… in Japanese, for my work. Yesterday a group of 40 first year high school students came to my department from Soma City, a town in the tsunami-affected region of Tohoku. I’m not sure why, perhaps as a quid pro quo for research we’re doing up there, but they were brought down for the afternoon and as part of the day’s events we organized them a two hour workshop on Global Health Policy. How do you do this for a bunch of bored 16 year olds? My department’s students, being very much closer in time to bored 16 year olds than me, managed to come up with a cunning scheme. After an initial greeting, they divided the students into eight countries, and set them a role-playing task based on public health.
The task: the students had to imagine they were representatives of their country at the UN. A new disease, “Disease X”, has been identified and declared an international emergency, and they have to decide what their country is going to do about it. Each group was assigned a “policy advisor” from the country in question – i.e. one of the students or staff – and where necessary a Japanese graduate student to help translate. They were given background information on all the countries in the room, including a few salient details about the country that might be relevant to the disease. Then the properties of the disease were explained. Disease X was in fact tuberculosis, so the basic properties were:
- one third of the world population is affected
- Treatment takes 6 – 9 months
- Vaccines are only effective in children
- It’s potentially fatal
- It is transmitted by coughing and sneezing
Because there weren’t enough grad students to go around, me and my student from Hong Kong (whose Japanese is very good) were given our groups without a single translator – the grad student who organized the session was nearby and could come over if we had any trouble. Our task was to guide our students to a plan for what to do, in 20 minutes, including time to write up the intervention on a shared presentation (conferenced through google).
The Plan: The background for Australia gave the students the salient numbers about Disease X (low incidence, low prevalence, low death rate) and the key aspects of Australia’s health challenges, which were high migrant inflows, inequality in health between Aborigines and non-Aborigines, and inequality in health between urban and rural areas. In fact, I had downloaded an article from the Australian and New Zealand Journal of Public Health that makes these differences pretty clear: incidence in Australia is 5.4 per 100,000, but in native Australians is 0.9, and in new migrants and Aborigines 6.6. Also in some parts of Australia it is even higher amongst Aborigines, as high as 13 times the rate for non-Aboriginal Australians.
My students didn’t have these detailed figures, only the bullet points highlighting Australian health challenges, and they immediately fixed on migration as a possible key driver of the disease. I had already told them about the three possible levels they could intervene (regional, national, international) and so, when they settled on migration as the challenge I asked them whether they would do national or international-level interventions. After a bit of debate they decided that there’s no point in trying to better control it at the border if the disease is going gangbusters overseas, so they decided to focus on development work in countries with high rates. They then started scrabbling through the country descriptions, comparing incidence and prevalence, and found the two countries with the highest incidence. Once they had identified which one had higher immigration rates to Australia (Bangladesh, made up by me on the spot – I guess the immigration rate is higher than Nigeria but I really don’t know), they examined the challenges written on the Bangladesh country sheet. One of the key ones was lack of access to healthcare amongst the poor, so they decided to send doctors and medicine to Bangladesh, in collaboration with local doctors (I had to point out this detail).
They actually decided on Bangladesh because (in their words) there’s no value to Australia in providing aid to a country it has no migration connection with, so it’s better to spend the money a country where the aid will benefit both countries. This may seem harsh, but it means they recognized a basic principle of tackling inequality (whether global or local) that I try to focus on in my work: with infectious diseases, there is a significant benefit to the community as a whole from reducing inequality by targeting those worse off, since the people with the highest disease incidence are also the ones who will drive the epidemic. By recognizing this they had identified a key difference between targeting those easiest to reach (who usually have the least problems) and those hardest to reach (and having the most benefit both in that group and in the community as a whole).
Once they had done this I told them the statistics on incidence amongst Aborigines, and pointed out that they didn’t necessarily need to look to Bangladesh to target a group that might be vectors for the disease. But actually rates of TB are much, much higher in Bangladesh than in Aboriginal Australians, so they probably ultimately made the right choice.
So, 20 minutes of group work, largely free of railroading by me, and my students had managed to come up with a fairly reasonable intervention plan that might even have some chance of working, and mostly through their own efforts to analyze the data in front of them – and this was their first ever experience of thinking about public health. It wasn’t entirely sandbox-y, but close enough – you can’t run a completely open session in 20 minutes. All but one of the other tables completed their work on time, and I like to think that this is at least partly because in our planning session the day before I gave a few basic pointers to the grad students about how to GM. I didn’t tell them they were GMing, of course, but that’s what they were basically learning how to do.
The denouement: Once the groups had all presented their results, one of the grad students gave a 10 minute presentation on what disease X really is – TB – and the important role Japan has played in developing prevention strategies. He then gave an overview of international health and our role in it, and one of the high school students gave a very cute bouncy speech – in English! – thanking us for the experience. It was all very cute and effective, and the students seemed genuinely happy to have solved the world’s problems in 20 minutes.
Reforming the WHO: Now, many people might have criticisms of the WHO, and might have expected that if our High School students were genuinely going to role-play a WHO experience, they would all sit down and refuse to compromise, and ultimately come up with a wishy washy motherhood statement that enabled every student to go home and make empty promises to their families. They didn’t do this! So this leads to three possible suggestions for ways to reform the WHO:
- Send the students from Soma City to the WHO and give them 20 minutes to solve the world’s problems
- Send the grad students from my department, whose boundless energy is truly a wonder to behold, and whose ability to ignore the magnitude of actual barriers to implementing a plan, and just do it anyway, is quite amazing
- Teach the current representatives at the WHO how to role-play, so they can come to solutions more efficiently
Which would be most successful? I’m guessing suggestion 1…
A well-rounded Graduate Education: I’m sad to report that the students of my department, though great in many ways, lack all the fundamental principles of a well-rounded classical education. None of them have watched Star Wars or Aliens, they don’t even know what role-playing is, and the primary texts necessary for a good understanding of public health – Lord of the Rings, Bladerunner, Conan – are not in their curriculum. How can they assess a problem if they haven’t been taught the critical skills outlined in the clash between good and evil in Star Wars? How can they be qualified to research women’s health without the basic grounding in feminism provided by Aliens? How shallow is one’s understanding of the human condition if one hasn’t been led to consider one’s basic humanity through the eyes of Deckard in Bladerunner, and indeed – how can they properly comprehend the real social and political impact of shortened life expectancy if they haven’t heard Roy Batty’s final speech? My god, at the end of the presentation they were reduced to quoting from a completely peripheral text by Jeffrey D Sachs. But I like to hope that yesterday they learnt a little bit about how to GM, so I’ve gone one small step towards laying the groundwork for a proper classical education. We’ll see if I can get them through the other texts by the end of their degree.
In fact, it’s essential, since they won’t understand my jokes until they have watched those movies …
fn1: since the early 80s, Australia has had a principle of not recording race on census and hospital forms. Instead, we record country of birth, so anyone who is a second generation Australian is recorded as “Australian.” We also record language spoken at home, and Aboriginality, but when we talk about “Australians” we don’t identify race. Eventually, one hopes, Aboriginality will also be able to be dropped from hospital records, but that’s a long time coming.
fn2: This is unduly harsh on the WHO. I know bashing international institutions is like shooting fish in a barrel, but actually the WHO does some pretty good work, in e.g. polio eradication, disaster response, handling outbreaks like SARS, etc. They may not be the best model or the best institution, but given their circumstances they’re doing an okay job, I think