Ebola and Conflict addendum: rainfall and HIV/AIDS
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In mid-November the international community was still seriously concerned about Ebola and its effects on West Africa. Some prominent figures even called Ebola a threat to international peace. My realist/cynical side figured the calls might simply be an attempt to raise awareness and aid, but I was intrigued by the question, has disease ever led to war?
In my Foreign Policy piece (USIP mirror) I examine the literature on how disease could directly or indirectly lead to war. The short answer is that disease does not lead to war, but depending on the exact effect of an epidemic and government’s response, disease could lead to other forms of conflict.
Two sections were cut for the final version of the article. First, we cut out the research on whether economic shocks lead to conflict using rainfall as an instrumental variable. This growing body of literature launched by Miguel, Satyanath and Sergenti is fascinating, but trying to explain instrumental variables proved unwieldy in such a compact article.
The other section was a quick data probe inspired by a report by the US Institute of Peace from 2001 that discussed how HIV/AIDS could lead to conflict in Sub-Saharan Africa. I pulled UNAIDS figures on the national prevelance of HIV/AIDS in 2001 and UCDP/PRIO data on whether a country experienced civil war in from 2002 to 2012. Dividing the countries up into quartiles based on the prvalence of HIV/AIDS gives the following figure:
If HIV/AIDS increased the possibility of conflict, we would expect that those with the highest rates of HIV/AIDS would be the most likely to experience conflict. However, I find that those countries with the highest prevalence of HIV/AIDS in 2001 also were the least likely to experience a conflict in the 10 years after. While not particularly rigorous or scientific, this simple data exercise challenges some assumptions and raises some questions.
When the OECD released their 2015 Fragility Report I remember looking at the penta-Venn Diagram of the different states of fragility and wondering why Afghanistan was not fragile in institutions, which was supposed to capture corruption among other governance issues. This question eventually led to a Monkey Cage post on my attempt to replicate their measures of fragility.
The OECD responded in a comment to the initial posting pointing out some problems with my replication while admitting certain errors. However, after a revised replication that incorporates those edits, all up on Github, I still get very different results.
I look forward to seeing OECD’s 2016 report as they have discussed some interesting revisions to their measure of fragility. Hopefully along with substantive improvements they will also incorporate improve their methodology especially by way of transparency. As the OECD continues to work with this data in order to provide a public good, the greatest good will come from being as public as possible.
The latest Freakonomics episode, How Many Doctors Does It Take to Start a Healthcare Revolution, Jeffrey Brenner, executive director and founder of the Camden Coalition of Healthcare Providers, uses Princeton, NJ as an example of over active hospital financing. The Coalition is currently working JPAL on an RCT of an care management program targeting healthcare system “super-utilizers” identified by healthcare “hotspotting”. From the transcript:
BRENNER: One of the problems is that we have a giant economic bubble underlying this where we have hospital financing authorities underpinning, that are run by states that help hospitals float bonds. And we have this giant bond market called the hospital bond market that’s considered very secure, very safe, good investment. And you know, that bond market has floated too much hospital capacity and created and brought online too many hospital beds, far more hospital beds than we need in America. So you know, the most dangerous thing in America is an empty hospital bed. In the center of New Jersey, near Princeton, a couple years ago, we built two brand-new hospitals. These are two $1 billion hospitals, 10 miles apart, very close to Princeton. So one is called Capital Health, and the other is Princeton Medical Center. I don’t remember anyone in New Jersey voting to build two brand-new hospitals. But we are all going to be paying for that the rest of our lives. We’ll pay for it in increased rates for health insurance. And, boy, you better worry if you go to one of those emergency rooms, because the chances of being admitted to the hospital when there are empty beds upstairs that they need to fill are going to be much, much higher than when all the beds are full–whether there’s medical necessity or you need it or not. So I’d be very worried if you live in Princeton that there are now two $1 billion hospitals waiting to be filled by you.
The RCT is fascinating, but also interested me since I spent two years volunteering with Princeton First Aid and Rescue on the ambulance taking patients to the $520 million Princeton Medical Center, opened in 2012.1
I do not recall taking anyone to the Capital Health Medical Center - Hopewell, opened in 2011, but Capital Health Regional Medical Center in Trenton was our go to trauma center. To get an idea of the layout, the map below shows the Regional Medical Center in red, the two new hospitals in green, and the old Princeton Medical Center in Orange.2
Map of past and current hospitals in the Princeton area.
The hospital construction was also brought up in a 2014 NYT article asking why a procedure in retired math professor was billed $5,435 at the Princeton medical center and $1,714 in Boston for the same procedure:
But that cost must cover some expenses in the United States not found in other medical systems. The area around Princeton has had a spate of new hospital building in the past five years. The University Medical Center of Princeton at Plainsboro, which has no connection to Princeton University, cost more than $500 million to build and has a curving atrium decorated with artwork from the hospital’s permanent collection. “It was like a luxurious museum,” Mr. Charlap said.
University Medical Center of Princeton at Plainsboro: curved for your health
I know little about health care finances and have no strong feelings about the hospital construction, which seems like it isn’t even the biggest factor in rising health care costs. I am happy to see that people are thinking about and questioning the status quo.
For my two cents, I felt that I transported many patients that did not really need an emergency room, not out of any financial interest but because of protocols. If a patient wanted to go to the hospital, I wasn’t qualified to refuse him or her by judging the trip unnecessary. Similarly, if a patient did not want to go to the hospital, they can deemed unqualified to refuse for a number of reasons including alcohol use. Often is seemed someone was of sound mind even after a couple drinks, but when there are liability concerns why risk releasing a not sober but medically sound student who could then turn around and sue you when he later electrocutes himself on the Dinky, Princeton’s iconoclastic rail car? The rules of when to transport is probably a relatively small factor in the larger world of health care costs, but from my view in the back of the ambulance it would also be worth a rigorous evaluation.
FOOTNOTES:
Technically the University Medical Center of Princeton at Plainsboro. ↩
Home to Dr. House, but the aerial shots actually showed Princeton’s campus center. Everyone lies. ↩
Alternative internet tabloid title: “7 Ways Afghanistan Kicks America’s Butt!”
Unemployment, insecurity, and corruption, are the biggest challenges facing Afghanistan according to the ASIA Foundation’s 2014 survey. The fraud allegations and controversial recount of the presidential run-off election might have made the list, but the survey ran before the preliminary vote totals were released.
Even before the elction though, pessimism was on the rise. The survey found that 40% of Afghans believe the country is moving in the wrong direction, a new high since the ASIA Foundation began surveying in 2004. If you are keeping up with US politics however, that number doesn’t look so bad. Throughout 2014, over 60% of Americans have reported that the country is headed down the wrong track.
Of course, when comparing across surveys you have to account for many factors such as different methodologies, sampling limitations, exact phrasing, and cultural significance. We cannot say that America’s track is more wrong than Afghanistan’s, whatever that even means. However, I believe these comparisons should make us think about both the face value comparison (why might Americans be more pessimistic?) and the issues of doing such a comparison in the first place (how is the data shaped by differences in culture, society, history, politics, economics, linguistics, and the survey methodology itself?).
With the goal of promoting additional thinking, I present the seven survey results where Afghanistan outperforms the USA:
1. Right Direction
On the other side of wrong-track coin, 54.7% of Afghans believe that the country is moving in the right direction. This is a slight dip from 2013, but overall still seems to be on a steady climb since 2008. In the United States you have to go back to 2009 in the Reuter’s Poll or 2003 in the NBC News/Wall Street Journal Poll to find that level of optimism in the US (see graph by Marist Poll).
2. Property Crime
Security is a major concern in Afghanistan; 16% of respondents report that they or someone in their family had suffered from violence or crime in the past year. Overall, violent acts (beatings, suicide attacks, murder, kidnapping, militant action, etc.) were more prevalent than property crime (Racketeering, livestock theft, pick-pocketing, burglary, vehicle theft). Between 6.5 and 13% of respondents reported some type of property crime (exact unknown because respondents were allowed to report two types). In comparison, the violent crime rate in the US in 2013 was only 2.3% according to the USA’s Bureau of Justice Statistics (BJS). However, the US may have a slightly higher rate of property crime - 13.1% of households.
3. Crime Reporting
The first response on property crime might be about what incidents go unreported. While Americans and Afghans may have different ideas on what constitutes a criminal act, as it is Afghanistan has a higher reporting rate than the US. The BJS estimated that Americans reported 46% of violent crime and 36% of property crime to police. In Afghanistan reporting of crime or violence increased this year to 69%.
4. Confidence in the Police
The difference in crime reporting may be related to each country’s confidence in their police. When a 2014 Gallup poll asked Americans how much confidence they have in the police 53% selected agreat deal or quite a lot versus the other choices: some, very little, or none. The ASIA Foundation’s survey found 73.2% are confident in the Afghan National Police (ANP). This is using a composite measure of people that agree strongly or agreesomewhat with three statements: the ANP (a) is honest and fair (b) improves security and (c) is efficient at making arrests. As more direct comparisons, 86% of Afghans strongly agreed or somewhat agreed that the ANP improve security; according to a Pew Poll 83% of Americans said that police were excellent, good, or only fair at protecting people from crime. Similarly, 88% of Afghans at strongly or somewhat agreed that the ANP is honest and fair, while 74% of Americans gave the police a fair or better rating at treating racial and ethnic groups equally.
5. Confidence in the Army
The higher levels of confidence in the police may be related to their role in fighting the insurgency. The Afghan National Army (ANA) similarly garners a high level of confidence. Using a composite measure again, 86.5% of Afghans agree strongly or agree somewhat with all three of the three following statements: that the ANA (a) is honest and fair (b) improves security and (c) protects civilians. The most recent 2014 Gallup Poll found 74% of Americans have a great deal or quite a lot of confidence in the US military.
6. Confidence in the Legislature
In 2013 the US congress’ ratings hit record lows; a Public Policy Polling survey found that Americans had higher opinions of root canals, head lice, traffic jams, cockroaches, and Nickelback. Gallup polls that year found that 10% of Americans had a great deal or quite a lot of confidence in Congress. This number dipped to 7% in 2014. Afghanistan cleanly clears this low bar with 12% reporting a lot of confidence in parliament as a whole.
7.Fair Elections
Before the announcement of the run-off election and the subsequent allegations of sheep stuffing and disputes over unity governments, the Afghan people were quite bullish on the elections. When asked about them, 63% responded that they were in general free and fair. If you ask likely American voters, only 40% think elections are fair to voters. Given what has happened since the US may have taken back the lead on fair-election perceptions, but that’s still not something to brag about.
Map of past and current hospitals in the Princeton area.
University Medical Center of Princeton at Plainsboro: curved for your health