Spring 2012

Global Health: A Story Rarely Told

‘Today while billions of dollars [in aid] are lost to corruption and dysfunction — and billions more save many lives — both traditional and new media are too often missing this important story altogether.’

By Stefanie Friedhoff
Last fall I pitched a story to a few colleagues at U.S. news organizations. I thought it would make a great investigative piece. The pitch started like this:
Almost two years after the devastating earthquake, Haiti is home to the largest cholera epidemic in the world. Cholera is a disease that can be prevented and treated easily—yet over 6,000 Haitians have died of it within the past year and over 450,000 have fallen ill. In the aftermath of a disaster, outbreaks of water-borne infectious diseases are typical but the inadequate response to the cholera epidemic in Haiti is shocking.
My pitch didn't succeed for a variety of reasons. A wire service passed because a long story on Haiti had been done three months earlier and it was too soon for another. A newspaper colleague replied that the cholera epidemic wasn't news anymore. A magazine editor said the foreign travel budget had been spent on covering the nuclear disaster in Fukushima, Japan. Finally, a broadcast colleague said such a story would contribute to compassion fatigue in the audience.

In global health, the stories that matter are rarely news … and the truth about how hard it can be to help people in need can indeed be numbing. After more than a decade as an international science correspondent and six years at the Nieman Foundation coaching global health journalists, I wasn't surprised. In global health, the stories that matter are rarely news; the resources and commitment it takes to investigate programs and major players are rarely available; and the truth about how hard it can be to help people in need can indeed be numbing.

In fact, as anyone who has ever tried to pitch a global health story knows, enthusiastic responses are rare. This reminds me of covering the genetic revolution in the 1990's, before journalists began to understand how deeply the discoveries in molecular biology were changing society. Even in 2001, when I was a Nieman Fellow, covering genetics was still referred to by colleagues and some prominent Harvard faculty as the "broccoli" among the topics a journalist could pursue. As a result, for years the public remained rather uninformed about the sweeping legal, medical and social implications of gene technology.

That has changed, obviously, and questions about how genetic information may transform our health insurance system, for example, are now part of the national conversation—thanks to excellent, in-depth reporting on the subject.

Just as with the genetic revolution, it is taking journalists time and effort to recognize, investigate and interpret the far-reaching political, social and economic impact of the globalization of health care. Global health is a phenomenon that many inside and outside of journalism are still trying to wrap their heads around.

A woman, infected with HIV, at a hospice in Harare, Zimbabwe. Photo © Kristen Ashburn.

What is Global Health?

Even the term itself is fairly new. The field used to be called international health. The change represents a new worldview: As industry, technology and the global spread of AIDS have made the world a much smaller place, health is increasingly being recognized as a social justice issue—one that underlies all other development, from the healthy growth of individuals to economic productivity and national stability.

Where international health dealt with infectious diseases in developing countries, global health today focuses on all health challenges, everywhere. It asks for cooperative action and solutions, not mandates for developing countries. It asks for shared responsibility for the welfare of all people. Jeremy Greene, the Harvard physician and historian of science, says, "Global health has become a visible and apparently universal good for our times, a moral imperative that has captured the imaginations of many around the world—albeit often to quite different ends."

To be sure, there has been some outstanding reporting on some of these developments, such as a 2007 Los Angeles Times investigation into the Bill & Melinda Gates Foundation's investment practices and some unintended consequences of donor generosity. But the rise of global health coincided with the collapse of foreign and explanatory reporting, and, as a result, many in traditional journalism, including the Los Angeles Times and The Boston Globe, had to abandon their initial efforts. Today while billions of dollars are lost to corruption and dysfunction—and billions more save many lives—both traditional and new media are too often missing this important story altogether.

In December 2011 about 30 freelance and staff journalists came together in Boston to share what they have learned covering global health. The workshop, co-hosted by the Nieman Foundation, and the Kaiser Foundation Media Fellowship Program, drew journalists from news organizations such as The Associated Press, The Guardian, The Times of India, Public Radio International's (PRI) "The World," The Lancet, and the nonprofit video start-up Global Health Frontline News.

A mother pays her respects to her son at a wake in Balti, Moldova. Like many inmates in the former Soviet Union, Dumutru Stupalov contracted multidrug-resistant tuberculosis in prison. Photo by David Rochkind/Pulitzer Center.

Major Obstacles

Drawing on our discussions and my experiences as an international science and health reporter and editor, I'd like to share five major obstacles to global health reporting as well as a few exemplary ways in which individual journalists and news organizations have overcome these barriers:

No foreign correspondents left to follow the story. Between 2001 and 2011, foreign health aid to developing nations quadrupled from $7.6 billion to over $28 billion. During the same period, 18 newspapers and two newspaper chains in the United States closed all their foreign bureaus. Without staff overseas or a travel budget, newspapers cannot assess promises and programs on the ground.

GlobalPost is one new media venture trying to fill the void. Its yearlong project "Healing the World" focused on the Obama administration's Global Health Initiative and delivered reporting from Nepal, Kenya, Guatemala and other nations to assess how the initiative is working. Up to that point, there had been little coverage of this flagship foreign aid program since it was announced in May 2009. In a departure from GlobalPost's for-profit model, this project was supported by the Kaiser Foundation Media Fellowship Program.

Health stories are rarely news.
Except for fast spreading infectious diseases such as pandemic influenza, most global health stories lend themselves to investigative and explanatory journalism, not breaking news. Few people will want to know that the World Health Organization (WHO) released a 100-page report on clean water. What people need to know is that in the absence of access to clean water and health care, diseases may appear that will not stop at borders but will end up sickening everyone, rich or poor. That's explanatory journalism.

What they also need to know, for example, is how much of the taxpayer money that the United States Agency for International Development (USAID) pumps into health projects worldwide actually reaches the people it is intended for and how much of it stays with U.S. contractors. That's investigative journalism.

Domestic newsrooms, however, are facing the same troubles as foreign bureaus, and many journalists with experience in explanatory and investigative journalism have been laid off. At the same time, nonprofit investigative journalism centers often have regional missions or focus on more traditional investigations.

By focusing not on breaking news from conflict and disaster zones but on in-depth reporting about the underlying causes of political crises, environmental disasters, poverty and suffering around the world, the Pulitzer Center on Crisis Reporting presents an interesting example of a new media venture that is trying to save foreign reporting while redefining it. The center has done some groundbreaking reporting on water and sanitation, for example, as part of its Downstream project. These multimedia collaborations with National Geographic and PBS's "NewsHour" are available online and are part of the center's outreach to schools and universities. The Pulitzer Center also works with Nieman Global Health Fellows on the production and placement of their reporting projects.

Finding the narrative in the issue.
Global health too often is viewed as a series of issues. HIV/AIDS is an issue, so is malaria, lack of sanitation, and the need for better health care systems in poor countries. But issues are not stories, and people, except for public health wonks, do not relate to issues.
“We cannot adopt the mindset and the jargon of nongovernmental organizations. If we want people to listen, we need to tell a tale.”


"I get too many pitches that are boring," said David Baron, health and science editor at PRI's "The World," at the recent workshop. "We cannot adopt the mindset and the jargon of nongovernmental organizations (NGOs). If we want people to listen, we need to tell a tale. We need to move people emotionally."

Baron did this, for example, by working with a reporter who pitched a story about maternal mortality in Haiti. He helped the reporter craft a narrative that allowed listeners to follow the journey of an American midwife, a volunteer, who arrived full of idealism, confronted unexpected challenges, and returned home with a more sober understanding of Haiti's complex health problems.

It's complicated. Even a reporter as experienced as Christine Gorman, a 20-year veteran of Time magazine who is now senior editor for life sciences at Scientific American, describes this field as "maddeningly opaque." Thirty years ago there were only three major international bodies designing international health policies and programs (WHO, the World Bank, and the International Monetary Fund) as well as a few key NGOs.

Today, there are thousands of NGOs of all sizes and several powerful new players, such as the Gates Foundation and The Global Fund to Fight AIDS, Malaria and TB. To put this in perspective, the Gates Foundation's annual budget for health programs recently surpassed that of WHO.

Just as in environmental journalism or business reporting on globalization, complexities are best conveyed when journalists find narratives that identify a problem, who's to blame for it, and how it affects us all. In her award-winning series "When Drugs Stop Working," The Associated Press's Asia-Pacific medical writer Margie Mason did just that.

While engaged in her Nieman global health fieldwork, Mason discovered that there was a young man with extensively drug-resistant tuberculosis in a Florida sanatorium—unbeknownst to the public. This meant that for the first time, a tuberculosis strain entirely resistant to antibiotics had entered the United States. It was the perfect segue into the broader story about how agricultural practices and bad policy decisions contribute to the rising problem of drug resistance.

There is very little training. If you were to start covering global health today, you'd find very little instruction on how to decipher World Bank reports or drug patent laws around the world, for example. While journalists are used to educating themselves on any given topic, professional organizations such as Investigative Reporters and Editors or the Association of Health Care Journalists (AHCJ) have long shown that reporters covering complex subjects benefit from tailored training that includes learning from experienced peers.

There is no professional organization devoted to training global health journalists. (To be fair, AHCJ and the World Federation of Science Journalists each feature a few sessions on related subjects in their flagship conferences.) And there are few in-depth online resources beyond what the Henry J. Kaiser Family Foundation offers.

The Road Ahead

Beyond the few distinct opportunities that currently exist—such as the Nieman fellowships at Harvard or the fellowships provided by the International Reporting Project at Johns Hopkins University—journalism schools have a role to play in pushing this beat forward, both via professional training and academic inquiry. In addition, the journalists who cover global health must come together to share experiences and resources and establish a way to move ahead. The seed for that was planted at the meeting in December.

There are a few other obstacles, such as compassion fatigue in audiences and the claim that global health reporters practice advocacy journalism. They are not unique to global health or the new media landscape, however, and have been addressed well by environmental journalists.

What has not been addressed yet is how journalists can get better at showing how global health affects local health. How drug resistance halfway around the world for example led to changes in how doctors in U.S. communities prescribe antibiotics for ear infections in children. How some African and Asian countries struggle to care for their sick because their health care workers are recruited straight out of nursing school by companies in the U.S. and the U.K. How the outsourcing to China of the production of many active ingredients in popular drugs has led to some holes in quality control that trouble even the U.S. Food and Drug Administration.
‘What Gets Attention, Gets Funded’
- Stefanie Friedhoff

Without such narratives, global health will remain an obscure and elite activity to many. Ten years from now, I hope the public will be as informed about the evolution and consequences of the globalization of health care as it is today about the far-reaching impact of the genetic revolution.

Stefanie Friedhoff, a 2001 Nieman Fellow, is special projects manager at the Nieman Foundation and a freelance journalist for U.S. and German media.

5 Comments on Global Health: A Story Rarely Told
Phuong Tran says:
June 23, 2012 at 11:48am
I am the health focal point for IRIN, a crisis newswire founded by the UN following the Rwandan genocide to address the lack of on-the-ground reporting and analysis on life threatening/debilitating issues.

Despite our long formal name and, therefore, typically strange UN-like acronym, we are completely editorially independent of the UN.

Headquartered in Nairobi, we have five news bureaus. I started in our West Africa bureau and am now based in Bangkok- still on the health beat. We are partners with (syndicated in) The Guardian's Global Development portal- in the aforementioned link provided in the article.

When Stefanie writes about the shortage of global health reporting, I assume that is mainstream media, which does not include IRIN (and its counterparts like AlertNet, Panos, Interpress Service, Allafrica.com, whose mandates are to focus specifically on global health and other humanitarian issues).

But as newswire services, some of our coverage can be syndicated/re-printed, at no cost in IRIN's case.

The points raised are valid. Even when there are news bureaus outside the US, they are in cities with adequate (a relative term) infrastructure for filing reports. It is not where the coverage needs are, necessarily, and travel is still arduous (to get to Indonesia'a West Papua province, or South Kordofan from Nairobi, is epic).

I just returned from the far west hilly region of Nepal where after trekking for hours to visit a sub-health post, I was told they had not had any journalists- local or international- since the height of the Maoist insurgency, about a decade ago. This in an area where the rates of acute malnutrition are above the accepted international emergency threshold of 15%, where almost half the under-five population is stunted.

If you are not already working with or are in contact with humanitarian news outlets like ours, I encourage you to read our material and to reach out for backstories.

Not only do we spend our time scanning medical journals, blogs and aid reports, we live in and report from the "field". So while Nepal, Vietnam, Equatorial Guinea and other countries on paper have already reached the Millennium Development Goal 5 of boosting maternal health, we can help explain why but also highlight stories the numbers hide. Universal access to ARVS? But what about dismal pediatric ARV treatment adherence due in part to packaging, storage and cold-chain issues? New improved vaccines? But how to transport, package and store when so little of a country is connected to electricity? New health facilities? But what about staff when most fled in a recent conflict, are going to higher-paying countries (including the US) and the remaining have minimal training? The push to focus on "growing" threat of NCDs? Even here in a middle-income country like Thailand it is hard to get cholesterol readings outside of cities.

From the "big" questions- what happens when donors control the public health agenda and muzzle scientific critique? Is it time to dismantle WHO? How to fix a broken health R&D system (is it possible for altruism rather than profit to drive health innovation)? Are we running out of antibiotics?- to the more scientific/pedestrian/news shorts, we are stretched quite thin.

I welcome your feedback and pitches. Hope those of us outside the US covering global health can also contribute to the conversation on boosting coverage. (Most of IRIN's readers are actually in the US).
Stefanie Friedhoff says:
April 12, 2012 at 12:02pm
Thanks to NPR and Richard Knox for this terrific piece on cholera in Haiti today: http://www.npr.org/blogs/health/2012/04/12/150302830/water-in-the-time-of-cholera-haitis-most-urgent-health-problem
Tom Paulson says:
March 26, 2012 at 10:37am
Thanks for replying Stefanie,

We talked 'offline' so I believe you know where I'm coming from on this. My concern was not so much about who got, or didn't get, mentioned in your article. It is about fostering true collaboration.

I recognize that you can't always include everyone in every endeavor. But as you note, there really aren't that many of us working as full-time journalists covering global health and development.

I sought you (along with Christine Gorman and others) out when I first suggested the idea of creating a global network of journalists covering this stuff. I contributed to Kaiser report on global health media.

There are perhaps (unfortunately) only a dozen or so journalists in the U.S. who I can identify as currently devoted to these issues. That's the problem here, as you so ably wrote. But it also means it shouldn't be that hard to get them all in one room, or at least on a conference call.

At the risk of sounding, well, cranky, those of us doing journalism up here in the soggy left-upper corner of the country often feel forgotten by the (self-appointed?) media centers of power. Yet arguably, Seattle is the epicenter of global health today.

Next time, at least give us a shout to let us know when you folks on the East Coast are trying to help us do our jobs better.


Stefanie Friedhoff says:
March 22, 2012 at 1:22pm

thanks for your feedback. I'm sorry I wasn't able to mention everyone doing great work or innovating in global health journalism.

I often bring up your site, www.humanosphere.org, as an important and groundbreaking resource. I praise it when I talk to students about global health reporting in Paul Farmer's 'Case Studies in Global Health' class at Harvard. Or when I moderate local panels on global health and media, pointing out that Boston is a place where your model could be replicated, since you cover global health as both a global and a local story in Seattle, a city that has a significant global health industry--just as Boston does.

I should have underscored that my article is not a comprehensive list of all resources or players; thankfully, even on this underpopulated beat, there are too many to mention in one piece.

Sarah Boseley of the Guardian writes an important blog, for example, http://www.guardian.co.uk/society/sarah-boseley-global-health and it is interestingly different from the Guardian's reportedly first venture into Foundation-funded content generation via both traditional and citizen journalists on its Global Development website, at http://www.guardian.co.uk/global-development

Global Health Frontline News is another interesting recent innovation, just a year old and with a start-up broadcast model, at http://www.ghfn.org/ Or take globalhealthhub.org, arguably the first to aggregate global health and development news from around the world using news verification software, occasionally also providing original content. There is www.scidev.net and PRI's Global Health and Development podcasts http://www.publicbroadcasting.net/pri/.jukebox?action=viewPodcast&podcastId=14483 and more.

Yes, it would have been great to have had you at the gathering in December. There are at least a dozen names on the list of people who would have been terrific voices to bring in. Yet funding is always an issue. In an effort to enlarge the conversation and be inclusive, for the few people we could invite from out of town, we focused on journalists who hadn't been at the discussion of Kaiser's "The Future of Global Health Journalism" report that you attended in D.C. in February 2011. The idea was to try and bring more voices we hadn't heard from yet, and then bring everyone together via a listserv to start collaborating, networking, and forming a community.


Tom Paulson says:
March 21, 2012 at 4:03pm
Thanks Stefanie for this overview,

I agree wholeheartedly. But I do have a bone to pick regarding 'collaboration.'

You write about how few journalists there are out there devoted to covering global health and development, mentioning some reporters you regard as notable exceptions (all, I think, former Nieman Fellows).

I admit I had hoped to see some mention of Humanosphere.org.

But no mention.

yet Humanosphere is one of the few sites in the U.S. devoted solely to coverage of global health and development, run by NPR affiliate KPLU in Seattle. But still, no mention of it in your lengthy article describing the state of global health and development news.

Yes, I'm being self-promotional. But what I'm really after is community support.

You wrote that we need to come together and that the seed for journalistic collaboration was planted at a meeting you held in December. I wasn't invited to that meeting, and only learned of it later when I read about it in GlobalPost.

I agree that collaboration will be critical to filling this gap. I agree with nearly everything you say here in this article.

But we need to actually work together, support each other, and make collaboration more than simply a concept.

There are today so few of us -- working journalists in the U.S. devoted to covering global health and development -- it really shouldn't be that hard to invite everyone to participate in the discussion.


Tom Paulson, www.humanosphere.org
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