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Investigating Health Policies That Save Lives

Jeremy Shiffman

Why do some diseases kill or sicken at least as many people as other maladies but attract far less attention and funding for treatment? 

That’s what Jeremy Shiffman, a professor of public administration and policy in AU’s School of Public Affairs, wants to find out. Shiffman, who joined SPA’s faculty in 2010 from Syracuse University’s Maxwell School, is a well-known scholar in the field of global health.

He’s also the principal investigator of a $1.1 million Gates Foundation grant taking the unusual tack of investigating six global health networks—on alcohol, tobacco, pneumonia, tuberculosis, maternal survival, and newborn survival. Shiffman and his colleagues want to understand why some networks effectively generate attention and resources, promote policy, and facilitate implementation of interventions, and some don’t.

Attention and funding devoted to another serious global health problem Shiffman has written about, AIDS, helps put the problem in perspective.

“AIDS is a terrible humanitarian tragedy to be sure, but as of about 2007 it received nearly half of all resources for major donors for global health,” Shiffman said. “Nearly half went to AIDS, but it represents 5 percent of the mortality burden in low-income countries.

“Meanwhile, other conditions—for instance pneumonia, malnutrition, diarrheal diseases, newborn deaths—keep causing huge numbers of deaths globally and get virtually nothing. So clearly burden, in terms of mortality, morbidity, illness is not an adequate explanation for this difference. And that’s kind of what intrigued me and led me to explore this question, and it led to the Gates grant.”

Shiffman added that AIDS research and treatment need more funding, not less, but so do other health problems.

Looking at Global Networks
One serious health issue he and his partners are studying: globally, alcohol and tobacco cause a roughly similar number of deaths and illness. In fact, alcohol may be worse because many measures of alcohol abuse exclude such behaviors as drunkenness that leads to spousal assault.

Yet tobacco controls attract far more grant money and attention from foundations and health officials.

Why? And what is the role of the network of global actors concerned with such issues? That’s what Shiffman and his fellow investigators are trying to discover.

Boiling down a framework he described in an article he published in the British medical journal The Lancet, Shiffman offered hypotheses to explain such funding and attention disparities:

  • Power of the actors who mobilize to address the issue. How effective are they?
  • Ideas used to portray the issue. AIDS, for example, can be portrayed as a public health problem, a human rights issue, a problem of development, or a security issue.
  • Global political context. A prime example: the Millennium Development Goals agreed to by U.N. members in 2000 address some but not all diseases. Align your cause with one of those goals and your chances for getting funding and attention are enhanced.
  • Characteristics of the issue. Some issues are easier to promote than others. Polio, for example, requires the simple step of inoculation, whereas other issues such as maternal mortality require more complex interventions.

The Need for Indicators
Policy makers prefer to devote resources to problems they can address; they like solvable problems. That way they can take credit for progress. But first they need indicators that a problem exists. In the United States, we have abundant data on disease prevalence. That’s not always true in low-income countries.

“Epidemiologists think of indicators and statistics as monitors, measures,” Shiffman said. “But I’m a political scientist and we often think of them as political tools. So if you get a credible national survey that shows that you have widespread malaria incidence in a country, that can become a tool for advocacy or a tool to alert policy makers to the persistence of a problem. In the absence of that kind of indicator policy makers may deny the problem even though it’s widespread.”

As for the motivation of richer countries making funding decisions, the result may have little to do with altruism. Plainly put, the question is often: Is this health problem a threat to us?

“They certainly perceive the various influenzas to be a threat to their own populace,” Shiffman said. “They do not perceive, say, cervical cancer coming from Nigeria or Indonesia. That’s not going to affect the health of the U.S. population, but they do perceive that avian flu could potentially affect the health of the population. So there are political incentives to prioritize some conditions over others.

“An even better example is diarrheal diseases. Diarrheal diseases in Nigeria, Congo, Cambodia are not a threat to us, but influenzas, AIDS are perceived to be threats to us. But diarrheal diseases kill many, many more children than any of these other diseases. But guess which ones get funded? The ones perceived as a threat to our own population.”

Saving Newborns
Saving newborn children has also been a longtime research interest for Shiffman. A $365,000 grant from the Saving Newborn Lives program at Save the Children USA, which is funded by the Gates Foundation, is helping him understand the political priority for supporting newborn survival measures in low-income countries.

Globally, about 3.5 million babies die annually before reaching the age of one month. That’s more than the number of people who die from AIDS and represents more than 40 percent of deaths for all children under five years. The vast majority of those deaths are in poor countries.

Until about a decade ago, the fate of very sick newborn babies in low-income countries was given scant attention. It was erroneously assumed that without high-tech medical facilities, which these countries lacked, little could be done to save such children.

Then things changed. Attention to newborn survival globally has grown. More and more international organizations and foundations, from UNICEF to Gates, got involved with the issue.

What happened? Shiffman and his colleagues are conducting surveys in four low-income countries—Bangladesh, Bolivia, Malawi, and Nepal—to find out.

One critical factor occurred in 2000, when Save the Children officials persuaded the Gates Foundation to donate $50 million to establish the Saving Newborn Lives program. Since then, Gates has kicked in another $60 million.

In the past decade it’s also been conclusively shown that community-based health workers without extensive training can make a big difference in saving newborn lives.

“It’s never one thing that causes these changes,” Shiffman noted. “It’s interactions between the availability of solutions, the availability of indicators to show the problem. So if you couldn’t measure the number of babies dying, people might not even know this is happening.”

Self-Discovery in China
Shiffman can’t point to a single personal incident that drew him to this field. But a look at an unusual sequence of jobs he took after graduating in 1985 as a philosophy major from Yale sheds some light on his development. After Yale, he spent a year teaching in China. Then, after earning a master’s degree in international relations from Johns Hopkins, he worked from 1988 to 1991 as a public relations executive in Hong Kong. Then, from 1991 to 1992, he became a social worker, doing community service work in Hong Kong with Vietnamese asylum-seekers.

“It is a strange progression,” he allowed. “At the time I could not see the logic of it, but as I look back every single experience has been immensely valuable and shaped what I’ve become.”

Teaching in China as a 22-year-old, his eyes were opened to the fact that not everyone is privileged.

“PR, public relations: It’s about communications; it’s about advancing issues; it’s about framing, positioning. Look at what my research is about now. Those are central themes in my research. So, while then indeed I was serving General Motors, Coca-Cola, DuPont, they did their positioning and marketing much more effectively than most nonprofit organizations who have much more worthy goals.”

And the move from public relations executive to social worker?

“I was doing PR and it was valuable experience, but I didn’t like it. At the end of the day I would go home and wonder what good I did. In the meantime, I’d been volunteering in the camps in Hong Kong with Vietnamese boat people where they were living in rather appalling conditions. So I had been going to the camps on weekends, and at one point I just decided to quit my PR job and I got a job with a refugee relief agency instead. We were serving unaccompanied minors, children who had come over on the boats without their parents and taking care of their mental and social health needs. I lost a lot of income in the process but it was more fulfilling.

“But then after that I did the PhD [at the University of Michigan], and part of that was because I wanted to try to function at a policy level and I thought in order to have more policy impact I needed to have more advanced graduate training. So as I look back it all makes sense, each one of those positions. At the time I was just thinking, ‘Okay, what should I do next month?’ But I don’t regret any of it.”