Archives of Failures in Global Health
Dr. Madhukar Pai
In global health, we love to talk about success stories and publish interventions that seem to work. Eradication of smallpox, dramatic decline in polio incidence, reduction in child mortality, etc.
But we also know global health deals with huge, complex, challenges. And involves several agencies and stakeholders with their own agendas and political instruments. So, failure is guaranteed.
Failure is a powerful tool for learning, and we can always learn from failed interventions and projects. Personally, I have learnt a lot from my mistakes in research and have written about it. I have also published failed efforts in peer reviewed journals. For example, we got a grant from Grand Challenges Canada to develop a point-of-care test for extrapulmonary TB. We tried but failed. But we still published the paper. I think my failures have made me a better researcher and a better teacher. But, in general, researchers have little incentive to display their resume of failures.
In the technology and business worlds, failure is expected and discussed in case studies and classrooms. There are compilations of failed products (think Google Glass, Palm Pilot, Segway) and companies (think Theranos, Blackberry, AOL, MySpace). "Fail early to succeed sooner" is a common mantra in Silicon valley. There is, in fact, a Museum of Failure. Who knew?!
I do not see a similar openness about failure in the global health arena. To be sure they are discussed in hushed tones in the corridors of global health agencies in Geneva, New York and Seattle, but not quite publicly, in a way that facilitates learning. There are few published case studies of failed products and interventions (e.g. case study books like Millions Saved do include a few, but not many). I am not aware of courses titled "Epic Fails in Global Health". If there was one, I would love to sign up!
Others have pointed out the 'success cartel' in global health. "The global health community must actively work to change its operating culture. In our own capacities as individual actors—whether as researchers or practitioners—we must stop operating from a place of scarcity, job insecurity and funding fears; we must learn to push back on rose-coloured reporting; and we must promote a culture that celebrates intelligent failure. By working with integrity, we can begin to break open the ‘success cartel’ in favour of real and realistic progress in global health," says Yogesh Rajkotia.
Books like "A history of global health" by Randall Packard do provide several examples of failed projects and interventions, and I am sure there are many more examples. While many donor agencies prefer to highlight success stories, funding agencies like the Bill & Melinda Gates Foundation and Grand Challenges Canada do anticipate failures and see their importance. Here is what Bill Gates wrote about the Grand Challenges initiative: "Grand Challenges is like a venture capital fund in the sense that it backs a lot of ideas—some of them pretty crazy—knowing that many will fail, but a few could have a big impact. I’ll be delighted if five years from now, 20 percent of the initial projects are being deployed and saving lives. And I expect that much of the other 80 percent will still advance the frontiers of science by eliminating dead ends or making discoveries that enable other big ideas."
So, here is an idea. What if we could crowd-source a list of epic failures in global health and compile them? It will serve as a reminder that failures are common, and that we need to expect to fail. With the right mindset, we can learn from our failures and do better.
The list below (linked to at least 1 source/additional reading) has already benefited from contributions by several individuals. Based on the suggestions I get, I will keep the list updated. At some point, the list can be re-grouped, perhaps as product failures, policy failures and program implementation failures. Thanks in advance for your contributions!
1. Failure to deliver on the Alma-Ata declaration: Despite the 1978 Alma Ata declaration on "Health For All by 2000", nearly half the world's population lacks access to essential health services.
2. Failure to adequately respond to the Ebola outbreak in West Africa: Several independent commissions have analysed the multitude of failures in the Ebola response, including slow response by WHO.
3. Failure of global malaria eradication programme: Encouraged by the early success of using DDT against malaria, WHO launched the Global Malaria Eradication Program (GMEP) in 1955. Fourteen years later, the campaign was discontinued when it was recognised that eradication was not achievable with the available means in many areas.
4. AIDS denialism in South Africa: The South African government's denial of the HIV epidemic have been blamed for the preventable deaths of between 343,000 and 365,000 people from AIDS.
5. India's failure to invest in health: Despite India's economic growth, the country spends little on health, and is ranked 127 of 188 countries in progress towards health-related SDGs.
6. America's failure to control gun violence: In America, guns kill over 30,000 people each year, and yet the country has failed to regulate guns and prevent ongoing violence.
7. Canada's neglect of Indigenous health: Despite the fact that Canada's universal health care system has been praised as one of the best and most progressive in the world, quality health care is out of reach for many Indigenous Canadians whose health status is substantially worse than non-Indigenous Canadians.
8. Failure of countries to fund WHO: The failure of member states to fund WHO at a level that is commensurate with its mandate, the agency has become reliant on voluntary and earmarked contributions, which creates a situation where external donors dictate the organization’s priorities and agenda.
9. India's premature declaration of leprosy elimination: In 2005, India declared leprosy to be eliminated and scaled-back on its leprosy programmes. Today, according to WHO, India harbors 60 percent of the world’s cases, with more than 100,000 new diagnoses each year
10. How drug companies blocked access to ARVs in Africa: At the height of the AIDS crisis, pharmacies companies and their political allies stalled access to generic ARVs, delaying access to live saving medicines.
11. Failure to achieve MDG-5 goal on maternal deaths: In 2001, UN member states agreed the millennium development goals, which included a call for the number of maternal deaths to be cut by three-quarters by 2015. While the MDGs boosted efforts, the goal was not met in the countries with the highest death rates. In fact, it was the target that made the slowest progress.
12. Failure of the United Nations to prevent & address cholera in Haiti: In 2016, the UN made a public apology for its role in the 2010 cholera outbreak in Haiti and the widespread suffering (and 10,000 deaths) it has caused.
13. Negative impact of the US Government's Mexico City Policy (global gag rule): Global gag rule reduces access to contraceptives and abortion care, leading to unwanted pregnancies, unsafe abortions, and preventable deaths.
14. How America is failing its black mothers: New mothers are dying in the US at rates higher than any other developed country. The CDC now estimates that 700 to 900 new and expectant mothers die in the U.S. each year, and an additional 500,000 women experience life-threatening postpartum complications. More than half of these deaths and near deaths are from preventable causes, and a disproportionate number of the women suffering are black.
15. Failure to control the price of insulin: Insulin is a 100-year-old drug whose wholesale price has tripled in ten years. The reasons why explain everything wrong with broken prescription drug market.
16. Canada's violation of international law during the Ebola outbreak in West Africa: Canada’s visa restrictions targeting Ebola-affected countries failed to meet the International Health Regulation requirements and therefore violated international law. Canada’s response went against public health authorities’ consensus views, the best available scientific evidence on disease transmission, and the WHO’s recommendations.
17. Iatrogenic hepatitis C epidemic in Egypt: From the 1950s until the 1980s, Egypt carried out large schistosomiasis control campaigns using intravenous tartar emetic, but needles were re-used. This resulted in a major epidemic of hepatitis C. By 2008, one in 10 Egyptians had chronic hepatitis C.
18. Failure to protect children from vaping and tobacco in countries like the US and Canada: In these countries teen vaping has reached epidemic proportions. The increasing use of e-cigarettes among youth threatens five decades of public health gains.
19. Humanity's failure to address climate change: Climate change is an unprecedented planetary emergency. And yet, the nations of the earth are doing very little to avert an impending, entirely foreseeable catastrophe.
20. India's failure to address child malnutrition & stunting: Despite economic growth and various schemes aimed at nutrition, India has unacceptably high levels of stunting. In 2015-16, 38% of children below five years were stunted and 36% were underweight. India is home to the largest number of malnourished children in the world. Malnutrition is more common in India than in sub-Saharan African countries where per capita income is much lower than that of India.
21. Negative impact of Andrew Wakefield's MMR - autism study: Despite the fact that Wakefield's paper has been discredited and retracted, the vaccine-autism link has continued to be accepted on faith by many, including prominent celebrities, and has led to a growing vaccine hesitancy crisis.
22. How the World’s First Dengue Vaccination Drive Ended in Disaster: In 2015, Philippines began the roll-out of Dengvaxia, the first ever licensed vaccine for Dengue. But because Dengvaxia mimics a prior encounter with dengue—which can prime a patient’s body to respond in a dangerous way to a second dengue infection, the vaccine caused deaths. The vaccine program was halted after 830,000 schoolchildren had been vaccinated. The WHO now recommends the vaccine only for those with a documented past dengue infection.
23. Failure of limited WASH interventions to improve child growth: As shown in large trials like WASH Benefits, limited WASH interventions—basic latrines, treatment of water, and rudimentary handwashing facilities—did not improve linear growth in children. The Nakuru Accord: failing better in the WASH sectoris a call for WASH Professionals to publicly commit to sharing their failures and learning from one another.
24. The failure to prioritize women and girls in the fight against AIDS: Adolescent girls and young women are still disproportionally affected by HIV. In eastern and southern Africa in 2017, 79% of new HIV infections among 10–19-year-olds were among females. An estimated 50 adolescent girls die every day from AIDS-related illnesses. And each day, some 460 adolescent girls become infected with HIV, despite the existence of condoms and new drugs that block infection.
25. A campaign to end AIDS by 2030 is faltering worldwide: In 2015, UNAIDS set a goal to “end AIDS as a public health threat” by 2030. Instead of galvanizing more resources, funding for efforts to slow the spread of HIV by treating all infected people has flatlined, and many countries, for a host of reasons, can’t or won’t mount aggressive responses.
26. Failure to address the NCD epidemic: Non-communicable diseases (NCDs) cause of 71% of the world's deaths. Despite some policy statements, there remains virtually no development of specific policies and programs to address NCDs in the countries facing the highest rates of premature morbidity and mortality. There is little money available. Health systems are still too weak to deliver quality services. Nobody has been able to articulate how NCDs fit into the call for universal health coverage.
27. Nigeria's failure to ensure routine vaccine coverage: Despite investments by Gavi and other donors, Nigeria is among the countries with lowest routine vaccine coverage in Africa - only about 50% of children have received 3 doses of DPT.
28. Negative impact of user fees on access to healthcare in Africa: The World Bank first promoted the idea that African countries should charge user fees for health services back in the mid-1980s. This was later formalized as the Bamako Initiative. This initiative failed miserably – especially in its primary objective of helping poor families access health care. Faced with underfunded services, high user fees, and non-functioning exemption mechanisms, poor families effectively stopped using public health facilities.
29. Failure of a US-funded circumcision campaign in Swaziland: A campaign called the Accelerated Saturation Initiative (ASI), pushed by the US, failed to achieve more than a fraction of its targeted goal, the circumcision of 80 percent of Swazi males between ages 15 and 49 within a year. In fact, the campaign was counter-productive to on-going efforts to promote condom use and behavior change.
30. Persistent impact of Apartheid on South Africa's health: Although Apartheid ended in 1994, the health of most South Africans remain plagued by a relentless burden of infectious and noncommunicable diseases, persisting social disparities, and inadequate human resources to provide care for a growing population.
31. Failure to address the opioid crisis in North America: The US is grappling with one of its worst-ever drug crises. More than nine hundred people a week die from opioid-related overdoses, and millions more Americans suffer from opioid addiction. More than 11 Canadians are dying every day on average because of opioids. Canada is the world’s second highest per-capita consumer of opioids, after the US, which has led to widespread misuse, dependence and addiction.
32. Market failure to develop new antibiotics: Decades of disinvestment have left perilously few companies active in antibiotic development. This poses a major problem for dealing with the growing threat of anti-microbial resistance. Companies pursuing immuno-oncology drugs, for example, attract investments, while those working on new antimicrobials struggle to fund development.
33. Failure to address global mental health: Every country in the world is facing and failing to tackle a mental health crisis, from epidemics of anxiety and depression to conditions caused by violence and trauma. Despite the burden of disease, government investment and development assistance for mental health remain pitifully small.
34. Failure to address arsenic poisoning in Bangladesh: Bangladesh’s contaminated well water is considered one of the largest public health crises in the world. An estimated 40 million people — one quarter of the population — are exposed to drinking water contaminated with arsenic. While the Bangladeshi government has largely downplayed the problem, donors and international agencies have largely turned away from dealing with the problem.
35. Failure of US abstinence programs to prevent HIV in Sub-Saharan Africa: The US PEPFAR has been the largest funder of abstinence and faithfulness programming in sub-Saharan Africa, with a cumulative investment of over US $1.4 billion in the period 2004–13. But research failed to find evidence for a relationship between PEPFAR abstinence and faithfulness funding and reductions in high-risk sexual behaviors among residents of recipient countries.
36. Failure to eliminate female genital mutilation (FGM): Despite UN and WHA resolutions and several international initiatives, FGM continues to be practiced in many countries, affecting more than 200 million women and girls globally, mostly in Africa, the Middle East and Asia. In eight nations the prevalence exceeds 80 percent.
Madhukar Pai is a Professor and a Canada Research Chair in Epidemiology & Global Health at McGill University, Montreal. He serves as the Director of McGill Global Health Programs, and Director of the McGill International TB Centre. URL: http://www.paitbgroup.org/
Originally published on Nature Microbiology Community blog on 29 July 2019.