Serbs Them Right

October 28, 2006

Serbia is voting this weekend on its new constitution. The controversial part is that the new constitution (necessitated by Serbia’s split with Montenegro, which opted for independence earlier this year) maintains that Kosovo is an “integral part” of Serbia. And most Kosovars disagree. Serbian politicians have urged citizens to either vote for the new constitution or risk “grave consequences”.

Kosovo is currently governed by the United Nations Mission in Kosovo (UNMIK), with security provided by NATO. Since most Kosovars want independence from Serbia, the UN will likely eventually give it to them, and hopefully Serbia won’t have the military might (or will) to resist seriously. So Serbia’s new constitution will likely have no impact on Kosovo’s actually status.

Instead, it could hurt Serbs themselves. Serbia is hoping to join the European Union sometime soon, and without protection for the rights of (or possibly independence for) Kosovars, Serbia’s chances of joining the E.U. are close to nil.

From my short time in the former Yugoslavia, I got the impression that everything I had read was more or less correct. Blind nationalism and religious self-righteousness were found on all sides. The Serbs just had better weapons, so the others suffered more.

Hard feelings are close to the surface between ethnic and religious groups. Over breakfast coffee in Split, right next to Diocletian’s palace, a former Croatian tank commander told me about fighting for “his country, his people”, gesturing that he smiled when he got to fight.

And I realized a sort of truth about pretty much every war in history. What group has ever gone to war without believing that fate, or luck, or righteousness was on their side? And what people have fought a war not believing God was on their side?


Quitting for Democracy

October 26, 2006

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This guy might be on to something.

Mo Ibrahim is a billionaire from Sudan (he has British nationality but was born as a Sudanese Nubian). He made his fortune by founding the cell phone company Celtel, which markets primarily in sub-Saharan Africa. Vanguard has some good background information.

When I was in South Africa & Zambia in 2004, I was shocked by the proliferation of cell phones. It seemed most of the people I met–rich and poor–knew more about cell phones and SMS-ing (text-messaging) than I did at that point. Well, more so in South Africa than in Zambia. In Mr. Ibrahim’s words, cell phones are better than computers for most Africans because they’re less expensive and you don’t need constant electricity. Many areas that have never seen landlines now have cellular coverage.

Mo Ibrahim sold Celtel to Kuwaiti telecom giant MTC $3.4 billion in 2005. And what’s he going to do with his money?

Yesterday The Guardian published a story on Ibrahim’s plan to offer a $5 million prize for African governance. Basically, each year a committee will select a democratic leader who has fought corruption and encouraged accountability, and pay them to quit.

Many African countries have transitioned to democracy since decolonization, while others are still mired in military dicatorships. But many governments that are democratic in name are anything but democratic in spirit, largely because grass-roots power and accountability don’t simply blossom overnight after hundreds of years of subjugation. One of the most impressive things about America’s government to me is that despite the massive power at stake, we’ve responded relatively peacefully to transitions in leadership for centuries, discounting the Civil War, of course. Well, at least for decades…

Many African presidents, while elected in some way, find ways to extend their power and crush the opposition. Egypt’s Mubarak and Zimbabwe’s Mugabe come to mind, and Uganda’s Museveni and South Africa’s Mbeki could be headed that way.

Ibrahim says that giving rulers motivation to step down and turn over the reins to their successor is vital for democracy, a fourth option besides “relative poverty, term extension, or corruption”. Meanwhile, Transparency International derided the prize as a reinforcement for African “strong men”.

I think the prize could have positive effects, depending on who it’s given too. But by itself it won’t be nearly enough to stem the tide of corruption on all levels of African government. Transparency International is correct in seeing the prize as incomplete solution to a multifaceted problem, but getting popular leaders to quit sure seems like a worthy goal to me.


Blunders of Bush

October 25, 2006

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“Stay the course.” If one repeats a mantra enough times it can become inseparable from one’s political persona. So what do you do when the pressure to change that view has become so great that to deny it would appear even more stupendously stubborn? The answer, it seems, is to say you’re not really changing anything.

Despite saying for months, even years, that those calling for a timetable for withdrawal are foolish, the Bush administration has now announced it plans to implement “benchmarks” in its Iraq strategy.

Allow me to play analyst for a bit.

Unfortunately, it seems that “staying the course”, “benchmarks”, and a timetable are all inherently flawed strategies, because they neglect the root of Iraq’s problems. If we stay the course, our troops will be caught in the middle of a bloody civil war. If we leave now, Iraqis will fight a blood civil war.

Why? Iraq is at its heart an unnatural state. Of course, many national boundaries have no connection to historical or ethnic realities, and many of those nations work (while others host the world’s bloodiest conflicts) . The problem is that in Iraq the current violence seems to be exasperating tensions between religious and ethnic groups that might have otherwise lived in peace.

Based on the escalation of Iraqi-vs.-Iraqi violence since the invasion of Iraq, we basically have two choices: Divide Iraq into three states now, or watch the Iraqis (or more directly, the extremists on all sides) ethnically cleanse themselves into three states.

One of my favorite books about the Middle East is called A Peace to End All Peace: The Fall of the Ottoman Empire and the Making of the Modern Middle East, which explores the history that led to the creation of such unnatural states as Iraq. (I particular enjoyed the sections describing the role of Winston Churchill in those events).

From historical accounts like this, and current events, it appears the only forces capable of holding Iraqi together have been oligarchy and the dictatorial rule of Saddam Hussein. For much of Hussein’s rule we found it useful to strongly support him as a foil to communism and Iran. Many of the war crimes Saddam is now being prosecuted for were pursued during his time as our ally. (Of course, this should surprise no one in light of our current support of Pakistan and Egypt).

And the oligarchic approach doesn’t seem to be working today. Juan Cole’s article at The Nation opines, “In a similar fashion, the US-dominated Coalition Provisional Authority has attempted to rule Iraq by using communal and religious leaders and corrupt expatriate politicians–the modern analogues of the tribal chieftains of an earlier era.”

In general, I think the analysis in Cole’s article is correct. A long-term occupation would be most conducive to democracy (and the least likely to be supported by the American populace) while a short term occupation (like leaving now) would likely lead to an authoritarian government. To this I add the option of a civil war resulting in two or three states, assuming the conflict ends without a clear victory by some despot.

The problem with a three-state solution, of course, is that Iraq’s neighbors hate the idea. The Turks spend enough of their money (and ours) suppressing their Kurdish rebels. A truly independent (as opposed to more or less autonomous) Kurdistan in northern Iraq would spell huge trouble for Turkey’s sovereignty in its eastern provinces. And Iran and Saudia Arabia aren’t about to consent to what Iraq might become. And the Sunnis would lose their oil of course.

So there are significant obstacles to overcome, and significant bloodshed ahead. But, given the stakes, I think pursuing a three-state solution is the only option that has a high probability of eventually resulting in regional stability. Until that is achieved, it will never really be “Mission Accomplished”.

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Souls on Ice

October 19, 2006

I just finished reading a fascinating (though lengthy) article on the fate of embryos called Souls on Ice: America’s Embryo Glut and the Wasted Promise of Stem Cell Research. This ties in well to some things we’ve been discussing into my (occasionally though not usually) enlightening course on medical ethics.

In brief, the article discusses how the massive use of fertility treatments like in vitro fertilization have led to the existence of thousands of frozen embryos– more than will ever be implanted, gestated, and born. There are only a few options for embryos: implantation, indefinite freezing, destruction through thawing, or destruction through medical research.

Many people who did not hesitate to undergo in vitro fertilization procedures now hesitate to donate their frozen embryos for research, and those embryos are accumulating in warehouses… somewhere. And embryonic stem cell research, contrary to some popular belief I’ve encountered, is not illegal. Rather, Bush vetoed federal funding for embryonic research (excepting a few pre-existing lines), but several states and many universities have procured other sources of funding to make up for the shortfall.

As for the ethics of it all, one of the weakest arguments Christians make for not pursuing embryonic stem cell research (and this one was made to me within the last week) is that somatic stem cells can be used for everything that embryonic stem cells can be used for. This is ludicrous as stem cells are by definition more pluripotent than somatic stem cells. In other words, embryonic stem cells removed early in development can differentiate into many types of tissue that somatic stem cells removed from adults simply cannot.

Another flawed argument often presented goes thus: “There are absolutely no medical applications from embryonic stem cell research.” Reply: Of course not- there hasn’t been much of it. In the 1950’s no one used the argument “there are absolutely no medical applications for DNA research” because there simply wasn’t a state of knowledge available that would lead to viable therapies. Seriously, why would many of the premiere medical researchers be publicly bemoaning the federal funding ban if embryonic stem cells were really nothing new?

The strong arguments against stem cell research are based on the moral status of the embryo. If an 8- or 16-cell embryo has the same moral value as an adult human, then pursuing embryonic stem cell research is tantamount to murder. In fact, these arguments are compelling and unavoidable if one believes the Bible is the word of God.

Of course, these arguments are only strong if one agrees with conservative Christians that the early embryo is of the same moral value as an adult- a conclusion not reached by many secular ethicists and liberal Christians with a less strict application of Biblical precepts to modern existence.

While I believe embryos are worthy of respect, I don’t assign them the same moral worth as myself, or someone dying of a possibly curable disease. In other words, destroying them needlessly would be wrong, as they represent potential human beings. But the needs of fully conscious humans with full personhood should not be secondary to an 8-cell blastocyst that no one has a problem with freezing. And I will continue to hope that embryonic stem cell research will be one area in the “culture war” where conservative Christians won’t succeed, because that triumph could hurt us all. Read the rest of this entry »


Quotes for Thought

October 18, 2006

Some quotes to ponder from two of my favorite doctors…

Dr. Jim Kim:

“There are more billionaires today than ever before. We are talking about wealth that we’ve never seen before. And the only time I hear talk of shrinking resources among people like us, among academics, is when we talk about things that have to do with poor people.”

“Farmer got hold of a pamphlet about how to equip labs in third world places published by the World Health Organization. It made modest recommendations. You could make do with only one sink. If it wasn’t easy to arrange for electricity, you could rely on solar power. A homemade solar-powered microscope would serve for most purposes. He threw the booklet away. The first microscope [at Partners in Health’s medical clinic in] Cange was a real one, which he stole from Harvard Medical School. ‘Redistributive justice,’ he’d later say. ‘We were just helping them not to go to hell.'”

Paul Farmer:

“God gives us humans everything we need to flourish, but he’s not the one who’s supposed to divvy up the loot. That charge was laid on us”.

“I recommend the same therapies for all humans with HIV. There is no reason to believe that physiologic responses to therapy will vary across lines of class, culture, race or nationality.”

“In an era of failed development projects, and economic policies gone bad, I sometimes feel very lucky as a physician, since my experience in Haiti has shown me that direct services are not simply a refuge of the weak and visionless, but rather a response to demands for equity and dignity.”

“Shuttling back and forth between what is possible and what is likely to occur is instructive and a lot of what shapes our sentiment.”

“I critique market-based medicine not because I haven’t seen its heights but because I’ve seen its depths.”

“For me, an area of moral clarity is: you’re in front of someone who’s suffering and you have the tools at your disposal to alleviate that suffering or even eradicate it, and you act.”


Why the United States Needs the World

October 18, 2006

Multilateralism may sound like something you had to learn in geometry, but it’s a great word that every college student should know. In the context of world affairs, it means working with other countries in broad coalitions and through institutions like the United Nations to achieve goals, instead of acting on our own (unilaterally).

Bashing the United Nations is a common pastime of political pundits. When things don�t get done, may people blame the United Nations itself instead of the countries that make it up. As Americans, we come from a tradition of independence and isolation, so these feelings are understandable. But hostility toward countries like France that often disagree with us, the United Nations itself and United Nations Secretary-General Kofi Annan is, at best, selfish, and at worst, terribly destructive. Here’s why:

United States dominance in the world won’t last forever. We’re used to being the most powerful country in the world both militarily and economically, and we are undoubtedly still on top. Right after World War II the United States dominated the globe in a way never seen before, but our lead has been shrinking ever since, as other countries recovered from the scars of war, and from that extended economic distraction we call communism.

Today we are anything but economically independent. We’re conscious of our dependence on foreign oil, but our dependence on other foreign goods is even stronger, and not likely to go away. In a consumer society, the desire for goods with ever-lower prices will continue to drive production to the cheapest locales, and wealthy nations such as our own will grow more and more dependent on countries like China and India. We might be able to win a war with China, say, over Taiwan, but neither of our countries can afford the level of decimation to our economies that would result.

And militarily, countries like China can in the long term simply muster greater numbers of troops and a broader production base to supply them. If we spent as much as the next 20 countries combined on our military (oh wait, we do) we might maintain a lead for a few more generations, but history teaches us that no nation can be dominant forever.

So the question we should ask is, how can we best advance our own economic interests and the moral principles on which our nation is built, acknowledging that we won’t always be able to bully other countries into submission? If the United Nations didn’t exist, we’d have to build something a lot like it.

If we find the United Nations difficult to work with, it is because it represents in a very real way the desire of nations from around the world. Our inability to gain support there is representative of how our self-serving foreign policy is viewed globally.

And as for Annan, his second term as Secretary-General ends in December, and the members of the U.N. are currently selecting his replacement. What many Americans seem to forget is that Kofi Annan was practically hand-picked by the U.S. because he was seen as being more favorable to America than other candidates. Compared to many of its member states, the United Nation’s leader is much more sympathetic to American ideals and interests.

Unfortunately, the unilateral actions of the current administration in Iraq have made it difficult to gain world support on other issues of great importance. Iran, having seen that we are willing to attack nations whose leaders we dislike with little world support, has rightly recognized that nuclear weapons are the only sure deterrent for an American invasion. And our strained relationship with the countries of the European Union has made working together to thwart Iran’s desire for nukes significantly more difficult.

The first step toward progress is recognizing that most of our past actions have been blatant attempts to advance our own interests, merely using moral arguments as a cover. If anyone mistakenly believes we invaded Iraq solely to restore freedom to an oppressed people, I would raise this question; why didn’t we intervene elsewhere, where conditions were worse, and where there might have been less resistance to American armed forces? The conflict in Darfur, a region in western Sudan, has killed at least 50,000 people in the last few years. Or how about intervening a few years ago in the Congo? While there is a tenuous peace now, the civil war that began in the Congo in 1998 resulted in the deaths of over 4 million people.

I am no isolationist calling for the selfish withdrawal of our troops from anywhere that looks dangerous. In fact, if we really want to advance the principles on which the United States is founded, like liberty and justice for all, there are enough terrible situations in the world to keep our troops fighting for years.

But our nation would benefit from picking its fights more wisely in the future. We simply do not have the resources to fix the problems of the world on our own. To find a path forward, we must learn to work with other countries, and abandon our instinctive hostility toward the United Nations.


Partners in Health

October 18, 2006

Boston was amazing. I wrote a report for the group that funded my trip, and I realized it would make a decent blog post. And I got to meet Paul Farmer, who’s basically my hero/role model in many ways. I don’t think it quite qualifies as a “hero” because that implies you idolize the individual. Dr. Farmer is a figure worth looking up to because of his extraordinary work ethic, the good he’s been able to accomplish for global health, and the fact that he is an icon for like-minded individuals.

Partners in Health’s 13th Annual Thomas J. White Symposium was attended by approximately 1500 people–students, volunteers, admirers, and donors of all ages–at the Kresge Auditorium on the campus of MIT in Cambridge, MA. Partners in Health (PIH) is a non-profit organization that has grown over the past two decades to include 4000 employees in Boston, Haiti, Russia, Peru, Guatemala, Rwanda, Lesotho, and soon in Malawi, who last year provided health care to over 1 million people, including 1000 on antiretroviral treatment for HIV. PIH has had a significant impact on global health policy because of the personal dedication of its founders and the principles on which it is founded, which were expressed well by the 2000 People’s Health Assembly in Savar, Bangladesh; “The attainment of the highest possible level of health and well-being is a fundamental human right”.

The symposium, designed to summarize the past year’s activities, and to outline the policy and programmatic struggles to come, began with remarks by Ophelia Dahl, Executive Director of Partners in Health, on the last year’s expansion of PIH�s operations into Rwanda. A video was shown that highlighted the adaptation of clinical models developed in Haiti, incorporating HIV and TB treatment with community health workers and housing support, for Rwanda.

The keynote address was given by Dr. Jim Yong Kim, current head of Harvard’s Division of Social Medicine, and co-author of Women, Poverty, and AIDS. About ten years ago, Dr. Kim and Dr. Paul Farmer, cofounders of PIH, demonstrated the possibility of treating patients with HIV and Multi-drug-resistant Tuberculosis (MDR-TB) in resource-poor settings. Their research findings changed World Health Organization policy, which had previously recommended against treatment in impoverished countries. Dr. Kim recently spent three years in Geneva as the director of the World Health Organization’s AIDS program, where he pioneered a campaign to get 3 million poor patients on HIV treatment by 2005. He spoke of the triumphs and pitfalls of working within the WHO bureaucracy, of which he was previously a well-known critic. While lauding the continuing research into new cures, Dr. Kim also introduced a new program at Harvard Medical School in Global Health Effectiveness, helping to improve worldwide access to therapies currently available in high-income countries.

Dr. Paul Farmer, who has become a minor celebrity to students of international health and development after being featured in Tracy Kidder’s Mountains Beyond Mountains, spoke charismatically about the interconnection of social and economic factors with the health of the poor, and about the continued need for an equity plan to prevent and cure treatable diseases worldwide. He also praised donors like Thomas J. White, the millionaire who made PIH’s early work possible, and in whose honor the annual symposium is held.

Other presenters included Lucette Fetire, a Haitian HIV patient and advocate who told her story of how PIH first treated her, then empowered and employed her as a community health worker to help her HIV+ neighbors. Dr. Ludmilla Kashtanova, director of PIH�s Russian programs, talked of treating MDR-TB in Russian prisons, and changing the course of Russian policy to prevent further spread of the disease. Veronica Suarez Ayala and Jason Villarreal, community health workers for PIH in Peru and Boston respectively, shared stories of their patients, sometime succumbing to disease, and sometimes recovering to help others.

Personally, I found the event extremely affirming and encouraging. Meeting many likeminded undergraduate and medical students was uplifting, and being in a large crowd that affirmed a belief I strongly hold�that people should not die of treatable diseases regardless of their country of birth�only helped crystallize my goals.