The Academy in the time of Influenza: American medicine and the Great Pandemic

American medicine up until the twentieth century was an unmitigated disaster. Or so argues (quite convincingly) John Barry in his fascinating book, The Great Influenza: The Story of the Deadliest Pandemic in History. The first two sections of the book cover a brief history of American medicine and medical research, and I’ve only just gotten to the outbreak of the pandemic that killed between 20 and 50 million people, according to the best estimates. For comparison’s sake, WWI claimed 16 million lives, and AIDS an estimated 33 million.

Barry highlights a strong link between war and disease, namely, the emergence of epidemics or even pandemics. I’ll return to a discussion of this thesis when I’ve finished the book, but for now, what has been most striking is the utter catastrophe that was American medicine up until relatively recently. While scientists and physicians in Europe, including Robert Koch, Pierre Louis, Louis Pasteur, and John Snow were pioneers in epidemiology, germ theory, and more, the study of medicine in America was stagnant, suggesting the importance of healthy academic and scientific competition on the European continent.

Evidence of the United States’ relative backwardness is abundant. Charles Eliot, who became president of Harvard in 1869, wrote in his first report as president that, “The ignorance and general incompetency of the average graduate of the American medical Schools, at a time when he receives his degree which turns him loose upon the community, is something horrible to contemplate.” When Eliot proposed reforms within Harvard, including examinations (of all things), Professor of Surgery Henry Bigelow, had this to say:

Charles Eliot, Harvard President 1869-1909

“[Eliot] actually proposes to have written examinations for the degree of doctor of medicine. I had to tell him that he knew nothing of the quality of Harvard medical students. More than half of them can hardly write. Of course they can’t pass written examinations…No medical school has thought it proper to risk large existing classes and large receipts by introducing more rigorous standards.”

At the end of the 19th century, Barry reports that American universities had “nearly two hundred endowed chairs of theology and fewer than five in medicine…” showing where both the money and the power lay.  It was ultimately the initiative of a few individuals, combined with big money from illustrious families such as the Hopkins and Rockefellers, that turned the ship around.

The Great Influenza is an excellent read, and fodder for thought not only for those interested in medicine, epidemiology, and virology (guilty as charged), but also for those interested in the academy as an institution – how it evolves or stagnates, and the factors that generate innovation and massive leaps forward in our understanding of the world.

Scholarships and Fellowships for African Researchers in 2014

There are a number of scholarship and fellowship opportunities for African students and researchers with deadlines in early 2014. I’m compiling a list below (descriptions from respective websites); please feel free to send along others.

EASST 2014 Visiting Scholar Fellowship
What: “The EASST Visiting Scholar Fellowship seeks to equip East African social scientists with the skills needed to carry out rigorous evaluations of economic development programs. Researchers will be based at the University of California Berkeley during either the Fall or Spring semester, and will receive a living stipend, round-trip economy class air travel to Berkeley, CA, and the opportunity to receive a $8,000 research grant to promote impact evaluation at their home institution in East Africa. While at Berkeley, fellows will be able to audit courses, present research, attend seminars, develop curricula and design collaborative research projects.”

Deadline: March 16, 2014
Application portal here.

Washington Fellowship for Young African Leaders
What: “The Washington Fellowship for Young African Leaders is the new flagship program of President Obama’s Young African Leaders Initiative (YALI). President Obama launched YALI in 2010 to support young African leaders as they spur growth and prosperity, strengthen democratic governance, and enhance peace and security across Africa. The Washington Fellowship, which begins in 2014, will bring 500 young leaders to the United States each year for academic coursework and leadership training and will create unique opportunities in Africa for Fellows to put new skills to practical use in leading organizations, communities, and countries.”

Deadline: January 27, 2014
Application website here.

Harvard South Africa Fellowship Program
What: “The Harvard South Africa Fellowship Program (HSAFP) is intended for South Africans who in the past were educationally disadvantaged by law and resource allocation under apartheid. In 1979 Harvard University began awarding these fellowships for a year of study in one or more of its faculties or schools. Harvard funds these fellowships from its own resources. Over the years more than one hundred and forty fellowships have been awarded to South Africans.”

Deadline: March/April 2014 (exact date TBD)
Application website here (still undergoing updates for 2014).

APSA Africa Workshop 2014
What: “The American Political Science Association (APSA) and the Higher Institute of Public Administration (ISAP) are pleased to announce a call for applications from individuals who would like to participate in a workshop on ‘Distributive goods and distributive politics’ in Maputo, Mozambique. The two-week workshop will be held from June 30th to July 11th 2014 at the Higher Institute of Public Administration in Maputo, Mozambique. The organizers, with a grant from the Andrew W. Mellon Foundation, will cover all the costs of participation (including travel, lodging, meals, and materials) for up to 26 qualified applicants. This year’s workshop will be conducted in English.

The Africa Workshops program at the American Political Science Association (APSA) is an ongoing effort to expand the capacity of political science research and teaching in east and west Sub-Saharan Africa. With support from the Andrew W. Mellon Foundation, APSA is undertaking a multi-year program to organize a series of political science workshops throughout Africa and promote the profession of political science across the region. Each year, the program brings brings together approximately 30 scholars from across Africa and the United States for a 2-3 week seminar or short-course that focuses on a substantive theme of interest to political scientists. Driven by a unique syllabus featuring classic and cutting-edge research, each workshop program includes lectures, discussions, topical presentations and debates, guest speakers, peer review sessions, professional development seminars, and local field trips. Participants are required to arrive with and present their own current research, which they will then continue to refine for publication. Through these workshops, participants become an active part of the growing international political science community with increased access to supportive scholarly networks.”

Deadline: March 14, 2014
Online application form here.

MSc in African Studies, University of Oxford
What: “The MSc in African Studies is a three-term, nine-month course designed both as a stand-alone interdisciplinary introduction to current debates about Africa, and as a preparation for doctoral research on Africa. This advanced degree programme provides an excellent foundation for those who wish to expand their knowledge of African Studies, prior to working for NGOs, the civil service, international organizations, and the media, or in other professional capacities.”

“The African Studies Centre is offering full scholarships for the MSc in African Studies for the 2014-2015 academic year.”

Deadlines: January 24, 2014, and March 14, 2014
Admissions website here, scholarships website here.

African Women Public Service Fellows
What: “Wagner announces a call for applications for the African Women Public Service Fellowship, a fellowship program made possible by a donation from the Oprah Winfrey Foundation, which expands the opportunity for African women to prepare for public service in their home countries. As fellows at NYU Wagner, African women study in one of two graduate programs: the two-year Master of Public Administration or the one-year Executive MPA: Concentration on International Public Service Organizations. The awards for either program will support tuition, housing, travel to and from the United States and a small stipend to cover books and miscellaneous expenses. Applicants commit to return to their respective home countries at the conclusion of the program with the goal of assuming a leadership position on the continent where they can meaningfully contribute to the challenges currently confronting Africa.”

Deadline: varies, see application timetable.
Application website here.

Carnegie African Diaspora Fellows Program
What: “The Carnegie African Diaspora Fellows Program (ADF) is a scholar exchange program, offered by IIE in partnership with Quinnipiac University (QU) and funded by a two-year grant from Carnegie Corporation of New York (CCNY). ADF will support 100 short-term faculty exchange fellowships for African-born academics. The program exemplifies CCNY’s enduring commitment to higher education in Africa. IIE will manage and administer the program, including applications, project requests and fellowships. QU will provide strategic direction through Dr. Paul Tiyambe Zeleza and an Advisory Council he will chair.”

Deadline: TBD
Learn how to apply.

Quantitative Methods Training at U-M African Social Research Initiative
What: “The African Social Research Initiative (ASRI) at the University of Michigan seeks applications for up to four visiting scholars to attend courses in social science research methods and analysis at the University of Michigan during the months of June-August 2014. The program is open to academic researchers who are enrolled in or have completed PhD programs in the social sciences and who are from, or reside in, one or more of the following countries: GhanaKenyaLiberiaSouth Africa, and Uganda.
During their time in Ann Arbor, visiting scholars will attend courses offered by two internationally renowned summer training programs at the University of Michigan’s Institute for Social Research (ISR). Applicants who are invited to attend the summer programs may select several options from amongst the four- or eight-week sessions offered.”

Deadline: February 14, 2014
Application details here.

Update: Rachel Strohm has a similar post, Fellowships for African Students.

Endangered books

IMG_2094
Jinja archives, Jinja, Uganda (2013)

My research of late has explored the responses of Muslim elites and communities to the arrival of missionaries and colonial administrators across Uganda. Sources primarily comprise of missionary accounts, official documents of the colonial administration, manuscripts and books by Ugandan intellectuals and scholars, and work by non-Ugandan anthropologists, most of whom were most active between the 1960s and 1980s.

The best and most detailed accounts tend to be authored by Ugandans, often those who played active roles in shaping the course of the country’s history. Unfortunately, these works are also the most difficult to find. Makerere University Libraries are perhaps the best resource, but you must have university affiliation to use the libraries and you cannot check out or, understandably, copy the books. Thus, many of Uganda’s most precious historical works are quietly locked away from the public.

I’ve identified a class of what I will call “endangered books”. These are books (or theses, etc.) that are now out of print or have never been published, and are virtually impossible to access or acquire without affiliation to a university with a very good library. Many of the authors have passed on, and are not able to lobby for the protection of their hard work. I don’t imagine there is a huge market for many of these books, yet unless steps are taken to republish them, a fire or two is capable of wiping out their existence.

I’m keeping a running list of these works below as I come across them. Hopefully I can convince a publisher to take interest in making sure these treasures do not fall victim to the decay currently facing many archives across Africa (see Jinja archives above). Please feel free to submit your own.

Endangered books:

UGANDA

Y.K. Lubogo. 1960. The History of Busoga. Jinja, Uganda: East Africa Literature Bureau.
Dan Mudoola. 1974. Chiefs and Political Action, The Case of Busoga: 1900-1968. PhD thesis, Makerere University

NIGERIA

Wahab Oladejo Adigun Nasiru. 1977. Islamic Learning Among the Yoruba, 1896-1963. PhD Thesis in the department of Arabic and Islamic Studies, University of Ibadan

Health information leads to…cheating!

Well, this is disappointing. A recent study in Uganda supported by Google and the Grameen Foundation, and implemented by Innovations for Poverty Action, has found a way to…increase infidelity.

When provided with information about sexually transmitted diseases via text messaging, cheating among participants more than doubled. Why?

Although the study and its findings have yet to be published, Bloomberg reports:

With the program in Uganda, which began in 2009, infidelity may have risen as women became more aware of the risks of cheating and insisted on going for testing with their husbands, said study author Dean Karlan, an economics professor at Yale University in New Haven, Connecticut. Some men resisted, leading women to deny them sex, which the men then sought from other women, Karlan said.

Basically, it appears that women wanted safer sex, while many men did not.

At first, this struck me as a classic case of unintended consequences, of good intentions paving the proverbial road to hell. However, having finished tearing my hair out (actually, gunning it through Ntinda wondering, what is wrong with these men?!), I realized we have actually learned something important despite the perverse effects of this intervention. Two things, actually. 1) men and women have different preferences regarding safe sex, and 2) women are willing and able to stand up for and protect themselves, at least in Uganda.

Now we need to understand why, faced with the same information as women, men made choices that did not improve their health and did not reduce their risk of contracting a sexually transmitted disease. We also need to find ways to support women to protect themselves and their families.

Looking forward to reading the paper; will update accordingly.

UPDATE: Ungated version of the working paper available here.

Your life as an experiment

Experiments are all the rage in the social sciences these days, or maybe I should say, in American political science and economics. Researchers are constantly on the lookout for opportunities to implement a randomized controlled trial (RCT), the goal being the identification of a causal effect of some treatment on some outcome — say, information about politicians’ behavior (like whether they show up to work) on voters’ perceptions, beliefs, and behavior (like whether they will support a politician in the future). The Poverty Action Lab has a nice summary of the goal and process of randomization here.

I recently learned that Steve Levitt of the blog Freakonomics, together with John List (both of the University of Chicago), are now recruiting you to be part of a study. Yes, you!

Sometimes in life you face a major decision, and you just don’t know what to do. You’ve considered the issue from every angle. But no matter how you look at it, no decision seems to be the right decision. In the end, whatever you choose will essentially be a flip of a coin. Help us by letting Freakonomics Experiments flip that coin for you.

You get to choose your decision (Should I join a gym? Should I get a roommate?) and then follow whatever decision the virtual coin makes (overview here).

I’m very interested to see where this goes, although I also wonder about selection effects. Randomization will still work (thus internal validity), but external validity (generalizability) may be limited. For example, after looking through the questions (of which very few applied to me) I decided I couldn’t commit to whatever decision was made by the coin. I find sometimes a coin flip helps clarify my position on something, but often because I realize the outcome of the coin leaves me with a bad taste in my mouth, leading me to choose the opposite. I wonder what types of people are actually able to commit to random assignment of an important choice in their lives (separation from a spouse? Yikes! Hope they don’t realize it was part of an experiment!).

If you are not a wishy washy type like me, try it out. Gezako!

2012 SFAS conference, “Mobile Africa”

This year’s annual conference of the Stanford Forum for African Studies will be held October 26-27, 2012 at the Stanford Humanities Center. All are invited to attend. Guest speakers include Francis Nyamnjoh (University of Cape Town) and Senegalese writer Boubacar Boris Diop, best known for his book, Murambi.

The full conference program can be found on the SFAS website.

Does women’s empowerment promote economic development?

Conventional wisdom and a number of recent papers say yes, but Matthias Doepke and Michèle Tertilt have a paper out that suggests we think twice about this relationship:

“In this paper, we examine the link between female empowerment and economic development from the perspective of economic theories of household decision making. We develop models that are consistent with the empirical observation that an increase in female resources leads to more spending on children. We use these models to address two related questions. First, we focus specifically on programs that target transfers to women and aim to raise female income, and ask whether such policies really make children better off. Second, we consider a wider range of policies, and ask whether alternative forms of female empowerment have similar effects.
While at first sight it may seem that existing empirical evidence is sufficient to answer these questions, our theoretical analysis shows that this is not the case. We demonstrate that the link from the observed empirical patterns to policy implications is far from obvious: the effects of policy interventions are highly sensitive to the details of the underlying economic model, unintended consequences can arise, and different forms of female empowerment can have opposite effects.”

Full paper available here.

In related news, happy Women’s History Month! International Women’s Day 2012 is this Thursday, March 8. More on this soon.

Name your price: it’s your life

Published online January 25, 2012.

Why small increases in price can lead to a steep decline in demand for essential products

A piece of nylon netting is a useful thing. It can be cast as a fishing net, hung as a curtain, or draped over a seedbed as protective covering. Netting can make a stunningly white wedding dress, or even a make-shift chicken coop.

One can also sleep under it, of course, to keep mosquitos from biting at night. Though insecticide treated nets (ITNs) are routinely distributed in malaria endemic regions, often subsidized by major donors such as the Global Fund, many worry that such campaigns are frequently futile. Anecdotal evidence from the Kenyan shores of Lake Victoria to the alters of Ugandan churches suggest that these bednets are sometimes quite literally cast aside or otherwise misused.

While misuse is certainly problematic from the perspective of those funding mosquito net campaigns, it also raises a broader question, and one with serious implications for public policy in malaria prevention and beyond: Do people value and use things that are given to them for free?

There are two competing arguments used to answer this question. The first argument says that people value more that on which they spend their own money or resources. Furthermore, people will spend some money, when they can afford it, on those objects that they perceive to be useful. A second argument says that if an object is perceived to be useful or of value, people will use that object regardless of whether they purchased it or whether it was given to them for free. The ubiquity of incumbent presidents’ campaign t-shirts in both opposition and stronghold areas is supporting evidence for those in the latter camp.

The mosquito net-cum-wedding dress is a classic illustration of the dilemma of freebies. The protective power of mosquito nets against mosquito bites and thus, malaria, is rather less effective when the net becomes a nuptial adornment or is tossed into a river, much less left in its packaging and stashed in a corner. The creative use of nets is thus often the go-to anecdote for those in the first camp of the freebie question.

Anecdotal evidence, unfortunately, can only get us so far in adjudicating between these two perspectives. Fortunately, a number of development economists have been systematically evaluating the extent to which people use services or tools given to them for free and those provided at a cost. While there is still no definitive answer, and while context matters, much of the evidence seems to suggest that people use many free goods at high rates, and often will not purchase the same products when provided even at very low prices.

A group of researchers at the Abdul Latif Jameel Poverty Action Lab, based at the Massachusetts Institute for Technology (MIT), recently wrote a report summarizing ten studies examining the question of whether user fees and cost-sharing increase or decrease the use of health and education services and products. The majority of the studies were conducted in Kenya, although some were also conducted in Uganda, Zambia, and India. Their findings are striking, and the title of the report says it all: “The price is wrong.”

Time and again, small increases in price lead to a massive decline in demand for products including water disinfectant, deworming medicine, mosquito nets, and soap. For example, one study in Kenya found that while over 80% of people used a mosquito net if they received it for free in a prenatal clinic, only 20% would purchase the net for $.60 (approximately 50 Kenyan shillings or 360 Rwanda Francs). Similarly, another study in Kenya found that while nearly 60% of people used water disinfectant when it was given to them for free, less than 10% would use disinfectant if charged $.30 for the same product. This general pattern appears to repeat itself in different locations and with different products.

Two things are thus evident. First, people are often unwilling to purchase a number of goods and services that promote health and education even at highly subsidized rates. Second, people often use those same goods and services at high rates if they are provided for free. Clearly, receiving something for free does not preclude its use. If we think back to the wedding veil problem however, it is also clear that some products may not be used as prescribed, fee or no fee.

Why are people so sensitive to price when it comes to potentially life-saving goods and services? Individuals and families weigh the costs, monetary or otherwise, of procuring and using goods and services against the expected benefits from using those goods. Bednet wedding veils notwithstanding, in most cases it appears that families perceive some benefit from using goods like mosquito nets and soap, since rates of usage are quite high when the product is free. Some speculate that people may not physically have the cash on hand to buy even very inexpensive products, or that other inconveniences, such as the time it takes to procure a product, may affect their decision. But these are only partial explanations. It is also possible that people do not believe products will be as efficacious as researchers and policymakers think they will be in promoting their health.

Available evidence suggests that people who receive goods and services for free often do use them, although the extent to which they will use them and how they will use them is subject to some debate. Even if there are large benefits to providing free bednets, water disinfectant, soap and the like, products that often provide benefits that extend beyond the individual recipient, the question of sustainability comes to the fore. In the short term, the provision of free goods and services, particularly those that promote preventive health behaviors (like hand-washing) may have large and positive effects on the health of families and communities. But ultimately, we need to better understand why people are often so unwilling to spend even small amounts on products that have the potential to keep their families much healthier.

Explaining health behavior

Pascaline Dupas has an excellent paper in the Annual Review of Economics: Health Behavior in Developing Countries. It’s well worth reading. Conclusion below:

Good health is both an input into one’s ability to generate income and an end in itself. As such, it is not surprising that a relatively vast literature is devoted to understanding the determinants of health behaviors. This literature has recently expanded to the study of health behaviors in low-income settings, for which good data are becoming increasingly available. This review is too short to be exhaustive, but it tries to present the most compelling evidence to date on this issue. The important thing to take away from this review is that when it comes to health behavior in developing countries, there are a substantial number of deviations from the neoclassical model. First of all, people seem to lack basic information, and sometimes have limited ability to process information, because of low education levels. Second, there are market imperfections and frictions, especially credit constraints, affecting people’s ability to invest in health. Finally, there seem to be some deviations from the rational model, with, as has been widely shown in developed countries, a nontrivial share of people exhibiting time-inconsistent preferences as well as myopia.
Overall, this suggests an important role for public policy when it comes to health. Above we identify four important demand-side policy tools: information, mandates, price subsidies, and financial incentives. All appear to have the potential to increase the sustained adoption of preventive behavior. But the success of these demand-side strategies is contingent on the supply side being adequate: on health services and products being available, with delivery and/or enforcement institutions that are effective. The issue of how to improve service delivery in health is outside the scope of this review, but it has been the focus of a number of recent and ongoing studies that will soon need a review of their own.