22 Bones in the Skull

Courtesy of the National Museum of Natural History
I actually took this photo last weekend, but I was reminded of it today when I went back to the NMNH for the Thelonius Monk International Jazz Competition

Zooironic

The Natural History Museum has an exhibit, the Orkin Insect Zoo, sponsored by Orkin Pest Control... hilarious!

This is the Hope Diamond out of its setting showing its brilliant 45 carats through 74 facets. This is the first time it has been on public display out of its setting.

Graffiti commissioned outside of my home.

How Capitalism is Attacking Postal Workers

I sadly did not catch what I suspect was an enthralling conversation about capitalism's misdeeds

Sunshine

I've been neglecting the blog for no reason. I have so much to talk about but I hardly ever make the effort to sit down and write.

As everyone who reads this blog should know I took the LSAT last weekend. I think it went well, but I'll be sure to notify everyone if it in fact it did go well.

With LSAT out of the way (fingers crossed) I have been thinking more and more about the personal statements I have to write for the law school application process. While I do 'have to', part of me is looking forward to it. As I look back upon the academic, and extracurricular pursuits [sic] I don't have a clear understanding of what they mean to my life. I can recall undertaking them to better myself, but I haven't assessed my progress. I don't know how I have changed, what I have gained, and if I have become a better person because of it.

In the most abstract sense I don't have a sense of my own identity. It's as if I am defining my personality, my identity. I'm excited and anxious about reflecting and articulating why the experiences in my life matter, and how they shaped me into the person X law school would want representing them.

This is the first weekend in months I haven't spent half the day taking an LSAT. I took full advantage of it by walking Eastern Market on Saturday morning. For those that have been to Pike's Market, I would say Eastern Market is much the same; an array of vendors, fresh fruit, vegetables, and herbs, with a few places offering fresh fish, meat, sausages, cheeses, and pasta (I really want to try to the pumpkin ravioli).
(Walking through a park near my home on the way to Eastern Market)

Andrew, my roommate, had a friend in town and invited me to go with them to Crafty Bastards. Crafty Bastards is a community event in Adam's Morgan with numerous hippy crafts (e.g. climbing belts adorned with decorations, specialty belts with bike lock holders) and 'indie' T-shirts. I briskly walked through the event and jut as quickly the festival lost its aura. I turned to walk out when people climbing a fence caught my eye. I knew I had to justify my decision for coming to Crafty Bastards so I spent 5 extra seconds to peer over the fence and beyond crowd to see what the commotion was about.

2 hours later I walked away from witnessing my first live b-boy/girl spectacle. Most of these kids were in high school, and some weren't that great, but others were not only great but inspiring. One of the b-boys aptly named 'half-step'. Half-step had a prosthetic leg and could break with or without his leg. He also made it to the third of five rounds by performing a handstand spin (half step did not complete nearly as many rotations).

Geocache

Geocaching- A worldwide game using GPS technology to find hidden caches.

GPS technology was first made available after a S. Korean aircraft, Korean Air Lines Flight 007, strayed into Russian airspace and was subsequently shot down. To prevent future occurrences President Ronald Reagan issued a directive making GPS freely available for civilian use.

To maintain the military advantage Reagan decided to limit the accuracy of commercial units to 300 yards of the coordinates. This was known as selective availability. In 1996, Bill Clinton recognized the importance of GPS to civilian users and issued a policy directive declaring GPS to be a dual-use system. In 2000 GPS units became accurate to within 60 feet.

Geocaching began in early 2000 by an Oregonian named Dave Ulmer. Within 3 days two people had used the GPS coordinates Dave provided on sci.geo.satellite-nav to find the cache Dave had hidden. The original stash was found in a black plastic bucket containing software, videos, books, food, money, and a slingshot. The idea was that the lucky geocacher who found the stash could take an item, and leave an item of equal or greater value.

Thus the age of geocaching was born. Today geocachers hide their caches in forest, fields, cities, and neighborhoods. Then the geocacher posts the coordinates online and waits for someone to find the cache. Usually the cache has a log book so people know who has found the cache, what they took and what they left. To play you simply have to have a GPS unit.

After you play a few times you can begin playing different types of geocaching games.
A unique ideas:

1. Project A.P.E. Cache
In 2001, twelve geocaches were placed in conjunction with 20th Century Fox to support the movie Planet of the Apes. Each cache represented a fictional story in which scientists revealed an Alternative Primate Evolution. These caches were made using specially marked ammo containers. Each cache had an original prop from the movie. Only a few Project A.P.E. caches exist today.

Climate Change Threatens Global Health

“Human society faces a global health catastrophe if climate change is not effectively tackled at the UN conference in Copenhagen in December,” a Lancet and University College London study warns.

The study released earlier this year predicts that increased temperatures caused by green house gasses will increase the incidences of tropical diseases like malaria, and dengue fever, causing health crisis in half a dozen areas.

For diseases like dengue there are no specific medical treatments. Of the 350 million people infected with malaria each year, over a million die. Right now we have the potential to limit the future suffering caused by what the authors call "the biggest global health threat of the 21st century." But to develop effective treatments for use later, we must invest in researching those diseases that disproportionately affect the poorest segments of our population now.

The lead author of the report, Professor Anthony Costello, Director of UCL's Institute for Global Health, said: "The big message of this report is that climate change is a health issue affecting billions of people. The impacts will be felt not just in the UK, but all around the world – and not just in some distant future but in our lifetimes and those of our children."

Professor Ian Gilmore, the president of the Royal College of Physicians, explains the current challenges: "There is a real danger that politicians will be indecisive, especially in such turbulent economic times as these. Should their response be weak, the results for international health could be catastrophic."

To avert the impending global health crisis doctors, researchers, and concerned citizens of the world must appeal to their political leaders to prioritize investment in research now.

I haven't read this since I wrote it.

This is part of an outline I typed while at the global health event on women's empowerment and gender equality.

I. Jeffrey L. Sturchio, Global Health Council

· Child mortality was less than 9 million in 2008, the lowest since they began tracking child mortality rates

· We will be focusing on women and girls, and the health issues around maternal health

o How do we maintain the focus on maternal health during the economic crisis?

· We intended the structure of speakers to maximize discussion, so please feel free to participate

II. Session 1: Women and Girls: Will we meet MDG’s 3,4, and 5?

· Tom Quinn, Center for Global Health, JHU

o Special thanks to Jeff Sturchio who was instrumental in bringing this together and representing the GHC.

o Thanks to global health and the foreign policy initiative.

o Tom Quinn directs the center for global health, and just finished a 3 day meeting at NIH where he heard from the new director of the NIH, Zeke Emanuel who is special advisor to Obama, and the OMB, and lastly from ambassador Goosby who replaced Mark Dybul. The three of them representing the US commitment to global health were unanimous in their efforts to broaden their landscape. Moving from emergency situation to a more horizontal plane to help health internationally and globally. And it is separate from the domestic process going on a couple blocks from here

o Let’s start with women and girls. Will we meet MDG 3, 4, and 5?

o Lynn Freedman, Columbia University will give a presentation and then Mark Dybul and Ruth Levine will chime in to discuss

· Lynn Freedman, Columbia University

o Thanks JHU for keeping the discussion going, b/c it is critical for GH and MDGs 3,4, and 5

o It is no secret that we are desperately off track for meeting the MDGs. I’ll address these and MDG 5.

o Let’s refrain answering the question can we meet the MDG, instead let’s talk about what we can do to jump start progress, to increase the speed of progress on these MDGs.

o Dr. Freedman’s focus is going to be much more 4 and 5, while linking to MDG 3( which is women’s empowerment, and education, and instead focus on the links to health)

o In her view right now the biggest obstacle to progress for GH, especially maternal health and child health is what she sees is a huge disconnect, what we talk about write about, and think about at the global level and then what countries are struggling with on the ground at the local level. Where the subjects of MDG 4 and 5 live and die

§ At the global level, we (the maternal health community) have intense focus on the ‘right’ packages of effective interventions. We have spent huge amounts of time identifying packages, and estimating their coverage, modeling how coverage and costs will reduce mortality, we focus on roadmaps. How do we reduce everything to few key messages for politicians and lead to funding. Nothing wrong with reducing things to key messages and we need to do it.

§ But at the local level on the ground people are struggling with stock outs of drugs, absenteeism, demoralizing health workforces. Systems that are sometimes abusive, that can neglect and impoverish people.

§ While there are islands of excellence, dedicated people in those systems, and we need to do a better job of using their success. But health systems are not functioning for those people that need them the most.

§ It’s not just that they aren’t being treated, but marginalization of the health system has become part of what it means to be poor in the world today. It goes beyond the biology of illness. Dr. Freedman thinks our field has engaged in marginal thinking. We think if we have some interventions and we have some money that that formula will lead to functioning health systems.

§ To meet the MDG we need a massive shift in energy, in collaboration, and surely in funding to the challenge of implementation.

§ Not any implementation: she has heard about results based financing, more than once she has heard people in high positions saying they care about the outcomes, and that they don’t care about the system. While she surely agree that saving lives is what this about. She would also argue that it is very much about a responsive well-functioning health system defined broadly, what happens in community, and other sectors devoted to health. That health system actually plays a crucial role in the building of a democratic society in poverty reduction.

§ We can see that if we view health as a social institution, like education and justice, it isn’t just a mechanical system, it is social. The structure of power that mediates access and distribution to resources all play out to a health system. As is true of gender. A huge system of power dynamics, the subject of MDG 3 is gender equality, and women’s empowerment. These play out through the health system. If we understand the health system as a social institution. Then it has the potential not just to marginalize or excluding people it can be a force for good. If citizens engage with that system, and exercise entitlements they are exercising rights and it becomes an asset of citizenship. When it comes to implementation we need to have a moral compass, the field of HR provides such a possibility, for a moral compass. Not only the legal obligations, but also the principles and values which can help us build a system that could build a practice of dignity, which would include a right to health and gender equality.

§ Ok, she works at a program in Columbia that focuses on how to get things done on the ground. But you can’t just have a beautiful talk about HR, so her mantra is that we have to have a bifocal vision. We need a big picture, but have to figure out how to deal with operational problems. She said bifocal, but then says she should be saying progressive lenses, b/c these pieces interact. Gender equality, and social determinants of health play out in the micro-politics of the system.

§ We see these in issues of street level bureaucrats. You could have the greatest program, but the people on the ground have the capacity, and often times the will to destroy the program.

§ So we need to build a program that pays attention to big picture and the interaction of concrete problems.

§ This will take a fundamental shift in the mental models that we have been using to address global health.

§ When it comes to implementation we engage in magical thinking. Usually it’s a black box and in a sense muddled to us who aren’t their on the ground everyday.

o Briefly, the big confusion we have in this field is that we fail to see interventions (clinical treatments) and implementation drivers (organizational issues that have to be resolved to implement, like incentives for workers) we often mix these things up. We need the ‘right’ interventions that meet the primary causes of death, and we also need effective implementation drivers. One does not magically flow from one to another.

o In the field of maternal and child health-she states that we have a pretty good consensus about what is the most effective interventions (She thinks it is home to hospital continuation of access. Epidemiologically speaking the moment of child birth is the most critical moment) Also consensus around family planning, and reproductive rights and health, and the implications that will have for health and development.

o But we have spent a huge amount of energy on defining these effective packages. This is our comfort zone. When the package doesn’t work we try to redefine the package of interventions. The way we make determinants about effectiveness is our comfort zone, but we don’t look at the implementation drivers which is separate and distinct. But we need to give different attention to implementation drivers.

o There are three different categorizations of implementation

§ Paper implementation putting policies into place in the law

ú When businesses are being monitored from the outside on paper implementation business literature says 80-90% of people in business actually stop at this stage. If they have a piece of paper that says the completed ‘x’ change that is enough to get by.

§ Process implementation- i.e. training in the field, new data collection techniques, checklists for treatment. This is a big part of the maternal and child health care (MCHC).

§ Performance implementation-Here we are making reference to the functional components that are actually used to deliver the goods. We almost always stop before we reach this performance implementation in MCHC.

§ The capacity to guide implementation is at the intersection of how we think about technical assistance, capacity development, and community engagement (process of trying to establish accountability mechanisms for the people who use them)

o We fail to acknowledge the different kinds of problems in GH, and that they require different kinds of solutions. (if Dr. Freedman had ppt here she would have shown us stolen slides from the overseas development institute, which gave a nice example between the different kinds of problems. They slides illustrate the differences between different kinds of problems using a simple puzzle, a rocket, and raising a child.

§ A simple puzzle is something like a difficult recipe. It is composed of a number of parts by has been replicated over and over. It tells you what you need and you get basically the same result every time. So something like baking bread.

§ Then there’s a complicated problem like sending a rocket to the moon. Its complicated, and requires a high expertise, but rockets behave in similar ways. If you get a rocket to the moon, you can probably send another.

§ Last, there is a complex mess or problem. In this arena formulas only have limited application, for example raising a child. There’s no guarantee that if you have success raising your first child that you will have success with the second child. The key is the relationships. It is not like sending a rocket to the moon. You cannot solve the component problems and then assemble the parts to form a rocket. Rather it is the relationship you build with the child. Every child is unique, just like the complex problems in health systems. We need to see health systems as complex adaptive systems. Stop using mental model of a machine; instead we need to use the model of complex adaptive systems. In the global field we have been allergic to the word complex, because we have failed to find scalable replicable ways to deal with health systems. But we have failed b/c we don’t look at the problem in the right way. We don’t grapple wit the complexity of the mess.

§ Dr. Freedman argues that if we shift the mental model, to thinking of health systems (as complex adaptive systems) not just machine parts, but thinking of the pieces as agents, people with the power to make decisions. When they do things like a health worker, a user, a manager they make decisions and it affects the environment and the environment adapts to what different people do.

§ This means causality is not linear; it’s really a feedback loop. It’s understanding what we do that affects everyone else in the system. It is fundamentally about relationships. The focus on the relationships not just the mechanical pieces. She argues that in a way the interventions we need to put in are relatively simple, but the implementation is important

§ Implications-

ú We need to build a new practice of implementation. In technical assistance and capacity development. She doesn’t think just setting the right set of outcomes will lead to results.

ú There is a new journal called implementation science, and we’re at the beginning, but we have a huge amount to learn from the business field. Coca-cola could get there, why can’t we?

ú We need new kinds of research partnerships, respect with field based partners. That’s the knowledge we need for implementation, it complements epidemiology

ú Need a different level of investment in accountability. The investments to women’s movements (things like transparency of information, budgets) empowering women’s movements and other civil society to confront these structures of power, are the big barrier of implementation. That means giving up some of the control.

§ We need to get real politically. How to move political systems to do this kind of transformation. I recognize that giving a lecture won’t do this. But ignoring it won’t work either. At political level there is an undeniable and insatiable desire for quick wins. But we need to think how we’re defining quick and what constitutes a win. Is it something you can count fast and celebrate you met the numbers> or is it the small change in adaptive system that can lead to a big result? If some of the things people are thinking about are safe child birth kits, the difference between a commodity, and a check list. I think I look to the checklist.

§ Most of all we need to commit to a shared vision of health system as social institutions. The fundamental issue of substantive, procedural, and distributive justice.

· Mark Dybul, Georgetown University

o Mark says he agreed with everything Lynn said.

o he picks up on the theme about how we talk about delivery of services, but also the structure that prevent us from delivering those services.

o When talking about health related MDGs, 6 is very important, there are health component in 1 (nutrition) and 7(water) as well. we have to focus on all of the health related to MDGs, although he is a little hesitant to talk about MCHC b/c it gets into aid loop. 20 years ago we talked about food, and 10 years ago it was MCHC, now it is back to food scarcity.

o Advocacy cannot get out in front of implementation, because when you can’t deliver people go and look to other things to support. This is how you get into aid cycles.

o Very easy to make the case that MCHC as central to health MDGs

o Dr. Dybul begins by emphasizing the point Lynn made, it’s our development structures that prevent reaching health MDGs. If you go to village and ask whether CDC, USAID, or an ngo are giving them their HC, or whether HIV should be separated from nutrition they will tell you they don’t care. But that is not only how we talk about it, but also how we implement it. PEPFAR was by far the most integrated. But we still do not have integrated development programs.

§ In PEPFAR we pooled our budget, we pooled HIV resources, food, education, women’s violence, gender equality and for the first time we had reporting of services on the delivery of women’s services. These approaches to pool funding were extraordinarily difficult. And trying to pool malaria, TB, and tropical diseases was really difficult. Our structure does not allow for this type of integration.

o Next step for Pepfar was partnership frameworks. The US government chose to commit to 5-10 years and see how HIV fit into development, gender, inheritance rights, how AIDS money fit into development, who else was in the space, how the government over time would take ownership, and how we would later only provide technical assistance. We’re also fortunate that Secretary Clinton believes in this.

§ In our current structures progress will be pulled back by politicians reverting to the old structure. Mechanistically we need to break out of that. We need to expand global fund for health MDGs so they can create their programs with 1 funding stream. But it will be very difficult in our existing structures.

o Let’s talk about quick wins

§ Maternal and neonatal health is the starting point for building health systems in a way that makes sense. Global health agents have very few cuts at people in the health system in developing world. But giving birth is predictable, if we take advantage of that moment well, then we can build trust and a health system.

§ There is a tendency in development that you cannot do anything unless you do everything which often leads to doing nothing. We can begin at the HC pyramid, as others are working on high level interventions. We can do clinics, facility based, that do 1-50 deliveries a day out in the community, and the levels beneath them. W/e the country does let’s just work within their laws and adapt to their community.

§ Look to MDGs 3,4,5, and 6, and health related aspects of 1 and 7 and you can do a series of interventions that we know work, and use that as your starting point. Train people to implement those checklists then provide kits to support them. If you start combining workers, checklist, kits and link them then you can start to get some quick wins.

§ We should also try to use existing structures, PMI, PEPFAR to try and use a new mechanism to implement

o Then talk about the structure

§ Talk about HR, outrage to advocacy to action

· Ruth Levine, Center for Global Development

o Dr. Levine basically wants to reinforce, with a slightly different perspective. When you recognize when women’s health is at the core of virtually everything that we care about in GH and global development broadly defined it is a really powerful moment to talk about how progress can be made.

o We need to face the facts that we’re dealing with a complex world.

o To genuinely make progress towards MDGs we need to build intellectual and conceptual and practical bridges.

§ Biomedical and epidemiological thinking of health conditions and solutions, or interventions.

§ The other bridge is how we think of the social determinants of health. Issues that Lynn was raising, economic, political empowerment. There cannot be just three camps, one that thinks about social justice issues the other that thinks about the academic setting, and the other about clinical interventions. The implications of building bridges in the practical sense is that we really try to engage outside of the health sector as it is currently defined with the education sector (as strong advocates for education as we are for health) to influence community norms about gender roles. To support work on social justice. Sometimes this will happens in courts, but we can also really push for government leadership nationally, and internationally pushing for laws against child marriage. People in health don’t feel comfortable with these all of the time, but it is important and linked to MCHC

§ There are a lot of people that think about health systems, emerging bridge between health systems, and those that know about interventions. There is progress being made now. In the new attention to health systems there has been a bit of an effort to apply a technocratic lens to health systems. What are the puzzle pieces you have the workers, logistics.

§ We think Canada’s health system is so different from the U.S it’s not that were different people, different technology, and it’s not just democratic, it’s a long history of decisions that have been made, it’s path dependent. There is not one model of health systems, or even three that can be applied in developing countries. All countries struggle with establishing quality of care.

§ It’s largely about politics. There may be actions that donors can take to foster leadership at the political level that can foster strong commitments towards MCHC.

§ Much of it is about politics at the local level. But it’s also about promising ways of addressing efficiency, and quality to create menu based options of things that might work in different venues, and the choices will be made by the drivers of social choices, the politics at social and national level.

o Performance incentives

§ Incentives provided to health workers and others, facility managers, district health officers for the achievement of different outcomes and deliveries incentives made to decision makers in households, or individuals if they behave in certain ways like taking TB medication, or their child to get HC.

§ When you look at performance incentives within the health system there is tremendous promise in different settings. The World Bank from significant resources from government of Norway starting pilot program to promote MCHC.

§ We’re starting to see from experiences in Afghanistan, Haiti and several other countries, and to be added to by the work the WB is doing will get a sense of where incentives can be useful, and what are the unintended consequences.