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Lessons in saying sorry

An apology is supposed to feel uncomfortable. After all, you did something WRONG. It is supposed to expose you and make you vulnerable. The movie, A Fish Called Wanda, provides a textbook apology by John Cleese after he is hung out a window by his ankles and schooled in the art by Kevin Kline.

In contrast to a fulsome apology, when it contains small flourishes to diminish your discomfort, it ceases to be an apology because it is now about you and your discomfort and not about the people you wronged. If you go so far as to try and suggest that the people who were offended need a new perspective, you really have stuffed it up.

Yesterday I had an opportunity to contrast two apologies and they could not have been more different in tone or impact. One was made by an extremely powerful voice in global health and the other was made by one of the many sincere workers in the field.

The power-apology was given by Richard Horton, Editor in Chief of The Lancet, who had approved the cover of the most recent issue. The cover was, in its entirety, a degrading observation about women. It reduced women to a reproductive body-part. The article, from which the cover quote was extracted was fine and, in the context of the article the text was relevant and reasonable. Decontextualised and displayed as the cover image, it was simply offensive. Think of putting a racist slur on a billboard that was extracted from an article on the horrors of racism.

Many readers were profoundly upset by the cover. They tweeted about it (giving rise to the hashtag #morethanavagina) and they wrote letters to the Lancet about it. With much cajoling, the Editor in Chief finally published an apology,

“I apologise to our readers who were offended by the cover quote and the use of those same words in the review. At the same time, I want to emphasise that….”

And here, in the second sentence, he lost it. He wasn’t apologising. Not really. It was insincere and an attempt to diminish the offence by suggesting that there were good arguments on both sides. He has undoubtedly made a difficult situation worse when his intention — badly executed — was to try and placate.

The contrasting apology, the sincere-apology, followed a large on line meeting to discuss a research protocol. One attendee (who had earlier raised pertinent questions about the protocol) inadvertently left his microphone open. He was heard to comment at the end of the meeting (in colourful and disparaging language) that the protocol was poor and should never have been funded. I missed the moment but as soon as I was told about it, I wrote to him. He replied.

I beg forgiveness for my unintentional comments. I had previously raised all the issues I needed to. So with this email I am begging sincere forgiveness from my colleagues. Sorry once again.

Now that is an apology(!), which will be circulated. I don’t know if it will be accepted by others but one cannot fault the sincerity of it. And that is in the nature of the genuine apology. You put yourself out there, take the risk, and hope the injured party will accept it. There was no prevarication and no attempt to diminish or justify the offence. He simply apologised.

In the absence of Kevin Kline on speed-dial, a sincere apology from those in power remains as elusive as a unicorn.

The original article was first published on on 28 September 2021. This version is very slightly edited.

W.H.O. still thinks health equals medicine.

Not a WHO Director (source: JHU, Medicine)

Health related, Director-level appointments in the World Health Organization (WHO) are not front-line health workers with well-honed clinical skills. They are Senior Management/Administration. They need to understand resources, politics, and systems. They need to be able to gather, balance and weigh evidence, lead teams, provide advice, develop strategy, and monitor and evaluate performance. All this is done with the support of qualified teams. Where disease-specific knowledge is required, medicine can be useful. It is not uniquely qualifying.

A year ago I wrote that public health is not a specialisation of medicine. Sadly, no one at WHO read the blog. I know this because of the four director level (D1) positions recently advertised by the WHO African Regional Office (AFRO): (i) Regional Emergency Director(ii) Director-Communicable and Noncommunicable Diseases; (iii) Director – Universal Health Coverage/Life Course; and (iv) Director – Universal Health Coverage/Healthier Population. Under “Required qualifications”, a medical degree with postgraduate qualifications in public health is stated to be essential for the first three positions. The requirement is marginally relaxed to “ Medical or health-related degree with postgraduate degree in Public Health or Social Sciences” for the last position.

The WHO view about the relationship between medicine as a qualification and the skills and capabilities required to fulfil the job — when you actually read the duties and responsibilities — is myopic. It is myopic because it creates a baseless, blanket exclusion for potentially excellent candidates. Why limit the pool of excellence that is available? No one is in any doubt that the health problems facing AFRO are massive. Hiring the best qualified people, not necessarily the best medically qualified people, will make tackling that problem a little easier.

Much has been written in the management and leadership literature about the need for diversity of thought at senior levels of organisations. The mantra is, do not surround yourself by cognitive clones. And yet, how much more effectively could one reduce the range of thinking than by restricting the thinkers to those who have all been trained to think in the same way? By identifying medicine as an essential qualification for jobs for which medicine is patently not uniquely qualifying, WHO entrenches particular ways of thinking about health and the delivery of its mandate. D1-Directors climb the ladder to D2-Directors. If you cannot qualify to be a D1-Director without medicine, you are excluded from climbing the ladder to a D2-Director. And thus, WHO develops a culture of thinking about health in which health equals medicine.

Who will cut that Gordian knot?

Flypaper financing: The sticky world of research overheads and indirect costs

As a child, I was always a little grossed-out by flypaper. They were like sticky streamers of death hanging from the ceiling; anything that touched them was lost forever, including the eponymous fly.

Indirect costs, also referred to as “indirects” or overheads, are the flypaper of global health research funding.

Indirects reflect the money from a grant that is caught by the Finance Department before it is made available to the researcher. The money keeps the organisation going: the lights stay on, the rent is paid, the cleaners and security guards turn up, and the management services work.

If a researcher wins a $100,000 grant, after the financial flypaper has caught the indirects, she might receive $80,000. Those who do not come from the worlds of research or global health and development may be slightly appalled by this 25% overhead. Some research funders are. They see the indirect costs as a kind of sleazy tax on the worthwhile research they are supporting. Other funders are reluctant to pay indirect costs or will only pay at a significantly reduced rate, such as 8%. I should also add that there are funders that are fully aware of the issues, and will pay the indirect costs with little or no complaint.

I understand why some funders don’t like the indirect costs. They want to achieve the most significant impact possible for every dollar spent, and this means they want as much of their money to go into doing the research itself and as little money as possible going into general organisational support. Of course, they also want great researchers, good research infrastructure, and appropriate governance and compliance mechanisms. And herein lies the funder-research paradox. There is an obvious relationship between strong research organisations and strong research. Strong research organisations are strong because they have good governance, financial oversight, HR policies and procedures, procurement processes that are transparent, fair, and competitive, decent infrastructure, access to library services, and they also invest in their staff. Continuous professional development of the scientific and non-scientific staff is crucial for the development of strong research organisations. All that (infrastructure, processes and staff development) costs money above and beyond the cost of doing the research itself — and it costs more money than one might think.

Funders need to recognise indirect costs as part of their achievement, not a hindrance to it. Through their funding, they support research and research organisations.

The failure to pay reasonable indirect costs, in effect, forces a form of cross-subsidisation. I know of one university that encouraged staff not to apply for nationally competitive grants because too little was paid by the funder for indirect costs. For every grant that was won, the university ended up having to subsidise the research by picking up the indirect costs. Any research organisation that does that for too long will find itself bankrupt. That was in the Global North.

The situation is different, and in some ways worse, in the Global South research organisations. If the research organisation is essentially regarded by the (usually Global North) funder as a data manufacturer (sample collector) and not an intellectual contributor to the science, there is a greater reluctance for indirect costs to be paid. This recalls the theme of “trickle-down science” that I have discussed in another post.

Having argued, however, about the necessity for indirect costs for research organisations to survive and develop, there can be a darker side to indirect costs. It is the daisy chain of financial flypaper — reminiscent of a recent story I read of a botched assassination in China. A hitman subcontracted an assassination to a colleague, who subcontracted the assassination to another colleague… Five assassins were in the daisy chain and each one took money off the top, before passing on the residual. In global health and development, the financial daisy chain can be seen in large contracts awarded to management companies that skim money off the top as indirect costs, and hand on the residual…

Multilateral agencies can do this with sub-awards. They receive a grant from, say the Gates Foundation, they’ll take out the indirect costs and pass on the residual to an implementing agency — often cautioning them not to overcharge indirect costs. It can also arise from the use of sub-awards offered by research organisations. I have even heard about organisations taking indirect costs from a grant and then a management fee associated with a sub-award before passing it on to the sub-awardee, which will need to remove indirect costs before passing on the residual to the researcher. This can even happen within the same organisation. I win a large grant. The organisation takes out indirect costs. When I pass on a sub-award to a colleague, like a hitman, I take out my management fee first.

Let me say it again, funders need to recognise indirect costs as part of their achievement, not a hindrance to it. Research organisations, however, need to be clear about which part of an award should truly carry an indirect cost and which parts should not.

A literary bibelot

Within a minute I swung from apoplectic to flummoxed.  My erudition had been called into question with an unkind gibe. A friend — truth be told, an impious ragamuffin — started this small, mental kerfuffle by suggesting I would not be able to use a set of 21 words in a single blog post. Was this louse, this piebald swiller serious, or was it waggish humour? Apparently, he was serious. There was no playfulness here.

I confess the challenge did give me the collywobbles. Could I obfuscate? Could I substitute an alternative, thesaurus challenging vocabulary and get away with it? Perhaps there was a set of lexical dregs or suppositious words to hornswoggle the reader. I had it …. a story laden with sesquipedalian, polysyllabic nonsense.

“The mountains ached for the moon to rise and break the thick, tenebrous night. The canvas of a small ketch caught the zephyr wind to pull it across the ….”

Ugh! Jabber! I had macerated this nubbin long enough. If I wasn’t careful I would choke on the challenge, and no wine to quaff. On the other hand, there would be a simple joy in succeeding. With an exuberant ululation from the balcony, I would announce my victory to the world, and he (he who had created this casus belli) would withdraw — vamoose — tail between the moose’s legs.

There was one small problem. Yenta. As in, “she’s such a Yenta”;  a person, especially a woman, who is a busybody or gossip. It was a little too xenophobic for my taste, not to mention misogynistic. What to do? I could not meet the challenge. Hubris won. Who was the moose now?