Failure: Learning & Hope. E Anne Peterson MD, MPH American College of Preventive Medicine Failure Institute, February 2016

Transcription

1 Failure: Learning & Hope E Anne Peterson MD, MPH American College of Preventive Medicine Failure Institute, February 2016

2 Failed interventions Costly in dollars and lives Undermine relationships (patient-md, PH program) Undermine relationships between NGO & the community they serve Due to: - wrong diagnosis - Wrong intervention - Right intervention wrongly programmed - Changed circumstances (drug resistance) - Didn t measure results

3 Dr. John Snow ( ) Why was it rampant in London? Why did so many people die? What do we do differently now?

4 Ebola W Africa: 2014 High media penetration to main messages but response was not as desired: still had late arrivals to ETU & secret burials and rapid continued transmission

5 Hospital in Zaire A life changing child

6 Well in Turkana, Kenya

7 Wells in Afghanistan

8

9 Recurrent Diarrhea in Refugee camp New Diarrhea Episodes and Soap Presence Nyamithuthu Refugee Camp, Malawi 1993 Soap Diarrhea /25 2/05 2/15 2/25 3/08 % of Households with Diarrhea 3/22 4/04 4/16 4/28 5/08 5/ % of Households with Soap Present 1993

10 Latrines never used

11 Rwanda exodus to DRC; ,000 killed in 100 days 1,103,000 Rwandan refugees > DRC Extraordinary death rates in refugee camps

12 Food Aid & School Feeding Past norms: Food aid & Feeding Centers Food Aid: American products delivered by ton Distribution centers for food aid & School Feeding Established platform Reaches children but mainly school age Improves school attendance Most studies no change in nutritional status Of school child or younger siblings

13 Therapeutic Feeding Centers - TFC Intense personalized care Few can be cared for (~100 children) 30+ days inpatient Transmission of infectious disease between patients Expensive but still High mortality rates Family member must stay with child - Lost income, child care

14 LF: Elephantiasis Lymphedema of the legs, arms, breast Genital disease in men Hydrocele, chylocele, scrotal lymphedema Chronic disfigurement Limitations in ADL, income Socially ostracized 120 million worldwide

15 Effects on the Lymphatic System Adult worms live in the lymphatic vessels DEC kills 50% nests. No hope if DEC doesn t work Surgical removal of lymph nodes common > worsening of lymphedema

16 World Vision Our vision for every child, life in all its fullness Children are the starting point of all World Vision s Christian community based relief, development and advocacy ministries. We intentionally integrate all programme sectors and ministry streams to contribute to children s well-being and the progressive fulfilment of children s rights at each stage of their lifecycle. These improvements are a primary measure of impact for all WV relief, development and advocacy work.

17 Staggering TDI Findings in World Vision Areas of work Unacceptable TDIs for all child health TDI Unacceptably high rates of child malnutrition - almost half of all children All regions affected: Africa, Asia have highest rates of malnutrition, especially among under five years % Stunted Stunting VERY HIGH GOAL APR EAR WAR SAR LACR MEER Region WV TDIs UNICEF National data from UNICEF

18 US Examples Puerto Rico early frontrunner in uptake of EMR but 2 years later only 6% of MDs are at meaningful use stage 2 AIDS outreach to MDs on use of HIV test no uptake in patient ID Urban FP program for addressing high abortion rate no new clients despite improved access Initial Medicaid expansion (ACA implementation?) slow intake, still many uninsured

19 Anthrax deaths in FL, MD.

20 Chitterlings Situation Analysis * 15 cases of severe diarrhea in Nov/Dec 1988 * Cases caused by Yersinia enterocolitica (YE) * Chitterlings preparation in home was the only identified risk factor * Analysis of buckets of chitterlings found pathogenic YE in 8 of 15 buckets * WIC intervention to mothers * No change in next year s outbreak curve

21 Failed interventions Examples Cholera in London Ebola in W Africa Clinical care in Zaire Wells in Turkana Wells in Afghanistan Medical supplies in Afghanistan Diarrhea in refugee camp Rwandan exodus Food aid, school feeding Elephantiasis World Vision malnutrition rates Anthrax FP expansion EMR Access to care: Medicaid/ ACA Chitterlings Pick 3 or 4 examples: 1) Why did it fail? 2) How could you determine? 3) What should be done differently? 4) What could you now do differently?

22 Assessment What was done the first time? Who? What information? What intervention? Policy assessment Program review What are you going to look at this time? What questions do you need to ask and answer? Where will you get your information? What will you do differently?

23 Dr. John Snow ( ) Why was it rampant in London? Why did so many people die? What do we do differently now?

24 Broad Street Pump

25 Cholera Beds Profound watery diarrhea Die of dehydration within hours to days Self limited disease If you can keep them alive for 4-5 days will survive

26 Ebola W Africa: 2014 High media penetration to main messages but response was not as desired: still had late arrivals to ETU & secret burials and rapid continued transmission

27 Community response to Ebola Conducted a community and FBO assessment in Liberia and sierra Leone: Oct/Nov 2014 High media penetration to main messages but response was not as desired: late arrivals to ETU & secret burials High fatality rate, small difference in ETU Don t touch : come to ETU if you have these symptoms Talk to the community. Their response was well reasoned 2/20/2016

28 Hospital in Zaire Preventing vs treating

29 Well in Turkana, Kenya Did not plan for repair capacity

30 Wells in Afghanistan Did not plan for fuel cost and availability

31 Too much & too little Did not plan for differences in population distribution and fertility rates

32 Latrines never used No one responsible for cleaning latrines Investigate cultural norms. Needed "his and theirs" latrines

33 Don t Promise Unrealized expectations can cause unintended harm Expectation Actual Base Gap = Dissatisfaction Gain Even implicit promises can create expectations

34 Insufficient rations of soap 10 New Diarrhea Episodes and Soap Presence Nyamithuthu Refugee Camp, Malawi Soap Diarrhea 1/25 2/05 2/15 2/25 3/08 3/22 4/04 4/16 4/28 5/08 5/19 % of Households with Diarrhea %of Households with Soap Present

35 Rwanda exodus to DRC; ,103,000 Rwandan refugees > DRC Extraordinary death rates Settled in volcanic wasteland Predictable WASH problems Predictable cholera outbreak

36 Food Aid & School Feeding Food Aid: American products delivered by ton - "Year of the yellow corn" Reaches children but mainly school age Improves school attendance Most studies no change in nutritional status of school child or younger siblings Family eating practices transference of home meals to children not fed at school

37 Therapeutic Feeding Centers - TFC Few can be cared for (~100 children) Transmission of infectious disease between Very vulnerable patients High mortality rates Family member must stay with child - Lost income, child care Better results with community or home treatments Can reach many more children for the same cost

38 Transformation of Food Aid Haiti: blanket coverage of age 0-2 & pregnant women works better than targeted treatment >> Preventive Nutrition Approach PNA Clear health benefits & more cost effective than targeting already malnourished children Afghanistan: Food Aid uses PNA approach Linked to MCH nutrition programs: PDHearth, YCIF Linked to Agricultural programs Mozambique: MYAP- next level of integration

39 (CMAM) Community Management of Acute Malnutrition(was CTC) For Severe Acute Malnutrition without complications Treat at home or in community - greater reach - and better results plumpy nut or RUTF (Ready to eat Foods) Fast & Effective! ~ 8 weeks Potential application in seasonal food insecurity or as preventive?

40 Lymphatic Filariasis Chronic Morbidity Lymphedema of the legs, arms, breast Genital disease in men Hydrocele, chylocele, scrotal lymphedema Chronic disfigurement Limitations in Activities of daily living Surgery often exacerbated progression of lymphedema

41 Lymphatic Filariasis Effects on the Lymphatic System Adult worms live in the lymphatic vessels DEC kills 50% nests. No hope if DEC doesn t work Past Understanding of pathophysiology blocked lymphatics Surgical removal of lymph nodes common > causes scarring & obstruction Normal New Understanding of pathophysiology Worms cause dilatation not obstruction Dilatation leads to dysfunction saggy, baggy lymphatics Abnormal

42 Simple infection & swelling control more effective Hygiene: Soap & Water Elevation of limbs Mild exercise Prevent entry wounds: Wearing shoes Treatment of fungal and bacterial infections

43 Staggering TDI Findings in WV ADPs Unacceptable TDIs for all child health TDI Unacceptably high rates of child malnutrition - almost half of all children All regions affected: Africa, Asia have highest rates of malnutrition, especially among under five years % Stunted Stunting VERY HIGH GOAL APR EAR WAR SAR LACR MEER Region WV TDIs UNICEF National data from UNICEF

44 World Vision is like an amoeba Began by addressing all needs that it met Very flexible but undirected Inefficient Small reach

45 But as it grew too many unconnected parts

46 World Vision Our vision for every child, life in all its fullness Children are the starting point of all World Vision s Christian community based relief, development and advocacy ministries. We intentionally integrate all programme sectors and ministry streams to contribute to children s well-being and the progressive fulfilment of children s rights at each stage of their lifecycle. These improvements are a primary measure of impact for all WV relief, development and advocacy work.

47 Health and Nutrition Core Focus: what we do and assure Requires re-focus; strategic alignment; investment in capacity DO Community-based Maternal Child Health Preventive multi-sectoral approach, with emphasis on nutrition & focus on children 0-5. Includes prevention of key communicable diseases (based on context, prevalence). ASSURE Equitable Access to Primary Health Care for families and communities In sponsorship programs assure that equitable access includes registered children & child monitoring reflects core focus Partners: Local health providers, government and ministries of health; local community organisations and businesses; UN agencies (WHO, UNICEF); NGOs and global health partnerships such as Global Fund; Partnership for Maternal, Newborn & Child Health

48 Health and Nutrition Example Don t Do (and rare exceptions) Requires careful transition EXCEPTION ONLY Clinical care Health infrastructure Annual medical check-ups Surgeries Specialty care medications Stand alone psychosocial interventions Medical equipment not linked to core focus School feeding for health outcomes (ok for education outcomes) DON T DO Provide health benefits only to sponsored children to the exclusion of children of similar status within the same program focus area Reproductive health interventions abortive in nature; contravenes WV reproductive health policy.

49 Achieving Health outcomes Do/Assure Health Community Based Maternal Child Health and Promoting Equitable Access to Primary Health Care Don t Do 49 Infrastructure Annual check ups for RC Most clinical care School feeding programmes for health purposes

50 US Examples Puerto Rico early frontrunner in uptake of EMR but 2 years later only 6% of MDs are at meaningful use stage 2 AIDS outreach to MDs on use of HIV test no uptake in patient ID Urban FP program for addressing high abortion rate no new clients despite improved access Initial Medicaid expansion (ACA implementation?) slow intake, still many uninsured

51 Anthrax deaths in FL, MD. Active surveillance in Virginia after first and great case identified in Florida Six inhalational anthrax cases in Virginia Early recognition of cases and no deaths

52 Failure Assessment What went wrong the first time? When did the error happen? What could have been done differently? When could it have been identified?

53 Project Monitoring 53 Managing Changes Initiate Planning Implementation - Monitoring Close Opportunities for changes Cost of Changes

54 Failure Prevention What will you do differently in future program design? What questions do you need to ask and answer? Where will you get your information? How and when we check to identify failures early?

55 Failed interventions Costly in dollars and lives Underperforming is another kind of failure Due to poor planning. Prevent by: Thorough best practice and cultural formative research Late recognition in adequate monitoring Prevent by: early and thoughtful monitoring Share failures as well as successes