Abstinence versus The Healthy Penis

The results of a US government sponsored study on abstinence-only education were recently revealed. The results may not surprise you--it doesn't appear to work. Abstinence-only policies have been a cornerstone of current domestic and foreign health-related programs, at significant financial cost. A funny and fascinating contrast to this failed health promotion strategy is the Healthy Penis campaign. This public health multimedia initiative has evidence to back up its successes and is quite a contrast to bland abstinence-only lectures.

Conference Eve

It is the day before the official start of the XVI International AIDS Conference (IAC) in Toronto. The global health paradigm shifting Gates Foundation's eponymous leaders will help open the plenary. Celebrities will be circulating. And, political leaders cueing. One fact about the IAC that seems surreal but is quite true is that the IAC is no longer held in the United States (where it was founded) because of the US policy of denying visas to persons living with HIV/AIDS. This year's conference will be the largest ever, with an estimated 25,000 participants to attend.

Big Pharma, Cynicism, and Truth

The 3rd International Film Festival of Uganda is ongoing in Kampala right now. I was fortunate enough to see The Constant Gardener this past weekend (for free!). A good movie about a corrupt pharmaceutical company (Big Pharma) running a dangerous drug trial on coerced Africans. Fiction, right? Can we just praise and dismiss this as an emotive, skilled, but ultimately cynical act of story-telling by a liberal, bleeding heart filmaker?

I actually hate conspiracy theories, but I'll be damned if I didn't read the following in the Washington Post the very next day: Pfizer faulted over drug trials in Nigeria. Pfizer happens to be the world's largest drug company if you're keeping track of such things. And, I'll be damned if I didn't meet a bunch of representatives from a contract-research organization (CRO) yesterday searching out sites in Africa for clinical trials of new tuberculosis drugs. It is almost enough to turn a pragmatic idealist into a paranoid cynic.

Photo: Kibera, an urban slum in Nairobi, Kenya where many scenes from The Constant Gardener took place. It is home to ~1 million persons living in rather depressing conditions. Taken 2001.

The Cultural Contradictions of International Research

Research in the developing world is quicksand, firewalls, and floods occasionally punctuated by light skies and cool winds. One thorny issue, suppressed to varying levels of depth in researchers' psyches, is the problem of ethics. Ethics not just in the sense of does Drug A's potential benefit outweigh its potential risk, but the foggier and subtler ethics involving cultural difference, the motivations, explicit and buried, of researchers and their collaborators, and the fundamental, overt power discrepancies between the North and the South.

Some folks talk of the 3 M's of global health: Missionaries, Mercenaries, and Misfits (a fourth M has also been proposed--Meddlers). Useful caricatures to a certain extent, but we certainly live in a more ambigious reality where many who work in RLS (resource-limited settings) have a mix of these characteristics--some of which may be in conflict. And the evolution/devolution from one M to another is a constant source of intrigue, talk, and concern.

What's God got to do with it?

Just as you can not ignore culture and ethnicity when confronting AIDS in Africa, it would be a mistake to dismiss the role of religion. Religion permeates so much in this arena, from missionary hospitals to PEPFAR policies to patient and provider beliefs and behavior.

Religion does not necessarily need to be a divisive force. A friend of mine, Jennifer Gross, worked at a Christian faith-founded hospital while in the Peace Corps though she was not Christian. And I happen to work with a Catholic faith-based organization, Reach Out Mbuya, while not being Catholic.

Photo: The motto for Kiwoko Hospital where Ms. Gross worked. A hospital in the middle of nowhere originally founded by missionaries. Interesting fact: Hospital has baby incubators run off solar power. Taken February 2005.

Modern Medicine Man

Chance, African spirits, or some other force crossed my paths with an American psychologist, Jamie Fish, who is working with and studying traditional healers in Uganda. Ms. Fish invited me, quite literally, into the forest to teach and learn with these healers. Curious, I did so and spent an enlightening time participant-observing their classes and reciprocated by answering their questions about HIV/AIDS.

Traditional healers significantly outnumber medical doctors in Uganda--a common phenomena in much of the developing world. To many, they are the frontline health care worker. How then do we incorporate them (or they incorporate us) into the care of the sick?

A pragmatic stance would be "Use what works." The rub with traditional medicine has long been proving it works. But the scientific method and traditional medicine need not be in opposition and, in fact, can be quite, ahem, complimentary. For example, the US has the National Center for Complementary and Alternative Medicine which uses scientific rigour to evaluate these types of therapies. And, one of the current best treatments for malaria, Artemesinin, is derived from a Chinese plant used by traditional healers for centuries.
Photo: Botany class at PROMETRA Traditional Medicine Training, Research, Treatment, and Demonstration Centre, Buyijja, Uganda, March 2006.

Why Did I Die?

One of our patients died yesterday. She did not die of AIDS or from a side effect of the HIV medicines she was taking. Instead, this is a young woman who had become pregnant with a child she did not want. She tried to self-abort her pregnancy (abortions are illegal in Uganda) and something went horribly wrong. She collapsed and died on her way to a local hospital.

This is not meant to be a pro-choice post. Or pro-women even. But to ask again the question as to how a person comes to such a place and end. And, of course, what can be done about it? The modest goods which might come from this sadness is to think more deeply about the context in which health care (HIV care in this case) must exist in to thrive, rather than to be so brutally and wastefully stunted.

Are you PeerSMART?

Some friends have asked what the heck I actually do in Uganda. Every day I have a different answer. But, one thing I am helping do is jump start a peer educator program, called PeerSMART (Peer Supporter and Mentor for AntiRetroviral Therapy). The premise is that people living with HIV/AIDS (PLWHA) on ART will benefit from having some of their peers as frontline service providers to promote drug adherence and monitor for illness and medication side effects. These peers may then help ameliorate the large health care provider deficits found throughout the developing world.
Photo: Inaugural PeerSMART class of the Rakai Health Sciences Program. Taken March 2006.

The Sickness of AIDS Denialists

Harper's, a historical and historically commendable magazine, has published in its March 2006 issue one of the more irresponsible and inaccurate articles in the modern recollection of mainstream media. For a magazine of its previous stature to publish the blatantly biased and poorly fact-checked article by AIDS Denialist Celia Farber entitled "Out of Control: AIDS and the corruption of medical science" is inexcusable and should have real consequences for its editors and publisher, not to mention the author. If you do read the piece, having this point-by-point guide to Farber's errors is quite helpful.

There is a wealth of scientific evidence on HIV as the causes of AIDS, the consequences of HIV/AIDS, and the beneficial effects of medicines for HIV (called antiretrovirals or ARVs.). The distrust of Big Pharma (collective name used by many for large, multinational pharmaceutical corporations) and other large, "establishment" organizations such as the government and academia, is not new, and unfortunately, not entirely unwarranted. But, paranoia and conspiracy theories must be distinguished from healthy skepticism and objective critique.

We are faced with the most devastating disease in history, and Denialists are delivering harm through self-deception, individualistic narcissism, and cynicism. I will not pretend to fully comprehend the psychology of these Denialists (though I think it may be helpful to try and understand them from a personality disorder perspective), but I believe their words and actions are sources of confusion and needless suffering, and, for some, believing in their disbelief can lead to an untimely, unecessary death. The sniping voices of the Denialists should not be given a larger audience through a magazine such as Harper's, and it is unfortunate and shameful that they were.

Money, Money Everywhere . . .

We are in a remarkable new era of philanthropy, especially for the global health community. Unprecedented resources (think Bill Gates) are now combined with a more rigorous, businesslike methodology to giving. But could we actually have too much money going into Global Health? As one works in the HIV clinics in Uganda (average yearly income ~$300 per person) and have the resource-limitations omnipresent in clinical decision-making, the obvious answer is an emphatic, No. Money alone, of course, is only part of picture; the human resource shortage is real. Certain organizations (some previously noted on this blog) help fill this gap, and others exist such as GeekCorps.org and medically-oriented volunteer opportunities. Still, a more holistic, large-scale approach to paying for and promoting global health careers would be ideal.
Photo: A Ugandan HIV clinic on wheels that visits rural communities once every two weeks.