Big ideas


In a year of many dispiriting headlines, “Fixes” still found the better angels of human nature at work.

O.K., so Time magazine has Greta Thunberg. But many other individuals also changed the world for the better in 2019. Here, for a second year, is a list of five whose contributions “Fixes” wrote about:

Scott O’Neill fights tropical disease

“People who understand dengue and live in transmission areas are horrified and scared.”

There’s a new weapon in the fight against mosquito-borne diseases.

Before 1970, only nine countries had experienced severe epidemics of dengue fever. Now, the disease is endemic in 100 countries, infects 400 million people a year and is intensifying rapidly.

Like Zika and chikungunya, dengue is spread by the bite of the Aedes aegypti mosquito, and no workable vaccine or cure has been found.

The normal public health response to mosquitoes is attack: spray pesticide, eliminate breeding grounds and help people ward off their bites. But these strategies have failed to control dengue. The world is desperate for something new.

Scott O’Neill leads a team that is doing just the opposite — adding millions of mosquitoes to areas affected by disease.

Professor O’Neill directs the World Mosquito Program, which is based at Monash University in Melbourne, Australia. The mosquitoes the program releases are infected with Wolbachia bacteria, which block their ability to transmit disease. Wolbachia occurs naturally in most insect species and is harmless to vertebrates and humans. When enough Wolbachia-infected mosquitoes are released, they take over the whole population.

The World Mosquito Program tests Wolbachia in 12 countries in Asia, Latin America and the Western Pacific. While it started releasing mosquitoes in 2011, large-scale trials are fairly new — and the evidence released this year is promising. The Wolbachia initiative has nearly eliminated local transmission of dengue in the parts of Australia where it has been tried. In Yogyakarta, Indonesia, Wolbachia zones had 76 percent fewer cases of dengue than other areas. Wolbachia has also led to reductions in disease in Brazil and Vietnam.

Kimberly McGrath heals trafficked children

"Now we know they really are just extremely traumatized youth.”

What happens to a child who is exploited commercially for sex?

Kimberly McGrath is changing the answer to that question. Historically, trafficked children have been arrested for solicitation and sent to juvenile court.

Today, all children sold for sex are, by definition, trafficked. Yet some are still arrested. Most are sent to group homes. “The core understanding was that these were defiant, rebellious youth who would rebel in a family,” Dr. McGrath said.

In 2013, Florida officials asked Dr. McGrath, who coordinates foster care services at the Citrus Health Network in South Florida, to come up with a different response. She started from the premise that these children were not defiant criminals. A vast majority had been abused, which made them more susceptible to the manipulations of traffickers. And they had never gotten help to recover from that abuse.

Dr. McGrath and her colleagues looked at what had worked for other traumatized children and adapted it to trafficked children. They educated not just therapists and social workers, but also foster parents.

It has been difficult to recruit foster families, but Dr. McGrath’s program has done it — finding courageous and dedicated families who receive special training and help from psychologists and social workers. This therapeutic foster care costs less than group homes, and the children do better in every way. “When foster parents are equipped and prepared to deal with their special needs, children thrive in family-based environments,” she said. “They really are just traumatized kids.”

Dr. Dixon Chibanda transforms global mental health care

"I started to realize that psychiatry in an institution is not the way to go. We have to take it to the community.”

Depression occurs everywhere. By some measures, it’s the world’s most debilitating disease.

But treatment is not everywhere. Even in New York City, less than 40 percent of people with depression get treatment. In poor countries, it’s closer to zero percent.

So what can be done in places with no public mental health care and only a tiny number of mental health professionals?

As with medical care, the answer is training nonprofessionals.

Every health clinic in Harare, Zimbabwe, has a “friendship bench” in its yard. It’s an ordinary wooden bench. Seated on it is a community health worker with a few weeks’ training in problem-solving therapy.

Patients go to the bench, talk to the health worker about their problems and come up with possible solutions. They go home and try them, and return.

The friendship bench was invented in 2006 by a psychiatrist, Dixon Chibanda, after a patient committed suicide. He had asked her to come see him at Harare Central Hospital, but she lived in another city and didn’t have bus fare.

Dr. Chibanda decided to bring treatment for depression to Harare’s health clinics. At first he wanted to train nurses and put offices inside the buildings, but the nurses had not enough time and clinics had not enough space. But what seemed like a setback is what has allowed the program to spread.

Now, there’s a bench in the yard of every government-run health clinic in Harare, and the practice is spreading throughout Zimbabwe and to other African countries. In a different form, the strategy has also reached New York.

Research shows that friendship benches are effective at treating depression. And what makes them even more valuable is that they are cheap and piggyback on government services. They provide a treatment that works — and that could reach anyone.

Dr. Rebekah Gee makes medicines affordable

"Why couldn’t we change health care in this country?”

Louisiana is doing two things no other state is doing about hepatitis C, which kills more Americans than all other infectious diseases combined.

One is that the state is suddenly treating more people.

Hep C is curable — but the drugs are astronomically expensive. Even the cheapest generic version in the United States costs $24,000 for a course of treatment. (In India, the same drug is $550.) Because of the price, state Medicaid programs ration the drugs. In 2018, Louisiana treated 1,200 people.

Contrast that with the period between mid-July of this year and late November, in which Louisiana treated 2,290 people.

Louisiana could do that because of the second innovation: The drugs were made a lot less expensive. In July, the state began buying hep C medicines in a new way. Just as you pay Netflix a flat fee for all you want to watch, Louisiana now pays Asegua Therapeutics $58 million per year for all the hep C medicine the state can use. That still means huge profits for Asegua, since the cost of making each new pill is negligible. If Louisiana meets its goal of treating 10,000 people in its first year of operation, from July 2019 to July 2020, that will cut the price per person to about $6,000.

Dr. Rebekah Gee, Louisiana’s secretary of health, adopted the scheme from Australia, where it has allowed Australia to treat seven times as many patients for the same money. Louisiana is the first state in America to do the same. The State of Washington is about to start as well. Other states are likely to follow.

Everyone talks about bringing down drug prices. But the power of the pharmaceutical industry has staved off reforms — except this one.

Phil Keisling deepens democracy

“For millions of citizens, especially those with uncertain work schedules, family obligations and other daily demands, the traditional polling place has now become the most powerful voter suppression tool of all.”

There’s a lot of attention, and rightly so, paid to Republican efforts to suppress voting. But there’s also a movement in both parties to expand voting. It abandons the traditional polling booth in favor of voting at home. It’s one of the most effective ways to increase turnout — possibly the best way.

Increasingly, other states are following the path first set by Oregon, which mails every voter a ballot. Voters fill it out at their leisure and mail it in or drop it off at a ballot center.

In next year’s elections, all voters in Oregon, Colorado, Washington, Utah and Hawaii will vote at home. California will soon follow. Large parts of North Dakota and Nebraska vote at home. In last year’s midterms, 69 percent of all votes in the West were cast by voters who received ballots in the mail.

Phil Keisling was Oregon’s secretary of state, in charge of elections, when Oregon began home voting in 1998. Now he leads the Vote at Home Institute.

The institute asserts that it saves taxpayers money (some election officials disagree). It argues that because the approach uses paper ballots, it’s secure against hacking. As for whom it helps, proponents in both parties claim it has bipartisan benefits.

Home voting probably doesn’t affect turnout in big elections. But it does in local elections, races at the end of the ballot, ballot propositions and judicial elections. Turnout for these elections can be in the single digits. For those races, a ballot on the kitchen table turns many more people into voters. So the answer to whom it helps is: democracy.

Tina Rosenberg is a co-founder of the Solutions Journalism Network, which supports rigorous reporting about responses to social problems. This opinion piece was originally published in the “Fixes” column of The New York Times.

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