A lot of people working in global health talk about the need for “transparency” and public accountability, but what does that mean? Why does it matter?
At the UW’s Institute for Health Metrics and Evaluation, it includes allowing journalists like me to sit in on even the most contentious internal debates and policy discussions. Last week, the IHME held its annual Board of Directors meeting — and I sat in for some of the closing remarks.
I’m highlighting this practice because, as I wrote yesterday regarding the editor of Lancet boycotting Seattle’s Pacific Health Summit, it still seems acceptable to many in the global health community to exclude the public — or at least keep them at an arm’s length from the true debates and discussions.
The mission of the IHME may sound wonky and perhaps boring — analyzing information aimed at identifying success and failure in global health.
But these number-crunchers are often controversial. After all, who wants their failures made public?
Oddly enough, even evidence of success can prompt angry attacks.
When the IHME last year published a study showing that maternal mortality had declined, some advocacy groups actually tried to get the findings suppressed — worried that the decline would hurt fund-raising for the cause. The New York Times also reported on the attempt to suppress the IHME study. Later, the WHO, which had originally denounced the IHME findings, revised its numbers in agreement.
I could provide plenty of other examples. The point is that Chris Murray, director of the IHME, and his colleagues frequently get people mad. And they are frequently dealing with complex, nuanced findings impacting massive, multi-million dollar projects.
At the board meeting last week, they talked about the difficulty of communicating all this to the media and the public. One board member complained about how time-consuming and frustrating it can be having to “chew the cud” for journalists who barely understand what questions to ask, let alone accurately report the findings.
Yikes. That made me wince.
So why do these guys fling the doors wide open? Principle.
“We do it on principle,” said Murray. “I think it’s important that people be made aware of what we are finding, how we do the work and what are the arguments.”
And there are almost always arguments, noted Peter Piot, former head of UNAIDS, co-discoverer of the Ebola virus and now head of the London School of Hygiene and Tropical Medicine. Piot is a board member at IHME.
While at UNAIDS, Piot was once asked to come act as “peacemaker” between the Seattle metrics nerds and the World Health Organization over some dispute. It’s not unusual for Murray to stir things up, he said, which is why there is so much emphasis on open discussion and transparency.
“Even the Gates Foundation, which funds the Institute, is not always so happy with its findings,” said Piot, noting a child mortality report the IHME put out a few years ago that got UNICEF all hot and bothered. “I ran into this when I was at UNAIDS, when new data came out showing we had the numbers wrong on AIDS. It was a difficult moment but I felt we had to be driven by the data, by the best evidence.”
Piot added that the question, the debates, will always be about who has the best evidence.
Transparency builds trust and understanding if not always peace and love
Without transparency, Murray said, the disagreements and debates become only more inflamed as competing organizations look for hidden agendas, motives or influence.
“I also think having these discussions in public improves the dialogue,” said Murray. “The public needs, and deserves, to know how these resources are being spent. And leaders in the field often are forced to more carefully construct or focus their statements because they aren’t just speaking to insiders.”
Right now, Murray and his colleagues at IHME are working to complete a massive study called the Global Burden of Disease which, if it’s anything like its previous two iterations in 1990 and 2000, will be both disruptive and controversial.
“I think it will be incredibly transformational, possible revolutionary,” said Lincoln Chen, director of the China Medical Board and a board member at IHME with too many other titles and affiliations (Harvard, Rockefeller Foundation) to list. The findings of the Global Burden of Disease, Chen said, almost certainly will redefine priorities in global health and shift the agenda.
And redefining priorities or shifting agendas always gores somebody’s ox, he added, so controversy is unavoidable. In addition, he said, some see the IHME as threatening the WHO’s role as the leading arbiter of how we’re doing and what we should be doing in global health.
“This institute is challenging the traditional power structure in global health,” said Chen.
Ending the compartmentalization of global health
Cristian Baeza, director of the health, nutrition and population program at the World Bank, is not on the board at IHME but came to the meeting last week anyway. Baeza agreed that what the IHME is doing is challenging the status quo, which he hopes will include challlenging the tendency for special interests to operate in isolation.
The value of open dialogue, he says, is it allows the greatest number of people in the global health community to have a say and prevent the tendency for more powerful organizations to narrow the focus.
“The global health community tends to talk in silos, the silo of vaccines, of bednets or some other specific intervention,” said Baeza. “But for any of these specific health interventions to really work, we need changes across the board — in nutrition, education, governance, economics or the like.”
A perfect example of how IHME’s work can force broader dialogue, he said, was a recent report that showed improving girls’ education in poor countries is the most effective way to reduce child mortality.
“That was a real eye opener for a lot of people,” Baeza said. The IHME is increasingly important in providing independent review of the global health agenda, he said, and doing so in an open, transparent way is critical to its success.