Credit Where It’s Due

January 13, 2009

What will be Bush’s greatest positive legacy? I think PEPFAR is a likely candidate, despite its flaws. I can’t think of any other program initiated by Bush that has helped so many people.


DC Hurts My Brain

January 6, 2009

Jonah Lehrer (of the Frontal Cortex, author of Proust Was a Neuroscientist) writes How the City Hurts Your Brain in the Boston Globe:

Related research has demonstrated that increased “cognitive load” — like the mental demands of being in a city — makes people more likely to choose chocolate cake instead of fruit salad, or indulge in a unhealthy snack. This is the one-two punch of city life: It subverts our ability to resist temptation even as it surrounds us with it, from fast-food outlets to fancy clothing stores. The end result is too many calories and too much credit card debt.

Don’t worry, there are benefits too.


Good News, Bad News

March 29, 2008

The World Health Organization has announced that polio has been eradicated from Somalia. This was an incredibly difficult task, given Somalia’s endemic violence and instability. And it took a huge effort:

More than 10,000 Somali volunteers and health workers vaccinated more than 1.8 million children under the age of five by visiting every household in every settlement multiple times.

However, this has happened before. Polio was eradicated from Somalia back in 2002, only to be reintroduced from Nigeria. The fact that polio was reintroduced from a country on the other side of the continent calls attention to the interrelatedness of disease control efforts in different countries (diseases know no borders) and the tragedies that occur when vaccination efforts clash with local cultures or religions.

But despite its tenuous progress in terms of total eradication, the WHO’s $4 billion polio campaign has made great steps forward:

When WHO and partners began their anti-polio campaign in 1988, the worldwide case count was more than 350,000 annually. The disease’s incidence has since been slashed by more than 99 percent and remains endemic in four countries: Afghanistan, India, Nigeria and Pakistan. Polio cases were also detected last year in Angola, Cameroon, Chad, Congo, Myanmar, Nepal, Niger and Sudan.

So that’s the good (albeit cautiously so) news. The bad news for Somalia:

Somalia’s Government Teeters on Collapse

If you read that and asked “wait, Somalia has a government?” you’re not alone. But it does have a government of sorts:

By its own admission, the Transitional Federal Government of Somalia is on life support. When it took power here in the capital 15 months ago, backed by thousands of Ethiopian troops, it was widely hailed as the best chance in years to end Somalia’s ceaseless cycles of war and suffering.

But now its leaders say that unless they get more help — international peacekeepers, weapons, training and money to pay their soldiers, among other things — this transitional government will fall just like the 13 governments that came before it.

Less than a third of the promised African Union soldiers have arrived, the United Nations has shied away from sending peacekeepers and even the Ethiopians are taking a back seat, often leaving the government’s defense to teenage Somalis with clackety guns who are overwhelmed.


The Draw of Dermatology?

March 20, 2008

This piece in the New York Times focuses on a married couple, both Harvard Medical School students, who are in their fourth year and waiting to find out about their residency placements. Like many medical students around the nation, they’re competing for competitive placements in specialty fields instead of going into less lucrative (and possibly less intellectually stimulating?) fields such as family practice and internal medicine.

And the competition is expensive:

Already saddled with about $330,000 in education loans, they borrowed $20,000 more so they could fly around the country this winter for about two dozen residency interviews each. All told, each applied to 90 such training programs.

The article makes me a little sad in general. I had a conversation at CGI U with a med school student who warned me about the “vortex” of med school. Paraphrased: “Everyone’s the same. You get to med school all idealistic, wanting to help people and stuff. Then you spend years and years studying and working, and you see the people ahead of you getting money. You see the doctors with the nice cars and comfortable lives, and you start to wonder when you’re getting yours? And you get into so much debt that you realize you have to practice, and practice well if you want to get out of that hole.”

I’m certainly idealistic about why I want to go to medical school. In fact, the struggle for me is deciding between larger scale health policy work–doing research, designing disease control programs, advocacy, etc.–and traditional clinical work, or how to balance both. I’ve never seen myself as one to get into private practice, or really even treating patients full-time as a traditional clinician. But the vortex sucks many people in.

The problem is ultimately not with the medical students who are drawn to dermatology and plastic surgery for the better pay. Medical students will inevitably be drawn toward the specialties that combine interesting work with the highest pay. From the NYTimes again:

“It is an unfortunate circumstance that you can spend an hour with a patient treating them for diabetes and hypertension and make $100, or you can do Botox and make $2,000 in the same time,” said Dr. Eric C. Parlette, 35, a dermatologist in Chestnut Hill, Mass., who chose his field because he wanted to perform procedures, like skin-cancer surgery and cosmetic treatments, while keeping regular hours and earning a rewarding salary.

The market simply isn’t working here. We need more (many more!) primary care physicians. There’s a lot more demand for services there. But people who have the money to pay more for cosmetic treatments and surgery skew the demand away from those who don’t have the money to get adequate treatment for more life-threatening conditions like diabetes and high blood pressure.

I’m not sure what the solution is either. I know it would need to be a large-scale systemic change; merely getting pre-med students to read about Paul Farmer isn’t going to change everyone. Maybe having a single-payer system where doctors are compensated as much or more for basic services as they are for cosmetic services? Or maybe a loan-repayment situation where medical school is even more expensive, but all loans are automatically repaid by the government for those not going into specialties. Who knows. Suggestions?


Focus.

March 11, 2008

Many Doctors, Many Tests, No Rhyme or Reason

All of our investments in high-tech medicine and tons of tests, as well as the drive toward further specialization, aren’t really having an impact on public health indicators like life expectancy and child mortality. But for those who want to go into medicine (like me) the sexy, intellectually-stimulating, cutting-edge, fiscally-rewarding work is in those specialties.

We need to have a different focus.

“In an age of explosive development in the realm of medical technology, it is unnerving to find that the discoveries of Salk, Sabin, and even Pasteur remain irrelevant to much of humanity.” – Paul Farmer

“The physicians are the natural attorneys of the poor, and the social problems should largely be solved by them.” – Rudolf Virchow


The Language of Abortion

July 5, 2007

Fred Thompson

And again (with a little more detail)

Interesting how this will play out for the uber-conservatives I know who support him.

Here’s one with a (compassionate) quote from Barack Obama, made by a conservative Christian (enjoy the music from Jaws especially):

The amount of in-fighting between Christians on the issue of abortion can be truly vicious. This sort of clip reminds me again and again how Obama’s worldview is closer to my own than to the majority of self-proclaimed Christians I know.

Rudy Giuliani on public funding for abortion (you can bet this one will end up in campaign ads for pro-life Republicans if it hasn’t already!):

And finally, Hillary‘s response on reducing the number of abortions (with some odd sidetracking, like saying ‘the free market has failed’–wtf?, but overall good):


On Domestic Violence

June 28, 2007

It’s everywhere.

The Observant Woman writes on a true story, “Our Disturbing Brush with Domestic Violence.”

A shelter for women that does excellent work I greatly admire is Rose Brooks in the Kansas City area. If more cities had a place like this, it would go a long, long way.


You Can’t Use Sex to Sell Condoms, Stupid

June 25, 2007

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My friend Jenna sent me a link to a great New York Times piece on a Trojan commercial that was rejected by Fox and CBS. In the commercial, anthropomorphized pigs fill a bar, talking on cell phones and hitting on women. One pig goes to the restroom, buys a condom, and promptly re-emerges as a handsome male, who then gets an inviting smile from a female bar patron.

“It’s so hypocritical for any network in this culture to go all puritanical on the subject of condom use when their programming is so salacious,” said Mark Crispin Miller, a media critic who teaches at New York University. “I mean, let’s get real here. Fox and CBS and all of them are in the business of nonstop soft porn, but God forbid we should use a condom in the pursuit of sexual pleasure.”

For the most part, condom manufacturers may be one of the best allies public health advocates have. The manufacturers goals of increasing usage falls right in line with the public health interest of decreasing sexually transmitted diseases and unwanted pregnancies.

“We always find it funny that you can use sex to sell jewelry and cars, but you can’t use sex to sell condoms,” said Carol Carrozza, vice president of marketing for Ansell Healthcare, which makes LifeStyles condoms. “When you’re marketing condoms, something even remotely suggestive gets an overly analytical eye when it’s going before networks’ review boards.”

Sex sells, but you just can’t use it to sell safe sex. Sad.


If You Don’t Like to Think About AIDS, Don’t Read This.

June 10, 2007

Nicholas Kristof wrote a piece recently entitled “Save the Darfur Puppy.” I think he was going for getting a reaction with the title, and it worked, at least with me. You’ve probably notice that the media loves stories about endangered species–always cute, cuddly ones, never rodents–because people are moved by these stories. On the other hand, a crisis like the genocide in Darfur is unlikely to get airplay commensurate with its magnitude. And likewise with AIDS, which despite being of tragic scale–two or three flaming World Trade Centers full of people dying every day–rarely hits the news, in part because it’s the same old, depressing story, every day.

So, when I saw that Truthdig had an interview called “Stop Ignoring AIDS and Africa,” I gravitated light-wards. The piece is an interview of Stephanie Nolen, the author of a new book called “28: Stories of AIDS in Africa” which tells one narrative of a (real, actual, living and breathing) human being with HIV in Africa for every one million of the estimated 28 million living with the virus. I certainly plan on reading this book, but here’s what really caught my eye–this picture:

And its caption:

Bongos, an 8-year-old HIV-positive boy, waits in a hallway at the Sparrow Rainbow Village medical clinic in Johannesburg, South Africa, in November 2005.

This really hits home, because I volunteered at Sparrow back in 2005. They do incredible work, and my few weeks there were extremely moving. Sparrow is an orphanage and adult hospice–a “village”–where those with HIV are cared for. The corridor in the background is the central part of Sparrow’s administrative center, which connects some of the hospital rooms (for the sickest patients), a kitchen, administrative offices, and even a makeshift morgue. Because most of the patients there receive some level of antiretroviral treatment Sparrow is really, sadly, one of the best places to be in Johannesburg if you’re a kid with HIV.

Here are some compelling quotes from Nolen’s interview on Truthdig:

You show people a picture of one sad-looking puppy and everyone runs for their wallet, and you tell them that 30,000 children die a day of diseases that can be prevented for less than a buck and nobody gives a rat’s ass. I don’t know what it is, what that says about us as a species, but I certainly know from a long time reporting about HIV in Africa that it’s true.

On narrating an issue where the statistics are numbing:

Their lives could not look more different in some ways than the lives of an American or a Canadian. But when you sit down in the little counselor’s booth in Malawi or Lusaka and they say to you, “You have AIDS, you’re going to die,” that doesn’t feel different than it would if you were in America. And it’s getting people to realize that those people had all—sure, they’re Africans—but they had all those same expectations around their lives. They want to graduate from high school, they want to start a little business, they want to, you know, persuade that really cute girl they’ve been eyeing for a long time to go out with them. It isn’t any different. You’ve really got to go, go really micro to make people understand that story, to get them past the numbers.

On finding stories of progress:

You know, I think we get very often this perception of it being a grim story where not very much changes…We also don’t hear that huge progress has been made in responding. There were, for example, when I started reporting on this full-time, there were fewer than 100,000 people on treatments and today there are 1.5 million in Africa. And everybody said, “You can’t do it, there’s no way you can treat in Africa.” Well, that’s a 13-fold increase in four years, and those people have better survival rates on treatment than most Americans on treatment do. So lots of victories.

On money and broken promises and the real roadblock to widespread treatment programs (trained health care professionals):

And there’s a lot more money available than there was….They need about $6.8 billion to meet those proposals, and they have, you know, like, $1.85 in change. Constantly, countries promise money and don’t deliver or don’t promise anything like what’s needed to respond. So we need money. I think, even more than money, these days we’re realizing that there are some more intractable problems that are going to need more creative solutions. So you can use that money to fly in boxes and boxes of pills. You can’t fly in nurses, doctors, pharmacists. I mean, you can fly in a few, but not enough to meet the needs of a whole, continent-wide healthcare program, right?

On the underlying economic inequalities that drive the epidemic:

You know, I meet lots of young women who’ve been given information about HIV but who are selling sex down at truck stops because their parents have died, they’re raising their siblings and that’s the only option that they have. So, you know, they say, “Fine, we’ve been told about HIV in the safe-sex textbooks, but HIV might kill me in five years or 10 years and we’re all going to starve to death next week if I don’t do this.” So, you can address some of the obvious things around prevention, but unless you change the factors that drive people into risky behavior, then you haven’t achieved very much.

And, a bit further afield, but still in Africa, on Darfur and the war in Uganda:

And, you know, it’s also interesting to talk about Darfur because, yeah, there are probably 300, 350,000 dead there and a lot of people displaced, but it is in fact a far smaller conflict than the war in northern Uganda which has been going on for 21 years. You have four times as many people displaced in northern Uganda. You have four times as many people dead. Well, when did we last hear about that one, right? I mean, Darfur is suddenly sexy because George Clooney goes there and, meanwhile, the war in northern Uganda that relies almost entirely on child soldiers … you don’t hear about that one.

On Bush’s PEPFAR program (providing treatment for AIDS in Africa):

Well, you know, I’ve done a lot of call-in radio lately where people call up and are yelling about the Bush administration letting people die, and here they are, spending all these billions of dollars in Iraq. Why don’t they do something in Africa? So I say to people, “Well, guess what? Actually the $15-billion, five-year program to intervene for AIDS in Africa, that the Bush administration dreamed up, has been the single greatest response to the pandemic ever.” And then there’s kind of silence on the end of the phone, you know?

And its problems:

…They’re saying a group that’s going to get U.S. funds to distribute condoms or put AIDS programs in schools or care for sick people, has to sign a piece of paper condemning sex work. And that’s like crazy moral language that just has no place in a place where people are selling sex to eat.

I like Stephanie Nolen. And I like Truthdig.

(If you’d like to learn more about or donate to Sparrow, please do so!)