Local causation and implementation science

If you want to move a successful intervention from here (where it was first identified) to there (a plurality of new settings), spend your time understanding the context of the intervention. Understand the context of success. Implementation Science—the science of moving successful interventions from here to there—assumes a real (in the world effect) that can be generalised to new settings. In our latest (open access) article, recently published in Social Science and Medicine, we re-imagine that presumption.

As researchers and development specialists, we are taught to focus on causes as singular things: A causes B. Intervention A reduces infant mortality (B1), increases crop yields (B2), keeps girls in school longer (B3), or…. When we discover the new intervention that will improve the lives of the many, we naturally get excited. We want to implement it everywhere. And yet, the new intervention so often fails in new settings. It isn’t as effective as advertised and/or it’s more expensive. The intervention simply does not scale-up and potentially results in harm. Effort and resources are diverted from those things that already work better there to implement the new intervention, which showed so much promise in the original setting, here.

The intervention does not fail in new settings because the cause-effect never existed. It fails in new settings because causes are local. The effect that was observed here was not caused by A alone. The intervention was not a singular cause. A causes B within a context that allows the relationship between cause and effect to be manifest. The original research in which A was identified had social, economic, cultural, political, environmental, and physical properties. Some of those properties are required for the realisation of the cause-effect. This means that generalisation is really about re-engineeering context. We need to make sure the target settings have the the right contextual factors in place for the intervention to work. We are re-creating local contexts. The implementation problem is one of understanding the re-engineering that is required.

 

The cartographic challenge of decolonising global health

A navigational chart from the Marshall Islands, on display at the Berkeley Art Museum and Pacific Film Archive. It is made of wood, sennit fibre and cowrie shells. From the collection of the Phoebe A. Hearst Museum of Anthropology at the University of California, Berkeley. Date not known. Photo by Jim Heaphy. (Wikipedia; CC BY-SA 3.0)

There are a growing number of papers in the peer-reviewed literature about decolonising global health (see). Pascale Allotey and I have discussed the problem in terms of “trickle-down science” (also see). That is, the way (global health) science is done, how it is prioritised, and who is advantaged. It is a description of science generally conceived and managed from powerful institutions in the global north, with implementing partners in the global south, their factories for data collection. We have also critiqued critiques that advocate a utopic version of global health, arguing that:

decolonising global health extends beyond relations between [low- and middle-income countries] LMICs and [high-income countries] HICs; it is also about the relationships within them. Decolonisation is fundamentally about redressing inequity and power imbalance.

The latest offering on the altar of peer review is a three-step roadmap to the decolonisation of global health and a call to join the authors on their journey. Maps, however, are tricky things. They are culture-bound and themselves tools of colonisation. Their design, content, and what they highlight and ignore require a shared and agreed understanding of the path and the goal. Woe betide the European sailor trying to navigate using the Marshall Islands stick chart.

Much as I applaud the idea of redressing the power imbalance in global health, this particular attempt is tone-deaf. It is presented as if decolonisation was waiting for six authors from three of the world’s wealthiest countries to explain it to “the colonies”. Readers will forgive the irony that the first and last authors of the roadmap are at the London School of Hygiene and Tropical Medicine (LSHTM) — an institution established to support the colonial administration of the world’s greatest empire — an institution that, to this day, encourages and benefits from neocolonial relationships with the global south. The authors note these kinds of relationships and bravely forge on.

In developing the roadmap, the authors draw parallels with the feminist movement. An apt analogy (tongue firmly in cheek) because who cannot recall the importance to the feminist movement of first having men in power explain how it should be done? The men were so quick to relinquish their power that one barely remembers the days of gender inequality. Who does not know (tongue back behind teeth) that women of privilege often powered the first and second waves of feminism? The movement systematically failed to account for class differences, colour lines, and culture — leaving many women behind—the voice matters.

Who has the right to speak for whom in global health is a challenge. In a previous article, I wrote about this very issue. Fighting over the legitimacy of the voice is always fraught, and passions can run high. Are voices from some countries/institutions with this or that history as a colonial master or servant more or less valued than others? Is it more or less hypocritical to privilege voices from LSHTM, Johns Hopkins University, or the University of Washington over those from Makarere University, the Tata Institute of Social Sciences, or the Oswaldo Cruz Institute?

“Decolonising” is ultimately about forgoing power and transferring power. It is something that has to happen between countries and within countries. There is a cacophony of voices, all of which should be heard — but they are not equally important. They do not all warrant the same time and space. The authors of “the roadmap” are neither transferring nor forgoing power. As the cartographers, they determine the path, the points of interest, and the rest stops.

The roadmap for decolonising global health should not be determined nor led by countries and institutions simultaneously holding the whip and the chum.

#decolonising #decolonising #globalhealth.

With any piece I write about decolonising global health, I always have two competing voices in my head: “this issue is important, say it” and “should I be the one saying it?” I will declare my conflicts, and you can decide if you want to listen to or shoot the messenger. I am a white male born in (not by choice) the British Colony of Southern Rhodesia. In virtue of privilege and choice, I have lived and worked in Australia and the UK, and for the last 12 years, Malaysia and Bangladesh. My partner and I moved to Southeast Asia. Then I moved to South Asia because we were committed to capacity building and decided it was no longer appropriate to work in the global health space while sitting in a high-income country. I have never held appointments at LSHTM, Johns Hopkins University, or the University of Washington.

The original article was first published on medium.com on 26 March 2021. This version is very slightly edited.

Mr Grammarly writes a novel

Mr Grammarly, the Grammarly family parrot (a New Zealand Kea). Renowned for its literary abilities and loathing of the passive voice.

Grammarly is a web-based service to support writers. I use it a lot but worry that Grammarly will homogenise the literary voice until we all sound like the Grammarly family’s pet—a parrot named “Mr Grammarly”. 

Grammarly provides advice on correcting punctuation, word use, and reducing the use of the passive voice (a challenge for anyone taught academic writing before 2005). It can also score clarity, engagement, and tone of delivery.

I find it incredibly useful, and I recommend it to my graduate students and staff. When it works, it’s fabulous, and as a native English speaker, the probability of horrible failure is low. I am not obliged to take all of Grammarly’s suggestions, and I have enough of a sense of the language to know when I can break a rule or when Grammarly is wrong. Non-native English speakers may not have the same advantage and need to work harder to make those decisions. Is the suggestion for a change in word good or bad, is the rephrased sentence clearer?

I became so sick of reading poorly written student drafts with basic spelling and grammatical mistakes that I began telling my students if they had not checked the text against Grammarly, I was not interested in reading it. And then, I started to receive drafts with bizarre word choices and ill-phrased sentences. I ran the drafts through Grammarly, and they came through with no suggested corrections.

Lesson number one, use Grammarly but use it with care.

I still had had this nagging concern about the homogenisation of the voice, and I decided to test Grammarly against great literature. My guess (let’s call it a hypothesis) was that Grammarly would reduce poetry to blancmange. As a well trained dust-bowl empiricist, I decided to test it. 

I cut-and-pasted the first page of three novels into Grammarly.

F. Scott Fitzgerald‘s, The Great Gatsby received an overall score of 86. There were six hard to read sentences, one suggested rephrasing, and a handful of suggested corrections. The “hard to read sentences” were the most significant challenge because (in the absence of a suggested rephrasing) I needed to keep Fitzgerald’s voice but rewrite. It was easier than I anticipated. Most of the “hard to read sentences” are “hard to read” because they are long—a series of full-stop separable clauses that Fitzgerald separated with semicolons. Grammarly and I could get Fitzgerald up to an overall score of 99, and the literary world rejoiced.

Ernest Hemingway‘s, The Old Man and the Sea received a very creditable overall score of 92. I thought that his short, terse sentences would give him an edge over Fitzgerald, and I was right. His use of commas, however, needed work. By accepting every change and a minimal loss of poetry (those island boys needed to learn to speak better Grammarly English), I could bring Hemingway up to a perfect score.

Finally, I Grammarly checked Douglas Stuart‘s Shuggie Bain—Booker Prize-winning novel for 2020. Straight out of the gate, he had an overall score of 99. It was the phrase “leaving him with the thankless task of running his deli counter and her rotisserie stand all alone” that denied him a perfect score. I didn’t think I could do better—sorry, Mr Stuart. If only Fitzgerald and Hemingway had Grammarly!

Grammarly does have an in-built preference for a particular style of punctuation, the active voice, and short sentences. These three preferences make sense. Grammarly supports readability, and literature is not necessarily about readability. Ask James Joyce! Short sentences are cognitively more straightforward than are long sentences with embedded clauses. The active voice makes it more transparent who did what to whom. Consistent, rule-based punctuation also reduces the cognitive load.

Nonetheless, beyond the use of active sentences and a preference for short sentences, Grammarly is remarkably good at leaving the authorial voice untouched. That was lesson two. We were not all going to sound like the family parrot.

You will be pleased to know that this 666-word piece has a perfect score. I wrote it clearly, the delivery was “just right”, and you found it engaging. I hope the Man Booker Committee will appreciate my 2022 novel written in short, active, well-punctuated sentences.

Palliative care tradeoffs

Is life so precious that any number of painful, lonely, frightened deaths is acceptable to preserve one life?

As a child, I competed with my siblings to see who could hold their breath the longest. I remember the increasingly desperate need to draw a breath as time slowed in proportion to discomfort. The idea that units of time are constant is made absurd when you need to breathe and can’t. It is almost painful. Then there is the sweet, instant relief as you give up. The spent air is forced out, and a lungful of fresh air is gulped in. The whole thing is followed by raucous laughter and calls for another round.

Wouldn’t it be grand if people dying from COVID could just laugh it off as they draw the next sweet breath of air? Immediate salvation from death by hypoxia. Families around the world prayed for those easy breaths as they bundle loved ones into cars, tuk-tuks, and rickshaws in a desperate search for air—and care. On arrival at a hospital, staff had to make a quick decision. With limited resources, they had to choose who would be left to die.

I was told of one hospital where the “not to be treated” were seated in a circle with a single oxygen mask to share between them. They handed the mask from one to the other until, like the ten green bottles, one by one, they dropped out of the round. A colleague’s mother gasped her last breath seated in that circle. In other hospitals, the COVID patients died supine and alone on cots and floors tucked away from the urgent task of saving lives.

I have spent two nights of my adult life taking one careful breath at a time. Asthma. I very rarely have it, and when I do, it is environmentally triggered. On the last occasion, it was 11pm. We were six weeks into the pandemic, and I was alone in my flat in Dhaka. Breathing had become work. Tiring work. I remember skipping breaths because it was restful. Although I was worried, arriving with breathing difficulties at the A&E  of a panic-stricken hospital seemed a bad idea. With judicious and relatively frequent use of a salbutamol inhaler, the worst of it only lasted a handful of hours before I settled into modest discomfort and sleep.

It is a poor analogy, and I cannot really imagine the feeling of dying from COVID. It did get me thinking, however. What tradeoffs should be made to provide decent palliative care for those COVID patients who are dying?

The standard triage arrangement in hospitals prioritises patients according to the severity of the condition and treats the most severe cases first. If you are waiting to treated for a broken arm and someone is rushed in with myocardial infarction (MI). The MI wins, at least in terms of the immediate allocation of resources. And this will be true, even if the MI patient is highly unlikely to survive. No one dies because of the choice to treat the worst-off first. This is in sharp contrast to battlefield triage (or triage in humanitarian emergencies), where resources are severely limited. The choice to treat the most severe cases will condemn others, who have greater chances of survival, to a needless death. Battlefield triage will put some critical patients beyond care, focusing resources on lives that can be saved.

For many doctors, the COVID pandemic was their first experience of battlefield triage. At its worst, the situation meant there was not enough oxygen, ventilators, personal protective equipment, or staff.

Given two patients who will die without treatment and only enough resources to treat one patient, who should be treated? One patient is over 80 and has multiple co-morbidities; the other patient is under 30 and has no co-morbidities. The patient under 30 would win that lottery for (potentially) live-saving care.

But what of our over-80 patient (Sarah)? Does she warrant any resources? Does she deserve any clinical management and care even though her death is inevitable? Without any healthcare resources, she will die alone, distressed and in discomfort over the next 24 hours. If the situation is particularly dire—as it was during periods of the pandemic when patient waves crashed against the hospitals’ doors—even giving staff time to Sarah will endanger other lives that could be saved.

I am setting up a tradeoff. Tradeoffs have been used extensively to identify people’s preferences for different health states. The classic tradeoff is the time tradeoff (TTO). It is used in clinical research (and patient management) to identify preferences between the length of life and quality of life. The TTO might look something like this.

Imagine you have 10 years of life left with chronic obstructive pulmonary disease (COPD). You could trade those 10 years of life with COPD for fewer years of life in perfect health. How many years of life in perfect health would be equivalent to 10 years with COPD?

If you would not give up any years of life with COPD to live in perfect health, you are saying that you have no preference for a life with COPD over a life in perfect health. They are equivalent with respect to time. The example I give here is bare-bones. Numerous variations of the TTO have been developed to estimate preferences for different health states. Another tradeoff, the person tradeoff (PTO), was created to evaluate the severity of various disease states. The flavour of the PTO is given in the following, and I will stick with COPD for consistency.

Imagine you could choose (A) to extend the lives of 1,000 healthy people by one year, or you could choose (B) to extend the lives of N people with COPD by one year. How many lives of people with COPD would you need to extend for one year to choose B over A?

Suppose you would not tradeoff any lives (that is, 1,000 healthy people living for an extra year is equivalent to 1,000 people with COPD living for an additional year). In that case, you are saying (at least within the calculus of the PTO) that you have no preference for a life with COPD over life in perfect health.

These tradeoffs are all focused on the valuation of years of life. In the TTO it is explicit because you are changing the amount of time that a single life is lived. In the PTO, it is implicit. You are not asked to vary the time of a single life. You are nonetheless trading years of life: 1,000 person-years in perfect health is equivalent to how many person-years with COPD?

The tradeoff I am proposing for palliative care (explicitly terminal care) is somewhat different. In the TTO and the PTO, you are trading things of an equivalent nature—time or person-years. In the scenario of palliative care, you are trading things of different kinds (apples and oranges)—life against a comfortable death.

How many comfortable deaths need to be achieved to forsake a single life? The reality is that a comfortable death need not take a lot of resources away from saving lives, but it will need some. If reallocating resources results in one extra person dying, how many painful, lonely, frightened deaths would need to be made comfortable deaths to make that tradeoff acceptable? I would be prepared to lose lives that could otherwise be saved if it meant that many people whose lives could not be saved were given comfortable deaths. This view is not reflected in many government policies and I suspect that until the tradeoff is made explicit and data gathered, there will be no progress in fair resources for palliative care. It would also be good if voices from the global south were reflected in such considerations