Failure: Learning & Hopec.ymcdn.com/sites/ chylocele, scrotal lymphedema Chronic disfigurement Limitations in ADL, income ... Past Understanding of pathophysiology – blocked lymphatics

E Anne Peterson MD, MPH American College of Preventive Medicine Failure Institute, February 2016

Failure: Learning & Hope

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

Dr. John Snow (1813-1858)

Why was it rampant in London? Why did so many people die? What do we do differently now?

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

Hospital in Zaire

A life changing child

Well in Turkana, Kenya

Wells in Afghanistan

Recurrent Diarrhea in Refugee camp

Diarrhea Soap

New Diarrhea Episodes and Soap Presence Nyamithuthu Refugee Camp,

Malawi 1993

0 2 4 6 8

10

1/

25

2/

05

2/

15

2/

25

3/

08

3/

22

4/

04

4/

16

4/

28

5/

08

5/

19

1993

% o

f

Ho

use

ho

lds

w

ith

D

iarr

hea

0 20 40 60 80 100

% o

f

Ho

use

ho

lds

w

ith

So

ap

Pre

sen

t

Latrines never used

Rwanda exodus to DRC; 1994

• 800,000 killed in 100 days

• 1,103,000 Rwandan refugees > DRC

• Extraordinary death rates in refugee camps

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

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…

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

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

Our vision for every child, life in all its fullness…

World Vision

“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.”

Stunting

42 39 42 44

22 18

3340

1824

4032

0

20

40

60

80

APR EAR WAR SAR LACR MEER

Region

% S

tun

ted

WV TDIs UNICEF

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

VERY HIGH

GOAL

National data from UNICEF

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

Anthrax deaths in FL, MD….

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

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?

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?

Dr. John Snow (1813-1858)

Why was it rampant in London? Why did so many people die? What do we do differently now?

Broad Street Pump

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

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

Community response to Ebola

Talk to the community. Their response was well reasoned

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”

2/20/2016

Hospital in Zaire

Preventing vs treating

Well in Turkana, Kenya

Did not plan for repair capacity

Wells in Afghanistan

Did not plan for fuel cost and availability

Too much & too little

• Did not plan for differences in population distribution and fertility rates

Latrines never used

No one responsible for cleaning latrines

Investigate cultural norms. Needed "his and theirs" latrines

Don’t Promise

• Unrealized expectations can cause unintended harm

Expectation

Base Gain

Actual Gap = Dissatisfaction

Even implicit promises can create expectations

Insufficient rations of soap

Diarrhea Soap

New Diarrhea Episodes and Soap Presence Nyamithuthu Refugee Camp,

Malawi 1993

2

4

6

8

10

1/

25

2/

05

2/

15

2/

25

3/

08

3/

22

4/

04

4/

16

4/

28

5/

08

5/

19

1993

% o

f H

ou

seh

old

s

wit

h D

iarr

hea

0

20

40

60

80

100

%o

f H

ou

seh

old

s

wit

h S

oap

Pre

sen

t

0

Rwanda exodus to DRC; 1994

• Settled in volcanic wasteland • Predictable WASH problems • Predictable cholera outbreak

• 1,103,000 Rwandan refugees > DRC

• Extraordinary death rates

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

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

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

(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?

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

Lymphatic Filariasis

Effects on the Lymphatic System

Normal

Abnormal

• 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 New Understanding of pathophysiology • Worms cause dilatation not obstruction • Dilatation leads to dysfunction

“saggy, baggy” lymphatics

Lymphatic Filariasis

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

Stunting

42 39 42 44

22 18

3340

1824

4032

0

20

40

60

80

APR EAR WAR SAR LACR MEER

Region

% S

tun

ted

WV TDIs UNICEF

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

VERY HIGH

GOAL

National data from UNICEF

World Vision is like an amoeba

Began by addressing all needs that it met Very flexible but undirected Inefficient Small reach

But as it grew – too many unconnected parts

Our vision for every child, life in all its fullness…

World Vision

“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.”

Health and Nutrition Core Focus: what we “do” and “assure” Requires re-focus; strategic alignment; investment in capacity

DO ASSURE

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).

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

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

Health

Community Based Maternal Child Health and Promoting Equitable Access to Primary Health Care

• Infrastructure • Annual check ups for RC • Most clinical care •School feeding programmes for health purposes

Achieving Health outcomes

Do/Assure

Don’t Do

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

• Active surveillance in Virginia after first and great case identified in Florida

• Six inhalational anthrax cases in Virginia

Anthrax deaths in FL, MD….

• Early recognition of cases and no deaths

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

Initiate Planning Implementation -

Monitoring Close

Opportunities for changes

Cost of Changes

Managing Changes

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?

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