Dude Where's My Landcruiser?

I wrote this back in late October 2006 and have no idea why I did not post it at the time. Still, as a synopsis of events in Uganda at that time, it covers most issues and, perhaps tragically, events are little changed today. We still have no peace accord with the LRA, we still struggle with malaria, electricity remains rationed and erratic and there is an acute fuel shortage. This time because of civil unrest in Kenya but also because the government gave away its strategic fuel reserve to its friends and forgot to ask for it back. But, thanks to a bulk buy of top-of-the-range SUVs for the Commonwealth Heads of Government Meeting last November [07] we have many more Landcruisers, Hummers, BMWs etc. The roads remain awful. The population continues to increase at an exponential rate, urged on by a Government which believes that Uganda's future development hinges upon 'growing a population large enough to create its own internal market'. As far as we are aware, we have not yet been stricken by Bird Flu, but who cares. We have Ebola Fever again.

Interesting Times
"May you live in interesting times" is popularly believed to be a Chinese curse but more likely owes its origins to a speech by Robert F. Kennedy in Cape Town, South Africa, on June 7, 1966. Nevertheless, it resonates with life in Uganda today.

The 20-year conflict in the north of the country is slowly but surely drawing to a close. An agreement called a Cessation of Hostilities has been in place for a month and the Lord's Resistance Army (LRA) has moved the bulk of its 'fighters' into agreed safe areas in southern Sudan under the aegis of the army of south Sudan, the Sudanese People's Liberation Army (SPLA). The next step will be for the LRA to agree to the release of 'non-combatants'-women and children. This will probably happen within a few days.

The political center of gravity of the final stages of the conflict has now shifted to the Hague in the Netherlands and has become far more complex. At issue are matters of international law and the outcome of the debate will have global ramifications. A synopsis of events is essential to understanding the current crisis. In 1999, in order to inject fresh political initiative into ending the war in the north, the government passed into Ugandan law, an Amnesty Act, in effect offering amnesty to all LRA insurgents who surrendered. From 2000 to early 2004 many LRA members sought and received amnesty. The senior leadership did not. In 2004 the newly formed International Criminal Court (ICC) in the Hague intervened publicly in the conflict, announcing that the Ugandan government intended to amend the national Amnesty law to exclude the senior leadership of the LRA and had [also] asked the Chief Prosecutor [of] ICC to investigate charges of 'crimes against humanity.' The amnesty law was amended and in late 2005 the ICC issued arrest warrants for Joseph Kony and the top leadership of the LRA on charges of war crimes.

From the outset, there was heated debate over the perceived 'outside interference' of the ICC (even though their involvement was at the request of the Ugandan government). Many northern Ugandans believed it threatened the short-term quest for an end to the war and prospects for long-term peace, which would have to be based upon reconciliation rather than retributive justice. Many, too, saw the ICC as the 'international community' meddling in sovereign issues.

Now matters have come to a head. When peace talks began, the Ugandan government stated publicly their wish for greater flexibility over the ICC arrest warrants, even suggesting they be dropped if there was a conclusive peace deal. The LRA have repeatedly stated they will not accept any deal that includes arrest and trial by the ICC. The ICC remains implacable, insisting that the warrants be enforced and those indicted brought to trial. The result is a complicated impasse with serious implications for the future of international law. In my opinion, fault lies with the ICC, which failed to appreciate the complexities of the Uganda conflict and acted precipitously. It will be fascinating to see who backs down and how.

The Pale Horseman
Even as the peace talks in Juba began to show promising results, a scary shadow was cast over them. Pestilence appeared in the town, in the form of confirmed H5N1 'Bird Flu.' An unknown number of local domestic poultry were found dead and dying of the disease and an unknown number have since been slaughtered. There have been no confirmed cases of the disease in humans. Given my last missive to this magazine, which dealt with H5N1 in northern Uganda, I feel like Jeremiah.

Juba, the capital-city-in-the-making of south Sudan, is about 200 miles from Gulu. The road between the two towns is a constant stream of vehicles carrying every animal, vegetable and mineral that can be bought in Uganda and sold to satisfy Juba's rapidly growing appetite. The outbreak was first reported there on Sept. 6. Since that date, information has been scarce and direction from Uganda's Avian Influenza Task Force has been of the 'don't panic' variety. No attempt has been made to stop the flow of domestic poultry in and out of the towns or to map the 'backyard chicken projects' spread across the north, so that when the disease arrives, swift intervention will be possible. There are so few resources available and so little planning and preparation has been undertaken, I suspect that when the disease breaks out in the IDP [internationally displaced person] camps, the government will have little alternative but to send in the Army to supervise the culling of birds. Given that domestic fowl are a vital cash crop in the camps, this move will further alienate the Army from the IDPs. We wait with bated breath and try not to cross the line between alert and alarm.

Re-Thinking Silent Spring
On Sept. 15, the World Health Organization (WHO) made an announcement forcefully endorsing the wider use of the insecticide DDT to combat malaria across Africa. In one sweep, the WHO reversed a 30-year old policy of ambiguity on the issue of DDT and poured gasoline on a fire that has burned in Uganda for years; the argument between health professionals fighting an uphill battle against the disease, agricultural businesses that worry about the threat to their markets, particularly in Europe, and ecological activist groups, mainly international.

The data on malaria in Uganda are mind-numbing. It is the single biggest killer of children under five, accounting for about 100,000 child deaths country-wide annually. The country's maternal mortality rate is about 550 for every 100,000 pregnancies, [and] malaria is a key factor in the majority of these deaths. But the figures mean nothing unless viewed in the context of day-to-day life in the country. Whereas a kid's sick note to school in the U.S. may read, "Johnny has had a cold," in Uganda it will more likely read, "Samuel has had malaria." It is the single biggest cause of [lost work] days; nobody bats an eyelid when Fred comes back to work, looking gray and thin after a week off. They assume malaria. It is quite simply a part of life here and always has been.

In the 1980s, HIV/AIDS hijacked the public health agenda in Uganda. Interest in malaria as a disease threat waned. In the past few years, as HIV/AIDS rates dropped and public fear diminished, malaria came back on the agenda. The problem was how best to tackle disease prevention. The optimum method, proven successful in the [United States] and southern Europe in the 20th century, was by attrition of the vector, the mosquito. There is too much water in Uganda to contemplate 'draining the swamp.' Most insecticides are ineffective or too expensive for large-scale use. The most effective and cheapest, DDT, was essentially banned by international opprobrium. Many donors wouldn't fund malaria programs that contemplated using DDT. Fresh flower and vegetable markets, particularly in Europe, threatened embargoes on products originating from regions using DDT. The only tool left in the box was insecticide-treated nets (ITNs).

They (ITNs) have not proved to be the 'silver bullet.' The science has yet to be done to prove why they have not had a significant impact. I can offer a [firsthand] observation. They work for me at home [in Gulu] because we live in a spacious house with a big, well-ventilated bedroom. It is relatively cool at night, even under a mosquito net. I have spent nights in small dark windowless huts and boiled under my net. I can imagine, but only just, what it would be like to try and keep the average Ugandan family of two adults and seven kids, living in a 12-foot diameter hut, under mosquito nets all night. The number of nets distributed is no indicator of use.

So the debate has turned again to insecticides and to DDT. This is neither the time nor the place to debate the detailed science of DDT but it seems clear that the infamous reputation it gained in the '70s owes much to the amounts and methods of use. The WHO, in reversing its policy, is advocating small concentrations of DDT be sprayed in emulsions onto the walls of huts, houses and other buildings, and only [up] to a few feet above the ground. [DDT is used in a form called 'internal residual spray,' indoors only and low down toward the ground. Mosquitoes usually rest about one to three feet above the ground.]

This form of precision use, in conjunction with ITNs, is another saga in the long war against malaria and seems eminently sensible. It is already used in 10 countries in Africa. But the battle has multiple fronts and the most intractable is the political. I can understand the reticence of the Ugandan Ministers of Agriculture and Export. They worry about the fickle markets of Europe and the potential impact on a shaky economy. The decision should be a national one, made by the government, weighing the economical, health and social risks. What I cannot accept is interference from international activist groups such as Beyond Pesticides, which campaigns against the use of DDT in Africa from the comfort of its mosquito-free moral high ground on E Street in [Washington], D.C. Particularly when they rationalize their position with platitudes of the caliber of, "[W]e should be advocating for a just world where we no longer treat poverty and development with poisonous band-aids, but join together to address the root causes of insect-borne disease..." I have a piece of advice for them. If you want a credible voice in the fray, come and live in Gulu for a year. And leave behind your unaffordable Malarone [an antimalarial drug that costs $33 a week] and designer packs of insect-repellent 'wipes.'

Demography And Destiny
This month has also seen the publication of the government's State of Uganda Population Report (SUPRE). It was a damp squib, meriting only brief mention in the middle pages of the national newspapers and not a whisper of national debate. The report's most hard-hitting line is to warn of the "[m]is-match between a population growth of 3.2 per cent and economic development." Closer examination shows what a 3.2 per cent growth means: the current population of 28 million will double to 56 million in less than 20 years and double again to over 100 million by 2050. The most staggering statistic: there will be 28 million 'job seekers' in 20 years time. This is set against an economy-already struggling to keep up with a rapidly growing population with ever-rising expectations-pole-axed by a catastrophic hydro-electric power-shortage, resulting from the drop in the levels of Lake Victoria. Plans to rebuild the power industry to get back to the levels of two years ago are estimated to mature in five years, [and] to get ahead of the game will take another five years [after that]. The best advice the authors of the report can offer is "[P]lan, plan, plan."

The level of debate in the media has bordered on the fatuous. It has included celebrating 'Uganda's natural fertility as gifted by Nature,' to blaming current economic woes on colonization, [and] to dire examples of economic crises in European countries with low population growth. If 'demography is destiny' was ever true, then it is so in Uganda. And the people are ignoring it.

Dude, Where's My Land Cruiser?
You would imagine with all these momentous events in train or just over the horizon, Uganda's leaders would be consumed with affairs of state, Parliament would be conducting all-night sessions on the future of northern Uganda, bird flu, DDT and plans for economic recovery. Not so. The most contentious current issue among Uganda's lawmakers is official cars for Members of Parliament (MP). This august body of individuals, totaling 300, is debating the necessity of each having an official car to travel to their constituencies. Moreover, given the appalling state of the roads and the huge numbers of road accidents, the MPs believe it vital that their cars be SUVs (Land Cruiser size) to give them better protection in an accident. Never mind the poor constituent who has to travel the same roads crammed on the back of open pick-ups. The cost of this essential 'perk' to the taxpayer? Uganda 20 billion shillings, about $10 million, and that does not take into account fuel and maintenance. [There are about 2 million shillings to $1,000 U.S.]

But this pales into insignificance when compared to the government's spending on official vehicles. A recent government report showed that it maintains a fleet of 11,000 'luxury cars,' mostly SUVs and double-body pick-ups. The total annual cost of fuel and maintenance is 54 billion shillings, about $27 million. There is no mention of capital costs, but at $40,000 per vehicle, I estimate the total at nearly half a billion dollars.

The Ministry of Health has almost 3,000, the Ministries of Education and Agriculture over 1,000 each. The most damning indictment is that few of these vehicles ever leave Kampala or the big towns, [and] most drivers reported they had never used four-wheel drive. They are used to ferry officials from home to office and meetings. The [State of Uganda Population] Report notes that the excessive number of SUVs in the Health and Education ministries was probably the result of the large number of donor projects they are required to run. That statement is worthy of further detailed examination and I intend to do just that. The other question that nags me is how much money comes from the Ugandan taxpayer to fund this obscene display of bureaucratic excess and how much comes from taxpayers in other nations?

The Turbo Effect

Last month, December 07 to be precise, I wrote that in order to mark World Aids Day 2007, I would resurrect a number of articles I had written in the dim and distant past, on the subject of HIV/AIDS and plonk them on this site. It seems to date I have only posted one. Keeping my promise and because i think this piece remains relevant today, I have another offering, The Turbo Effect. Here it is essentially unedited from its original, published in US Medicine in 2002. It may, one day, be of interest to some wandering soul.

Cognitive Dissonance
In 1957 a Stanford University social psychologist Leon Festinger published his theory on behaviour called cognitive dissonance. In simple terms it is the distressing mental state in which [in Festinger’s words] people "find themselves doing things that don’t fit with what they know, or having opinions that do not fit with other opinions they hold”.
Festinger considered the human need to avoid dissonance as basic as the need for safety or to satisfy hunger. It is a drive to be consistent, so strong it can make us change our belief in an effort to avoid a distressing feeling. The more important the issue and the greater the discrepancy between behavior and belief, the higher the magnitude of dissonance that we will feel. In extreme cases cognitive dissonance is like our cringing response to fingernails being scraped on a blackboard—we’ll do anything to get away from the awful sound. After a year of near total immersion in HIV/AIDS in sub-Saharan Africa, I am struggling with an acute bout of “the CDs”.

Hard Talk
The source of my discomfit is a series of review articles in the International Journal of STD and AIDS 2003: 14. The authors are a group of international scientists whose principal author has a rather catchy name, David Gisselquist PhD. The articles address the factors that account for the rapid spread of HIV/AIDS in Africa. I admit that when I first read them, although my interest was piqued I was most influenced by the opinions of ‘my elders and betters’ in the world of HIV/AIDS and public health who abound in Nairobi. They almost unanimously dismissed the articles and the studies that underpin them as “flawed science”. About ten days ago I sat down to watch a current affairs program on BBC World satellite TV called “Hard Talk”, which specializes in the contentious and the topical; grilling those brave enough to subject themselves to inquisition. On this occasion, to my surprise and delight it was the aforementioned Gisselquist and some luminary from the London School of Tropical Medicine and UNAIDS. The ensuing battle was short sharp and painful, for my money Gisselquist came out on top and I once again set about the rather turgid prose and dense tables that epidemiologists deem as the only fitting means to publicize their science. The “CDs” set in after the first iteration.

Sex Central
The authors’ thesis is that almost from the outset of the pandemic, the consensus amongst influential AIDS experts has been that heterosexual transmission accounts for the overwhelming majority of adult HIV infections in Africa, yet the scientific evidence to support such a belief is questionable. They argue that the conventional wisdom regarding adult HIV infections in Africa emerged as a consensus in 1988. In that year,
the World Health Organization’s (WHO) Global Program on AIDS circulated estimates that 80% of HIV infections in Africa was due to heterosexual transmission, 10.8% from mother-to-child transmission, 6% from blood transfusions, 1.6% from contaminated medical injections and other health care procedures, and 1.6% from men who have sex with men (MSM) and injection drug use (IDU). Estimates for heterosexual transmission have inched upwards since. According to the World Health Organization’s 2002 World Health Report, ‘current estimates suggest more than 99% of HIV infections prevalent in Africa in 2001 are attributable to unsafe sex’.

They further argue that if experts had treated the consensus as an hypothesis—which it was and still is—and had used it to guide research to test competing hypotheses, it could have played a constructive role. Unfortunately, many experts have accepted the consensus as fact and not seen the need for further research to test its estimates. The result has been that the consensus has suppressed inquiry and dissent as researchers in Africa—and in Asia and the Caribbean—have often assumed sexual transmission without testing partners, without asking about health care exposures, and when conflicting evidence nevertheless emerges—such as infected adults who deny sexual exposures to HIV—routinely rejecting it.

Turbo Charge
The key to the Gisselquist et al argument is that studies in Africa show that sexual activity levels in the general population are comparable to those reported elsewhere, especially North America and Europe. Moreover, transmission efficiency studies amongst African couples produce estimates remarkably similar to studies of couples in the developed world. So, their argument goes, if African sexual behaviour is comparable to North American and the virus moves between heterosexual couples with the same efficiency north or south of the equator, why has the disease moved so much faster in Africa than in the developed world and why has heterosexual sex been more effective as a means of transmission in Africa than the developed world? What additional factors cause the so-called “turbo effect” that has enabled the disease to spread so rapidly compared with other regions of the world?

Quality of Care
The authors examine the history of AIDS in Africa from 1983 to 1988. Through extensive literature searches and studies they demonstrate that during the period there was considerable debate about the role of healthcare in the spread of the disease. They produce both anecdotal and science-based evidence to demonstrate that during this time, poor healthcare practices had a considerable impact on the spread of HIV/AIDS. Contaminated blood products and the use of unsterile needles for the administration of drugs and vaccines were acknowledged as key factors in the spread of the disease in certain regions of the Continent. This was recognized by experts but considered of secondary import to sexual activity.

They go on to argue there is evidence to show that in those early years of the spread of the disease, health care exposures caused more HIV than sexual transmission in some regions of Africa; suggesting that as much as half of all adult infections during that time were related to healthcare exposures.

Interests, Assumptions and Opportunism
Why was this evidence ignored? The authors argue that papers published around 1988 reveal a number of considerations that might have encouraged a mindset prepared to see heterosexual transmission as the driving force in Africa’s HIV epidemic. First, it was in the interests of AIDS researchers in developed countries—where HIV seemed confined to MSMs, IDUs, and their partners— social groups outside of general society - to present AIDS in Africa as a heterosexual epidemic devastating “ordinary people”. In a prominent 1988 article in Science, Piot and colleagues argued that ‘Studies in Africa have demonstrated that HIV-1 is primarily a heterosexually transmitted disease and that the main risk factor for acquisition is the degree of sexual activity with multiple partners, not sexual orientation’ .
Second, there may have been an inclination to emphasize sexual transmission as an argument for condom promotion, coinciding with pre-existing reproductive health programmes and efforts to curb Africa’s rapid population growth. Third, the role of sexual promiscuity in the spread of AIDS in Africa appears to have evolved in part out of prior assumptions about the sexuality of Africans. Fourth, health professionals in WHO and elsewhere worried that public discussion of HIV risks during health care might lead people to avoid immunizations. A 1990 letter to the Lancet, for example, speculated that ‘a health message—e.g., to avoid contaminated injection materials—will be misunderstood and that immunization programmes will be adversely affected’ .
In summary, peripheral and opportunistic considerations combined with an increasing display of cognitive dissonance amongst the cognoscenti to cause the evidence to be misinterpreted or completely ignored.

Yesterday’s News
Some might argue, “so what?” Even if its all true, these were events of nearly 20 years ago. Even if the quality of healthcare was a significant factor in the spread of HIV/AIDS in the 1980’s it no longer holds true. Across Africa basic healthcare has considerably improved and healthcare providers are well aware of and take precautions against the spread of HIV through faulty practices. Moreover, few would doubt that today heterosexual sex is by far the most likely means of transmission.

Trust Me I’m a Doctor
There are a number of reasons to be concerned about these studies. First, they raise genuine questions about the fidelity of scientific thought 20 years ago and do little to persuade the reader that things have changed for the better. Why should Africans trust those [predominantly from the rich developed world] who promised so much and yet have had little impact on the disease? Second, the image of African sexuality and promiscuity as the almost exclusive cause of the disease and the major focus for intervention tends to a patronizing even racist attitude towards the problem. Third, there is a growing body of opinion that circumstances and vested interest are driving those who manage HIV/AIDS in Africa to deal with it in a vertical or stove-piped manner, independent of other health issues; to view it as one scientist described as “HIV exceptionalism” . If we fail to realize that HIV/AIDS is yet another [albeit terrible] infectious disease to add to the many that plague Africa, there is a danger that we will fail to strengthen our public health and health services. The result will be a resurgence of poor healthcare services and practices as a significant factor in the continuing spread of the disease, a complete loss of trust in healthcare systems and an increase in disease of all kinds in Africa.

The Gisselquist writings bother me. I commend them to anyone interested in HIV/AIDS in the developing world. Flawed science or not, they raise questions about the blind faith we seem to place in science and our ability to accept conventional wisdom without demure. The problem is we have in turn asked millions of helpless people to trust us and if we lose that trust the battle against HIV/AIDS will receive a serious setback. The least we can do is re-examine the evidence and re-open the debate. Africans deserve the truth. As to whether I believe in the “turbo effect”, yes. Though I very much doubt that I will ever be able to identify it. I have one consolation; writing this has eased my cognitive dissonance.

Kleptocracy in Crisis

Kleptocracy in Crisis
Three of the happiest years of my life were spent living and working
in Kenya. Today I sit in the relative calm of northern Uganda and
view, with great sadness but no great surprise, the events of recent
weeks. I would have kept my counsel had I not read three articles on
the subject in recent days, one really irritated me and the other two
inspired me to scribble this piece. The first article was in the
Washington Post, by Caroline Elkins, a Harvard professor and author of
a history of the end of colonial rule in Kenya, Britain's Gulag. I
have read the book, along with the much better, Histories of the
Hanged by David Anderson. Sadly her thesis degenerated into an
anti-British tirade within a few chapters and never recovered. As one
critic offered, "I shudder for those of her students who expect
academic rigour: Elkins doesn't let facts stand in the way of a good
rant". Her WP article, followed the same trajectory.

I much preferred the latest two essays by Richard Dowden on the Royal
African Society's website, http://www.royalafricansociety.org/
But it was the excellent Op-Ed piece in today's [ 08 Jan] Nation, a
Kenyan daily newspaper, that really galvanized me into type. It is at
http://www.nationmedia.com/dailynation/nmgcontententry.asp?category_id=25&newsid=114132

Like the author of the op-ed piece, Macharia Gaitho, I am not surprised at the crisis in Kenya, its
been a long time coming, but the factors have been in place for many years.
What we are witnessing is a concatenation of events, most beyond the
control of Kibaki, Odinga or any current leader: Here are a few:

Ever-increasing population pressure ( 9m to 30m in 45 years)
Over 80% of the population squeezed onto less than 10% of the land ( 80% of Kenya is arid or semi-arid land)
A very young population (the average age is just 18 years)
An economy that cannot keep pace with population growth
Or the
Rising expectations of the rural and urban young and poor
Ever-increasing Urbanization
A yawning chasm between the rich and the poor
A leadership that shamelessly misappropriates the nation's resources
and exploits the poor, primarily through promoting tribal differences
Endemic corruption at every level of society

The result, a huge population of young people whose relatively simple
expectations, the dignity of a job and some disposable income to buy
the odd Tusker beer, watch the Premier League on TV and maybe one day buy an old
Toyota, appear to be receding with each passing day. Long-term
sustainable improvement in the quality of their lives, is no more than
development jargon

There is an unknown number of young men without jobs in Kenya. Thirty
years of military experience and six years in humanitarian aid work in
Africa has convinced me 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. It is the dignity and sense of purpose that is
as important as the salary. Men without jobs view themselves as
outside society, disenfranchised and owing nothing to their community
or society in general.

Not only do they not have a job, there is little hope of ever finding
one. They do their best to find some means of 'income generation'
-selling puppies, songbirds, sunglasses and mobile telephone
paraphernalia, filling in potholes [and then digging them out again]
and general panhandling - only to have their noses rubbed in the mud
daily by sneering Wabenzi and patronizing Muzungu in their SUVs.
Moreover, though tourism is a vital part of the economy it also
enables poor Kenyans who come in contact with tourists ( and for that
matter immigrant Europeans and Asians, expats in NGOs, missionaries
and the UN) to see 'how the other half live' and to contrast their own
lives and prospects. These hugely angry young men [and some women] are
fertile ground for the seeds of anarchy and social upheaval. The
portent to this storm has long been obvious in the high levels of
violent crime endemic to the country, not for nothing is Nairobi known
as 'Nairobbery'. The rise of the secret and violent Kikuyu sect,
Mungiki and its mirror organization, the Kalenjin Warriors, was also a
harbinger of terror to come.

Complacent, comfortable institutions like the UN, other International
Organizations and NGOs have ignored the gathering clouds and offered
no more than to help Kenya rearrange the deckchairs on their Titanic.
Who knows how many millions have been spent on sensitization workshops
and 'income generating activities'. Even when disaster happens, the
first into the breach are the UN and NGOs. Where are the government
institutions, where is the Corporate Social Responsibility of Kenya's
big businesses and the donations of Kenya's super-rich?

What we are witnessing is the culture of co-dependency. The Kenyan
government is doing the minimum to help the urban and rural poor, the
victims of current violence. The 'aid industry' critically dependent
upon such disasters to justify their existence, jobs and fundraising,
are again vying for time on CNN. In some respects, the 'aid industry'
is complicit in the disaster, refusing to tell the truth to power, for
fear they be PNGd and jumping into the breach at the first opportunity
and without caveat. In their actions and attitudes I can hear echoes
of 'The Whiteman's Burden' – 'we [Westerners] have to save the poor
Kenyans because their Government and civil society cannot'

Even through the narrow prism of the TV camera, it is clear to see
that the majority of those committing acts of violence in this civil
upheaval, are young men, of every and any tribal and political
affiliation. Their only common denominators are anger, frustration and
poverty. They have nothing so they have nothing to lose and are
focused on destroying all and everything, I suggest this is classic
nihilism. I would make Frantz Fanon's, in The Wretched of the Earth,
mandatory reading for every would-be Kenyan leader. What we are
witnessing in Kibera and Eldoret he describes as 'catharsis through
violence'.
It is mendacious and misleading for observers to imply that this
social conflict is primarily about Kikuyu- Luo tribal enmity. Though
tribal differences are a strong feature of Kenyan society and a factor
in this crisis, it ignores the fact that Ex-President Moi, one of
Kibaki's closest advisers and both Moi's sons and the long-time
enforcer for the for the Mount Kenya mafia, Simon Biwot, all deposed
from their Parliamentary seats, in this election, are of the Kalenjin
tribe. It is groups of young Kalenjin men, the so-called Kalenjin
Warriors who have been putting the Kikuyu to the sword. If this was
simply tribalism, Kibaki would surely have pressured Moi and the Kalenjin leaders to intervene.

Blaming yesterday's colonialism and today's tribalism is to suggest that Kenyan's, both the leadership and the people, have no responsibility for current events and no control over their futures, that it is their inexorable destiny. No amount of blaming the past can excuse the appalling leadership of today. This is the soft bigotry of low expectations.

In his excellent book on Command in Battle, Rick Atkinson describes
how every night, the then Commander of the 101st Airborne Division in
the Gulf War, General Patraeus, asked the same trenchant question,
"Tell me how this ends". Here are my offerings.

I concur with Macharia Gaitho, the Genie is out of the Bottle. At best
we will have slow return to simmering discontent. A government of
compromise, presided over by an uncomfortable partnership of Odinga
and Kibaki will maintain power, using the crude tools of patronage and
tribalism. Neither man has much to offer that is radically new or
different. Both are aged, as rich as Croesus, hugely self-absorbed and
remote from the people, though Odinga casts himself as a populist.
Either or both will fight for the status quo and will use the tools of
state to crush any resistance.

The young, unemployed and disenfranchised, will return to violent
crime, mostly robbing the poor but occasionally the rich, and the
pressure will slowly build up until it explodes again in the future.
Spinoza offered, "There is no hope without fear and no fear without
hope". Maybe he is right, maybe the fear created by this current bout
of violence will galvanize Kenyans into radical change. It will take
much courage and huge effort. The biggest hurdle will be to break down
the 'culture of the Mzee', a veneration of the elderly, particularly
old men, a deeply entrenched taboo that suffocates, original thought
and innovation, the prerogative of the young.

In practical terms, there must be a more equitable distribution of the
nation's wealth, mainly through the creation of jobs, lots and lots of
them. Building a modern national infrastructure, roads, railways,
electrical grids and water and sewage systems would employ a lot of
people for a very long time. It would also be a far more useful way to
spend foreign aid than 'workshops on sensitization, income generation
activities, IECs' and the usual paraphernalia of the 'aid industry'.

I am making these comments as a Muzungu, living [ relatively]
comfortably in northern Uganda. I am however,
not a fool, I can see the same dark clouds on the horizon as I saw in
Kenya, perhaps bigger and more ominous. The population is growing at a
frightening rate and the nation's leadership is in an advanced state
of cognitive dissonance. Corruption is pandemic and the leadership
presides over another shameless kleptocracy. To watch Ugandan society
up close and personal is to observe Darwinism in action, only the
strong survive.

But the young, and they are huge in number, want more than a life of
subsistence. Urbanization is almost as rapid as population growth. Not
so much because there is no land to work, there is more than in Kenya,
but because the young want more than a life in a hut, with a parafin
lamp and to hoe a row of maize. Among their many aspirations, they too
want at least to be able to watch the Permier League on TV at the
weekends. Those few hours in front of the TV are used for far more than supporting a favorite team (though the support borders on the fanatical) It provides the [predominantly] young men with a meeting place to discuss the issues of the moment, including politics and also gives them a window on a wider world, one with seemingly endless opportunities and wealth. Here's a thought: Is football a revolutionary force which will shape Africa's future?

Predicting the future is no more than entertainment but without the
sort of radical action I have suggested, I am pessimistic for the
future of Kenya, Uganda and indeed much of Africa. I offer only this
quote 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

The Lord's Gift and Flying Toilets

Living With Corruption
It is 9th December 2007 and I have just watched, for the third time in two days, a CNN special program entitiled, ‘Living With Corruption’, yet another first rate documentary on Africa by the incomparable Sorious Samora. Maybe it is just because I live in Africa and have great interest in the subjects he covers of maybe it his totally unpretentious manner, but I find him one of the best documentary producers around today.

As the title suggests, ‘Living With Corruption’ takes a hard look at corruption in Africa. Some might ask, so what’s new, it’s a subject well chewed over by the media on an almost daily basis. This film gives a new slant, it looks at how corruption rules the lives of the ordinary man and woman in the street. It demonstrates all too horribly and clearly how corruption pervades every level of society, and Samora suggests the entire Continent.
This at times infuriating film depressed and angered me on a number of levels; first because it reminds me of what I have witnessed almost every day of my past six years in east Africa and second because in many ways, Samora is ‘preaching to the choir’, the people most likely to see this film will be people who already know and have an interest in the subject. These are the same people who have witnessed the issue for years and have failed singularly to do anything to change it, I count myself amongst this group.

I doubt that the USA’s domestic CNN channel will make room in its twittering vacuous 24 hour ‘news cycle’ for a program as sober as this. Not least because CNN’s Directors have long since assumed [ or indeed created] an American audience with the attention span of a humming bird, that simply could not concentrate for almost an hour.

Of the many scenes that angered me, the shots of Samora walking at night down narrow alleys of Kibera slum in Nairobi ranked pretty high. His camera pans to the streams of raw sewage and describes the plastic bags under foot as being filled with human waste. There is such a dearth of pit latrines in Kibera, (as in most urban African slums) that the people have solved the problem by shitting in plastic bags and then hurling them as far away from their own dwellings as they can. The practice is called “The Flying Toilet”.

When I lived in Nairobi some years ago, I wrote a piece in early 2003, about HIV/AIDS and public health, essentially criticising the then ‘new’ PEPFAR initiative as being too narrow in its focus. My argument then and now is that attempting to stem the tide of AIDS by offering medicines to those in need is in many ways a pointless task. Giving medicines to people whose living conditions are so appalling they cannot find clean water with which to swallow their medications and cannot find food enough to re-generate their lost body weight, seems an exercise in futility that does no more than make the donor community feel good in the short term.

I entitled that piece The Lord’s Gift and Flying Toilets. Watching Samora’s film prompte me to revisit the piece, it is depressing to see that almost five years on so little has changed for the better and most for the worst.
I have reprised the article below…………..

Medicines for the Hungry
Even if it all comes together and “the Feds” get the money and resources to do what the President has directed, I have serious doubts about the [plan’s] overall impact on the disease, at least in East Africa, because it takes too narrow an approach to the issue and offers a single templated solution. The Harvard economist Jeffrey Sachs recently commented: “…the US administration has latched on to a simplistic vision of what to do, based on a single example, Uganda. It knows little of measures in place in other parts of the world, and that each country needs to shape the best local response”.

I think he’s right. My brief sojourn into HIV/AIDS in this part of the world has taught me that there is no template: even communities abutting each other need different plans of attack. But above all else it has taught me that it is a disease of poverty and that no plan will work unless it deals directly with the underlying social causes of poverty as key objective. A Kenyan friend puts it more bluntly. “Giving medicines to the hungry that live in shacks with no heating, lighting or toilets, consume dirty water and are illiterate will not reverse the scourge.” Another commented: “No community or government can tackle disease when its people are barely surviving on $1 a day.”

This Hecate’s brew of hunger and AIDS is impacting upon Kenya in a multitude of ways. The Country has a population of about 30 million, around 80% live in rural areas and could be broadly considered as farmers. But the demographics are changing rapidly. Farmers who once grew cash crops such as cotton and peanuts cannot find enough healthy members of their family to harvest so they have turned to subsistence crops like maize. But when disease stalks the land on a biblical scale even subsistence farming fails. So the people, particularly the young move to the cities to find security and work. HIV/AIDS is accelerating the pace of urbanization in Kenya and in doing so it is creating another dimension of social problems, which in turn must shape the way HIV/AIDS is managed in those communities.

Living in a Ditch
Kenya’s capital, Nairobi, is a city of approximately 2.2 million and growing daily. Over 60% of the population lives in slums euphemistically called temporary settlements and the numbers are growing at an unstoppable rate. The most infamous is slum is called Kibera. It has the dubious distinction of being the biggest in Africa, with about three quarters of a million people occupying 226 hectares – three-square meters per person. It was most trenchantly described by the BBC’s East Africa correspondent, Andrew Harding as, “Wood fires, fried fish, excrement, and rubbish – the rich stench of 800,000 people living in a ditch…six hundred acres of mud and filth with a brown stream dribbling in the middle…and at least one third of Nairobi lives there.”

The majority of Kibera’s residents work in and around the city, in light industry and the service sector. Most live in tin-roofed shacks connected by mud tracks, which usually double as open sewers. There is an erratic electricity supply for those who can afford it. It is a dangerous place to live. Robbery and violence is commonplace. Drugs, prostitution and heavy drinking of an illegal and potent homebrew called Chang’aa are common recreational activities. The police rarely patrol; vigilantes provide security for a price and sometimes exact terrible punishments: ‘necklacing’ is not uncommon for theft


Lord’s Gift
TB and dysentery are endemic and there are frequent outbreaks of virulent infectious diseases such as meningitis and hepatitis. Rats and other vermin are constant health risk. The HIV prevalence is estimated to be 20% (5% above the national level) but I have failed to find out how this figure was determined). Public health standards would shame a refugee camp. There is little or no running water; contractors bring in most in aging water trucks with logos such as “the Lords Gift” painted down the side. It is sold at exorbitant prices and carried home every day by women and children. Only a hardened Kibera dweller would drink it without boiling. The sewage system is a combination of open sewer and pit latrine. But as numbers multiply there are not enough latrines and in desperation, people resort to the “the Flying Toilet”. In simple terms those with no access to a latrine evacuate into plastic supermarket shopping bags and hurl them as far away from their own shack as they can. The result needs no description.

Reality Check
Now: against this medieval background lets remember our clear and simple mission is to reduce the number of new HIV infections, treat a number infected with Anti Retroviral Therapy (ART) and a considerable number more for the opportunistic diseases of AIDS. In this scenario prevention through education and behavioral change is an uphill struggle. Clinical diagnosis and medication are overshadowed by the need for clean water an adequate diet. How effective will ART be when the patient drinks water laden with cryptosporidia and eats one meal of porridge a day? For those who will never receive ART and who will spend their last days in their shacks in what is euphemistically called Home Based Care, the greatest need is a clean place to lie, a caring nurse, relief from pain and a death with dignity.

This is the reality that our “Emergency Plan for Aids Relief” must deal with. It can only succeed by a broad approach, socio-economic, educational and health. Each country stricken by this plague has unique problems and each must deal with them in an individual fashion. It requires the complete involvement of the people, communities and government. Solutions cannot be designed and imposed by even the most clever, generous and wealthy outsiders. America cannot solve this problem alone and in a way of its own choosing. To have any hope of success, we must act now, the numbers are growing inexorably. It needs huge sums of money, focused, trained human resources and a ‘coalition of the willing’.

This last cliché raises another spectre. If by the time this reaches print we are at war in Iraq, then war will eclipse every other international human priority, HIV/AIDS included. Wars divert attention; wars consume resources. Will America still be able to meet its promises?

George and the Dragon

Today is World AIDS Day 2007
I decided my contribution would be to dig up all the old pieces i have written on the subject and dump them on this 'Blogsite', if for no other reason than to enable me to track my life against the progress of the disease. I am not happy about where we are but have not yet lost hope.
Here is a piece written back in July 2003. Plus ca change.

George and the Dragon
“But overall the passage of HIV around the world has continued roughly as if we had done nothing” – Richard Feachem, Executive Director of the Global Fund. January 2003

George
George is a good doctor. He has been practicing internal medicine for almost 5 years, works about 60 hours a week and gets paid about $1,000 a month (his government salary doubled this year). In his free time he is studying for a Masters in Public Health. He is a man with a mission, to save his country from HIV/AIDS. It is an uphill struggle; most of his patients present with the range of opportunistic infections that signal full blown AIDS. He counsels them, tests those who consent to testing, treats what he can, keeps them in hospital until they are fit to walk (60% of the beds in the hospital are taken up by HIV/AIDS patients) counsels them again about diet, clean water and avoiding infection and sends them home. Every day a half dozen join the 700 or so who die from AIDS-related diseases in Kenya.

Today George is very angry. He has just been asked to speak to a man who attended the Voluntary Counseling and Testing (VCT) centre adjacent to the hospital. The man has received his HIV test result. After an hour of patient explanation and guidance he is intransigent, adamantly refusing to inform his sexual partners of his HIV status. In pre-test counseling he disclosed that he was married and that his wife and year-old daughter were living with her parents in Busia, Western Province. He admitted to having a “regular girlfriend” who is pregnant. Smoldering with anger, George heads back to the wards. He tells me. “Even if I could find his wife or girlfriend and get them to counseling and testing, without his consent I am breaking legal and ethical guidelines and could be out of a job. How did we get to the point whereby some foolish law prevents me from telling a household that help is needed and death is on the way?”

HIV Exceptionalism
How indeed? The answer lies in part in the genesis of HIV/AIDS as an epidemic in the USA and its perception as a “homosexual” problem. Randy Shilts in his definitive social history of the disease, ‘And the Band Played On’, exquisitely catalogues the epidemic and its management in the early years. Fear of an unknown, incurable and deadly disease combined with a set of social and moral values loosely known as “homophobia” to create a level of discrimination and stigmatization so powerful that the needs of disease management and public health were overwhelmed by social imperatives. HIV/AIDS was no longer a disease it was a political movement. Out of the turmoil rose the phenomenon of ‘gay rights’, which were designed to protect, at first those suffering from HIV/AIDS and eventually all homosexual men and women from the worst excesses of stigmatization.

A unique coalition formed between the gay community, public health practitioners and civil liberty proponents to avoid prevention measures that might “drive the epidemic underground”. The traditional tried and tested public health measures of disease notification and contact tracing used for diseases such as typhoid, TB and syphilis were abandoned, and medical confidentiality was replaced by anonymity. The new strategy, based upon voluntarism, stressed mass education, counseling and the respect for privacy. This special approach to HIV/AIDS, as opposed to other infectious diseases, dubbed “HIV Exceptionalism” became the norm in the USA. The focus on voluntarism and what had transmogrified from ‘gay rights’ to ‘human rights’, shaped the policies of the Global Program on AIDS at the World Health Organization, which in turn informed the policies of nations around the world, in particular, Sub-Saharan Africa. George’s ability to use the standard tools of disease management to deal with a pandemic which threatens to overwhelm Kenya today is constrained by the peculiar political imperatives of a nation thousands of miles away and two decades ago.

Stigmatization
“The public policy challenge is to fight the discrimination at the same time that we fight the virus, not to assume the permanence of the discrimination, exalt it, and argue backwards from there against effective disease control” – Chandler Burr, The Atlantic Monthly June 1997
While no cure exists for HIV/AIDS, we do know enough about the virus to prevent its spread. But after almost 20 years of effort and countless millions of dollars we have signally failed to do so. Why? The more I stare at the problem the more convinced I become that the single biggest hurdle to overcome is stigmatization. It is all-pervasive. The developed world stigmatizes the developing world; Africa in particular it seems has only itself to blame for HIV/AIDS, the issue cursorily dismissed by one commentator as “over-population and over-copulation”.

Within Africa the perception of HIV/AIDS is still shaped by ignorance, misinformation, myth and superstition. Fears of becoming a social outcast deter many from seeking advice and help. Those living with the disease, though often showing little signs of illness, are shunned by their communities and discriminated in every aspect of their lives, even healthcare. Those who seek medical help frequently receive scant care because of discrimination by healthcare workers. The terminally ill, are left to the care of friends and family who rarely have the medical skills to cope and whose own fears result in stigmatization and even neglect. Above all, women are the most stigmatized, often forced into sex to survive and abandoned or brutalized when they become ill from the results.

Although human rights laws can and do protect against discrimination in employment, education and healthcare they can do little to protect against stigmatization which is far more pernicious but less easily defined and identified. In their ground-breaking article in the Lancet in 2002, De Cock et al argue that the real irony is treating HIV/AIDS differently from other infectious diseases almost certainly enhances the stigma surrounding it. Replacing the well-tested precepts of confidentiality with anonymity has created a cult of secrecy, which as the disease progresses, is impossible to maintain. Nevertheless, secrecy remains the orthodoxy despite the fact that promotes rather than breaks the destructive silence surrounding the disease and divides the known infected from the undiagnosed and uninfected. We will never beat the disease unless we get it out in the open

Normalization
“People will not agree to be tested until the results provide them with more than just a death sentence’ – William J Clinton. February 2003

There is a growing body of opinion within the healthcare professions that HIV exceptionalism, whether for principal or pragmatism, has broken nearly every tenet of infectious disease control and public health management and has failed to prevent the spread of the disease and to protect society at large. Richard Feachem’s comment chillingly echoes the result. In Africa the most obvious result is a complete lack of accurate data on the disease. Most prevalence rates are obtained by complex extrapolation of data obtained anonymously from antenatal clinics designated sentinel sites. HIV/AIDS is rarely entered in death certificates and yet treatment decisions are based upon the assumption that a patient is infected. Truth to tell, we simply don’t know the size of the problem. We can only judge it by the numbers who get sick and die on a daily basis. But why should we be surprised? In the USA and Europe today it’s estimated only half of those infected by HIV are aware of it.

So what is to be done? It is hardly likely that we could return to the authoritarian practices of yesteryear (although Canada’s experience with SARS shows that even “liberal” countries set limits on human rights). Five years ago De Cock and Johnson lead the debate to re-examine current practices; they termed it “normalization.” The concept is further enlarged in the 2002 Lancet article. De Cock describes a new model expanding considerably the practice of HIV testing backed up by enhanced access to care. As Anti-Retroviral (ARV) drugs become more widely available there will be an increased need for testing and more to offer than “just a death sentence”. He discusses four contexts for HIV testing: mandatory testing, VCT for prevention; routine testing for delivery of specific healthcare interventions and diagnostic testing in individual medical care.

Mandatory testing has little utility outside specific situations such as military service. VCT is to be developed as a means of prevention by testing people who are well rather than sick; in universal know-your-status campaigns. The idea being to use VCT as a tool to reduce secrecy and stigmatization. Each test site would be linked to institutions offering care for the infected. Routine HIV testing, which differs from mandatory testing in that it implies a default policy of testing unless an individual specifically elects not to, would be become standard practice in antenatal obstetrics and the management of all sexually transmitted diseases. Finally, diagnostic testing would become routine management for those diseases currently recognized as opportunistic infections such as tuberculosis. Although this does not sound too radical it is a major departure from current practice

I would add to this concept social marketing campaigns of a scale never before attempted. Analogies between the war on disease and terrorism are hackneyed but just as terrorism can only be tackled by addressing the social issues in which breed it, the same is true of HIV/AIDS. It is much more than a simple “bug kills host” argument. Social change on the scale necessary to combat HIV is critically dependent upon an informed public with rising expectations, eventually creating demand. Most of the social marketing campaigns I have seen to date have been to say the least, amateur. I want to see the guys who sell Budweiser at the Superbowl sell HIV prevention to the world.

The Dragon
Whilst researching this article I came across a book in the AMREF library, by an old friend, the former New York City Health Commissioner and Assistant Secretary of Defense (Health Affairs) Doctor Steve Joseph. I confess that I had never read the book “Dragon Within The Gates” until now. It is a fascinating read and eerily prescient. His description of attempting to use the standard tools of public health in particular contact tracing and being thwarted by vested interest echoes down the years. But the greatest resonance came from his accounts of conservative opposition to condom distribution and the fury resulting from his halving the original estimates of HIV infections in the city, which he argued were based on shaky extrapolation of shaky data; thereby threatening research funding. Plus ca change! I have loaned the book to George.

XTB and Mandatory Volunteering

Consumption
Her name is Maria. Her eyes staring at me over the blue paper face-mask are clouded with fatigue. She sits in silent surrender as the conversation, in English and Spanish, ricochets past. Her entire being concentrates upon lifting rail thin shoulders and pulling in tiny gasps of air into a concave chest. Maria is a beautiful 17 year- old girl and she has Pulmonary Tuberculosis (PTB). The clinical notes tell us it is of a type, resistant to almost every medication available to treat the disease. Maria has what the denizens of international health call Extensively Resistant Tuberculosis. Shortened to the acronym, XTB, it sounds like the name of a new sportscar. Without a miracle, Maria will not live to see her eighteenth birthday, she has what in the old days, before the advent of antibiotics, they called Consumption, virulent TB that is consuming her lungs and there are no longer drugs to cure her, she weighs 70lbs.

Maria is one of a dozen patients lined up quietly, trying to find shade from the stunning heat, outside the back door of the Coliseum Sports Stadium in Buena Ventura, a port city on the northwest coast of Columbia. They are at the back door to avoid the mass of people queueing at the front entrance. Those people are here to see the primary health care teams deployed from the USNHS COMFORT on this its eighth stop in its four month odyssey around the littoral of South America and the Carribean. Our small group of patients all has TB and each has a form of the disease resistant to many or all the medications known as first and second line TB drugs. At best they have Multi-Drug Resistant TB (MDR) at worst, XTB.

They have come to see us because…well because we are here and they have exhausted every other option. To be precise, a microbiologist from the local office of the Ministry of Health (MOH) responsible for the scientific work to determine the level of resistance amongst TB patients in the city, has identified and gathered together over two dozen patients in dire straits. Stricken by MRD TB they are unable to find or afford the expensive options. She has brought them along to get whatever help we can offer. In terms of immediate relief, it is not a great deal.

I am an observer, assistant to a quietly professional Infectious Disease physician, Lieutenant Commander Todd Gleeson, as expertly conducts a detailed examination of each patient and confers through his interpreter with the microbiologist, patient and relatives. Masked up, we escort each in turn to the portable xray machine where a masked technician quickly takes a chest xray and we confirm the extent of the damage through and instant image on a laptop screen. Only a couple of those we assess show any sign of improvement since their last examination. What more is to be done? We are somber when we consider the options. The dozen we have assessed are, we are told, only a few of many more.

When we consult with our collegues, including local medical practitioners, conducting the general primary care clinics, it is apparent that TB is a common disease in the City and in the Region. Equally worrying, conversations with the local practitioners and the symptomatic evidence of our patients suggest that HIV is very present in the community and increasing in frequency. What we are witnessing is a public health crisis in the making and there is little we can do other than sound the alarm.

Finally it is agreed that the COMFORT can provide some limited medication for the most needy and less resistant. A meeting is held with the local MOH authorities exhorting them to sound an urgent warning to the Columbian Government and to seek help from the NGO ‘Partners in Health’ – an organization with great experience and expertise in TB in Latin America. The MOH is also urged to ask for help from the CDC and the Pan-American Health Organization, an agency of the World Health Organization that deals with health issues in Latin America. Gleeson and I muse about the future and the very obvious re-emergence of TB as a global health threat. I offer that we might yet see the return of the Sanitorium as a key means of controlling the disease. We are both silent.

Challenging Travel
Columbia has been the most challenging and in many ways the most rewarding of COMFORT’s ports of call to date and not just because of the burden of disease. The Ship has not been able to reach its intended rendezvous, alongside at Buena Ventura and has anchored off the coast, some miles from the secondry destination Bahia Malaga. Though the latter provides demanding and rewarding medical work, the population is small. The weather has been awful, with heavy rain showers and low cloud.

Getting to and from Buena Ventura has been an adventure for most and a serious challenge for some. It has required us to leave the ship early in the morning, around 6am, travel by small boat to the Columbian naval base of Bahia Mallaga and there transfer to a US Army Blackhawk for a twentyfive minute flight into the City. At the end of a long, hot and damp day, the journey has been most times repeated in reverse, though by late in the afternoon the seas are often much much more lively and the return boat journey long, wet, stomach-churning and exhausting.

Occasionally the lucky few have been picked up from Bahia Malaga or even Buena Ventura, by the tireless and intrepid ship’s helicopters. On a couple of occasions the weather has been bad enough to strand medical staff in Buena Ventura. Thanks to the outstanding work of the US Embassy’s military contingent, known as the MILGP, being stranded has been a far from uncomfortable experience, which I for one, have very much enjoyed. It might have been better from the outset to plan for at least a cadre of medical and administrative staff to stay ashore throughout. Much valuable time, which could have been spent with patients, was consumed travelling.

Rewarding Moments
There have been many rewarding moments during the mission so far. Sometimes I have been lucky to observe the COMFORT’s crew when they happen. Often they have been found in the camaraderie generated by overcoming the challenges of difficult journeys, long demanding days, seemingly endless flows of patients and cooperation to determine a particular diagnosis and a plan of care. Other times they have been found in an individual heart-felt offer of thanks for a kindly ear, expert advice and medications where needed. Sometimes too, through the pride of a successful intervention that alters a life and the uninhibited gratitude of a patient.

One of my favorite moments occurred in Buena Ventura. It concerned a man who was brought to see us in a wheelchair, having been shot in the back some six months previously. He was a fit-looking fifty-year old with a young wife and son. His clinical notes indicated he had a ‘paralyzed left leg’ with a lower leg brace to prevent foot drop. He had been unable to move his leg and confined to the wheelchair since the attack. He has come to the COMFORT convinced we could remove a bullet purportedly lodged in his back and with that enable him to walk again. When he was told that was not possible (an old x-ray showed a small-calibre bullet resting against a lumbar vertebra but not near the spinal column) his face crumpled and the whole family began to cry.

Nonplussed by this sad display we began a detailed physical examination. This showed, other than his wasting left leg, a very fit man with a ‘fully functional physiology’. Yet he had been in the wheelchair from the moment he had left his hospital bed, almost immediately after surgery. Asked if he had ever been encouraged to stand on his ‘good leg’ he shook his head. As luck would have it, the COMFORT’s Physical Therapy Department had deployed a comprensive capability in the Coliseum. Expert advice was sought, from the USAF and Candanian Medical Services PTs.

In short shrift our patient was gently but firmlycajoled and assisted to stand up from his chair and offered a pair of crutches. After some basic instruction he took a faltering step. The first in six months. To his obvious delight and with the encouragement of all around him he soon was able not only to bear weight on and move his ‘good leg’ but also to push his ‘paralyzed leg’ past the good one. In the expert opinion of the physical therapists, our patient would walk, probably unaided within weeks, given intensive therapy. A physician from the local hospital promised the therapy. The family cried again, this time because they were happy.

Volunteering Not Compulsory
No better story exemplifies the challenges of the Columbia Mission and the character of the ship’s crew, military and civilian, than the saga of our last day ashore. It began in the usual way, staggering out of our ‘racks’ (bunk beds) at 4:30am. Shower, shave, coffee, breakfast for those with cast-iron constitutions and muster in the CASREC (Casualty Receiving Department and the launching point for every move ashore) by 5:30am.
It did not take long to determine today was going to be a dificult day. The seas were choppy, the mist was dense and there was a continous drizzling rain. We adopted the usual posture, known to paratroopers as “hurry-up and wait”.

After an hour, the weather was little changed and it was pretty certain the ship’s helicopters would not fly, but at least one of the ship’s small utlity boats, known as hospitality boats, was prepared to make a run for Bahia Malaga where the weather was better and the Army Blackhawks would ferry us to Buena Ventura. Twentyfive volunteers were asked for. It was important we go because we had made commitments to patients from the day before and we had a great deal of medical equipment still in the Coliseum. Of the twentyfive who stood up to go, most were what I called ‘the usual suspects’ the same group of doctors, nurses and medics who seemed to be in every difficult mission, four were Project HOPE Volunteers, two doctors, two nurses, all younger than me - just. I had no choice but be the fifth.

Almost the moment we crossed from the lowered lifeboat to the hospitality boat, the rain began in ernest. As soon as we rounded the Ship from the sheltered leeward side, the boat began to rock and roll. Trying hard to avoid the rain and the sea spray we eyed the waves and held on to the boat, some including me, chattering away to settle the nerves. It wasn’t the choppy seas that bothered us, we trusted the Mariners piloting the boat; it was being seasick.

Half an hour into the journey the boat really began to bounce about, caught by increasing cross-winds and a rip-tide running up the river, a river we had to enter. Our craft began to buck so alarmingly, I would not have been surprised to see Captain Ahab on the prow with a harpoon and a big whale to port. Finally, after many more exciting and drenching moments, the boat made the relatively calm waters of the estuary and from there chugged quietly up to the pier in Bahia Malaga.

There we found to our dismay that the weather had beaten us ashore and the helicopters would not be flying until the rain and very dense low cloud cleared. Not to be defeated, we regrouped, cared for those who were seasick, found shelter and food and hunkered down to to wait out the weather. I wandered to the water’s edge with a couple of the boat crew, seasoned sailors; they were in no hurry to fight the tides and the seas back to the ship. Their advice was we all get some rest. I took it, determined I would not rush to take the boat back, I advised the four Volunteers to do the same. I was sure the weather would clear and the ship’s helicopters would pick us up, eventually. I was going to wait for them; they agreed to do the same.

I scrounged some old mats and a piece of plastic and was soon snoring; only to be woken by the boat’s coxwain who quietly informed me he was, “about to make a run back for the Ship and that much to his dismay, the four, the ‘HOPIES’ were volunteering to accompany him.” More than a little grouchy I found my intrepid comrades and crossly demanded to know what on earth they were thinking, the journey back would be as miserable as the one in and it was poor judgment to make the boat crew responsible for them. My final admonishment was, “Just because you are HOPE Volunteers, it doesn’t mean that *@##* Volunteering is Mandatory!” Chastened, the four settled down to wait. Two hours later the weather began to clear and the air was soon filled with the welcome thump of helicopter blades. We were on our way ‘home’.

As a young army officer, I once had a Commanding Officer who told me, “Your job is to give your soldiers tales to tell without getting them killed”. I think its fair comment that COMFORT’s time in Columbia gave many of its crew, civilian and military, tales to tell. Tales they will enjoy for years to come and which set them apart from the people who were not here with us.

Health Diplomacy - Tales from the USNHS COMFORT

Leviathan
The MH60 Knighthawk describes a graceful anti-clockwise arc, suddenly to our left a huge red cross looms out of the grey sea. The aircraft turns its nose to the cross, levels up, utters a long shudder as it bleeds away airspeed and lowers itself to the ships deck. The moment the wheels are firm, a host of ground crew in colored jackets descend on the helicopter, in seconds it is secured to the deck, doors opened and we are ushered through the roaring wind of the blades, to the sanctuary of ‘Flight Ops’. As I remove my life-vest and helmet the Knighthawk’s engine tone becomes more urgent and it slowly lifts away, headed back to the shore to collect patients. I am home from teaching at the local medical school.

Home is a white-painted leviathan known as the USNHS T-AH 20 COMFORT; its official title is a hospital ship but its actual presence beggars description. It is almost one thousand feet long, eight floors high and weighs 69,000tons. It has a complement of over 800 souls and carries enough food and water to feed them for a month. It has twelve operating rooms, an enormous ER known as CASREC, cutting edge ICU and post-op capability, state-of-the-art laboratories and a radiology department that would be the envy of any mid-sized American hospital. It has the capacity to manage up to one thousand patients and bring them on and off by air or sea. It is a fully capable trauma hospital at sea, and it is huge!

The COMFORT has been my home for over two months. We have sailed together from Norfolk Virginia to Belize, Guatemala, and Panama, through the Canal, Nicaragua, El Salvador and most recently Peru. As I write, we are heading north again towards the coast of Ecuador, the seventh country in a planned twelve nation tour that began in early June and will finish in October in Suriname.

Health Diplomacy
I am part of an experiment. The brain-child of the Under Secretary of State for Public Diplomacy and Public Affairs, Karen Hughes, it’s called ‘health diplomacy’, the use of national healthcare assets, military and civilian volunteers, to ‘win the hearts and minds’ in strategically important parts of the world, in our case, Central and Latin America. The US Navy has long held it has a vital global role in providing humanitarian relief in natural and man-made disasters and has used assets, including the COMFORT’s west-coast sister-ship the MERCY, in previous operations. The MERCY responded to the Asian Tsunami and the COMFORT to Hurricane Katrina. Recently the US Navy has sought to expand this role to more deliberate, planned humanitarian operations, specifically the provision of healthcare support in under-served areas of the world. In 2007, there are two such missions underway, the COMFORT is operating in Latin America and the USS Peleliu, a helicopter carrier, is working in Southeast Asia. This congruency of international policy and US Navy doctrine has produced a new and fascinating turn of events.

The experiment is novel not only because it is a new role for the Navy and particularly Navy medicine, but also because it deliberately includes contingents from the US Public Health Service and, more contentiously, civilian Non Government Organizations (NGOs) two in particular. Operation Smile, an NGO specializing in reconstructive surgery for cleft lips and pallets, and Project HOPE, a Virginia-based NGO with a long history of working aboard ships to deliver healthcare to under-served areas of the world. Both NGOs feature volunteers, individual doctors, nurses and other healthcare specialists who give their time and expertise for weeks at a time to serve on the ship and ashore in various countries.


Some will raise their eyebrows at the concept of NGOs working so closely with the military. I reserve my judgment; it is too early in the experiment to draw definitive conclusions. I view the Mission as a form of ‘armed reconnaissance’, the Navy is using its reach and power to identify needs in various countries, addressing the immediate needs where it can. The NGOs in turn use their expertise to determine the numbers and types of long-term capacity building projects that are feasible and begin work with the host countries to establish them. One thing is for certain; at the end of this Mission I will have a more informed position than most of my NGO friends. I will most definitely let them know.

Project HOPE
As a HOPE volunteer, I am the COMFORT mission medical director and will serve on the ship for four months. I manage the Volunteers during their stay on the ship. They come aboard in four waves, each of about 20 Volunteers and stay three missions each time. The twelve missions will see almost 100 Volunteers serve on the ship. They provide general surgery, primary healthcare and education, with a heavy emphasis on the latter. HOPE seeks volunteers with specific expertise, experience working in austere environments, good education skills and a strong streak of independence. The independence is an essential attribute for balanced living in a powerful Navy culture but it can cause the odd headache. I describe my job as ‘Manager of the La Scala Opera House’ I have more than one Diva to deal with daily. I nevertheless am in awe of the experience and sheer dedication of the average HOPE Volunteer.

In addition to the Volunteers, HOPE provides what it calls ‘Gifts in Kind’. The HOPE Regional Director for Latin America gathers from the country MOHs, ‘shopping lists’ of medical equipment and medications which individual countries need and find difficult to acquire. HOPE HQ approaches the US manufacturers and businesses in general to donate or buy these resources. They are delivered to their final destinations aboard the COMFORT and presented to the MOH for distribution. This huge generosity of US businesses amounts to millions of dollars annually and is another example of the private face of American altruism.

Tales to Tell
Each country we have visited has presented a uniquely different environment, cultural and working. Advanced teams visited each country months ago and plans were instituted by the US Embassies and the Governments, particularly the MOHs. On arrival the COMFORT either anchors off the coast or [preferably] comes alongside in a port. Up to three teams deploy to undertake primary healthcare missions in separate locations, a fourth to teach. In addition the surgeons deploy in the first few days to triage patients for surgery on board the ship. There is a substantial complement of SEABEES aboard; these redoubtable engineers turn their hand to any construction and repairs that they can accomplish within the ships stay in the country.

There are sufficient tales to tell from the journey so far, to fill this magazine and I will save them for a future date. They range from bouncing down the Guatemalan coast in a storm, the ship is a converted oil tanker and too light for its size so rolls around in a disconcerting [and sickly] fashion, to passing through the Panama Canal (a modern Wonder of the World), through ending up in Nicaragua at the same time as President Hugo Chavez and on Sandinista Day, to the trials of the Crossing the Equator Ceremony. We have seen all manner of people and all manner of illness, fixed some and not others but made many friends.

Emerging Themes
We are now in the second half of our Odyssey and though it is too early to draw absolute conclusions I have some pretty firm ideas about both the good and the not-so-good of the Mission to date. The first point I think it vital to make is that this is a training mission. We set off on the 15th of June over 800 souls from the US Navy, Army, Air Force, US Public Health Service, Canadian Defense Forces and NGO volunteers. Few if any had ever seen each other before let alone worked together. Most, including the majority of the Navy medical staffs had never been to sea before. It was only to be expected that the learning curve for all would be vertical and life would be difficult. It was, and at times painfully so. It is hard to reconcile learning a task and practicing for real at the same time. But this is the reality of the modern Navy, constant turbulence.

We learned quickly and by Panama had grasped the main lessons and were beginning to work together. Peru has witnessed that truly military phenomenon, ‘the Team’, forming in almost every department of the ship. These tight little groups have cultures developed around shared experience and a vernacular that is impenetrable to the outsider. Though we may not appreciate it now, the often painful learning process we went through in each hot and dusty medical site, every frustrating encounter with a creaky communications system, was necessary to produce this very essence of the military culture, the ‘Band of Brothers’.

Competing Imperatives
We have learned too that it is difficult to reconcile two competing imperatives, to visit our ‘medical diplomacy’ on a large number of countries in a relatively short period, and provide substantive medical care in each target country. The latter takes time and the former does not allow it. The result at times has been the disappointment of unmet expectations, frustration amongst clinicians who felt their medical abilities constrained by time and resentment from indigenous medical staffs who felt excluded from events. It could be argued that no matter how long we stayed we would only be ‘scratching the surface’ and that is true, but longer would have been better. We are learning to compensate by making our procedures slicker, using our advance teams to set tighter, more achievable schedules and focusing in on what we do best. Still, the lines at the main primary care site in Trujillo Peru would have put a football match to shame. I contend that future missions would benefit from a more targeted approach, less countries and longer stays.

Trojan Horses
At the tactical level we have learned valuable lessons which we will continue to expand and exploit. The first and by far and away my favorite is what I have nicknamed ‘the Trojan Horse’ approach. The countries we have visited and will visit are overwhelmingly agricultural; animals are an essential element of Everyman’s wealth. It therefore follows that healthy animals mean wealthy owners and wealthy people are healthy people. Yet we did not grasp the full import of this until Nicaragua. Given the current political environment of the Country, we not surprisingly met resentment and disinterest in our offers of primary healthcare. A decision was made at one site, to lead with the USPHS Veterinary Medicine team offering healthcare to animals, principally horses, Nicaragua abounds in horses and they are an essential part of society. The effect was a sudden huge interest in all we were doing including human health. The ‘Vets’ had provided the catalyst to our primary care program. I believe this approach, combining animal and human healthcare in coordinated teams at the community level is a vital lesson learned and key model for future humanitarian operations.


Cabbage Patch Dolls
The second lesson concerns training and education, which should underpin our capacity building in every target country. We must expand our education initiatives and include them in every aspect of our healthcare delivery, from surgery to health promotion, dental care to veterinary care. The first tenet is that all training and education should be through the MOH and the medical teaching institutions and should include host nation teachers and interpreters. This takes a great deal of preparation and planning.

Training and education should be both culturally relevant and shaped to suit the needs and technology of the recipients. To this end we have instituted what I have called ‘come-as-you-are’ first aid at the community level. Rather than teach using the sophisticated technology of the US military, we have shown the Navy Corpsmen how use materials commonly found around households and workplaces as first aid appliances. Even more innovatively, the HOPE midwives teach the management of obstetric emergencies using a cardboard MRE box, Cabbage-Patch doll and a length of parachute cord. With these simple tools they can teach an array of techniques to manage deliveries. The local health workers are enthralled, both with its simplicity and the fact that ‘if it’s good enough for Americans, it’s good enough for us’.

The COMFORT of Home
The COMFORT is the center of our World and though we often complain about the food, the smells, the noise and lack of privacy (I like most ‘officers’ share a small cabin with seven other men) we know it is our safe haven, cool in the tropical heat, with familiar routines and friendly faces and the best hot showers I have experienced in my life. It also houses some wonderful technology and great people. I am fascinated by the Radiology Department which houses a CAT-Scan and is so sophisticated I view it as the modern Anatomists Laboratory. We no longer cut up bodies to see how they work, we map them from top to bottom, inside and out and travel their three dimensional digital images like modern explorers.

I am in awe too of our helicopters and their crew, who never seem to stop working. They fly tirelessly from dawn to dusk and whilst the rest of us are snoring they lovingly take their machines apart and reassemble them under the night sky. Without them and the redoubtable ‘pirates’ of the Military Sealift Command who ferry us faithfully to and from the ship like modern Charons, in almost all weather, we would most times be able to do little more than stare at distant shores.

So here I am for another two months. Some days I feel a little like the character that shot the albatross in the Rime of the Ancient Mariner. Others I am as excited as a latter-day Walter Raleigh. I have already learned much, seen a great deal and met some wonderful people, on both ship and ashore. I look forward to writing more tales and thoughts from our medical Odyssey.