Month: March 2014

The perils of hubris: review of “The Idealist” by Nina Munk

A masterful character study and window into the human experiences of the development enterprise.

In “The Idealist”, author Nina Munk, has done a masterful character study of Jeffrey Sachs; her narrative captures his brilliance and passion, as well as his hubris and hyper-sensitivity to criticism. Her book also portrays, at a human level, some of the persistent challenges and characteristic failings of the development enterprise.

Anyone with even a passing interest in the efforts outsiders make to “develop” poor countries and poor people will want to read this book. It should be required reading for development students and professionals.

The early section conveys Sachs’ impressive intellectual gifts and achievements (tenured Harvard professor at 28). Most of Munk’s narrative, however, focuses on his efforts to help developing countries. He starts out providing advice to Bolivia and Poland – on macroeconomics and stabilization – topics close to his research, and, on which he is an acknowledged expert. These early contributions are viewed positively. He provides similar support to Russia’s more problematic reforms in the 90s. Discussing Russia’s disappointing results, Sachs blames Robert Rubin, Dick Cheney and Larry Summers (p 22). This is the first manifestation of his delusions about the primacy of influence outsiders have on how a country or society evolves; it is far from the last.

Despite the Russian disappointments, Sachs had acquired a taste for engaging in real world events, and especially helping to fix other countries. In the early 2000s, he broadens his activities well beyond his professional expertise, and sets his sights on ending poverty in the developing world.

Sachs determines the world’s poor are stuck in a “poverty trap” and an intense package of coordinated support (a “big push”) is what is needed to get them out. He contrasts this with traditional development assistance which he perceives to be too piecemeal and fragmented. Eventually, this led him to launch the Millenium Village initiative. Sachs passion and advocacy skills allowed him to mobilize millions of dollars to demonstrate the transformative power of this new, and improved, development strategy. In researching her book , Nina Munk spent considerable time over 6 years in two “Millenium Villages” supported by the Sachs-led project. The effort pays off; this part of the book really shines. Munk tells the story of implementing Sachs’ vision in a Kenyan village (Dertu) and a Ugandan one (Ruhiira). She captures essential elements of the complex relationship between “the helpers” and those whom they wish to help. Her portrayal of individual aid recipients and implementers is compelling and compassionate. She conveys much of what is involved, on the ground, up close and personal, with implementing aid. And, she captures something of what it feels like to be a recipient of development assistance. In doing so, she captures, at a human level, some of the persistent challenges and characteristic failings of the development enterprise.

Munk shows how important a compelling vision is to mobilizing attention and funding. And she shows the mechanics of how this vision can break down when it meets reality and real people. She shows just how it is that “top down” approaches to helping far-away people fail.

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Time to rethink fat consumption, if you haven’t already

A study “Association of Dietary, Circulating, and Supplement Fatty Acids With Coronary Risk; A Systematic Review and Meta-analysis” published March 18 in the Annals of Internal Medicine should be the “nail in the coffin” of the lipid hypothesis (linking saturated fat consumption to coronary heart risk). I want to help out, to hammer one tiny nail in the coffin of this zombie idea. Herewith, my hammer swings.

The study is a systematic review of all available evidence on the lipid hypothesis, including observational studies, prospective cohort studies and RCTs. Taken together, the evidence does not support any link between consuming saturated fat and coronary heart risk. Its “surprising” results have come up in several conversations this week; one friend (you know who you are) speculated that the research may have been funded by a nefarious, self-interested funder (the beef industry perhaps?). This is not the case – as you can see if you follow the link above.

My friends, and many others, are suspicious because the finding conflicts with so much existing evidence. Except, they do not; rather, the finding confirms the balance of existing evidence. The findings are at odds with current dietary guidelines and conventional wisdom. This is a very different issue altogether.

Since this issue has come up in several conversations, I want to lay out what I  discovered when I examined the evolution of the evidence for this hypothesis, as well as the evolution of dietary guidelines.

The origin of the lipid hypothesis lay in poor handling of then-available observational data. To wit, Ancel Keys’ Seven Countries Study (1980), which examined observational data on changes in fat consumption and heart disease levels of different countries. It was named for the seven countries that saw an increase in heart disease cases correspond with increased fat consumption; the study ignored considerable additional observational data that was available at the time – which, taken together, supported the linkage – but weakly. Nevertheless, Time magazine covers, and sadly, national dietary guidelines based on the findings followed.There have been many more observational studies since then. Taken together, their findings do not support the lipid hypothesis. Check out this excellent overview of the evidence.

The mechanism? The concern over fat gathered steam when studies showed that saturated fat increases LDL cholesterol — the bad cholesterol — the artery-clogging stuff. They assumed this increased the risk of heart disease. When further studies did not confirm saturated fat elevated coronary heart risk, researchers started to dig more deeply into the mechanism. They found the more important predictor of risk is the ratio a person has of LDL to HDL, the good cholesterol. Note, compared with carbohydrates, saturated fat can increase HDL and lower fat deposits in the blood called triglycerides, which, is protective against heart disease. Heck, even the American Heart Assn admits this. In fact, more recent studies, such as those examining the health effects of consuming full-fat dairy – see here and here, suggest there are health benefits from eating higher saturated fat diets.

Nor do subsequent prospective, cohort studies (e.g. Framingham) support the lipid hypothesis. See this systematic review Siri-Tarino, P. W., Sun, Q., Hu, F. B., & Krauss, R. M. (2010). Meta-analysis of prospective cohort studies evaluating the association of saturated fat with cardiovascular disease. The American journal of clinical nutrition, 91(3), 535-546.  They foundno significant evidence for concluding that dietary saturated fat is associated with an increased risk of CHD or CVD”.

Many RCTs to measure the effects (in terms of fatal or non-fatal heart attacks) of saturated fat have been either inconclusive, poorly designed, or completely unsupportive of the hypothesis. A few such studies are (I could not find a systematic review of only RCTs):

  • Research committee. Low-fat diet in myocardial infarction. A controlled trial. The Lancet 1965;2:501-4.
  • Rose GA, Thomson WB, Williams RT. Corn oil in treatment of ischaemic heart disease. British Medical Journal 1965;i:1531-3.
  • Research committee to the medical research council. Controlled trial of soya-bean oil in myocardial infarction. The Lancet 1968;ii:693-700.
  • Dayton S, and others. A controlled clinical trial of a diet high in unsaturated fat in preventing complications of atherosclerosis. Circulation 1969;40(suppl 2):1-63.
  • Leren P. The effect of plasma cholesterol lowering diet in male survivors of myocardial infarction. A controlled clinical trial. Acta Medica Scandinavica 1966;suppl 466:1-92.
  • Woodhill JM, and others. Low fat, low cholesterol diet in secondary prevention of coronary heart disease. Adv Exp Med Biol 1978;109:317-30.
  • Burr ML, and others. Effects of changes in fat, fish, and fibre intakes on death and myocardial reinfarction: diet and reinfarction trial (DART). The Lancet 1989;2:757-61.
  • Frantz ID, and others. Test of effect of lipid lowering by diet on cardiovascular risk. The Minnesota Coronary Survey. Arteriosclerosis 1989;9:129-35.

This brings me back to the just-published systematic review of the available evidence from all three methods (observational, prospective cohorts; and, RCTs) Chowdhury, R., S. Warnakula, et al. (2014). “Association of Dietary, Circulating, and Supplement Fatty Acids With Coronary Risk: A Systematic Review and Meta-analysis.” Ann Intern Med 160(6): 398-406.

Which, unsurprisingly, found that “current evidence does not clearly support cardiovascular guidelines that encourage high consumption of polyunsaturated fatty acids and low consumption of total saturated fats”.

Let us hope government guidelines will finally be changed to reflect the evidence. We can’t take such a change for granted though. The folks involved with developing dietary guidelines have been ignoring the evidence they are wrong for quite awhile (see here and here).

I am not giving dietary advice. I am encouraging my many econometrically literate friends to take a look at the evidence themselves. Like me, I think you will be surprised what you find.