The New Yorker’s Article on Fecal Transplants is Excellent

Fecal bacteria sample

On Fecal Microbiota Transplant (FMT), from a recent (excellent) New Yorker article by Emily Eakin:

“Nothing in health care works ninety per cent of the time,” Mark B. Smith, a microbiologist at M.I.T. who is a co-founder of OpenBiome, the stool bank, told me. Zain Kassam, a gastroenterologist who is OpenBiome’s chief medical officer, put it this way: “It’s the closest thing to a miracle I’ve seen in medicine.”

This piqued my interest; as Darius Tahir put it on Twitter,

Pretty much. I’ve written about fecal transplants and the microbiome a number of times in the past few years – see here, here, and here, for starters - and am glad to see some of the same research discussed in this article.

Book-Blogging: Making of the Atomic Bomb, by Richard Rhodes

The_Making_of_the_Atomic_BombRichard Rhodes’s Making of the Atomic Bomb is not for everyone.

For starters, it’s long – really, really long.  It’s also fantastically dense, serving as not only a history of the atomic bomb but also as a history of nuclear science, anti-Semitism in eastern Europe, and of World War II. And it can be a slog – at times, a hard read and a boring one to boot.

But it is the book to read if you want to learn about, well, the making of the atomic bomb and the Manhattan Project.

For that reason, writing a review of it is pretty much unnecessary: either you’re the type of person to read this book, or you’re not. If you are, I highly recommend it; if not, I don’t think you’ll like it.

Instead, after the jump I’ll list a few of the sections I highlighted while reading on the Kindle, mostly because I thought they were interesting or provided a unique perspective or thought.

Life-Saving Poop, Now in Pill Form

Ingesting fecal material is an excellent way to pick up some pretty nasty diseases, like cholera, typhoid fever (as I can personally attest), and a variety of other diarrhea-causing agents that, together, kill 800,000 children five years or younger each year. That’s 2,200 child deaths each day. It’s horrifying.

But paradoxically, ingesting cleaned, filtered, and safe fecal material can save lives, too.

Fecal bacteria sample


Researchers at Massachusetts General Hospital have created a pill containing filtered fecal material that successfully treated 19 of 20 patients with Clostridium difficile, according to a study in the Journal of the American Medical Association. 

It’s worth repeating: this is a poop pill. And it holds the potential to save tens of thousands of lives every year. 

Though the study was quite small, it shows that fecal transplants – an extremely effective but tedious and labor-intensive procedure – can be accomplished using two or three days’ worth of simple-to-ingest pills. If larger clinical trials are successful, this will be a game-changing therapy.

Clostridium difficile, or c. diff, is a disease that is resistant to many antibiotics and kills 14,000 Americans each year. I wrote a lot about it for a Project Millennialpost last year, but the short version is that c. diff is a hospital-acquired infection that becomes problematic once a patient’s microbiome is altered – often by antibiotics that kill many types of bacteria but spare c diff.  Unconstrained by the “good” bacteria (yes, I’m simplifying here), c. diff takes over the microbiome, causing diarrhea, fever, abdominal pain, and sometimes septicemia.

Treating a c. diff exacerbation with the traditional antibiotic regime can take weeks (often in an inpatient setting) and isn’t all that effective. Fecal transplants, by contrast, lead to quick recovery and are very effective; they don’t actually wipe out c. diff, but in restoring microbiome homeostasis they “tamp it down.” And the procedure works.

More trials need to be completed to ensure that a fecal transplant in pill form is as safe and effective as early results indicate.  If the trials are successful, this therapy will be an absolute medical game-changer.

In addition to being easier to carry out, a fecal transplant in pill form will mitigate the yuck factor (even if it doesn’t entirely get rid of it). The pill fecal transplant works in a matter of days and would likely be done on an outpatient basis, which would save thousands of dollars per patient and free up hospital beds for other patients.  And finally, it bears repeating that the therapy works.

Intriguingly, this modest success opens up the possibility of pill fecal transplants for other ends, like treating depressing and losing weight. Of course, much more research needs to be done in these areas, but the prospect of probiotic therapy for various illnesses would be significant.

Isn’t science cool? Scientists and doctors have managed to turn one of Death’s surest weapons against it, if only a little.

One-Fifth of Americans Worried About Getting Ebola Yesterday

Via Teju Cole's excellent satire at the New Yorker

Via Teju Cole’s excellent satire up at The New Yorker

Over one-fifth of Americans worried – in the past 24 hours - about getting ebola, according to a just-released Gallup poll. Six Americans are believed to have contracted ebola (a number which may or may not include the man who had ebola in Texas, Thomas Eric Duncan, who passed away this morning), and the risk is effectively non-existent, but almost one-in-seven Americans thinks that is is “very likely” or “somewhat likely” that they, or someone in their family, will get ebola.

The Gallup poll wisely compares perceptions of ebola now to the H1N1 outbreak in 2009 (also known as the swine flu):

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In other words, Americans are as concerned about ebola – a disease that poses no risk to them – as they were about the swine flu, a disease that may have infected over 10% of the American population and that killed 3,900 Americans. (This number, of course, is also only a fraction of the number of Americans that die each year from the “common” flu)

Any disease with a high case fatality rate is going to cause people to worry, and doubly so for a “new” or “foreign” one. But a cool, calm, and collected media apparatus would be able to tamp down fears of ebola if it was interested in doing so. That’s not good for gaining eyeball share, though, so organizations like CNN are sensationalizing the “outbreak” of ebola in America by comparing it to – and yes, this is true (see above) – ISIS, a terrorist group. This is disgusting and immoral in and of itself, but it also takes away mindshare from more pressing concerns, like getting a flu shot.

So no, America, despite what you hear on the radio or the television, ebola is not a threat to you. Do literally anything else but worry. Get a flu shot. Donate to MSF/Doctors Without Borders. Help – in whatever way you can – to reduce the ebola threat to Liberians and others in West Africa.

America’s Food Aid Policy is the Worst

America’s food aid program, Food for Peace, is “by far the most inefficient and expensive food assistance delivery system in the world, and one that delays or deprives sustenance to potentially millions of people who desperately need it,” according to a Medill School of Journalism/USA Today investigation.

The entire article is worth reading (as is the whole series), but here’s the kicker:

Of the total of $17.9 billion that USAID spent in the decade from 2003 to 2012, $9.2 billion of it went toward transportation costs, including shipping, handling and storage, or 22 percent more than the $7.4 billion spent on actual food, according to the data analysis and information provided by USAID. And more than a third of the transport costs – $3.3 billion – went just for ocean freight costs. That’s more than 16 percent of the entire Food for Peace budget.

I’ve written about American food aid policy before, so won’t get too far into the weeds, but the overarching issue is that a small group of people and organizations – large farmers and American-flagged ships – are receiving a significant subsidy while everyone else – other American citizens, small farmers in low-income countries, etc. – each only pay a little.

In economics parlance, this is the “concentrated benefits, diffuse costs” problem. It leads to interest groups pressuring Congress to create and pass rent-seeking legislation, which Congress does because a) Congress; and b) Congress feels no backlash from other American citizens or the small farmers in low-income countries that are hurt by the legislation.

There’s a lot more to be said, but I want to read through all of the Medill/USA Today articles before getting to it. In the meantime, you should too.

Is Social Enterprise For Cynics?

Typical pit latrines in Mukuru Kwa Ruben, an informal settlement in Nairobi. This is what the government provides for the people

Typical pit latrines in Mukuru Kwa Ruben, an informal settlement in Nairobi. This is what the government provides for the people. Social entrepreneurs can do better.

Charles Kenny, a Senior Fellow at the Center for Global Development, is one of the sharpest minds on international development and always a delight to read. But I found his latest article, on the naiveté and cynicism of social enterprise – which he pins mainly on Millennials – a bit off the mark.

In the article, Kenny argues that social entrepreneurs are naïve, anti-institution, anti-big business cynics who are improperly substituting small-scale solutions to massive problems that require massive solutions via a large, competent central government.

Kenny is absolutely right that modern infrastructure – roads, sanitation networks, electrical grids and the like – is necessary for long-term health, development, and growth, and that small-scale solutions aren’t perfect substitutes.

But his solution, such as it is, relies on projects that require years of work carried out by competent governments, and he fails to articulate a plausible medium-term solution that will improve the lives of the people living under incompetent governments now.

Kenny creates a straw man of a social entrepreneur who expects to replace the government’s role wholesale. In my experience, this is the aim of few, if any. Social enterprise is certainly not a perfect solution and it’s not a perfect substitute for large infrastructure projects; nevertheless, it holds promise to quickly, sustainably, and successfully improve outcomes and to (temporarily) alleviate suffering.

It’s worth clarifying what a social enterprise is. The most basic definition, while overly broad, is a good place to start: any organization, for-profit or otherwise, that uses market mechanisms to achieve a social goal. That’s it. In many states, a company can legally incorporate as a “benefit corporation,” a designation meant to protect the social aim if it’s in conflict with the goal of producing profit. Many for-profits choose to also apply for “B Corps” status, a stamp of approval that designates the business as socially and environmentally “good.”

In the article, Kenny refers mostly to smaller for-profit social enterprises using innovative technologies to solve a social problem. He argues that they are naive for thinking that using markets to solve global problems would have a significant effect:

Forget bureaucracies, charities, foreign aid, and big multinationals, they might say, the best way to fight global poverty is through the right blend of innovation and business savvy. In its own way, this is simply a new brand of naiveté. The fact remains that poor countries can’t develop without a big, traditional private sector that creates jobs, and the smartest innovations can only go so far without functional governments to provide basic services and infrastructure.

Note the straw man “they might say.” Why not just ask? Extreme poverty is important to end, but so are deaths from inadequate sanitation, improper health care, and a variety of social ills.

Kenny then argues that social entrepreneurs are not just naive, but cynical too:

The social enterprise movement is built on cynicism about the public sector and large-scale private enterprise. A recent survey of 12,171 people aged 18 to 30 across 27 countries found that while 68 percent thought they had an opportunity to become entrepreneur, only 45 percent believed one person’s participation could make a difference in the current political system. For cynics who nonetheless want to change the world for the better, social enterprise offers an attractive alternative to the snail’s pace of institutional change. With a double bottom line of profit and social impact—and the right killer app—social enterprises can innovate their way to a better world.”

Emphasis mine. Let’s set aside the fact that the data point above doesn’t say anything about how cynical Millennials actually are – if anything, 45% sounds pretty high! – and that “the social enterprise movement is built on cynicism” is, well, a pretty cynical claim to make.

What’s most important is that, as Kenny recognizes, institutional changes takes a long time. It’s hard to do, and harder to do right:

Fixing the infrastructure problems and low-quality health and education services takes more, better government—even if the services are contracted out. For all the valuable work they do, social entrepreneurs can’t replace the state’s role, and they can’t function nearly as effectively where governments are poor, incompetent, or corrupt.

Kenny is absolutely correct that an effective government is needed to fix the hard and soft infrastructure problems that plague low-resource countries.

But this won’t just happen tomorrow, or next month, or next year; building functioning institutions, water pipelines, and a health care workforce can take years. Faced with the choice of being outraged about inequality or getting to work, social entrepreneurs are choosing both.

The social enterprise model isn’t borne of cynicism; it’s the logical conclusion many pragmatists come to when large infrastructure projects take decades and when traditional aid and charitably fails to sustainably improve outcomes.

To se why, take Nairobi, Kenya’s gleaming capital city and one of the most developed places in Sub-Saharan Africa. It has a population of over three million, fully half of which don’t have access to piped water or a sewage grid. The pipes and the grid will eventually be in place – the plan is to build them out by 2030 – but until then the sanitation situation is a humanitarian disaster, especially for women and children.

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Sanergy’s solution for the neighborhoods and citizens the government has failed

With respect to sanitation and clean water, Nairobi’s government has failed half of its people, and traditional aid projects have been unable to do much better. Seeing these failures, a few social entrepreneurs from MIT started Sanergy, an organization that developed a toilet and a business model to sustainably improve the sanitation situation in many of the informal settlements of Nairobi. It seems to be working. (I visited Nairobi to report on Sanergy last year; you can read the resulting article at The Daily Beast)

In my experience, social entrepreneurs don’t see their organizations as perfect substitutes for strong, effective governments and institutions; they see them as sustainable, reliable stopgaps that improve the lives of people now, while governments slowly improve. This doesn’t seem cynical; it sounds pragmatic and realistic.

The argument implicit in Kenny’s piece is that social entrepreneurs should stop wasting their time outside of the system and instead work within governments – or, at least, foment outrage to effect necessary change. This is impractical – most would not be effective agents of change in, say, Uganda’s Ministry of Health – and many entrepreneurs are entrepreneurial precisely because they don’t like working within the strictures of stodgy, bureaucratic institutions. And we must not forget that in too many low-resource and infrastructure poor countries, outrage and protest are met with violence and unlawful arrest.

None of this is to argue that social enterprise is the silver bullets that will finally rid the world of extreme poverty, decrepit infrastructure, and inadequate institutions. It isn’t.

Kenny is right: ending extreme poverty and deaths because of poor infrastructure will take competent, effective governments; massive investments in infrastructure projects that are maintained and improved over time; and consistent, well-paying jobs for the growing middle class.

And to be sure, many social enterprises are either ineffective or actively harmful. Most are too small to have anything resembling the sort of effect a government infrastructure project could have, and as governments improve some social enterprises will have to step out of the way. But there’s a role for social enterprises to begin to immediately improve health and education outcomes while governments shape up and prepare to do what’s necessary to lift their citizens out of extreme poverty.

Near the end of the piece, Kenny writes, “Cynicism about government is useless. We need outrage at its performance.” There is a place for outrage, sure, but it’s taxing and often generates more heat than light. Action is better.


Check Out Stromae – a Great Musician You’ve Probably Never Heard Of

If you combine the visual aesthetic of Fonzworth Bentley and Prince, the synth-heavy beats of Kayne West, and the ennui-laden poetry of a talented Belgian guy, you’d have Stromae.

Stromae, the stage name of Paul Van Haver, a Belgian with Rwandan roots, is a very good musician and an even better performer that you have probably never heard of – if you’re American, anyway. If you’re European, you definitely have heard of him and you probably love him.

A Belgian friend on a Great American Tour invited me to Stromae’s recent concert in New York City, and it was a great show: lively, packed, and well executed. Stromae is a capital-P Performer who clearly loves being on stage, and easily bantered with the large crowd about the proper name for french fries (“Belgian frites”) and the language skills of Americans.

The show smartly used a large projection behind Stromae and his band extensively and creatively; a few songs featured a crowd of virtual “backup dancers” that seemed to be meant to evoke soldiers, and a song about cancer had a creepy, shadowy spider of some kind that creeped and crawled throughout the song.

It was a great time and I highly recommend checking out Stromae’s music, even if you don’t speak French (I don’t). As others have noted, he manages to blend melancholy, weary lyrics about disease, death, and economic stagnation with infectious beats without forcing it; he is a European and Millennial voice without seeming to mean to be, or want to be.

Here’s his breakout song from a few years ago, “Alors on Danse” (“So We Dance”):

And the lyrics to the first verse of that song, translated to English (though I can’t vouch for the total accuracy of the translation, it gels with what Google Translate comes up with):


When we say study, it means work,

When we say work, it means money,

When we say money, it means spending

When we say credit, it means debt,

When we say debt, it means bailiff,

We agree to being in deep shit

When we say love, it means kids,

When we say forever, it means divorce.

When we say family, we say grief, because misfortune never comes alone.

When we say crisis, we talk about the wold, famine and then third world.

When we say tiredness, we  talk about waking up still deaf from sleepless night

So we just go out to forget all our problems.

So we just dance… (X9)


Kind of dark, right? A few of his other songs I really like are “Formidable,” “Carmen,” and “Ta Fete.” Anyway: check Stromae out on Spotify or iTunes, and get to one of his concerts if you can.

Book-Blogging: The Teacher Wars, by Dana Goldstein

teacher-wars-cover picLearning about the past is useful for a lot of reasons, but it’s perhaps best for tamping down hubris – for bringing some needed skepticism to the “Great New Idea” to solve the seemingly-intractable problem of the day. Many Great New Ideas aren’t great or new, and a failure to appreciate the past imperils the future.

American education reformers are perpetually in thrall to this or that Great New Idea, as Dana Goldstein shows in her fantastic new book, The Teacher Wars. From the birth of the modern education system in the 19th century to today’s fights over tenure and value-added pay-for-performance, individuals and organizations have always brought forth teacher-centered reforms meant to improve the quality of American education – and have generally failed to create the change they seek.

As Goldstein puts it, “The history of American education reform shows not only recurring attacks on veteran educators, but also a number of failed ideas about teaching that keep popping up again and again, like a Whac-A-Mole game at the amusement park.”

And in American education, no Great New Idea has failed as many times as rating teacher effectiveness:

“For over a century, school reformers have hoped that tweaking teacher rating systems would lead to more teachers being declared unfit and getting fired, resulting in an influx of better people into the profession. But under almost every evaluation system reformers have tried—rating teachers as good, fair, or poor; A, B, C, or D; Satisfactory or Unsatisfactory; or Highly Effective, Effective, Developing, or Ineffective—principals overburdened by paperwork and high teacher turnover ended up declaring that over 95 percent of their employees were just fine, indeed.”

The current reformers – technocrats like Bill Gates, Arne Duncan, and President Obama – want to use the test scores of students to evaluate teacher effectiveness, employing “value-added measurement” to do so*.

At first pass this sounds reasonable, but Goldstein lays out a few problems with doing so. Perhaps most importantly, American society has always expected way more from teachers than they can reasonably accomplish:

“Effective teachers can narrow, but not close, achievement and employment gaps that reflect broader income, wealth, and racial inequalities in American society. This reality was demonstrated by the most celebrated value-added study ever conducted. Economists Raj Chetty, John Friedman, and Jonah Rockoff tried to figure out if teachers who were good at raising test scores were also good at improving their students’ long-term life outcomes—in other words, if value-added was a good proxy for some of the other goals, aside from raising test scores, that we want teachers to fulfill… One finding was that the current achievement gap is driven much more by out-of-school factors than by in-school factors; differences in teacher quality account for perhaps 7 percent of the gap.”

That critique isn’t limited to value-added measurement, of course, but it’s worth making clear: we spend a disproportionate amount of time and energy worrying about teacher effectiveness when the vast majority of the achievement gap is wholly out of their control. Any reform movement that doesn’t address a variety of socioeconomic factors is bound to fail to have a meaningfully large effect.

More to the point, it’s not clear that reforms centered on value-added measurement will even improve student outcomes:

“Research from the National Center on Performance Incentives at Vanderbilt University found that where teachers had been eligible for bonuses according to value-added ratings, whether $3,000 per teacher in New York City or $15,000 per teacher in Nashville, student outcomes did not seem to improve.”

Another reform championed by many progressives is to end, or at least severely restrict, teacher tenure.  While I’m still sympathetic to this idea, Goldstein’s book convinced me that it is largely a distraction – something that takes up too much space on the reformist agenda and that emits more heat than light. Teacher tenure has outlived its original use (more or less to protect teachers from prejudice and the whims of patronage), but it’s not obvious that ending it would actually improve the academic outcomes of children.

(To be clear: I still think there’s a case for ending teacher tenure – especially the contracts that give tenure after an unusually short amount of time teaching – but it seems to me that the most salient benefit of doing so is that it would simply move the conversation away from tenure and to issues of greater importance)

Whatever the teacher-centric reform du jour, changes based on the assumption that there is a large cohort of bad teachers simply haven’t led to the types of large-scale improvements that reformers seek. There is no question that bad teachers exist – and they should be identified and potentially removed – but there are far more good and teachable teachers that can be made better. Or, put another way: any reform that doesn’t focus on turning good teachers into great teachers is wholly missing the point and – in contrast to the high-minded Helen Lovejoy-like rhetoric and appeals to “think of the children!” – shows that some reformers are more comfortable appealing to equity and fairness in the adult job landscape.

One piece of today’s education reform that Goldstein leaves out of the book is the role that technology and innovation is playing now, and may play in the future, for teachers and students alike. This makes sense, of course – the book is a history book focused on human teachers, and, well, the teaching profession has been a bit slow on the uptake – but it’ll likely be a new front in the “teacher war” that’s worth exploring and understanding now. Some efforts, like the Los Angeles Unified School District’s attempt to bring iPads to all the students in its district, have failed pretty spectacularly. But others won’t.

Goldstein ends the book by offering a number of ideas to improve the education system, including paying teachers more – and sooner; allowing more opportunities for teachers to grow and develop new skills and responsibilities while still being able to teach; focusing on principals, too; using tests and value-added measurement as tools but not the tools; and getting rid of archaic and unnecessary last-in first-out (LIFO) teacher layoff policies. All are common-sense reforms that, though politically difficult, put the focus on promoting an environment that will produce better teachers and, hopefully, better student outcomes.

The Teacher Wars is a great book that I highly recommend. Goldstein synthesizes a wealth of knowledge about the American education system** into a fair, balanced, and nuanced look at today’s education system and its reformers, and shows how history is, as ever, repeating itself. She neither deifies nor vilifies teachers and reformers – judging by most coverage and rhetoric, not an easy thing to do – and instead offers concrete, data-based recommendations for moving the conversation to more productive ends.


*To lay out my bias, I would also consider myself a technocrat, though a skeptical one

**Goldstein’s trenchant and useful analyses of the history of teacher unions, Teach for America, urban teacher residencies, and the charter school movement are left out of this review because of length, but are excellent, too