There is no silver bullet and frankly you probably don’t need one. It is far more important to be able to find the right kind of gun, be able to load the gun, be able to aim the gun, and perhaps most importantly, be able to figure out where the werewolf is. –Matthew Oliphant
I always scratch my head a bit when the global health community is dismayed at the revelation that one of its previously hailed “silver bullets” is revealed to not be the miracle cure it was thought to be. The latest disappointment making its way across the blogosphere right now is microfinance: after shady lending practices and harassment of borrowers (driving some to suicide) were uncovered on the part of commercial microlenders in India, the development community began wringing its hands at the unfolding political scandal. The forced retirement of Muhammad Yunus, founder of the Grameen Bank, Nobel laureate, and pioneer of the microfinance institution, looks like the proverbial nail in the coffin of microfinance’s status as the one-stop solution for ending poverty. Now experts are holding panel discussions to debate whether or not microfinance “works.”
This is not the first time we have found ourselves crestfallen at the failure of a silver bullet. When evaluating the results of his “Grand Challenges in Global Health,” Bill Gates admitted that the organization had been “naïve” in its expectations of breakthroughs in vaccine development. He underestimated the time it takes to move new products from the lab through clinical trials and manufacturing. “I thought some would be saving lives by now,” he said, “and it’ll be more like in 10 years from now.” Tell me about it: I worked for a biotechnology start-up in college, and the time it took to get approval for phase I clinical trials allowed bad management to completely unravel the company – it took less than five years. By the time we got the green light from the FDA, the company was being bought out, and we never got to test the product.
Many are also astounded at the current descent from grace of Greg Mortenson, of Three Cups of Tea fame. Details of his inspiring Quixote-esque story of building schools for girls in rural Pakistan and Afghanistan are now being questioned, and donors are appalled at reports of mismanaged funds and schools being used as storage sheds. But don’t we already know that graft happens, and rookies make (sometimes colossal) mistakes? How reasonable was it to expect the Central Asia Institute, Mortenson’s charity, to “fix” Afghanistan by building schools? On the other hand, why are countries and large-scale donors pulling funding and creating a fuss over the graft that the Global Fund revealed through its own investigations?
Why are we continually disillusioned when the simple solutions to the complex problems of global health and poverty turn out to not be so simple? Part of the problem is marketing. Saundra Schimmelpfennig, who has made it her mission to point out and tackle issues surrounding charity (mis)representation and shady fundraising practices, points out that
Whether it’s TOMS A Day Without Shoes or CAI’s Pennies for Peace, schools and teachers are using what are essentially commercials for a charitable product to teach children about the larger world and philanthropy. As is the case with most commercials, these “awareness raising activities” often distort or over-simplify the problems faced in ways that benefit their own organization.
This is extremely worrying as the children brought up on these myths and misconceptions are going to turn into businessmen, philanthropists, and lawmakers. How will the decisions they make be impacted by a distorted view of what the world is like and how to really help?
Another part seems to be that despite each revelation, we are constantly drawn to the prospect that we will somehow still find that magic “something,” that the next innovation or big idea will be the much-sought-after silver bullet. Despite coming to terms with his naiveté, Gates is now saying that energy innovation is the key to beating climate change. Programmers are busily developing cell phone apps in the hope that cell phones can help end poverty.
The problems that we devote our careers to tackling are nowhere near simple, and it is unreasonable to expect to find simple solutions to them. Heck, we don’t even adequately fund the silver bullets we already have. As professionals more knowledgeable than me continually point out, our best bet is to strengthen health systems, focus on measurable improvements, admit and learn from failure, and – perhaps most importantly – have a little patience.
by Kate McQuestion E-mail
In 2006, an article in the New England Journal of Medicine cited the substantial success of the implementation of a routine checklist on reducing catheter-related infections in the Intensive Care Unit of a Michigan Hospital. This story was shortly followed by media uptake the WHO Patient Safety Checklist, which, when utilized, reduced surgery-related mortality by almost 50%. The clinical use of checklists has become a hot topic for clinical quality improvement advocates, and as such, they been generally embraced in some areas of clinical practice.
Could this kind of tool be effective in public health?
The concept of a checklist is, intentionally, simple. The checklist serves as a mechanism to combat human failures of attention or memory—particularly in high stress or repetitive environments. The overall goal of a checklist is not only to ensure that each item is checked-off as prescribed, but to ensure an environment that promotes teamwork and professional discipline. Due to the ability of checklists to make complex systems approachable, they have already been widely used in industries such as aviation and construction, and now are advancing in medicine as well.
HIV prevention efforts, too, involve complex systems consisting of dynamic target populations, multiple programmatic efforts, and a lack of measurable quality indicators—all in all, making sustainable quality improvement challenging.
Checklists might provide a standardized method to ensure basic quality improvement and program management practices in an environment where pressing need may often lead to deficits in consistent and quality programming. Furthermore, they can be used as a tool to increase quality by improving communication, both internally within an organization, but also with the members of the target population being served.
It is a common complaint that too little emphasis falls of clinical delivery sciences, but it is fair to say that even less falls of preventative services delivery. NGOs working in HIV prevention need to keep better track of both the outcomes and impact of their programs. With out measuring results, it is hard to identify best practices and improve quality standards. HIV Quality Improvement Checklist tools could serve as a constant reminder for NGOs to monitor and evaluate results, thus improving health of communities world-wide.
- Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Eng J Med 2006; 355: 2725–32.
- Gawande A. The Checklist Manifesto: How to Get Things Right. Henry Holt and Co: New York, 2009.
- Haynes AB, Weiser TG, Berry WR, et al; Safe Surgery Saves Lives Study Group. A surgical safety checklist to reduce morbidity and mortality in a global population [published online ahead of print January 14, 2009]. N Engl J Med. 2009; 360(5):491-499.
Kate McQueston is a Master of Public Health Student at The Dartmouth Institute for Health Policy and Clinical Practice and Intern at the WHO Regional Office for Europe Division for Communicable Diseases.