I tend to be suspicious of fads. Call me conservative. but even in my 20s, I never bought in to the 1960s saying, “Never trust anyone over 30.” Say what? I’m also wary of public health fads: “community based” and “sustainability” are among them. Don’t get me wrong. These can have value for shaping policy and practices in positive ways. They can also create a cachet that becomes a selling point in its own right without adding significant value. Worse, they can divert attention away from essential characteristics of the intervention that contribute to long-term effectiveness.
Example: I heard a wonderful clearly presented talk during the ASTMH meeting in Atlanta last year. The PowerPoints illustrated a large randomized cluster trial that was being conducted to test a community based dengue vector intervention. It was obviously well-planned and was being conducted carefully. Someone had been convinced to put a lot of money into the effort. It included many kids wearing project tee-shirts, community volunteers and parades. Wow! After I heard it, I thought, “Positive results are so likely that it’s almost not worth doing. This is a no-brainer.” followed immediately by the pregnant question, “And then...?”
When the excitement and parades are over, when the tees have been relegated to dusting cloths, when the donor’s money is dried up, what remains? We should be concerned not only for what happens when the program is operating, but what happens when it ends. Does any benefit remain? I’ve asked the question before, but it’s more timely given the current malaria prospects.
I’ll offer a characteristic of interventions that we should be emphasizing: DURABILTY. Durability is an intrinsic factor that exists independently of external influences. “Able to withstand wear, pressure, or damage; hard-wearing.” It is important to note that it is an outcome that can largely be predicted a priori. It indicates how long the intervention will yield a positive effect when the intensive effort to sustain it is withdrawn. A Ferrari is flashy and goes fast, but for durability, I’ll go with the Toyota. What distinguishes sustainability from durability?
Sustainability in part is determined by extrinsic factors that cannot be controlled: IF resistance does not develop; IF funding continues at the current rate; IF compliance levels remain at the optimal rate: IF the country control plan is submitted on time.
In contrast, following are features of interventions that I suggest lie on either extreme of the durability spectrum.
Excitement is transient. Acceptance is durable.
Intrusiveness is fragile. Invisibility is durable.
Exceptional funding levels are…exceptional. Stable, low-level funding (or less) is durable.
Suppression is not durable. Elimination and eradication are.
Intensive community activity is not durable. Background positive effects are.
Readers will correctly point out several failures and exceptions to all of the above generalizations. Have at it. The fundamental point stands. Interventions that have intrinsic durability are superior to merely sustainable ones. Durability can result from intensive community-based interventions, but only if they result in outcomes on the durable end of the spectrum. Exceptional funding for LLINs can result in durable interventions, but not merely by distributing bednets without consideration of what happens when the campaign ends. HOW an intervention is performed can afffect it's durability.
Durability can be built into any intervention, but the dismal prospects for resurgence of malaria indicate that in spite of spending a lot of money (and exhausting donors?) on interventions that were almost certainly claimed to be "sustainable," precious little durability has been created. I’d like to see this word appearing in a lot more publication titles in 2013.