Tuesday, January 6, 2015

OK it's January 2015, time to resurrect this blog. Not least because my friends are in Liberia working on Ebola, notice I did not use that dreadful term 'fighting' and I hope to join them soon

Tuesday, June 8, 2010

Appropriate Medical Monitoring

I see that today's ( 8th June 2010) New York Times has an editorial on the involvement of medical personnel in torture. Physicians for Human Rights has issued a report concerning the alleged involvement of doctors and other medical professionals in harsh interrogation by the US military and other government agencies. Back in 2004, I wrote a piece for US Medicine on just this subject. Sadly, when the magazine changed hands they ditched the website on which the original article was published. I thought for posterity's sake I would republish the piece here. I like to think that the medical profession has learned its lesson from the debacle of Guantanamo and 'extraordinary rendition' but sometimes I worry.

Appropriate Medical Monitoring (published July 2004)

‘If nothing can protect the nation against itself, neither its traditions nor its loyalties nor its laws…then its behaviour is no more than a matter of opportunity and occasion. Anybody, at any time, may equally find himself victim or executioner’ – Jean-Paul Sartre

The Prisoner
He lay very still with his eyes closed, feigning unconsciousness. He was a big man and had put up a fight. He had a large gash over his left eye and his knuckles were bloodied and torn. The head X-rays were negative and the ‘doc’ completed his exam. He told the medic to clean him up and up and stitch the eyebrow.

They were alone in the cubicle, the medic, the prisoner and the sergeant who brought him in. “He is one bad b…..d,” the sergeant told the medic, “killed six of my soldiers this month.” He pushed the pistol further into the prisoner’s neck. “ On three I knock you over and he gets it. We say he tried to escape. OK?” The medic froze. The sergeant’s eyes were scary. The cubicle door opened, “Need any help stitching him up?” said the nurse. “Yes please,” replied the medic and the moment was past. Not Baghdad 2004 but Belfast 1970. The medic was me and, to this day, I do not know what I would have done had the nurse not opened the door.

In thirty years of service as military ‘medic’ this was not my last ethical crisis or moment of self-doubt. Safe in retirement I can say more often than not a combination of good luck and leaders wiser than me, saved the day. I am therefore well aware of the minefield I am about to negotiate, but I am worried for my friends in the US military medical services.

It begins with the Congressional hearings on the debacle at Abu Ghraib. I, like most of the world, sat transfixed throughout, angry as the catalogue of events unfolded but aware war is terrible and once good people are often brutalized into committing unspeakable acts. The more I heard the more concerned I became. Whether, as seems increasingly unlikely, this was an isolated incident perpetrated by a group of ill-trained and poorly led junior ranks, or the tip of a sinister iceberg of systemic abuse of prisoners, the damage to the reputation of the US military is huge.

But as I listened to the unrelenting and incisive questioning of lawmakers, I felt better. Whatever wrong had been committed, this was American democracy in action. The truth would come out. Justice would be done. I was reminded of Churchill’s observation, “America always does the right thing, but only after it has explored every alternative.”

Coercive Interrogation
The debate spread wider than Iraq, to Afghanistan and Guantanamo. Details emerged about interrogation described as “coercive interrogation practices”. It seems for some time the Pentagon has authorized the use of a number of techniques, including sleep deprivation, sensory deprivation and forced prolonged positioning as part of interrogation. Lawmakers were assured that these coercive techniques were only used under very limited circumstances. “Every case required the approval of senior Pentagon officials -- and in some cases, of the Defense Secretary. Once approved, the harsher treatment must be accompanied by appropriate medical monitoring”. A red flag went up. I wondered who was doing this ‘medical monitoring’ and what was involved.

Over the past weeks I have scoured every available source from the New York Times to the Army Times. Meanwhile increasingly graphic detail has appeared in the media and it is clear there is more to this than the macabre theatre at Abu Ghraib. A catalogue of events, accusations and allegations would be a pointless exercise. Moreover, many investigations are in train and I am in no position to know all the facts. I can however, offer a couple of comments on the most contentious issues. First, did those at Abu Ghraib act without authority? Answers might lie with the senior officer at Guantanamo who in his inspection report of Abu Ghraib stated, “Detention operations must act as an enabler for interrogation.”

Second, do “coercive interrogation practices” amount to torture or cruel and inhumane treatment? It seems to depend upon where you ask the question. The Pentagon is emphatic it does not [use torture]. When questioned as to whether the techniques listed as authorized for ‘coercive interrogation’ (apparently there are 24 interrogation techniques approved by the Secretary of Defense in a classified directive in April 2003) a Pentagon spokesperson offered, “… The techniques on the list are consistent with international law and contain appropriate safeguards such as legal and medical monitoring. "

This position appears at odds with the US State Department. Its annual Country Reports on Human Rights Practices routinely acknowledges the following practices as torture and/or ill treatment:
· sleep deprivation
· forced/prolonged positioning
· forced nakedness and sexual threats and humiliations
· blindfolding or hooding
· isolation, loud music, witnessing or hearing torture
· mock executions, threats to family and insults

This debate is far from over. The Wall Street Journal and the Washington Post have begun a public dissection of a number of Department of Justice, Pentagon and Whitehouse memos from 2002 and 2003, dealing with the legal definitions of torture and the limitations of the Geneva Conventions as applied to US Forces. I smell Pulitzer. The recent decision by the senior military commander in Iraq to ban all forms of harsh treatment of prisoners, suggests there are also serious concerns in the Pentagon regarding both the interpretation and practice of the laws of war in recent years. But I digress; my concern here is not with specific ill-treatment but with aspects of medical involvement.

Medics and Interrogation
I have found no evidence that any individual US military healthcare professional has been directly involved in the torture or ill treatment of prisoners – in Abu Ghraib or elsewhere. However, it is clear that healthcare professionals have been complicit to varying degrees in what I will refer to as ‘coercive interrogation practices’ – the clue is in that odious term ‘appropriate medical monitoring’. There are further indications in the Congressional evidence referring to procedures for interrogation, “The guidelines were the product of three months of discussion between military lawyers, medical personnel and psychologists, and followed several incidents of abuse of prisoners at Guantanamo”.
In a May 13,2004 article in Stars and Stripes, Major General Geoffrey Miller [Commanding General at Guantanamo] implied direct medical involvement at least in Guantanamo interrogations, in his quote “keeping prisoners hungry must be supervised by medical personnel. Also, wounded or medically burdened detainees must be medically cleared prior to interrogation.”

Is the involvement of healthcare professionals in the interrogation of prisoners, whether - defined as ‘coercive’, ill treatment or torture – always wrong? Unequivocally, yes. I would go further; healthcare professionals even where they don’t directly participate but advise and train others, facilitate ill treatment or torture and are as culpable as the perpetrator.

I make such sweeping statements with the confidence that history and international law are on my side. The first support I offer is that of the World Medical Association (WMA) (a global institution formed under the aegis of the USA after World War II to address the issues raised by the medical atrocities committed by Nazi doctors). In 1975 the WMA issued the Declaration of Tokyo, which laid down basic precepts for the medical profession and human rights:
The doctor shall not countenance, condone or participate in the practice of torture or other forms of cruel, inhuman or degrading procedures, whatever the offence of which the victim of such procedures is suspected, accused or guilty, and whatever the victim’s beliefs or motives and in all situations, including armed conflict and civil strife
The doctor shall not provide premises instruments substances or knowledge to facilitate the practice of torture or other forms of cruel, inhuman or degrading treatment or to diminish the ability of the victim to resist such treatment
The doctor shall not be present during any procedure during which torture or other forms of cruel, inhuman or degrading treatment are used or threatened
The doctor’s fundamental role is to alleviate the distress of his or her fellow man, and no motive, whether personal, collective or political shall prevail against this higher purpose

Contravening Medical Ethics
The second justification for my argument comes from the UN, which has specifically addressed the ethical obligations of doctors and other health professionals in its clumsily titled document, The Principles of Medical Ethics Relevant to the Role of Health Personnel, Particularly Physicians, in the Protection of Prisoners and Detainees Against
Torture and Other Cruel, Inhuman, or Degrading Treatment or Punishment (1982).
The document states unequivocally ‘It is a gross contravention of medical ethics, as well as an offence under applicable instruments… to engage, actively or passively, in acts which constitute participation in, complicity in incitement to or attempts to commit torture or other cruel, inhuman or degrading treatment and punishment.’
It also states:
Health professionals may not participate, actively or passively, in torture or condone it in any way.
"Participation" in torture includes evaluating an individual’s capacity to withstand ill treatment; being present at, supervising or inflicting maltreatment; resuscitating individuals for the purposes of further maltreatment or providing medical treatment immediately before, during or after torture on the instructions of those likely to be responsible for it; providing professional knowledge or individuals’ personal health information to torturers; intentionally neglecting evidence and falsifying reports, such as autopsy reports and death certificates.

Medically Approved
What might make a healthcare professional get involved in ill treatment or torture of prisoners? Some may attempt to justify their complicity by contending they are obliged to obey orders. Others may claim their presence was necessary to protect the patient in situations where interrogation might go too far. Both are morally bankrupt arguments. Healthcare professionals must recognise that in using medical skills and knowledge to further the aims of the interrogators by making their job easier or reducing risk, they are complicit in any actions deemed to be inhumane. This is all the more insidious when it appears to stem from a concern for the welfare of the detainee. The repulsive expression “appropriate medical monitoring” illustrates the point. It suggests that techniques used will be subjected to medical professional scrutiny and approval. Thereby making them safer and humane?

Poor Training
Experience leads me to believe deliberate involvement of medical professionals in ill treatment of prisoners is rare. Most healthcare professionals err as a result of poor training. Many have scant awareness of prisoner’s rights or their own responsibilities to prisoners. Many too are ill-equipped to deal with moral dilemmas and ethical risks they face. They may have to decide for example whether loyalty to colleagues is more important than the interests of a detainee alleged to be a dangerous terrorist. If, as seems probable, US military healthcare professionals have been involved in “coercive interrogation practices” in Iraq, Guantanamo or elsewhere, I want to believe it was out of poor training and ignorance.

Urgent Action
All the signs are that in the near future the US government and armed forces will be severely censured by the international community, not only for events in Abu Ghraib but also for its general treatment of prisoners, particularly the use of harsh interrogation techniques. There is little doubt that ‘medical monitoring’ of such treatment will be condemned. There is an urgent need for action. First, medical participation in any form of interrogation must stop immediately. Second, the Pentagon should issue an unequivocal ban [on medical involvement] and clear directions for the future. Third, a thorough investigation should take place, of all military medical involvement, active or passive, in alleged prisoner abuse and in ‘coercive interrogation’. Finally, there should be a detailed review of current training of military healthcare professionals in the Geneva Conventions and Human Rights law. An improved training curriculum must be quickly implemented. Absent such urgent action, I am convinced there is grave risk to the ethical reputation of the US medical services. We [in military healthcare] have been teaching and practicing the Geneva Conventions unambiguously for over 50 years, they are our laws. Once you tell people its OK to break the law, there is no telling where they might stop

As a postscript, the reader might wish to know the prisoner I treated was released from detention a few days later, ‘for lack of evidence’. He continued to kill British soldiers for another ten years. The last I heard he was running a used car business and doing nicely.

Tuesday, September 23, 2008

My Magnificent Octopus

“ Black Adder: “What have you got there Baldrick?” Baldrick, “I have written a story. My Magnificent Octopus.” Blackadder: “I think you mean Magnum Opus”.

Baseline Study

We are in our last month in Uganda and will shortly be returning to the US. The end of an era, we will have done six years in East Africa. It has been an experience I would not have missed for the world. I have been back at school for all this time.

My final task has been to undertake a Baseline Study on Malaria, AIDS and TB grouped under the latest aid acronym (MAT) in Luwero and Kiboga Districts, in Central Uganda, for a major NGO. In many ways the results summarize what I have discovered about health and healthcare in this part of the world over the past years and I think it might be worthwhile sharing them.

Just to give some context, the two districts are archetypal Uganda, rural, heavily agricultural, poor infrastructure and communications and little disposable income. There are almost three-quarters of a million people living in the area. The burden of disease, particularly malaria, HIV/AIDS and TB is very high, malaria overwhelms the healthcare system the whole year round.

The Study was designed in three parts: first a detailed survey of every health facility in both Districts, from hospital down to Health Facility Level II - the clinics that serve Parishes, which contain a number of villages - about 75 health facilities in all. Second, a household Knowledge, Attitude and Practice (KAP) sampling survey covering about 100 households in each District, rural and urban, total population over 200 households comprising about 1500 people. Third, a detailed examination of the information systems.

It was great fun and hugely educational. I visited and talked with healthcare workers and the people they serve, many miles from the nearest town or paved road. I saw up close the results of the millions of dollars of aid that the USA and other countries pour into development in Uganda and other African countries annually

A Perfect Storm

In summary, the study identified a ‘perfect storm’ resulting from the concatenation of number of events: a rapidly increasing population ( the Total Fertility Rate is 6.9) with a concurrent huge increase in the incidence of infectious disease, particularly malaria; rising expectations amongst the population, resulting from increased awareness and education; Uganda’s healthcare workforce crisis, there are severe shortages of trained healthcare workers at every level; de-centralization of healthcare, which has spread healthcare resources even more thinly, and chronic under-resourcing and neglect of the national healthcare system. The result is two Districts whose healthcare systems are in crisis. My experience suggests that they are indicative of the rest of the country.

In order to give my story a little more life than a turgid Study Report, I have decided to use the format of a [very lengthy] email I wrote to a long-suffering friend, describing my findings and thoughts on the issues. It may not follow the rules of grammar but I hope it makes the subject less dense


Everyone [we interviewed] knows what causes it and where ‘mozzies’ live and breed. Everyone knows who is at greatest danger, moms and babies. Everyone knows how best to protect themselves and families, Insecticide Treated Nets (ITNs)
Yet less than 40% of the population has an ITN in their houses, very few have two. If you read the newspapers and the advertising of the UN and big NGOs, you would imagine the entire country draped in the ‘things’. Despite the imploring of Bob Geldorf and the rest, the promise of ‘nets for all’ is a myth, we found one facility with a dozen
nets available for hand out in over 75 facilities we surveyed. Almost all [ITNs] are bought and at large cost to families with little disposable income.

Healthcare workers complain constantly about advising moms at ante-natal clinics (ANC) to use a net and yet don't have any to hand out. It is really bad for morale.
Uganda needs to flood the market with free nets to the point where they have no retail value, and there are enough spare to decorate wedding venues and to use for fishing nets, both common practices here

About 60% of all patients visiting health facilities at every level, are diagnosed with malaria. 97% are diagnosed symptomatically. About 60% are diagnosed by nursing or health assistants, with very little training or experience. About 30% are diagnosed by volunteer Village Health Team (VHT) or Community Medicine Distributors (CMDs)
workers, with a couple of weeks training on an array of diseases. About 90% of suspected malaria patients are treated with Artemisinin Combination Therapy (ACT). The drug is handed out by formal health workers and volunteers, like M&Ms.

ACT has rapidly become the most sought- after drug in the Ministry of Health (MOH)
inventory. MOH offer it free of charge. It has become a source of alternative income for many healthcare workers who either sell it to their patients or to businessmen who shift it to DRC and Sudan. The result is an erratic and unreliable supply of ACT. Patients worried about availability, take the drug for 2 of the 3 days prescribed
and then horde the rest, for the next attack on them or their children. It does not take a PhD to know what constant and widespread subclinical exposure of any drug does to its efficacy I think we are on a fast track to ACT resistance, which I believe will be quicker and more terrible than the Chloroquine/Fansidar debacle

60% welcomed Internal Residual Spraying with DDT, 20% opposed the
idea, 20% didn't care. IRS has started in the North, Apac and Oyam Districts, with very good results It has now been stopped thanks to a court injunction lead by British American Tobacco (BAT(U)) and Dunavant Cotton Int. They worry that DDT will leach from the homes and contaminate their crops. The idea of organic tobacco beggars my imagination and vocabulary.

The strategy of providing intermittent preventive treatment (IPT) with sulfadoxine-pyrimethamine (SP) to pregnant women, though great in theory ( it offers considerable protection to pregnant mums when they are their most vulnerable) is hugely flawed. Most women only come to a health center once during pregnancy,
so they only get IPT1, they need the second dose, IPT2, for better protection, few get the latter. Only 30% of Ugandan women deliver in a health facility.

My general comment about Uganda's Roll Back Malaria plan is it might more aptly be named Operation Sisyphus.


Everyone knows how it [HIV] is spread, 'sex and needles'. Everyone knows how to prevent infection, condoms, faithfulness and abstinence, in that order of import
Knowledge appears to impact little upon behavior. Condoms are available free, even in the most remote locations. Few men use them consistently. Fertility rates in both Districts are estimated at 7. Multiple sexual partnerships, particularly males fathering children with more than one woman, are commonplace.

Prevention of Mother To Child Transmission (PMTCT) is less well known about and the practice very poorly organized. Only 10% of interviewees knew the details. Again, the problem is that PMTCT relies upon regular ANC attendance and subsequent delivery in a health facility. I cannot see the current 30/70% balance changing in the near future. The healthcare system could not cope

Everyone knows about Anti Retro-Virals (ARVs). Everyone knows about HIV testing. Many women test, usually at ANC but often too at outreach clinics now known as HIV Testing and Counseling (HCT): note the change from ‘Voluntary’. Few men test. It seems they don't want to face the truth. HIV testing remains difficult to find in rural areas. HIV testing is scary for all and still carries much stigma. There is a distinct lack of national leadership in testing. The Tanzanian model, the President and First Lady testing in public, is one that. should be copied here. My conversation with the local Anglican bishop, that he might lead a local public HIV testing ‘fair’, fell on stony ground.

ARVs are limited in distribution and erratic in supply. The nearest supply point for a rural villager is Health Center III, at the sub-county level a two day round-trip for many people. Long gaps in ARV treatment are commonplace. HIV treatment in general, is threatened by inept and corrupt national management of medicines and medical equipment by the National Medical Stores (NMS). The term 'Stocks Out' ( medicines have run out) has been incorporated into the national languages. The number of new cases of HIV is increasing faster than the number being put on ARVs
Current methods of prevention appear to be having little impact. There is a dearth of new ideas in prevention

Tuberculosis (TB)

Pulmonary TB is reaching epidemic proportions in both districts. An alarmingly small number know how TB is spread. If you don't know how a disease is spread how can you protect yourself? Few make the connection between HIV and TB. Many TB patients are HIV +. The data is too erratic and poor to give an accurate picture of the % of TB/HIV. Almost 50% of TB patients we found in our survey remained positive at the end of treatment with first-line drugs and had to begin second-line treatment. Directly Observed Treatment Strategy (DOTS) therapy is taken seriously but is undermined by the erratic supply of drugs from MOH. I have had a cough since half-way through the survey

Health Facilities and Staff

Morale in the healthcare system is at an all-time low. MOH is viewed as incompetent and corrupt, by staff and patients. Government is viewed as uncaring and mean-minded with regard to funding healthcare. Salaries and conditions of service for all healthcare workers are so poor as to encourage corruption and neglect.
Kiboga District hospital can fill only 28 out of 88 established nursing posts. Most Level II facilities have about 25% of staff, about two healthcare workers. The quality and experience of staff is as much a concern as the numbers. Many posts are filled by individuals who lack the required qualifications, training and experience. The result is a high level of [symptomatic] diagnosis and treatment, well above the level of staff competency. Less than twenty of the sixty five healthcare units surveyed have working laboratories, it is little wonder that symptomatic diagnosis is the norm.

Housing and accommodation for staff is as big a problem as pay, it stymies recruiting and undermines morale. Continuing professional education is jealously guarded as the prerogative of the most senior staff. Many healthcare workers run private clinics and shops selling medicines, resourcing them with misappropriated medical supplies.
Without this option they would merely subsist.

Very few facilities have any form of power supply and most close at night Few have running water, the staff carry it in jerry cans from the nearest well. Disposal of medical waste is totally ad hoc and quite frankly dangerous. The only hospital in Kiboga hospital has not had running water in 21/2years and has no incinerator either. The daily bonfires are nauseatingly smelly.

The NMS has a contract with a private company to remove out of date medicines. it has never visited the hospital. Out of date medicines are stacked outside next to the hospital kitchen. There is not one functioning ambulance in the entire Kiboga District.
The total annual drug budget for Kiboga is UGSH 200m. Given a population of 280,000, this allows UGSH 770 (50c) ppa.

Some Suggestions

Given the extent of the problems I have detailed in the report, it would be of little value for me to leave it all hanging in the air. As a soldier, I was taught to argue to a decision rather. than simply a conclusion. So I have a few suggestions to offer.

I think we should enhance malaria diagnosis at HC II level through a Malaria Rapid Test and increase community-based oversight of malaria treatment with ACT through a DOTS approach. I think we could increase IPT2 provision by delivery through CMDs and VHTs and increase the availability of ITNS by the same method. There is an urgent need to initiate regional Preventive Education programs for PMTCT and also for TB. There is a vital and urgent need to refurbish clinical laboratories if we are to have any hope of improving diagnosis and treatment.

Finally, and again to quote Baldrick, “I have a cunning plan” to increase the number of men who test for HIV. It involves Corporate Social Responsibility and the 2010 Football World Cup. I will resist the temptation to elaborate further and save the details for my future essay

The Culture of Co-Dependence

Well! That is my "Magnificent Octopus" . Six years in Africa has convinced me the only way we will break the 'Culture of Co-dependence' we call Aid but should properly call Charity, is to find some new ideas. We must centre our thinking around business development and job creation. The dignity of a job is vital for the future stability of Africa's ever-growing and youthful population.

I frequently upset my fellow travelers with what I offer as new ideas, and they consider to be unfair sniping at the Aid Industry. I am currently proposing a six-month moratorium on workshops and conferences. I am informed it would do untold damage to the hotel and catering industries as well as Coca Cola and numerous
Chinese tee shirt and baseball cap manufacturers.

I have also developed an irrational antipathy to certain aid industry jargon; its use has the same effect on me as dragging fingernails down a blackboard. To name a few: sensitization, holistic, gender-based, participatory and most irritating of all ….. youth-friendly! A more patronizing expression is difficult to imagine, it suggests that the young are incapable of understanding the same information as adults, whereas the truth in my experience, is the opposite. Perhaps it is time to take a break.

Saturday, May 24, 2008

More Frantz Fanon Than Xenophobia

I watch with sadness, but no great surprise, the horrors being played out in the townships of South Africa: they were inevitable. Overnight, the arcane term xenophobia has become part of African discourse, describing seemingly incomprehensible, irrational violent acts by a section of South African society.

The extent of African leaders’ cognitive dissonance over this issue is exemplified by the Kenyan Foreign Minister Moses Wetangula in a recent comment, "[A]long its bumpy road to independence, South Africans were scattered all over the continent, including Kenya. "We gave them tremendous and admirable hospitality (...) The last country anybody would imagine would engage in xenophobia is South Africa."

The Minister has lost the plot. This tragedy is not a manifestation of racial or ethnic hatred. It is about economics in its crudest form. Outsiders, legal or illegal, Zimbabwean or Ugandan are hated because they are competing, often successfully, with poor South Africans for jobs and wealth. Despite the rosy picture of South Africa as the economic engine of the Continent, social and economic inequality is institutional. The gap between rich and poor is a chasm, at its deepest in the townships around the big cities, where the majority of the population are young, poor and uneducated. The nation has an unemployment rate about 40%, much higher in the townships and the majority are young men. South Africa has an unenviable reputation for violent crime, mostly perpetrated by the poor on the poor

Over the past decade, despite expansive promises from the government, little has been done to improve the lot of the urban poor. Their seething anger has finally exploded into awful violence against the nearest and most vulnerable, poor immigrants.

It is ironic that a Kenyan political leader would announce, he was perplexed by South Africa’s crisis. His inability to draw parallels with recent events in Kenya is depressing. The trouble in South Africa has similar echoes. I was not surprised then either.

The Kenyan crisis was a long time coming, but the factors have been in place many years; ever-increasing population pressure with over 80% of the population squeezed onto less than 10% of the land. Kenya has a very young population (average age, 18 years) and an economy unable to keep pace with population growth, rapid urbanization and the ever rising expectations of the poor urban young. There is a yawning chasm between the rich and the poor, a leadership shamelessly misappropriating the nation's resource and endemic corruption at every level of society.

The result is a vast number of young men without jobs in Kenya. I contend the most dangerous creature on Earth is a young man without a job. This is as true of Newcastle, New Orleans and Najaf as it is Nairobi. Young men without jobs view themselves as outside of society, disenfranchised and owing nothing to their communities.

Not only do they [young Kenyans] not have a job; there is little hope of the majority finding one. Moreover, and here there are clear echoes in South Africa, though tourism is a vital part of the economy it also enables poor Kenyans who come in contact with relatively affluent tourists, to see 'how the other half live' and to contrast their own lives and prospects.

These angry young men are fertile ground for the seeds of anarchy. The portent to the recent storm had long been obvious in the high levels of violent crime endemic to the country, not for nothing is Nairobi known as 'Nairobbery’ and comparisons made with Johannesburg. The rise of the secret and violent Kikuyu sect Mungiki, and its mirror organization, the Kalenjin Warriors, were also harbingers of terror to come.
Even through the narrow prism of the TV camera, it was clear that the majority of those committing violence were young men; their common denominators, anger, frustration and poverty. They had nothing; so having nothing to lose, focused on destroying all and everything. The gangs on camera in Kisumu looked and behaved exactly like the ones in Gauteng.

For those who still cannot see the writing on the wall, I suggest Frantz Fanon's, The Wretched of the Earth. What we see in Gauteng today and Kibera months ago, he describes as 'catharsis through violence’.

Those who prefer their logic on a bumper-sticker will continue to cluck and prattle about tribalism and xenophobia. What we are witness to in Africa today, is much more; the concatenation of three irresistible social forces: the unequal distribution of wealth, population pressure and the revolution in rising expectations.

The ‘have-nots’, particularly the urban poor, can see how little they have, measured at first hand against the urban ‘haves’. They want a share. If anyone wants to know what comes next, try A Tale of Two Cities by Charles Dickens.

So what of the future? The violence in South Africa will simmer down much as it has in Kenya. The young unemployed, will return to violent crime, mostly robbing the poor, occasionally the rich, and the anger will slowly build up until it explodes, more violently, in the future.

Spinoza offered, "There is no hope without fear and no fear without hope". Maybe the fear created by this current bout violence will galvanize South Africans and Kenyans into radical change. It will take much moral courage and huge effort. In practical terms, there must be a more equitable distribution of the nations’ wealth, mainly through the creation of jobs, lots and lots of them.

A word to the wise; Uganda must draw lessons from both these crises. I see the same dark clouds on the horizon. Corruption is endemic, the gap between the rich and the poor, huge. The population is growing at a frightening rate and the nation's leadership is in an advanced state of denial on this issue. It is even younger than Kenya’s at less than 15 years. As optimistic as I am about Uganda and its wonderful people, it is plain to see that current economic growth is an order of magnitude behind the population boom and the people’s ever rising expectations.

Moreover, the young are rapidly rejecting traditional lives as agriculturalists and urbanization is almost as rapid as population growth. Not because there is no land to work, but because the young envision more than what they see as life in a hut, with a paraffin lamp and hoeing a row of maize, far from friends and the Premier League on GTV. Yet many who migrate to the towns and cities fail to make a living. The ever-rising crime rates across the nation and the recent terrible spate of violent crime in Kampala are testament to the growing anger and frustration of the urban poor

Prediction is no more than entertainment, but without radical new thinking and bold action, I am gloomy about the future of South Africa, Kenya and indeed Uganda. I offer only this from a man much cleverer than I.
“A world of this magnitude of inequality is inherently unstable. Peace is in the palm of the devil” - Fouad Ajami

Tuesday, May 13, 2008

Now For Something Completely Different

“Insanity: doing the same thing over and over again and expecting different results.” 
Albert Einstein

Back in 2005, I wrote a piece for a US healthcare magazine with the hugely pretentious title, ‘Of Hamlet and Per Diem’, I am now embarrased about the name, but article itself attracted considerable email flak, which was fun, It began as a discussion of Uganda’s long battle against HIV/AIDS and went on to describe how the focus had been lost, through a mixture of corruption, ideology and above all, a lack of original thinking, particularly in the hugely lucrative arena of HIV/AIDS Prevention. As a finale, I offered what I considered to be an original idea. Here it is in its in edited form:

“If, as I have argued, Uganda’s HIV/AIDS strategy is dysfunctional, what is to be done? Well, we cannot continue doing what we have always done and when it shows not to be working, try harder and throw more money at it. The time has come for original thinking and novel approaches. The key must be to reduce the opportunities for misappropriation, get more of every dollar donated, to land on the final target and develop long-term independence by making individual Ugandans responsible for their own health and future.”

“Here is my ‘out of the box’ idea. Somebody out there give me $1m, no strings attached. I will put it in a Ugandan Bank. I will then advertise for 1,000 volunteers from the next intake of Freshers at Makerere University. All will be required to undergo an HIV test. The first 1,000 ‘negatives’ will have a bank account opened in their name, a ‘health savings account’, containing $900.”

The contract will be they remain negative until they graduate. Immediately before graduation, they will be tested again and those still negative will have unrestricted access to their savings account, to do whatever they please with both the original sum and the interest accrued. How individuals stay healthy - ABC or any variation thereof - is a personal and private concern. If the project is a success, it will be repeated and widened, dependent on donor interest and funding ( if I had access to the $200m from the Global Fund I could impact on 200,000 people). This may seem a lot of money for a relatively small number of people, but in my time in Africa I have seen much more spent for much less impact.”

“I can hear the howls of indignation from the politically correct. ‘This concept smacks of bribery, it has no place in respectable social science’ etc. I offer the following for consideration:
Many more than 1,000 will volunteer; the ‘Positives’ will be able to seek treatment and long-term care, the ‘Negatives’ will know their status and adjust their lives accordingly
1,000 ‘at risk’ individuals will be trying to stay out of the ‘risk pool’ for three years
Money spent on administration will be minimal (much less than most current prevention programs).
Opportunities for misappropriation and mismanagement of funds will be negligible
On successful graduation, the capital sum plus interest accrued, will go directly to the individual, without caveat.
The money will probably be spent in-country on an individual basis.
Each individual will be incentivized to make personal decisions regarding their current and future health status.
Individuals will recognize that they are capable of determining their own future.”

“I doubt that, at first blush, I have convinced many that this idea is anything more than the crude use of financial reward to manipulate social behaviour. That might be true, but is it any more odious than many current schemes? At least it has no moral or ideological strings attached, requires minimum administration and does not lend itself easily to misappropriation. Has anyone out there got a better idea?”

Now why have I reprised this piece of public health apostasy “bordering on the immoral” (as one critic described it) at this time?
Well it seems that not everyone thinks it’s nonsense, the World Bank appears to have at least one person who inhabits the same parallel universe as me. This report by the Financial Times in late April 2008 outlines a program that aims to provide a financial incentive to encourage people in Tanzania to ‘avoid unsafe sex’:

[T]housands of people in Africa will be paid to avoid unsafe sex, under a groundbreaking World Bank- backed experiment aimed at halting the spread of Aids. The $1.8m trial – to be launched this year – will counsel 3,000 men and women aged 15-30 in southern
rural Tanzania over three years, paying them on condition that periodic laboratory test results prove they have not contracted sexually transmitted infections.
The proposed payments of $45 equate to a quarter of annual income for some participants. The programme, jointly funded by the World Bank, the William and Flora Hewlett Foundation, the Population Reference Bureau and the Spanish Impact Evaluation Fund, marks an important step in the fight to tackle Aids, which claims 2m lives a year.
In spite of billions of dollars spent annually on treatment and prevention worldwide, there were about 2.5m new HIV infections in 2007, predominantly in Africa. Carol Medlin from the University of California, San Francisco, one of the researchers, said: “We hope
this ‘reverse prostitution’ will make people think hard about the long-term consequences of their short- term behaviour.”
The Tanzanian experiment is a big advance in efforts to test public health ideas more rigorously, with some participants placed in a control arm not offered payment in order to track the effects of the
programme precisely.
“Conditional cash transfers” have already been used in Latin America to motivate poor parents to attend health clinics, and have their children vaccinated and schooled. The designers of the Tanzanian programme believe that payments of $45 when combined with careful counselling could play an important role in reducing HIV infection, especially for vulnerable young women.

The study will be conducted by the Ifakara Health Research and Development Centre in Tanzania, in conjunction with researchers from the University of California, Berkeley, the University of California, San Francisco and the World Bank. The Tanzanian trial programme, which is still subject to fine-tuning and ethical approval, will not specifically test for HIV, which is costly and already widely conducted in the country. It will use proxies , including gonorrhoea, and guarantees any participant found to be infected receives state treatment.
By Andrew Jack in London
Published: April 25 2008
The Financial Times Limited 2008

Whilst I am not yet saying, “I told you so!” I am encouraged that the HIV/AIDS industry might at last , after 20 years and countless billions of dollars, be trying to find alternatives to wornout and anemic ‘prevention’ activities encapsulated in meaningless jargon like, ‘sensitization’, ‘community mobilization’, ‘user-friendly youth services’ and ‘behavioral change’. Prevention strategies that are rarely if ever rigorously evaluated and yet judging by the numbers ( 2.5 m new cases in 2007) appear to be as effective as African road-signs.

In researching this article I came across one of the key architects of this concept of ‘conditional cash transfers, a chap with the splendid name of Meade Over., a Senior Fellow at the Center for Global Development, where he works on issues related to the economics of efficient, effective and cost-effective health interventions in developing countries. And his work is very impressive. His thinking is refreshingly original. Anyone who has an interest in HIV/AIDS would do well to visit his blogsite at: http://blogs.cgdev.org/globalhealth/2008/04/pay_for_prevention_a_1.php

I recommend not only the short article on ‘Pay for Prevention’ but also his working paper on the failure of Prevention and its future impact on the President’s Emergency Plan for AIDS Relief (PEPFAR)

After six years in East Africa peering closely at a disease that has killed millions, brought out the best and the worst in people and made many of the latter wealthy, I know I am at risk of incurable cynicsm. This glimmer of new thinking gives me fresh hope. I am still looking for a donor!

Sunday, April 27, 2008

World Malaria Day

This past week has seen World Malaria Day, aimed at focusing the world's resources on irradicating this ancient and terrible disease. On Sunday I caught and article in the Washington Post, 'Eradicating Malaria Worldwide Seen As a Distant Goal at Best'
The article, well written and compelling, stirred me to write down my thoughts on the subject.

I live in a place that has the highest number of infected mosquitoes in the world, a District in northern Uganda. That's what the Ministry of Health and WHO tell me. It also has the third highest fertility rate, 1.2m babies born each year. Average age of population 14.9yrs. Put the two together and you get a huge infection rate that without radical action will continue to grow with the population explosion. Most deaths from malaria are babies, kids under five and pregnant women. It is not just deaths either, my town has a huge number of disabled children, their brains damaged by being boiled by malaria fevers or by being directly infected by the parasite

There is no silver bullet solution. My current work, a baseline study on malaria/HIV/TB gives me a close up view of the reality of malaria. The people tell me they cannot live 24/7 under an ITN, they often get bitten in the evening, eating supper or doing homework. They tell me too I should try sleeping under a net in a 12' hut crammed full of people on a red hot airless night. I can imagine. I have a big net in a 12' bedroom and a fan on all night. When the electricity fails (often) I sweat buckets and find it hard to sleep. I understand why, despite the risks, the people don't use them every night.

Moreover, most people here view malaria the way people in the US or Europe view a bad cold, and sometimes thats how it affects fit, healthy adults with partial immunity. So data on the disease is hugely inaccurate. There are already reports of ACT resistance, though no confirmed data. . I am not surprised, ACT like other antimalarials, is frequently used without firm clinical diagnosis. If the symptoms disappear after ACT treatment, it must have been malaria. ACT is costly; the stuff, now given free by MOH, it is often stolen, repacked and ends up for sale in village shops and even in neighboring countries. Health centers in my District, which have no ACT, direct patients to buy from the 'chemist shops', often supplied by the same healthcare workers. Selling medicines is often justified as the only means of subsidizing very poor salaries.

The nation's healthcare system is overwhelmed by population pressure and the burden of disease and under-mined by shameless corruption. The brain drain of healthcare workers, migrating to the US, Europe and other developed countries, to escape the appalling conditions of work and pitiful salaries, is accelerating the dissolution of the national health service.
There is no history of any nation with a ruined healthcare system ever successfully conquering any infectious disease, least of all one as old and complex as malaria

IRS, using DDT, the cheapest, most effective agent, has just begun here. It remains to be seen whether the expansion of the malaria campaign into a coherent, focused effort to include IRS, ITNs, ACT and education will have lasting impact on the disease, but I am pessimistic, without a vaccine.

As expected the campaign to use IRS is being dogged by the pious ranting of the self-appointed guardians of Africa's ecosystem, as if Africans were too stupid to understand the arguments and reach their own decisions. I have little time for such organizations as Beyond Pesticides. One would do well to remember that its staff earn a comfortable living through this NGO, lobbying on behalf of poor Africans. They have very comfortable offices, alongside the the lobbyists of E Street in DC. Their office rent would buy a huge number of ITNs.

They know the scientific evidence they quote is based upon massive use of DDT as a pesticide in US agriculture in the 1960s, when planes were used to dump tons of DDT per acre on cotton fields and fruit orchards. Even with this massive industrial overuse, the evidence, after 50 years of scientific scrutiny, connecting DDT with diseases in humans is thin indeed. IRS will use less DDT in a year across the entire country, than was dumped on a few acres of US cotton in the 60s

My advice to anyone who wants a credible voice at the table, is to come and live here, out in the countryside, away from the Cities, for a couple of years. To live without expensive Malarone prophylactics and designer insect repellants and about 200 miles from the nearest capable hospital

They are welcome to come with me to the villages to convince people they need to use an ITN all the time. They could also try and explain their version of the facts regarding IRS and DDT; tell mothers that "DDT can be passed on in breast milk". For many it will be an irrelevance, they will not be feeding their dead babies.
4/27/2008 7:15:09 AM

Saturday, April 26, 2008

The Global Health Workforce Crisis

‘Over several decades, a global health-workforce crisis has developed before our eyes. The crisis is characterized by widespread global shortages, maldistribution of personnel within and between countries, migration of local health workers,
and poor working conditions.’
- World Health Organization. World health report 2006

There Were Reports
In late February I was surprised to find our home-town, Lira in northern Uganda, in the international news. And it wasn’t a 60 word paragraph by Reuters. Lira made it all the way to the hallowed ground of the Lancet Editorial; fame indeed! Actually one might better describe it as infamy.
Now I for one know the temptation of purple prose, but I expected more of the Lancet. Given our remoteness from London, or for that matter, anywhere on Earth, I can only surmise the Editor got his information from the Ugandan ‘Dailies’, which delight in hyperbole. The result was an opening paragraph that read:

“Earlier this month, medical workers at Lira Hospital in northern Uganda went on strike to demand unpaid allowances promised by the government for working in this war-torn area. Seven patients died. There were reports of bodies decomposing in wards and women in the maternity ward assisting with each other’s deliveries. “

Let’s set the record straight. I was there when it happened. The lady that keeps our house went into labor; I took her to the hospital, witnessed the chaos and took her to a private clinic. I wrote a blog about it called ‘Super Tuesday’. I followed events very closely for the next few days.

The healthcare workers went on strike because they had exhausted every other option. They had been promised the money for almost a year, every other healthcare worker in the Region had received an ‘allowance’ and they had been stone-walled. This is not uncommon. Teachers commonly go for months without being paid their tiny salaries of about $100 a month. It usually happens because some bureaucrat has ‘eaten the money’, a local euphemism for stolen it.

The brave but na├»ve District Medical Officer of Health, was publicly derided when he suggested that the ‘seven patients who died’ would have died with or without healthcare workers present. Knowing the resources available to the hospital, I do not doubt him. ‘Women assisting each other with their deliveries’ is another hyperbole. Most Ugandan women come to deliver in hospital with droves of mothers, aunts and sisters; some with their own village birth attendant. That’s how the deliveries were done. As for, ‘bodies decomposing in wards’; this a hot place, there are no undertakers. Funerals take place pretty quickly.

Global Forum
The irony of this strike is that it took place a few weeks before the first WHO Global Forum on Human Resources for Health, hosted in Kampala. That, I suppose is why Lira made the Editorial, coincidence. I did not attend the Forum; no report has yet been published. I have however, received anecdotes aplenty. Given the scale and political complexity of the [healthcare workforce] crisis, it is not surprising that the meeting produced a lot of heat but little light.

What happened in Lira was a reflection of events played out every day across Africa, which has 25% of the world’s disease burden and only 3% of the world’s health workers. The reasons as to why this imbalance exists are manifold, but the political heat centers around one argument, the migration of healthcare workers, trained in Africa, at African expense. The accusation is they are lured away by unscrupulous recruiters with promises of huge salaries, to meet the ever-rising demands of caring for the aging population of the developed world, leaving their own countries bereft and in crisis.

In the eyes of many, this is yet another example of predatory exploitation of African resources by the developed world. In condemnation, the Lancet editorial ends with a pious flourish, “[R]icher countries can no longer be allowed to exploit and plunder the future of-resource poor nations” . Such sanctimony suggests migrating doctors and nurses are victims of a modern slave trade. Nothing could be further from the truth. Many leave because it is in their nature to explore and seek advancement; but for the majority it is because working in healthcare at home is under-paid and overwhelming. Moreover, despite the promises of the international community and the proclamations of African governments, in most countries, there are no signs of things improving, rather they are getting worse.

Responsibility for the distortion in the healthcare workforce can as easily be laid at the feet of the huge numbers of Non Government Organizations and International Agencies as it can ‘malign foreign recruiting agencies’. It is they (INGOs) who recruit the cream of the public sector, offering in-country salaries and employment opportunities that cannot be matched by governments. It is the dream of many of my medical friends to get permanent employment with ‘a big international NGO’ or better still the ‘Holy Grail” of international healthcare employment, the WHO.

The extent of this distortion is evinced by the number of surgeons and surgical staff in Africa. Uganda for example, has about 75 general surgeons and ten physician anesthetists for a population of 30 million people. Most live and work in Kampala. The majority of surgery is performed in rural hospitals by the equivalent of family physicians. Why this dearth of surgical capability? In part because the public sector pays poorly, private surgery is limited and few INGOs are into surgery, so rarely hire surgeons. Better by far to enter a career in public health and specialize in HIV, TB and Malaria, that’s where the [NGO] money is. To emphasize the point, Makerere University recently restricted entry into its Masters in Public Health program to physicians.

The reasons for Africa’s healthcare worker crisis are too many and complex for reasoned debate in this essay. They will no doubt be the subject of many future PhD theses. I will offer a few comments about two factors, using Uganda as an example; few countries on the continent are markedly different.

The first is that of population pressure. Uganda is undergoing a population explosion. The national Total Fertility Rate - about 7 - is the third highest in the world. As a result, despite the ravages of war, disease and staggeringly high maternal and infant mortality rates, the population has leapt from 6m in 1962 to about 27m in 2007. Moreover, average life expectancy has dropped, mainly due to HIV/AIDS, producing a skewed population with a mean average of 14.9 years. Barring some apocalyptic event, Uganda’s population will reach 60m by 2025. Economic growth is nowhere near keeping up with this massive and rapid population increase; every aspect of national infrastructure is overburdened. Electrical power is rationed, schools are overwhelmed with pupils and have pitiful resources, roads are falling to pieces as fast as they are built and emergency services non-existent in most of the country. Uganda has for example, ten fire trucks; four are in Kampala. Nowhere is this overburdening more obvious than in healthcare.

I offer a few anecdotes in illustration; first in the arena of mother and child care. I am currently working on a project in Luwero District, central Uganda. Recently I visited the largest healthcare unit in the District, called a Level Four health center; there is no Referral Hospital, though there are about a million people in the District. The unit is small, old and in disrepair. The maternity unit has ten beds and one delivery room with one table. When I looked in, there were 15 women who had delivered in the past 12 hours, five were on the floor. The overworked but dedicated midwife told me they averaged 450 deliveries a month. She added that other smaller District health centers were similarly overstretched. This is in an area where about 60% of women deliver at home.

My next-door neighbor is the only surgeon in Lira hospital. He was away during the strike, but some weeks before he had experienced an incident that exemplified the sheer weight of his work and the paucity of resources. Late one evening a truck loaded with worshippers returning from a ‘Revival’, overturned about ten miles from town. The town has no emergency services; the casualties arrived in traditional fashion, in the back of private vehicles, usually pickup trucks co-opted by the police as ‘Good Samaritans’. By the end of the night he had 90 casualties; seven had died instantly or en route. His only assistants were a family doctor doing Ob/Gyn, an Anesthetics Officer and a handful of nurses. Help, in the form of one doctor arrived the following day. It took him three days and nights to complete the surgical care for his 90 patients.

A few weeks ago, in a town not far from here, a furor erupted over the town mortuary. Plans to refurbish the unit had run out of money. However, the doors at least were fixed. This, according to the town council was major improvement. Prior to that, dogs had chewed of parts of bodies and local ‘thugs’ had used the place to skin stolen goats and cows that would end up in public butchers. The council stated that hygiene remained a problem however. “The mortuary has neither a refrigerator nor is connected to electricity and given there are no drugs for preservation of bodies, some end up rotting”.

As I was preparing to write this article I glanced at a short byline in a national daily. I offer it verbatim. “Close to 200 health centres across the country can no longer offer immunisation services after they ran out of gas for the refrigerators in which the vaccines are preserved. In a] survey done in 22 districts by a concerned party within the Ministry of Health, out of 534 health centers sampled, 198 had stopped offering the services by the beginning of March. There has been no delivery of gas to the centres since January
15. Vaccine shortage poses grave risks to pregnant mothers and their babies who risk missing the tetanus immunity at the time of delivery. Uganda has at least 1.2 million children born every year countrywide”.

Corrupt and Inept
The second issue is that of Corruption and Ineptitude, so inextricably linked I consider them as one. Corruption has permeated every facet of public healthcare in Uganda, from the very top to the remotest health center. The reasons range from shameless greed at the top to survival at the bottom. But at root the problem is OPM (Other Peoples Money, a euphemism for foreign aid). Ugandan healthcare attracts huge amounts, too much for an inept bureaucracy to manage. The temptation to ‘eat it’ or miss-use it are huge, the results glaringly obvious. Headquarters MOH in Kampala has so many SUVs in its parking lots it has earned the sobriquet ‘Ministry of Land Cruisers’. Few of these vehicles ever leave Kampala city limits.

The previous Minister of Health and his immediate staff, currently face charges of misappropriating millions of dollars of Global Fund monies. Funds meant to buy and distribute anti-retroviral drugs, drugs for TB and antimalarials. A glance at the inquiry findings shows it was done with breath-taking impunity. My favorite anecdote concerned evidence given to the initial inquiry. The judge was shown a receipt for fuel for an MOH vehicle traveling thousands of kilometers around the country on “HIV sensitization duties”. The vehicle registration on the receipt belonged to a Caterpillar tractor. My friends were not amused; they called it ‘stealing from the dying’.

The upper-mid level of the Ministry has followed their leader’s example and the new Minister is not strong enough to break their stranglehold. The National Medical Stores (NMS) an autonomous governmental organization is so riddled with theft and ineptitude it has become a national scandal. The current Minister has publicly stated he wants the boss sacked, as yet to no avail. The NMS is the only means of supply and distribution of medicines and medical equipment to the public healthcare system. Its reputation for incompetence is all-pervading. The project I am currently working on has a caveat in the proposal regarding the availability of medicines and medical materials for HIV/AIDS, TB and Malaria, one line reads, “[N]MS itself has systemic problems that lead to stocks out”. That is a huge understatement.

Lira District health centers currently have no AARVs and have not had for months. Neither do they have the new antimalarial, Artemesin Combined Therapy (ACT) but I know at least four ‘chemist shops’ in town where I can buy them and just about anything else. Where and how they got them, the traders will not say. The same would probably be true in most of the country.
At the bottom of the food chain, a District Medical Officer of Health has just been charged with stealing a refrigerator and gas bottle from one of his health centers. It was found in his quarters, filled with beer. There is no word of the vaccines.

Ineptitude is not the sole prerogative of the MOH. Some of its INGO partners appear to have either given up their Sisyphean task or in some cases let the rock roll downhill. You will remember the anecdote about the maternity wing in Luwero. Directly across compound from this building there stands a brand new construction, built by one of the most renowned INGOs. Locked and never opened, it was built as a ‘center for acutely-malnourished children’. A laudable purpose, but acutely-malnourished children seem to be in short supply locally. The building would make a great new maternity unit.

About 10 miles out of town, down a very long muddy track, with a few small villages, there is a brand-new maternity unit, built by the same INGO. It dwarfs the Level Three healthcare center it serves, has about 50 beds and all the equipment required outside of emergency surgery. The problem is nobody uses it. Well; about 5 women a month have given birth in it since it opened, which is probably a good thing because it does not have one toilet, bath or shower. The midwives have dug a latrine outside. I just cannot figure out how it came to be built there, but there is a huge new house a little further down the track.

In conclusion, I admit to only touching the margins of the crisis Africa faces in healthcare and its healthcare workers but I hope I have provided some light and thought for debate. I will add one more comment. I consider the idea that doctors, nurses and other health workers born and trained in Africa should be prevented from working abroad to be abject sanctimonious nonsense. Why stop at healthcare workers? Why not ICT workers? University professors?

We should ask young doctors and nurses why they leave this beautiful, tropical country, their families and cultures, for the cold rain of Manchester, England or the frigid plains of North Dakota.
When we have listened to the answer, we will be some way to fixing the problem.