The Best Album of 2006

The Best (& Bravest) Album of 2006 may be the recently released "Taking the Long Way" by the Dixie Chicks. In 2003 just prior to the Iraq War, lead singer Natalie Maines said the following at a London concert,"Just so you know, we're ashamed the president of the United States is from Texas."

The response back home was immediate. Country music stations boycotted their music, former fans burned their CDs, death threats arrived, and Natalie eventually had to move from her native Texas. Country music has thrived on themes of patriotism, lonely soldiers, and American pride since 9/11. Some would say this has been done honestly and earnestly; some would say ideologically. The story of the Dixie Chicks is illustrative then of how one of country's own disagreed, was labelled a traitor, and now, has emerged defiant and stunning as the War continues and our President struggles.

Returning to the Garden

As may have been hinted at, I am back on US terra semi-firma. Peace Corps Volunteers (PCVs) have said that the hardest thing about their program is not the going or the staying, but the returning. Hard to compare my 3 months to their 2+ years, but I have an inkling of what they mean.

More specifically geographically, I am outside my hometown of Savannah, Georgia. Savannah has been called the most beautiful city in North America. It is also famed for being the star of the nonfiction book Midnight in the Garden of Good and Evil. It's history is long (for an American city) and its beauty, natural and designed, is unparalleled compared to any other city in the US (except perhaps for San Francisco). What does this have to do with Global Issues? Well, see the Bruce Feiler article from the NYT I blogged on from a while back for one type of answer.
Photo: The fountain in Forsyth Park, Savannah, Georgia. (Photo by Chris Jeffords).

The Making of a Better Person

Spending time in the poor countries of our world may make one a better person, but I am not sure it necessarily makes you a happier one. There are simply innumerable ways to lose varying levels of innocence here at a rapid rate (e.g. experiencing death, poverty, injustice, repression firsthand) which can lead to guilt, disillusionment, bewilderment, and, at the end of the pot-holed road, despair. Resilience then becomes such a vital characteristic to possess and grow in this land.

A strange counter to this weariness of wordly souls may be the following phenomena: It could be that it is the relativeness of poverty, not the absolute level, that determines a person's health and social outlook. Will then a middle-class non-black Westerner (called mzungu in Luganda) suddenly thrust into a position of relative wealth and power in Africa reap the physical and psychic benefits of an increase in social position? Or (as has been reported at some of the seedier bars of Africa) will this unearned status elevation lead to a life of gluttony and corruption with the requisite associated unhealthy behaviors? Case studies requested.

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.

Beeping as Metaphor

Throughout Africa, many people will call from one mobile phone to another and deliberately hang up before the call is answered . . . but just long enough to have call missed and a number/name appear. This phenomena is called "beeping" or "flashing".

Beeping itself is free. It usually can be interpreted as a request for the beeped to call the beeper back, thus placing the financial burden of the call on the person beeped (due to most mobiles in Africa being based on prepaid rather than monthly charges). However, beeping can also have more subtle meanings. While seemingly nonspecific, contextually it can send a very specific message such as "I am outside waiting" or "'Thinking of you."

It can be remarkable what is able to be conveyed when you are forced to keep it simple--A ring tone can proxy for freedom of speech, a text message can rally a protest, and a beep can start an affair. It is said that necessity is the mother of invention, but human curiosity and finding new ways to flirt certainly help to move things along. . .

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.

Lake Victoria Triathlon

I "competed" in a triathlon for the first time last week as part of a team (I ran and please ignore the fact that we came in next to last). Lake Victoria is under significant environmental pressure, as are many water sources throughout the world. Running through the back roads of Africa, dirt paths, lush valleys, fascinated children, et al., reminds me of my runner friend Will Harlan, editor-in-chief of Blue Ridge Outdoors, and his wife, Emily Diznoff, a family physician and my magnificent friend since medical school. Together, they have been consistent, thoughtful friends of the environment for many years.

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 $100 Laptop

Nicholas Negroponte, co-founder of the MIT Media Lab and member of Motorola's Board of Directors, wants to build a $100 laptop to distribute (not sell individually) to children in the developing world. The premise of this endeavor, which will require technologic innovation as well as significant financial committments from governments to purchase these computers, is that such a device would provide children a tech-based leveraged education and enable them to better learn and succeed in a globalized world.

Some folks, such as Bill Gates, seem to think the idea is not worth the effort. Google apparently disagrees. One common critique of such enterprises is "This money could be better spent elsewhere (on food, vaccines, bednets, etc.)" or what might be called the Transitive Argument (refer to your math textbooks prn). I do not fully prescribe to this argument, because I am not always convinced that money which does not go to one thing would have gone to another.

Time will tell if the $100 laptop turns out to be just a fanciful idea or one that does begin a small revolution in education. Regardless, this type of project has captured the imagination of a group of people who might not otherwise be as engaged in thinking about solutions to the world resource gap, and this fact alone is perhaps enough to earn the initiative some level of support.

I Volunteered for What?!

Quasivolunteers (the chronically underpaid with do-gooder jobs), along with true volunteers, are everywhere in Uganda. Among this crowd, of which I will count myself included, the processing of 1.Coming here; 2.Being here; and 3.Going back; is an immediate and often prolonged (perhaps unending) internal/external discussion.

While at RSPH @ Emory, it seemed to me that there would always be a significant minority of good-hearted people who would go abroad and return disheartened and disillusioned. (A similar phenomena occurs with bright-eyed students entering medical school and transforming into cynical professionals). Is this avoidable? It appears we are reliant upon the good will of certain persons to "volunteer" for the altruistic jobs of an unequal world. This does not seem to be adequate as the needs still massively trump resources--human and financial. It is not, in the words of development folk, "sustainable."

It could be because most of us are NOT saints (shocking!). To paraphrase, this group of individuals has not perfected goodness, but they have seen what it means to be a good person and to want to strive for it. Recognizing that this cadre still finds the following occasionally attractive and sometimes irresistable: hot showers, tv, money, etc., . . . relative luxuries in an external environment of poverty, humanizes these humanists. And, brings us closer to a workable reality and, therefore, sustainability.

So, how to approach this issue. There do appear to be some good resources out there. And, I would refer back to the Global Health Corps previously noted on this blog as a good idea whose time has come, yet due to lack of political will has not.
Photo: A different type of California Salon. Taken in Ghana 1999.

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.

Show Me the Passport.

I had a feisty conversation with some Canadians last night about whether Americans or Canadians are more internationally-focused (or really, which country was more insular). It is interesting to note that probably only 1/4 to 1/3 of Americans over 18 even have a passport. However, Mark Twain counseled caution, in a way, of travel snobbery. This having been said, I think I would err on being too well-traveled than too lightly. And, having done so, to try to keep learning humility in the process.

Are Double Lattes Sinful?

The Economist recently published an interesting article about Starbucks and its founder, Howard Schultz. While it may seem easy for some to villify any large, multinational corporation, Mr. Schultz seems to have done some very positive things with and within his company. For instance, that Starbucks gives comprehensive health insurance for all employees working >20 hours is commendable (though sad that his model is an exception to the rule). One striking fact from the article is that Starbucks spends more money on health premiums than on coffee! Personally, I would be thrilled if Starbucks starting opening stores in this part of the world.

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.

The Next (Same) President

The elections in Uganda are over. The current president, Yoweri Museveni, won again. Overall, most seem to be relieved, as it would have been absolute chaos if Museveni had not won. The main challenger is protesting the results though, and it remains to be seen how his future (and his sometimes rowdy supporters) will play out. I was actually in a remote game park during the elections and found out the results via, you guessed it, a Uganda SMS mobile phone text messaging service
Photo: Voting in Kalisizo on Election Day.

Election Eve

Well, things are heating up around here. The Ugandan elections are tomorrow and there has been some low level rioting in the capital. However, friends and family will be happy to know that I am in the semi-rural Rakai District currently, away from the capital and will be leaving tomorrow for a game park near the border of Rwanda. Our escape plan is to move into Rwanda if things go truly awry in Uganda (times have changed so quickly that Rwanda has become the escape route for potential political chaos in this part of Africa). Many ex-pats have acutally left already, hotels around the smaller city of Entebee, where the airport lies, are full, so that if there is an airlift people will be able to get to the airport quicker! I am at the Rakai Health Sciences Project (RHSP) now, in a very nice, new building (with wireless internet) and trying to get my project off the ground. Much more on RHSP to come.

Good Governance

Somewhat alarming were the recent deaths at an opposition gathering in Kampala. What does it mean to have good governance? The US government established some potential critieria for their Millenium Challenge Account, but it has subsequently been criticized for giving out very little money. And, some might argue American inconsistency with some of the principles we are espousing. While it may seem patent that good governments and economic development are directly related (Mugabe trashing Zimbabwe's economy is a good example), the reality is probably a bit murkier.