In his book, The Emperor of All Maladies, Siddhartha Mukherjee tells the history of the fight against cancer. It’s a grand saga involving scientists, doctors, patients, and politics, all wielding their best tools to find better treatments and ultimately a cure. And of course, the tale is not over: the scourge continues, though much progress has been made, and an increasing number of bright spots are appearing.
As I read, I see parallels between the evolution of that medical “war” and the struggle against poverty waged by the international development community, or at least the part of that struggle I’m part of, the struggle to give people financial tools to better their lives. The more I read, the more I see, until in each corner of the cancer story I find parallels with our own sector and its searches for solutions.
In the early 20th century, surgeons began to treat breast cancer with radical mastectomies in which not only breast but also lymph nodes and many of the neighboring chest muscles were taken. The more radical, the greater the chances of success, went the theory. By mid-century, chemotherapies appeared. They represented another radical approach in which patients were brought to the brink of death as chemicals attacked cancerous and normal cells alike. In both cases, Mukherjee argues, brute force substituted for the absence of a deep understanding of the causes and behavior of cancer. The medical profession simply applied the tools at hand, raising the intensity as high as patients could tolerate. The tools sometimes cured the patient, but more often postponed the inevitable recurrence, a partial success. According to Mukherjee, the surgeons and chemotherapists who wielded these instruments were so convinced of their efficacy that they closed their minds to alternatives (including each other’s solutions), scoffed at attempts to measure success through rigorous trials, and downplayed the suffering imposed on actual patients.
Maybe you’re already seeing parallels…
In the late 1970s and early 1980s, some development organizations began to “treat” poverty with microcredit. As with surgery and chemotherapy, the rationale behind this treatment was straightforward and plausible, so microcredit proponents (myself included) focused on spreading the work far and wide across the globe, not bothering about rigorous analysis of outcomes, but counting on high repayments and continued demand as signals that the treatment worked. A few decades later, digital financial services emerged and generated similar worldwide enthusiasm around a different set of products and techniques.
As the 21st Century turned, the “randomistas” joined in the microfinance/financial inclusion conversation, insisting that randomized trials, modeled on the trials used to test medical treatments, be the gold standard for measuring efficacy. Financial service providers raised many of the same kinds of objections to clinical trials that surgeons and chemotherapists had raised – about the ethics of randomization, the appropriate duration of trials (How long does success take?), biases inherent in even randomized methods, and so on. Nevertheless, in both medicine and microfinance, the trials, taken as a whole, served to temper high-flung claims and provide a sobering picture of how much progress had actually been made. The recent issue of the American Economic Journal, devoted to microfinance, is the rough equivalent of key papers in the Lancet or JAMA.
The exuberance with which microfinance was pursued resulted in several crises of overindebtedness among clients. Just as surgeons and chemotherapists often discounted the patient suffering inflicted by their treatments, so microlenders often failed to notice that many of their clients were falling into debt traps. Mukherjee describes how cancer patients, taking a cue from AIDS-inspired groups like Act-Up, began to organize to demand more from providers. Just as with debt protestors in microfinance, the client voice was raised infrequently and in unpredictable ways. Nevertheless, even a few emotionally-charged personal stories can ignite change, as they did in Andhra Pradesh in 2010.
Among the heroes in the cancer story, according to Mukherjee, are the scientists who sought to understand how cancer works. Recent learning about genes and the molecular biology of the proteins that carry out genetic directives provides the basis for treatments that are both more effective and less toxic than the previous generation. The analogous basic research in financial services are efforts such as financial diaries that seek a deep understanding of how clients conduct their financial and economic lives. In both medicine and financial services the translation from basic understanding to effective treatment is long, spotty (i.e. not every problem has an easy solution), and only now really gaining momentum. In both cases, deeper understanding revealed that there would be no simple, one-shot cure.
So here we are in 2015 with an array of players, each providing pieces of the solution. Surgeons and chemotherapists, microlenders and digital financial service providers all have important techniques to offer, if they collaborate with other practitioners and with researchers. Patient care and consumer protection are ever-present concerns. In both “wars” progress is evident, with the best tools reaching more and more people.
The strong medicine in these two histories steer us toward an appreciation for the contributions of pioneers, openness to a variety of solutions, and humility in expectations. And, by the way, The Emperor of All Maladies is an excellent book, even if you’re not looking for parallels.
Have you read?