Lessons of Millions Saved 'holding up very well': CGD's Glassman

Over the past 25 years, few books have influenced global health more than the Millions Saved series.

The original Millions Saved: Proven Successes in Global Health, published in 2004 by Ruth Levine at the Center for Global Development (CGD), chronicled the health revolution in low- and middle-income countries (LMICs) by highlighting 17 of their successful large-scale efforts to improve health.

Amanda Glassman, the Center’s Executive Vice President and CEO of CGD Europe, co-authored in 2016 the third and most recent version of the book Millions Saved: New Cases of Proven Success in Global Health, which profiled 22 health interventions around the world, including 18 successes and four that, for one reason or another, fell short when they were scaled up.

Glassman said they especially wanted to examine value for money in global health programs and understand system failures to help continue the health revolution in LMICs that “keeps mothers and babies alive, helps children grow, and enables adults to thrive.”

Now, more than five years since the latest edition, we spoke with Glassman to see how the Millions Saved case studies are holding up in a world that has shifted dramatically, and to learn what’s next for the research.

Exemplars News: In your 2016 edition, you featured 18 success stories and four less successful interventions from sub-Saharan Africa, Latin America and the Caribbean, and across Asia. How have the success stories held up?

Glassman: We haven't revisited that explicitly, [but] I think many of them have held up very well. Polio continues to be eliminated not just in Haiti through sustained vaccination efforts, but also in India and Pakistan, who have continued to vaccinate against Polio despite COVID-19, despite border conflicts, despite huge deepening poverty associated with the COVID-19 shock. I believe there are less than five wild Polio virus cases in the world so far this year, which is pretty remarkable in terms of long-term impact. Another example would be some of the cash transfer programs that we looked at, for example, South Africa's child support grant, which transfers a small amount of money to the woman head of household to take care of her children. That program was scaled up during COVID-19 and I expect that it's had an effect on mitigating some of the negative economic impacts of COVID and all of the knock-on effects that generates for women's wellbeing, their children's nutrition, and health seeking [behaviors]. Another really important example, which I think should be inspiring to us as we think about vaccinating against COVID-19, is the big effort to vaccinate against meningitis A across the Sahel. I've started to see people mention this more often because there was the worry that, 'OK, we're doing all that we can to increase vaccine supply and get vaccines out to people but can low-income countries actually deliver at scale?' Well, this program really shows they were able to cover hundreds of millions of people in a couple of months in some of the poorest countries in the world.

Exemplars News: The problems facing the world now, including COVID, are different from the problems in the past. Broadly, do the lessons from Millions Saved still apply?

Glassman: I think they certainly do. We have four criteria that we use to identify cases of proven success in global health or what you would call Exemplars on your site. One is that they address an important health problem. Right away, one of the difficulties in dealing with COVID-19 was that we weren't sure how important a health problem this would actually end up being in low middle-income countries. Then we saw the Delta wave hit India and we knew this was important and it's going to be important for all age groups. That, I think, has flipped the switch and gotten the whole global health community and the development community really thinking about how to deliver vaccines and other countermeasures to countries.

The second is impact and showing impact at scale. One issue that drives me absolutely insane is how bad we are at recording deaths and cause of death in a timely manner. What we've seen in COVID-19 is that many of the countries that we've been engaging with for many years still don't have a very good death registration processes. That really has turned out to be a huge impediment to getting impact and understanding what's happening with the pandemic in each country. Whereas before, you would say, "Ah, 40 percent of deaths go unrecorded in Sub-Saharan Africa. Well, that's a problem. Someone should deal with it.' Well, it was a problem for the HIV/AIDS response, and it's a big problem now when we need something more like real-time data. The good thing is that you see people using new methods and data sources to be able to figure out what's going on. Anything from burials, hospital occupancy, those kinds of data are being brought to bear to triangulate what we know from the totally inadequate civil registration systems. Showing impact and then figuring out how that goes is more and more important. Likewise, how many people do we have to vaccinate? Where do they live? How to locate them? If you look at the Millions Saved stories, it's a lot about finding the people who could benefit the most from the interventions using census data, using household surveys, using mobile phones, and that is hugely important as we think about rolling out COVID-19 vaccination.

The last criteria that we used to select the Millions Saved exemplar cases was, were programs able to show impact over time? I've given you some examples where programs remain in place and actually adjusting to circumstances, learning dynamically. I hope we see more of that going forward.

Exemplars News: One of the lessons of Millions Saved was that successful programs made wise choices about the interventions or tactics based on the best available scientific evidence. Now, more than ever, we’re living in an age of misinformation. Is that making things harder in global health?

Glassman: The debate on masks is a perfect example of how easy it is to spread misinformation during this period. However, we also have very good evidence of what works. Regarding mask wearing, it was actually very rigorous evidence from Bangladesh – not the United States or the United Kingdom. Some economists there trialed a quite rigorous intervention to see if wearing of masks in poor communities could actually reduce transmission of disease at very low cost and they were able to show an impact very rigorously. That one study in this one place, building on their existing evaluations of other programs, actually ended the debate. We now have very good evidence. I think that's the kind of evidence we try to highlight in the Millions Saved cases.

Exemplars News: Another of the lessons of Millions Saved was that successful interventions and programs require partnerships and coalitions to mobilize technical, financial, and political resources, domestically and internationally. That obviously hasn’t happened very well with COVID. Why do you think that is and what can we learn for next time?

Glassman: At the beginning of this whole effort, the existing systems that we had to track disease and its spread, and to track our interventions to stop disease, were really not well thought through. Governments themselves didn't have the systems to put data out in real time, even in the United States. In the United States, we got most of our information from a coalition of university professors who would go through the hospital data that was available on the Centers for Medicare and Medicaid Services website and from journalists who took the time to look at the source data and put it out there because government just couldn't get their act together.

I also think a shared understanding of what's happening is really important to building coalitions, a shared understanding of the problem, and that the evidence of the problem is so clear that there's no problem to act. There has been a wishful thinking phenomenon this entire period. What's amazing, and it must be something about human psychology, is that even between waves [of disease], we are always thinking 'Maybe this is it, maybe now we're sufficiently vaccinated, maybe -even if we stop doing everything we know about what works (distancing, masking), maybe COVID-19 will just go away magically. Maybe there won't be new variants that can overcome the vaccine efficacy.' I think that's one obstacle that we face building these coalitions.

Another issue is that the global system was not built for crisis, not built for a pandemic, the scale or the resources available, the finance, research and development of medical countermeasures. The scale of existing manufacturing of vaccines. We went from, I think, 7 billion vaccines produced globally every year to something like 12 billion. It's just an order of magnitude difference. There were always going to be problems. What this crisis has shown is the need for more effective coalitions and partnerships. There's not going to be one entity in charge or one government that can work for the entire world. That's not the world we live in. Getting a coalition that can work during crisis is the big challenge for us going forward.

Exemplars News: A further lesson from Millions Saved was that not one, but many political leaders – sometimes across political cycles – sustained their health efforts over time. At the same time, we’re also seeing the rise of deeper and more bitter political divisions around the globe. How can this be countered?

Glassman: We need to have absolutely bulletproof evidence and, second, very good evaluation arrangements to illustrate the costs and benefits of what we do. Many of the issues that became very contentious [with COVID] were based on very reasonable concerns. There are major economic consequences associated with lockdown. Nobody denies that and those trade-offs between disease control and economic activity were different in Lagos than in New York City. Evidence helps to depoliticize some of these bitter arguments that we saw in the public domain. Likewise, with interventions like masks or distancing, we should trial them. We could have been trialing this right from the beginning. Another example is how to reach people with vaccines. I'm always shocked that we are not doing more experiments, not experimentation in the sense of does a vaccine work or not, but what is the best way to reach different populations with vaccination services? What is the information people need to take decisions? What drives vaccine hesitancy and what can we do about it? There should be science around these issues, all the time. It's not just R&D for the technology. It's also social science for figuring out what works for uptake of our countermeasures and how they work. If we look at vaccine hesitancy from polling, it’s clear that at least 75 percent to 80 percent of the political spectrum will accept rigorous evidence as a basis for adoption. There's always going to be a group that will believe otherwise. Also, evidence needs advocacy, too. Once you have your evidence, you have to continue to communicate around it systematically. It's not enough to publish paper in a journal – it's about using the information that you've learned and sharing with people using different approaches. Maybe the silver lining to COVID-19 is that people really seem to understand clinical trials now. They understand the regulatory process. We have a more educated populous now about how biomedical innovation happens, how technologies reach people, what are the benefits and costs from uptake? Maybe there is a silver lining at the end of this.

Exemplars News: A further lesson from Millions Saved was that not one, but many political leaders – sometimes across political cycles – sustained their health efforts over time. At the same time, we’re also seeing the rise of deeper and more bitter political divisions around the globe. How can this be countered?

Glassman: Right. Here's a good example: we were all working on COVID and writing papers and saying, "This is an emergency. Why isn't the U.S. government treating it as an emergency?" And one of my colleagues, Jeremy Konyndyk [former Senior Policy Fellow at at the CGD and currently Executive Director of USAID's COVID-19 Task Force] did a Twitter thread about the basics of how disease spreads and he likened it to pooping in a pool. You test the water to make sure it's gone before you get back in. Everyone knows that. No one's going to hassle you about that. That’s science. And then he likened that to COVID-19 – that we had to get the transmission down enough so that it would be safe to get back in the pool. That twitter thread and some related media coverage got more hits than anything else that we had written or spoken about related to the pandemic. It's a little depressing for those of us on the wonkier side, but on the other hand, I think it's a really important lesson about how you communicate around evidence and how to reach people where they are, as you were saying.

Exemplars News: Could you give us an update on Millions Saved? Where is the work now? Where is it headed?

Glassman: Since the second edition of Millions Saved, we have Exemplars in Global Health actually, which has started to do more of the real-time investigation of what's cost-effective and impactful in global health. I'm really glad to see Exemplars happening. I'm hoping that we can update the book with new and different features. There's some pieces of our work that I think are still really important, especially when we talk about limited public budgets, a little boring and wonky, but we need to talk about what it costs to get things done and the political economy around implementation. Not just producing the evidence, but how high-impact programs and policies happen in the real world.