, and universal primary education.

The problem is that money tends to collect around these simple soundbites instead of rather complex problems. This sets up an optimisation problem across the wrong parameters. Ideally, we should worry about optimally distributing funding across different systems in different countries (or, even better, just across governments), where those systems in turn have to optimise their allocations across problems within their sector.

Instead, as funding gravitates towards hot issues we find ourselves faced with an entirely different optimisation problem, one in which funding is allocated across countries within that sector. For example, the HIV/AIDs industry allocates more money to Malawi than Ethiopia, as Malawi’s HIV burden is higher. This would be a reasonable way of allocating resources only if the global funding for each issue was optimally allocated. But it’s not – it’s decided through desperate PR trench warfare between issues which leaves less popular ones out of the game.  Owen Barder accurately describes the situation in his fantastic new post about the dangers of global advocacy:

The development industry seems to be riddled with people whose main job is to divert money  to their good cause.   The advocates are united by a strong belief in the priority that should be given to their sector (education, water, AIDS etc). They convince themselves that they are speaking for real interests of the poor, which they consider to be unaccountably neglected by everyone else. Within many aid agencies there is a permanent state of low intensity bureaucratic warfare for resources, sucking up the time and attention of staff as they fight to defend and expand funding for the causes they work on.  They deliberately stoke up pressure in private alliances with civil society organisations – many of whom they fund – to raise the political stakes through conferences, international declarations, and publications with the aim of committing funders to spend a larger share of aid resources on their issue.  Territory is captured and held by way of international commitments in summit communiques.  But for the aid budget as a whole these are zero sum games, and everyone would be better off – and many lives would be saved – if it stopped.

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Sine qua non

menintights

Sorry, I couldn't resist

Cecilia Dugger’s recent article in the NYtimes highlights South Africa’s faltering efforts to fight HIV/AIDS through large-scale male circumcision. It’s a decent read, although Dugger’s angle is tangent to that of the current medical consensus: mass circumcision is an extremely cost-effective preventative intervention and should be pursued with zeal.

A quick primer for the unfamiliar: in 2005 a randomized trial in Uganda revealed compelling evidence that circumcision reduces a man’s chance of contracting aids by roughly 50%. A round of follow-up trials confirmed that, at least within the span of the trial, that circumcised men were better-protected. The WHO declared the intervention a worthwhile one, and with the past few years we’ve seen unprecedented levels of mass circumcision around the continent.

This is mostly fine and well – the intervention has been proved to be effective in the short term – I’ve always had a few concerns though (I’ll warn you that, as usual, I’m out of my depth here – this is why we need a health blogger!):

A recent study in the Lancet reported what many have suspected: male circumcision does absolutely nothing to prevent male-to-female transmission of HIV. Thus, while circumcision will obviously protect women indirectly by reducing the chances their spouse will contract HIV (at least, in the limited time span of the randomized trial), it will do nothing for them if their spouse ends up contracting the virus, or already has it.

This essentially means that the first line of defense against HIV remains the condom. Health of workers understand this, and so continue to push condom use alongside the circumcision. However I’ve seen little effort to estimate the long run behavioral effects of the intervention. The original Ugandan study determine that the intervention didn’t substantially chance behavior, but this was back when the intervention wasn’t known to be effective. Now since circumcision is known to be partially effective, many men may now decide to trade off some of that protection for extra pleasure. A good measure of the elasticity of promiscuity would go a long way (I never thought I’d ever write elasticity and promiscuity in the same sentence).

There are some troubling anecdotal signs that men may be using the circumcision as their only means of protection. This quote from Dugger’s article stands out:

Even without government involvement, demand for the surgery, performed free under local anesthetic, has surged over the last year here at the Orange Farm clinic.

When was the last time you read a story about excess demand for condoms in the South African press? These men are clearly not all going to go on using condoms – it’s actually quite likely that circumcision is acting as a substitute for condom use – men would rather take the snip and accept a little risk.

This isn’t necessarily the case, but we’ll never really know unless we start observing behavior in the long run (most of the medical trials are abandoned prematurely due to ethical reasons – when the intervention clearly works the health workers are compelled to offer the control t treatment). We need to be sure that (i) we aren’t creating perverse incentives and (ii) we aren’t crowding out condom use.