Monday, June 27, 2011

The Emperor of All Maladies by Siddhartha Mukherjee

An excellent and interesting ‘biography’ of cancer.

A friend did a succinct and informative review, so I have copied that below.
Though at 592 pages (or 21 hours of audio, as I experienced it) The Emperor of All Maladies may seem daunting, it will be well worth your time if you are at all interested in the topic. I absolutely loved it. This “biography of cancer” is well written, engaging, and extremely informative on a broad spectrum of factors relating to cancer and human society’s struggle with it, from the point at which it appears in the historical record up until today.
In addition to presenting a fascinating medical history, this book really showcases the interplay between research, clinical practice, corporate and political interests, activism, and patients themselves. It also delves into the lives and careers of many pivotal figures in the endeavour. Importantly, the author does not shy away from covering the unfortunate turns as well as the breakthroughs, thereby exposing the ethical issues that inevitably arise when imperfect humans confront matters of life and death with incomplete knowledge. Perhaps the most sure sign of the book’s success: I again find myself wondering why I am not pursuing a career in medical science.
I would like to add that in addition to enjoying the various forays into people, politics, medicine, tobacco and HIV, I felt that the primary benefit of the work was a greater understanding of how things have come to be and how science has progressed. Once upon a time it was thought four humors caused illness; now we know there are cells and genes, and various biological molecules. The randomized controlled design of scientific experiments is less than 100 years old. At one point it was thought nicotine was good for you. It is fascinating to think about all the things that had to happen to have things as they currently are. The book suggests such analysis throughout but also more specifically near the end.

I highly recommend it.

Monday, June 20, 2011

More Than Good Intentions by Dean Karlan and Jacob Appel

More Than Good Intentions is an outstanding overview of microfinance and other development programs that is both informative and highly readable.

Many works on international development focus on an inspiring personal story at the cost of presenting more rigorous data indicating whether a program or project has actually worked. Kaplan, an economics professor at Yale, and Appel, a field researcher, wisely achieve the near opposite by presenting honest and critical accounts of interventions while using personal stories to highlight the complexity of people’s lives and their concerns. They believe in using science to critically evaluate programs and projects and combine it with psychology to learn why people do what they do. This passage sums up their perspective: “To make a difference in the fight against poverty, we need more than good intentions, more than what sounds good, more than what looks good anecdotally. The answer isn’t always what we want it to be, and frankly that does not matter.” (p.276)

At the core of their methodology is the randomized control trial (RCT). To truly understand if an intervention or treatment works, one must compare it to a similar group that did not get the treatment. Science has used control groups for many years, most popularized by medicine, but development programs rarely do such a thing. Kaplan presents study after study that used RCTs and honestly describes what works and what doesn’t.

After setting up the methods, More Than Good Intentions explores microcredit in detail and then presents chapters on microsavings, farming, health, education and sex. Their exploration of microloans suggests caution to those who have seen them as a panacea: sometimes loans help and sometimes they harm. Beyond microcredit, every chapter has case studies to provide the reader with some insight into the complexity of development projects and a personal story indicating just how complicated and frustrating the environment can be. Sometimes the program works and sometimes it doesn’t. Or, sometimes it works for a certain part of the population and not at all for the others.

For example, it was thought that a lack of school uniforms may be a reason for children’s absences, so a program provided a uniform to one group and none to another. It seemed to have no effect, until the numbers were broken down further. It turns out that if a child already had one uniform, it didn’t make a difference, but if the child did not already have one, it did increase attendance. Further, and to demonstrate what I mean by complexity, if one is truly concerned about increasing attendance, then it might be far cheaper to provide deworming (worms can cause abdominal pain, anemia, malnutrition, and extended malaise). This is because generating an additional year of attendance from deworming costs $3.50 per student while generating an additional year of attendance with the uniform giveaway program costs $100 per student. Of greater concern are the programs that cost much more but do not increase attendance more than deworming. Of course, it depends on what one wants to achieve. Rarely is it just one variable (i.e., school attendance) that should be of interest. What happens when you try to compare the effects on family dynamics, a child’s self-esteem, etc. Can you glimpse the complexity?

The authors are quick to urge caution about extrapolating any one success (even through RCTs) to all other contexts. This is wise and far too infrequent. Brief reflection and minor knowledge indicates that “no size fits all,” yet we often hear of the same intervention supposedly being applicable in many contexts whereas it is probably only applicable in some (and then altered to fit the particular environment).

The excellent charity evaluator site GiveWell thought highly of the book but also had some valid criticisms. See the whole review here, but I’ll just mention that they think basic RCTs are not enough and there should be a third comparator group—cash transfers equivalent to the cost of the program. Additionally, they think More Than Good Intentions focuses a bit much on interventions/programs that are proven through microevaluation (e.g., mircosavings, chlorine dispensers for clean water) instead of those that are proven through both microevaluation and macroevolution (e.g., immunization, bed nets and TB treatments).

I very much enjoyed reading this educational and engaging work. It can be useful for many types of readers but would particularly be a great introduction for those who are interested in learning more about international development but have been skeptical about a lack of rigour. I found its perspective a welcome breath of fresh air. In short, people are irrational, even poor people. But since we want to assist them, let’s figure out the best way to do it using science and compassion.

I highly recommended More Than Good Intentions.

Human Rights: A Very Short Introduction by Andrew Clapham

A useful and informative work that examined the history and development of human rights and the human rights perspective. Although off to a structurally slow start, I found it quite worthwhile, especially the chapters on torture and the economic, social and cultural rights.
In addition to the general discussion, I also appreciated learning that often the supposed historical landmarks in human rights were just the result of appeasing shifting power balances instead of sincerely intended notions of equality or dignity (i.e., the Magna Carta or the Bill of Rights).
A handy introduction and reference.