On Skin Color, Epidemiology and Bias

My father is a cardiologist in a small town in Wisconsin. Heart disease is as much a pillar of our community as are beer and the Packers, so he sees a lot of patients. My father, awkward socially, likes to challenge himself to make personal connections with his patients. Sometimes he uses the word "good" instead of "well", or "ticker" instead of "heart". I know it makes his brain twitch to do this. My father is the sort of person who enjoys reading Kant and taking notes (in unusual-for-a-doctor perfect cursive, with a fountain pen). He also enjoys listening to Mozart piano concertos. In short, he is an insufferable intellectual, thoughtful and mostly introspective, using Tolstoy when he wants to make a point.

When I was a child, my father had a patient come to see him. The patient entered the room, saw my father, hesitated, then turned around to the nurse who had led him there and asked: "Does he speak English?"

As an Indian man growing up as a minority in several different countries, my father's intellectualism was a form of rebellion. He knew that because of his name and skin color, he'd be expected to be a certain way. He was as smart as he could be, to prove everyone wrong. (In other teenaged attempts to culturally assimilate, he ate McDonald's and watched wrestling.) This plan could've worked: our race is one of those races that (at least now, though not then) is seen as a group of smart, hard workers, and the effect of my father's skin color on his children was diluted by my mother's Germanic blond hair and blue eyes. We learned to politely explain "what" we were to countless people who didn't know us too well. And for a long time I didn't think about race, my race, anyone else's race. I knew I didn't belong, but I didn't think about why. I just didn't.

When I was in high school, terrorism became a national security threat, and brown people with AK-47s were on the news a lot. Kids say offensive shit to each other all the time in high school, just testing boundaries. For me, it took on an interesting color after the 9/11 attacks. (Terrorist. Towelhead. Sand nigger.) I wasn't angry; I knew they were joking. I just wished I could be white so I wouldn't remind people of what happened.

It wasn't until about halfway through college that I realized I would never, ever be white. Yes, I understand how melanin and genetics work. But I'd thought, as my father did, that if I did things a certain way, people wouldn't notice my skin color as much. Ten years after I started college, I still sometimes hear the "war whoop" when I explain I am half Indian. Just a few days ago, a (drunk) friend told me that if immigrants received citizenship based on beauty, no Indian people would ever become American. (Instead of walking away, I laughed and showed him a picture of my beautiful brother. His response: "Yeah, but he's only half.")

I am not upset that I will never be white. I like my chameleon skin color, a hue that my friend Jason refers to as "cinnamon sexy". I'm upset that I know others will see my non-whiteness before they know about my love of bluegrass music or Japanese food or my scientific ability. And my skin color will tell them things about me that I haven't said out loud (I do yoga! I drive a Toyota! I have a temper!). And most of those things my skin color said will be wrong (I don't know how to wear a sari. I hate lentils. I think chakras are bullshit). This is the problem of bias, a problem I know well as an epidemiologist.

Bias is the insidious notion we have as humans that any information is good information. It's even more pernicious among scientists. If the information is available, we use it. If the information is used, we draw a conclusion based on our results. Once we draw that conclusion, we rarely go back to the information to see whether it's really valid. It isn't. Thinking a doctor licensed to practice medicine in the US doesn't speak English hurts that doctor who is trying to connect with you. Thinking a Black person is dangerous because of their skin color hurts them in a much more serious way (Trayvon Martin. Mike Brown. Eric Garner).

You might think this isn't about race, but let my story above prove to you that it is. If a young, published, straight-A student with a cardiologist dad is put in the position of defending their own existence, imagine how much worse it could be.

I'm lucky that my skin color says things like "smart" and the mildly annoying "not beautiful" to others. I am fortunate that my skin color doesn't say "dangerous", "violent", "thug", "criminal", or thousands of other equally untrue and revolting words. My father is fortunate to be in the position of actively helping those that might fear or dislike him based on his skin color. He can change their minds through his actions. Many don't have the opportunity to do so. (To be fair, none should have to.)

The Essentials of Public-Private Partnerships

So. Public-private partnerships. They're everywhere. Everyone is talking about them. But what are they exactly? There is no real consensus.

(Aside to English majors: Yes, my introduction is not subtle. I'm still working on this writing thing. But hey, at least I used an aside to admit that fact. Do I get points for that?)

If you wanted to be a minimalist (or a tautologist), you could say that public-private partnerships are partnerships between public and private sector entities. But then you'd have to define the term "public sector", which, as it stands, can include actors ranging from local governments to NGOs to academic institutions (which are usually private for-profit organizations, as my checking account is painfully aware). And the "private sector" certainly includes the large, multinational corporations we're used to thinking of in this context (pharmaceutical companies like Merck and Novartis, mobile technology companies like Siemens and Ericsson, financial institutions like KPMG and Pricewaterhouse Coopers), and on and on. But it can also include private individuals who offer health care separately from the government. For example, it's likely your own doctor is a member of the private sector, even if you live in a developing country. (Of the children who receive medical treatment in low-income countries, most are seen by a private physician.)


It should be obvious at this point that the private sector has what you call "reach" in low-income countries. How many times has an aid worker wandered into a remote village in Africa, only to be offered a Coke? And a side note to whatever record label owns the music of the Jonas Brothers: Good job on getting those guys all the way to Bangladesh. Seriously, respect.

So how does this relate to public health? If you're a company looking to sell your product in a low-income country, you have to first invest in the infrastructure. This means developing distribution networks--maybe you will have to learn the hard way which truck is best for the sloppy terrain during the rainy season. It also means overcoming cultural and language barriers (Coca-Cola's marketing campaign in China is an excellent example), as well as logistical problems like heat (melting chocolate), humidity (soggy biscuits), and iffy electricity (poor lighting, electrocution hazards, and so forth). Many of these problems are the same problems that public health workers face when working in low-income countries, only they apply to providing adequate healthcare for women and children (cultural barriers), education about health behaviors (language barriers), maintaining cold chains for vaccines (a classic logistical nightmare), and so on. And improving infrastructure isn't the only way that the private sector works for public health. If a company's main product is health-related, like Uniject, LifeStraw or Plumpy'Nut, working towards better public health is unavoidable. Additionally, financial institutions can aid economic development (and by extension, access to good-quality health care) by encouraging investors to consider investment opportunities in low-income countries. KPMG already does this for the Millennium Cities Initative. So it seems that the goals of public and private sector entities are more closely aligned than is obvious at first glance.

Ultimately, though, the end-game of private sector actors is to make money. This isn't pessimism, it's just a fact--the only way a business can exist and thrive is by making a profit. If it is not profitable, it will ultimately fail. In fact, it's irresponsible for a business to act against this basic principle of turning a profit. And this is the point that bothers so many people in the world of public health: What happens when the interests of public health and the private sector diverge?

This is perhaps best explained by Nestlé’s marketing of infant formula to women in low-income countries. In the 1960s up until the 1980s, Nestlé marketed infant formula to women with the message that it was better than breast milk (it is not). Since early and exclusive breastfeeding is a crucial part of newborn health, it is believed that such marketing was at least partially responsible for high infant mortality and malnutrition rates in these areas. The example of Nestlé shows a very clear conflict of interest between the public and private sector, but there are more subtle situations. For example, suppose a telecommunications company provides its services to a hospital system. The entire patient list is entered into an electronic database, doctors can share e-records and lab results quickly, and billing becomes much easier. But it's also in the telecommunications company's best interest to increase prices once its competitors are gone. In one scenario, health care providers could end up paying more than they can afford--at the cost of other services--to use the system upon which they are now reliant. Public sector actors are painfully aware of this possibility, so some take a pretty hard stance against the idea of partnering with the private sector. One journal article refers to the entire construct of the public-private partnership as a "neoliberal Trojan horse".

So the private sector has the power--and the prerogative--to make money, even if that sacrifices public health (after all, that's not the mission of the private sector). It stands to reason, then, that in order to enter into a partnership where both the private and the public sector have equal power and equal footing, the public sector has to have some pretty major backup. For example, some of the most successful global public-private partnerships started out under the auspices of the World Health Organization, or with the support of the UN and national governments. GAVI (the Global Alliance for Vaccines and Immunization) is one of them; the Global Fund for AIDS, TB and Malaria is another. There's no denying that GAVI and Global Fund are ground-breaking, innovative and effective organizations. And since the 1990s, scores--perhaps hundreds--of actors have taken their cues from GAVI and GF, forming partnerships across sectors.


A "partnership" is often described as two different actors working towards the same goal. In the case of global public-private partnerships, the goal is not always the same: the private sector's goal is to make money, and the public sector's goal is to protect individuals. But both actors need the same thing in the short term: stable infrastructure, a healthy population (physically and economically), and a receptive environment. And luckily, both public and private sector actors face the same risks should they fail: a waste of money, time and resources. Therefore, those who are uneasy about public-private partnerships for public health should look towards strong accountability measures, especially extensive monitoring and evaluation. These measures will keep businesses in check and ensure that they are fulfilling the terms of the partnership; they will also add pressure to public sector actors to ensure that their actions are worthwhile, cost-effective and within a certain budget. (They have the added benefit of giving actors hard evidence that the partnership is working.) Without such measures, partnerships are doomed to fail--just as private and public actors are doomed to fail on their own without them. As Atul Gawande so succinctly says, if you want to be better, you should count things.

I'll just end with this stray observation. In the course of reading articles for this post, I came across the same unfortunate typo again and again. So the PSA for this post is: the real essential of public-private partnerships is the 'l' in the word "public".

On Maternalism and Advocacy

So, I'm in Bangladesh right now, fighting what is apparently the mother of all eye infections (I know, I was totally blindsided--har har har), eating bananas and drinking a lot of tea. I'm also supposed to be working on my internship research, but as half my vision is out of commission and I made the staff doctor recoil in horror this morning, I've been spending all my time online screwing around instead, "resting".

Imagine my interest and delight, then, when I noticed via Twitter that Save The Children UK has sent three "mommy bloggers" from the UK to Bangladesh. The bloggers, writing from the perspective of being mothers, write about their experiences with other people's children--malnourished, fighting tuberculosis and diarrheal diseases in un-pretty, government-run hospitals. They stories are touching, heartbreaking, and real--one woman writes about a mother who begs her to take her malnourished, sick baby back to the UK with her, so the baby will live. These are not superficial or rare problems, and as heart-rending as they may be, they aren't journalistic sensationalism. These women write from the heart, and have been really effective at raising awareness about some of the problems in child health in Bangladesh. You can read their posts at nixdminx.com, mummy-tips.com, and sleepisfortheweak.org.uk.

In reading their blogs, though, I noticed that there seems to be a lot of talk about how lucky we all are to live in the Western world instead of this barren country. Although I understand that these are the echoes of people trying to come to terms with a completely different world (as I currently am doing the same), they may not be interpreted as such by the people reading these blogs.

In the comments section, I found no mention of how the mothers' counterparts in Bangladesh must feel, seeing their children sick and being unable to help them. In the discussions, there was only a contrast between how wonderful and rich the UK is, and how difficult it must be to live in Bangladesh--indeed, how difficult it must have been for the UK mothers to even see such things. Although this may be true to a certain extent, it doesn't engender a spirit of teamwork--it rather "others" the group that needs help. This makes it is more like charity, which doesn't make sense to me. Bangladesh is a country, with citizens, rules, and a culture. It has newspapers, police officers, and a national budget (which is not as large as the US budget, but still). As a state, it has a duty to be involved in the health of its citizens. Why are the rest of us in the Western world acting as if we're doing them a pure favor? Why can't we both work together towards the same goal?

The same thing occurred to me when I read the New York Times article about the battle over the intellectual rights to Plumpy'nut, a high-calorie tool in the fight against global severe malnutrition. The main point of the article is in itself fascinating and perhaps something for a different blog post. But what struck me most was the attitude taken towards Plumpy'nut at a fundraiser:

As volunteers sold raffle tickets for a Dior handbag, Salem delivered a practiced speech. Earnest and attractive, with wide brown eyes, she told the audience that her father, a member of an Indian merchant family, grew up in Tanzania. “There are over a billion people in our world that are malnourished,” Salem said. “It’s a shocking statistic. The good news is there’s a very simple solution.” And that, she said, was Plumpy’nut. “It’s really revolutionary, because it doesn’t need to be mixed with water or refrigerated,” Salem continued. “And the most miraculous part is, it will transform a child from literally skin and bones to certain survival in just four to six weeks.” This transformation, seen in before-and-after photos — on one side a sick and wasted child, on the other, a chubby, smiling one — was the promise that captured imaginations far beyond the technocratic community of specialists that originally developed Plumpy’nut. “People love a silver bullet,” says the prominent nutritionist Steve Collins...After Salem spoke, she began squeezing dabs of Plumpy’nut onto plates and passing them around, assuring the partygoers that the brownish goo was surprisingly tasty, with the consistency and sweetness of a cookie filling. Everyone ate it right up.

There is, of course, nothing wrong with trying to convince those with money and power to use it for public health programs like Plumpy'nut. But the danger, again, is that this type of advocacy encourages a spirit of charity, rather than teamwork.

You might be asking yourself at this point, why I should write about any of this? Why am I judging people who want to help but can't devote their lives or livelihoods to such causes? Why am I pretending that developing countries don't need help?

The idea of teamwork rather than charity is important for several reasons, the most important being that "teamwork" is more sustainable. From an organizational point of view, simply throwing money at a problem will do nothing except waste money--whereas continued communication with programs in-country encourages the strengthening of the in-country system, allowing it to eventually function on its own. And from a donor point of view, I'd argue that teamwork is more rewarding to those who are giving to the cause. By being aware of where the money is going and who it is helping, and receiving feedback, donors have an opportunity to personally connect with those they are helping. Rather than just a Dior bag, those people will have stories to tell about people like them who just happen to live elsewhere. In the long term, this kind of communication will be useful in building relationships between people and countries. This promotes public heath on so many levels besides just increasing the budgets of programs.

These posts are meant to foster discussion and debate; if you are stopping by and disagree with me, please let me know. I'd love to hear your point of view!

Woaaaahhh guest appearance.

My friend Kriti is one of those badass people you kind of wish you could be, but she's too nice to know it. She let me contribute to her amazing blog about public health this week. Check it out!