health, life, and everything else

In memory of Gai Anyuon

2012-01-22T07:28:00.000-08:00

I just received an email from John Alier, the pharmacist at Malek Clinic , that Gai Anyuon, former UU student and nursing school graduate, passed away from tuberculosis. We had hired him to be the nurse at the clinic, but when he discovered he was suffering from TB he left to Kampala for treatment. We were all hoping he would eventually return in good health. He is second from the right in the above photo, which was taken in a truck lot right before he escorted all our cllnic building materials from Kampala to Sudan last May.

Like most Sudanese, Gai was reserved and quiet. But he had an inner strength in him I will likely never fully understand. We met up with Gai in Kampala after landing in Nairobi, our home base. He helped us with our shopping for building materials and participated in our endless evening meetings to discuss how the clinic would be run. He was painfully thin and frail, and had a hacking cough that in retrospect I should have considered might be TB. I thought he had pneumonia but he vehemently denied being sick. He probably desperately needed the job.

We sent frail Gai with all of our wares in a 20 ton truck on the 10 hour drive from Kampala to Malek. He didn't complain once about his health or comfort. He asked for a reasonable sum of money to eat food on the way. He went without basic needs for 2 days while the rest of us traveled far more comfortably to Sudan. He dealt with treacherous border officials, keeping the goods safe and fending off thieves and bandits. He didn't have an inch of flesh on his bones, but he never complained.

Gai was a knowledgeable nurse. I never saw him in action but through our conversations about how to provide health services to the people of Malek, it was clear that he was an intelligent clinician. He anticipated challenges that we would face and brought them up early, so that we could conquer potential roadblocks. My mom and I were definitely outside our element providing health care in a Sudanese village, so Gai's practicality was important (of course, along with Deng and John Alier, too). But again, even though Gai often brought up needs that we could not address due to the rural setting or financial constraints, he was accepting of the limitations and ready to improvise.

I don't know much about his personal life, but I know he was a husband to an "educated" wife, as he described her. I pray his family is safe and well. His quiet perseverance in the face of significant personal and professional challenges is a humbling example to me that I won't forget.

Holding Pressure

2011-12-01T04:41:00.001-08:00

It’s been awhile since my last writing and it will probably be awhile more before I’m in that thinking frame of mind again. But there have been so many poignant moments so far in residency that each one deserves its time to be savored. It is for me as true as ever that medicine is a labor of love for the beautiful rawness of humanity.

As the intern, lowest of the low and even more so because it’s surgery residency, for me to be in the operating room is no small feat. Even if all I’m doing is removing a catheter (the procedure takes five minutes tops), I’ll take it. The other day, we had three such cases scheduled. Having become nonchalant about these “surgeries”, I was somewhat annoyed—after you yank the catheter out, you have to hold tight pressure at the neck so the punctured vessel can clot off. For fifteen minutes. In fifteen minutes, I could complete 5 other necessary tasks! Instead, I’d be pressing on a neck in a sterile field for a total of 45 minutes. What a waste of time.

The first case was an elderly African American lady wearing a grey sweatsuit and shiny crocodile shoes. After completing all the preoperative paperwork, I positioned, cleaned and draped her neck to make sure the field was sterile, and called my attending before injecting the lidocaine and starting the dissection. The catheter came out easily. The attending left swiftly, and I was left sweating in my mask under the bright lights, holding pressure. Five minutes went by in silence. The OR nurse, Jean, asked me what dressings I wanted. They were retrieved. The patient lay quietly, patiently awaiting her reprieve. The fifteen minutes finally ended and I checked for hemostasis, placing a neat pressure dressing on her wrinkly neck. Jean and I transferred her from the table to a wheelchair while she muttered about wanting tea and pancakes. Then I ran off to complete other tasks before the next case.

The next patient was another elderly man with a heavy Caribbean accent. He was with his wife, who was sleeping next to him in the holding room. He had a good-natured disposition and a long grey beard that ended in a sharp point. I did his paperwork and interrogated him at rapid pace to make sure his blood pressure was controlled (it wasn’t), that he was not on a blood thinner (he was), and that if he was on a blood thinner that he knew why (he didn’t) and his most recent INR (ditto). I wanted to get this done as soon as possible. The attending didn’t answer my phone so I called another attending on service, who agreed to supervise. We waited ten minutes. The attending finally showed up. The case went the same, with the exception of the patient needing extra lidocaine for the pain.

When the catheter came out, I braced myself for another fifteen minutes of emptiness. I wanted to take my mask and sterile gloves off and pull my phone out for entertainment, but that would violate our sterile field. To my surprise, the patient broke the silence. “Ah, what I wouldn’t give for some fish and grits right now,” he said. My eyes, previously glued to the clock, turned to the wispy tufts of hair on his chin. I didn’t like grits at all. The OR tech laughed and chimed in, “It’s always a good time for fish and grits!” They shared a slow and hearty chuckle. “Ya, it is,” my patient said. “I got a granddaughter who live across the street. I make her fish and grits every day and she call me Papi and don’t let no one else call me that.” I asked him how he makes fish. “Well, I had one of the dialysis nurses at me house the other day. She said she never had such good fish. You got to steam it in lemon juice with some dry onion and cumin and butter. If you do it right, ain’t nothing better.” We all shook our heads, imagining a perfectly steamed fish. Our time was up and I put the dressing on. We helped Papi up from the table. “I want a hot coppa tea,” he sighed.

I signed his paperwork and walked back to the floors, back to checking boxes off my to-do list. It was a slower walk and I felt more human. I had been transported into my patient’s world for a few moments, a world that was abstract and foreign to me, but real and wonderful to him. Holding pressure was the perfect time to step into his life outside his disease, with no responsibilities other than mechanically achieving hemostasis. Hard to remember in a field where you are always under pressure, but so worth remembering.

My dad always taught me that there are many ways of seeing the same thing, and it’s up to each person to see what’s in front of them in the correct way—the correct way being the way that is most beneficial to you and everyone around you. Residency is tough: there are rude people, unfair hierarchies, rough hours and inequalities. But medicine is a privilege: we are privy to everything in a person’s life for a critical slice of time. To isolate the body and ignore the human in front of us would not only do a disservice to the patient, but cheat us of the best part of this profession: its humanity.

Truth Unfolding

2011-10-16T04:25:00.000-07:00

When I was a medical student, I loved surgery because it stood for truth in my mind. There was no lying or covering up or giving 50% or even what you thought was 100%. Whatever you did had to be exactly precisely accurately 110% correct.

Now I am realizing that demand on a whole new and sometimes frustrating level. As a resident, I am not just pretending to care about patients while I try to pass exams. I am actually responsible for their care. There are times when I'm the only surgeon scrubbed on a case (simple ones, of course) or the only one writing and reviewing admission orders on a patient, or seeing them on discharge when they leave the hospital. Am I giving 110%?

Surgery is truth. You can't cover up a bleeder--you have to fix it right then and there before you move on to any other step of the operation. Your sutures have to be exact--if they aren't, the fascia will dehisce and the patient will wind up at your door with a complication. Or if your skin sutures aren't good, the skin will bunch up and heal with an ugly scar--your fault. There's no hiding, there's no room for error, your mistakes are like a mirror staring back at you.

So how does one go about being perfect if there's no room for error? No one is perfect but God. I have been frustrated with this thought recently, wanting to do the very most excellent best for my patients in the OR and on the floor, but my ignorance and lack of experience make that feel nearly impossible. I haven't seen or done or practiced or been taught enough. I am reading with a renewed vigor; for the first time I truly believe that my studying pancreatic cancer will make a real difference in someone's life. I never felt that way as a student--it was much more nebulous.

The answer is always the same of course, it's just my mind that runs in circles back to the same conclusion after running the mill of my silly human emotions. The only thing to do is work as hard as I possibly can to learn whatever I can, squashing ego and laziness.

The beauty of this formula is that it's good for my soul as well as my profession.

New Moves

2011-08-18T04:18:00.000-07:00

Five months ago I was sitting on a couch in the dean’s office of my medical school in Irvine, California, five miles away from my favorite beach. It feels like a couple weeks ago. It was about an hour after every fourth year medical student received an email from the central body that matches students to residency positions. That Monday match email is succinct: either “congratulations. You matched.” Or “you did not match”. I received the first, my husband the latter. Hence the couch.

“Well, you matched in Philadelphia,” my dean said, looking straight at me. He probably knew it would blow me away. Worse things have happened. To me, even. Much worse. But somehow this felt really big. In that moment, I saw my gracious dad lose a few pounds of muscle, a few hairs, and another couple of inches. I saw my beautiful mother gain a few curves, muscle aches, and fine lines. I saw my sister struggle with her post-stroke husband without my help. I saw her two beautiful little boys growing up without Farah Aunty there to do the airplane and a million other little things they’ll probably never remember but mean the world to me. My world would go on without me.

Two months into residency in Philadephia, that will all probably come true. All of it except the part about my world going on without me. Initially, I focused too much on what I was leaving behind, and not enough on what I was going to. I have a wonderful marriage I’m only beginning to discover, new friends and old ones to connect with and keep in touch with, and the job of my dreams to pursue. There’s a whole new city to explore, a whole new body of homeless people to serve, so many new opportunities to be at peace with God.

More senior residents at my hospital and others are weathered and weary. I don’t know what it feels like to be a resident for several years (or even several months!) but I pray that I wake up every day feeling like I’m living the dream. I hope I always think drawing an arterial blood gas is a cool procedure, and prepare for it with similar attention (but not trepidation!) years into my career, carefully positioning the patient and examining the operative site. I hope I am soft around the edges, turn around to make sure I didn’t miss something someone said, and remember to smile. It took a long time to come to where I am, a lot of blessings strung in a long row. Philadelphia might have been a blow, initially, but in the end, I can’t help but feel that much more motivated to be the best person and surgeon I can be here—it is literally the singular reason I find myself on this side of the country. Naïve and idealistic? Sure, let that be me.

I’m on my way back home to California just 6 weeks into residency; my assigned two-week vacation happened to fall in August. My nephews will no doubt have learned all kinds of new things and I can’t wait to see them and all my family and friends. But I’m also at peace with life in Philadelphia. The geography is ancillary; the real work of life is simply to constantly seek out ways to be better. And there are many.

The Malek Diaries - 5/17/2011

2011-05-17T11:07:00.002-07:00

California. :)

We're back in California, recovering from jet lag and finishing up some very important conversations with contacts in Juba. The trip was a very fulfilling experience despite the myriad challenges we faced and the many issues that are still unresolved with the clinic. To provide a service like medical care in such a needy community as Malek in a country so overrun by NGO's and international bodies is really tough. South Sudan has been in civil war for so much of the past 60 years, and has depended so heavily on outside aid for sustenance and decision-making, that the government itself is incapable of providing any essential services for its own people. To fit into a model like that is a challenge for any NGO, and even more so for a small, family-operated one like us.
Having said that, some real progress has been made. The building will God willing be complete in 30-45 days, and we have solid staff onsite to supervise and take ownership from the very beginning. The people of Malek and surrounding bomas (aka village areas) are on board. We have blessings from the county and state officials, and are in the process of partnering with the national government and other agencies that work with NGO's to ensure sustainability over time.
One of the most important things I learned in this process was how essential an exit strategy is to a project proposal. Our proposal was 15-20 pages long, depending on the version, and had many details in it. It did not, however, have an exit strategy, as Dr. Baba requested from us in his Juba office two days ago. He explained very patiently that many NGO's, including those working in Jonglei State building clinics, have failed because they want to be completely private, and run out of funding after awhile, or contact the government when they are running out of funding, by which time it is too late for the government to sustain the clinic because they have not provided for it in their budget. By this time, the community has become accustomed to receiving care, and is left with nothing. We have heard this story too many times. According to Dr. Baba, the best way to avoid this is to involve the government early on, which we are in the process of figuring out how to do. We all have one goal: to provide sustainable, high quality, affordable health care services to the people of Malek and surrounding villages.
We are nowhere near the end of this project, a fact that is intimidating but exciting. Even with government participation and ownership, our close involvement, especially in the first year of operation, will be crucial. We have many ideas, including setting up a rotation at the clinic for health care workers from home, expanding the clinic to include more services such as a maternity ward, an operating theater and more beds, and endless other possibilities. It is easy to build a building. It's keeping it going in a sustainable, functional way that's hard. God willing, we will keep learning along the way.
Thanks for reading, and thanks to my amazing mom for being the best part of the trip!

The Malek Diaries - 5/11/2011

2011-05-17T11:07:00.001-07:00

Malek.

On Monday, we went to SCOM to buy the rest of the block for the dividing walls. SCOM's office is very near Malek; the company is using land formerly owned by an oil company that moved out when war broke out in 2008. SCOM is run by a group of unfriendly Maldovians producing block at $2 each and making a hefty profit.
After we got our block loaded onto a hired truck, we transported it to the clinic site and unloaded it as a community. This week, Anyuen and Alier will move to the clinic site as their living quarters are also in the process of being built.

Later in the day, Deng told us that the women in the community had some concerns they wanted to share with us. We had specifically wanted to meet with them, too, so we were excited about the opportunity. It has been difficult to meet with the community as a whole because they are at work planting maize and sorghum in preparation the rainy season. They were concerned about not having a woman employee at the clinic to confide in. There was also a traditional birth attendant at the meeting who was eager to learn more skills as she has no formal training. Their worries were real and helped us understand their needs. We are working on addressing them through a community elected female liaison and considering formal midwife training through a nurse contact we met in Bor. We assured them that primary health care can only be achieved with healthy women and children, so their active participation is crucial.

Talking about health opened other doors. One elder woman told us they are powerless in their culture--they have no say in important decisions and are beaten if they disobey the men in their families. Girls are married early in life because their marriage brings their family a dowry of 100 or so cows. Their fathers are eager to trade them for the cattle, attempting to regain what they lost in marriage (their family had to pay cows to marry the women who became their wives). If the women refuse, they can be killed by their own brother, father or uncle. A 17 year old girl was beaten to death by her father last month for deciding to marry a man with no cows. A similar story was later relayed.
The women said they confided in us because we came as two women with so much independence. It gave them hope. I asked them if they thought educating their daughters was important. They all agreed, but said school is too expensive and fathers want their daughters to marry as early as possible--after primary school if there's a suitor!

The burden of these cultural barriers is catastrophic. The only thing I can think of to lift these women up is an education for their girls. They agree. The majority of their daughters will not go to high school. They will be married/traded for cows,have a baby every year, and raise poor children who are also uneducated.
It also occurred to me that microfinance might empower the women of Malek. I asked them if any of them make anything to sell. Only one of them answered yes. But the market is so far away, several hours by foot. They have nothing to sell and no one to sell it to. I learned about microfinance in my MPH training but the sense of powerlessness of these Sudanese women made me understand their desperate need for financial independence in a much more immediate way. Microlending won't solve all the problems these women face, but maybe it will empower them, and cultural changes take time.

Today, we met with another physician at Bor Hospital, Dr Samuel, who answered a lot of our questions regarding some of the challenges of working in South Sudan and particularly in a rural area. It felt strange asking him questions like "what do you do for diarrhea?" and "what prenatal/perinatal care can be offered in a rural health care setting?" but the practice of medicine is so different here.

Next, we held a clinic for the community. It was clear that many problems were related to basic hygiene. The most heartbreaking cases were the babies with diarrhea. We did some counseling on basic hygiene, but the lack of sewage and running water make it so tough. We saw another patient with complications resulting from a combination of poor dental hygiene and dehydration (ill spare you the details). Public health interventions are definitely going to be crucial to the clinic's success.

On the way home, we shared a matatu with one of Deng's cousins Aton who works with a microfinance company in Bor. It turns out they are already lending to groups of women in Malek. Surprisingly, the default rate is high, and when the clients don't pay, the company may take the money from Aton's salary. Then she is left to fight for her money with the women.

Today was our last day as a team in Malek. It was far too short and I can't wait to be back again, God willing. Tomorrow Mom, Mayen and I will go back to Juba and meet with the Ministry of Health for registration and licensing of the clinic under our nonprofit. Then it's back to Nairobi for me and Mom, and back to Bor for Mayen.

The Malek Diaries - 5/7/2011

2011-05-17T11:06:00.002-07:00

Malek.

We are very excited to finally be in Malek. The Juba Bor highway is much improved, and the journey was beautiful, full of plants and animals. The acacia trees and neem trees are amazing, and the Nile is awesome. I have to admit though: Sudan is incredibly hot!
The first thing we did after our sweaty four hour trip was to stop at the clinic, where community members were unloading the truck full of building materials, including 215 bags of cement! When everything was unloaded, it was time for a soda break. Deng, Mayen, Mom and I headed back in the Land Cruiser to securely store all the meds and supplies near the primary school. Then we went to Bor, the nearby town and capital of Jonglei State. While walking, we ran into Garang, another Californian Lost Boy setting up a small business in Bor. It was good to see him in Sudan, carrying a paintbrush on his way to oversee workers at his shop site. Bor really needs more independently owned businesses.
Next, we met with Mayen's cousin Dr. Mabior, a doctor at Bor Town Hospital. Dr. Mabior trained in Cuba as part of a group of students who went there for medical training. I got the second biggest shock of the day when he greeted me in Spanish and proceeded to speak it fluently! (The first biggest shock of the day was finding gyros in Juba at Konya Konya market.) He arranged for us to meet with a contact who can give us some insight on how private clinics in the area are run, and specifically how services and treatments are priced. We want our clinic to be accessible and affordable, as well as financially sustainable, God willing.
The next day was a very important day, as we planned to meet with the community to formally discuss the clinic, introduce John Alier (pharmacist) and Gai Anyuen (nurse), and manage expectations. The meeting was held in the open air in a large circle, and community members came to the center to speak. Jacob Malual (UU alum helping with the clinic since 2010) translated. Women attended and spoke as well, some of them simultaneously shelling peanuts. Children played with cow dung figurines nearby. It was a community affair.
The meeting went very well, despite my apprehensions. We came to an understanding that the clinic will not be free, but will be affordable. The emphasis was on sharing responsibilities and ensuring quality and sustainability. We also made an agreement that the clinic will be named Universal Unity Health Clinic, not to reflect our organization but to acknowledge that health is a universal need that unites us. Tribal warfare is a big problem in South Sudan. We envision the clinic treating "the Dinka, Murlee, Nuer, Mundari, black, white and purple all the same." The community responded in agreement, saying they welcomed all except those who wished the clinic harm. It felt like a true meeting of the minds, and the feedback I received from attendees was thankfully very positive. Phew!
At the end of another long day, we met with our Kenyan engineer, Daniel. We negotiated with him to reduce his charges and finish the building in 30 days, God willing. Now that we have brought all the materials, work will start immediately. The rainy season is coming, so time is precious.
Today, we are going to get more blocks to finish the inner dividing walls of the clinic. We are also planning some health education sessions for the community that should be a lot of fun, including eliminating standing water, disposal of nonbiodegradable trash, child nutrition, and methods of birth control.
My dad always said that communication is one of the most challenging things in life and he was definitely right. It has been an extreme challenge on this trip, even within our own UU team. But when people come together and share ideas, something amazing happens. Our minds open up to endless possibilities and we learn some fundamental truths about life.

The Malek Diaries - 5/3/2011

2011-05-17T11:06:00.001-07:00

Juba.

After many unforeseen challenges and small but precious victories, we finally got everything loaded on the 20 ton truck. Thankfully, we found almost everything we needed in Kampala for the clinic. What we were not able to get (32 Y8 bars!) we will find here in Sudan. After the past five days, I know more about barbed wire, carpentry, and how to tell if you're getting a good product or being taken for a ride than I ever imagined would be necessary!
Gai left last night to accompany the truck to Sudan. There are two border checkpoints to cross, and we are praying for their safe journey.
As far as the rest of the team, Mom and I just arrived in Juba, the capital of South Sudan, this afternoon. We met up with Mayen, who brought all the medications a few days ago. Deng and Mario will arrive in Juba tomorrow and we will all set out to Malek together on Thursday, God willing. Kuai, who has been instrumental in our UU scholarship program, will meet us in Malek. We are very eager to get on the ground and start the work of finishing up the construction, setting up the clinic, and meeting with the community to discuss their concerns and priorities as we move forward!
We could not be more thankful for your support. We are also humbled by the kindness and humility of the Ugandan people (with the exception of exactly one vendor). We pray for Gai's safety on the road with the truck, as well as for Deng and Mario en route to Juba.

The Malek Diaries - 4/30/2011

2011-05-17T11:05:00.002-07:00

Kampala.

The past couple of days have been action packed, thankfully with lots of headway being made here in Uganda. As some of you may know, Kampala has recently experienced a slew of riots due to an unbearable rise on taxes on gasoline. The Walk to Work campaign, championed by political figure Bisgeye, has incited a lot of disruptive fighting on the streets. Friday was particularly bad, as Bisgeye was violently attacked by police chiefs on Thursday.
As far as our work was concerned, after Friday's excitement, things cooled down quickly. By Friday evening some shops had opened again and we even set out looking for our generator. Today (Saturday) was an extremely productive, long, sweaty day, full of bargaining, starting at 7am and ending 15 hours later discussing prices in the dark! The good news: we got almost everything (and everything major) on our list. Incredibly good news!
Tomorrow, we'll visit all our vendors, pay for our wares, and make some last price comparisons. We hope to be en route to Juba in our 20 ton truck by Monday, God willing. Riots are expected to pick up again then, making it impossible to do anything. We are grateful to be safe and sound and on schedule. We are also very grateful for the help of Mayen, a UU alum who just arrived in Juba with the medications we purchased in Nairobi.

The Malek Diaries - 4/27/2011

2011-05-17T11:05:00.001-07:00

Nairobi.

Yesterday, we started the morning off by going to MEDS (Mission for Essential Medications and Supplies). Their office is a little fast from Ngong Road, where we are based here in Nairobi, but we used the missionary car to get there early so we could confirm our order. Our list of items is long, and we wanted to make sure we got everything!
When we got there we realized it was going to take longer than expected. Inexplicably despite three months of correspondence as well as having prepaid for our meds, the folks at MEDS were not expecting us! Over the next few hours we counted and recounted meds, made sure we had everything on our list, got some extra ranitidine and omeprazole for good measure (it seems like everyone had gastritis or ulcers, Kenyan as well as Sudanese!) and packed and labeled the boxes to our satisfaction. The delay notwithstanding, the people at MEDS were kind, good natured and helpful and we got it all sorted out.
We set off from the office in a matatu to go to lunch before visiting a local kenyan bank to open an account. Back when UU was working only in Kenya, we had little need for trans East African country banking. Now that we are in Uganda and Sudan, we need a bank account with a presence in all those countries. KCB fit the bill, so we took our business there.
Meanwhile, we finally got in contact with Garang. We were eager to speak to him after receiving his cost analysis to see whether traveling to Uganda for our purchases was a wise idea. His recommendation was to make the trip to Kampala since prices and availability were more assured there. He also told us some sobering news: his uncle was killed two days ago by a Murlee. His communication was delayed because he was attending the funeral. Our prayers are with his family.
On the bus ride home I saw two gentlemen dying on the street. Initially I was ready to yell to let me off the bus to do something to help, but I realized quickly how powerless I am, in so many ways. It also made me realize how much Kenyans themselves struggle to piece together a living. Over 50% of them are unemployed. This in arguably the most stable country in the region. How can we excite Kenyan med students and health professionals to work at our clinic when they themselves need a hand up? It's not the bleeding heart, champion of the poor mentality we have in our developed countries. Those ideals are a luxury here.
Over breakfast at Mayfield, I met a sweet Caucasian girl who I assumed to be American. It turned out she was born in Kenya, has lived here all her life, and is actually a junior in high school at a very well established school for missionary children in Kijabe, a small town with a prominent hospital staffed year round by foreigners. I wish our clinic can end up like that. Kijabe Hospital and Rift Valley Academy are deeply entrenched in the missionary community and culture, which keep it funded and running. In fact, I was surprised to read that Theodore Roosevelt himself commissioned the building of the academy back in 1906!
But UU work is not missionary work. Our work is health and education: sound minds and sound bodies. While we don't subscribe to the missionary culture, one thing we would do well to adopt from them is the idea of really getting to know the community before proposing a change, even if we think we know better than they do about things like disease and hygiene. We need to observe and listen first instead of talk first. That requires humility and patience in just the right dose.
Deng arrived safely last night with his wife and is staying at Mayfield as well. Today, the plan is to make our travel arrangements to Uganda. Mayen will be going straight to Sudan with the 90 kg of medicines and supplies. In Uganda, Deng, Mario, Mom and myself will make all our purchases and hopefully make it to Sudan early next week, where we will finally meet up with Garang and Kuai, two other vital members of Team UU.

The Malek Diaries - 4/26/2011

2011-05-17T11:04:00.000-07:00

Nairobi.

We arrived in Nairobi two nights ago and have been making progress on our plans to buy the medical supplies and materials needed to finish the clinic building. Yesterday, we met with many of our students to follow up with their issues, including school fees, paperwork and any medical illnesses. We met with Nhial and Jool, high school students (Nhial just graduated!), and Deng and Thion, both medical students. Deng is in his 3rd year, Thion in his 2nd. We also met with John Alier, who has a diploma in pharmacy and will be going to Sudan with us. We also met with the rest of our team, including Mario Bol, a Lost Boy from San Jose, CA, and Mayen, a Universal Unity graduate who has been invaluable in our education project in Kenya. Deng, who many of you remember from our fundraiser event, will be arriving tonight.
Today, we are going to MEDS, a warehouse for nonprofits that sells reliable medications at low cost. We will pick up the medications we ordered for the clinic there. We will also have a meeting to decide, within the next two days, whether we will purchase the generator, windows, plaster, doors and other materials to finish the clinic building from Kampala (Uganda) or Juba (Sudan). We have done an extensive cost analysis with the help of Garang, another Lost Boy currently in Juba, but we want to make sure we get the best value as well as the best materials for the clinic, so it's an important decision!
From the medical/clinical side, we have also got a hold of a malaria net distribution evaluation questionnaire to evaluate the 500 nets passed out during Deng's and Jordan's trip last year. Evaluation is a crucial component of any public health intervention and one we are trying to be particularly mindful of as we move forward. We also have a contact knowledgeable in latrine interventions and are planning community meetings to discuss the logistics and community readiness for a dry bathroom vs. pit latrine project. Communication is everything!

Dr. Cynicism

2011-02-01T07:09:00.001-08:00

I'm on my last heavy-duty rotation of medical school, spending four weeks in a surgical ICU in Southern California. It's hard to believe that four years has passed. I know that I've changed throughout medical school, but I can't cleanly delineate how, or whether it's a positive change.

I remember worrying about changing in the beginning of medical school. I didn't want to become cut and dry, lacking in human spirit. I know so many physicians who treat their work like it's a day job, and that's not why I worked so hard to get into this field. I was reaching for something larger than life, some sort of zen or nirvana or self-actualization that I believed could only be achieved by dedicating my life to healing others. To doctors, I know now that this reasoning sounds insufferably common. To me, it just sounded true.

As part of my training in the SICU, one of our professors suggested we read a recent article in the New Yorker on death and dying, and the trillions of dollars spent on heroic measures at the end of one's life. I see this firsthand every day on our unit: for instance, there's the 60-year-old man with terminal lung cancer, sedated and paralyzed, on a ventilator forcing a measured volume of air with a measured content of oxygen at a measured volume of pressure through his chest to keep him alive because he can't breathe on his own. He and his family wanted us to do everything possible to keep him alive. Last week, the surgeons decided to put a permanent breathing tube in his throat to make him more comfortable. He came out of the procedure retching and nauseous, inexplicably more uncomfortable now than before. He died the next evening.

Dr. Gawande's article spells it out nicely, with similar heart-wrenching stories of people choosing the illusion of an ugly life over the inevitability of a "more" peaceful death. Interestingly, however, Gawande hints that the onus is at least in part on health care professionals to manage patients' expectations. After all, they are not as equipped as we are to make treatment decisions. Then again, who are we to decide the course of their lives?

At the heart of this struggle is, as my professor declared, America's unwillingness to accept death as an inevitable outcome. I'm sure our nation's litigious tendencies, particularly fearsome in the field of medicine, don't help. Sounds pretty hopeless.

So as a fourth-year medical student entering a system plagued with staggering costs, wasteful practices, and complex social injustice, is there a role for optimism?

I have asked myself this question about optimism many times and no matter what situation prompts me to question my natural tendency towards it, I always come out with the same answer. Whether it's building a clinic in South Sudan, bringing eco stoves to the Chiapan mountains, being there for an ailing family member, or petting a lame dog, the answer is always the same: you must act.

But why? Why should you intubate the terminally ill cancer patient who has essentially no physiologic reserve, sedating and paralyzing him so you can have a machine breathe for him in his last days of living, robbing him from any hope of interaction with his wife and daughter? For the preservation of life? For the preservation of dignity, if you define dignity as honoring your patients' wishes in their darkest moments of dying?

And why should you spend $2,000 risking your life and future to travel to a war-torn village in Africa the world has no use for, to bring health care to a place struggling with far more basic provisions like peace and water?

For that matter, why tell anyone to quit smoking?

I am convinced, more than ever, at the risk of sounding egotistical, that the job of physicians is to bring hope to their patients. This is not an unbridled brand of hope, whereby an 80-year-old patient can take up salsa lessons after her bilateral hip arthroplasties. No. It is a measured hope, where the physician essentially counsels his patient, "This is what you can expect if you do this, and that is what you can expect if you do that, and I will help you understand what your decisions entail, how they will affect your life, and how you can get where you want to go." We give people choices by giving them knowledge. If you don't tell your diabetic patient what can happen if she doesn't control her blood sugars, how can you expect her to care? She didn't go to medical school. YOU did.

I'm sure the situation is not as simple as I'm laying it out here. It is far more complex. But at the heart of the matter is still the patient's best interests, and far too often, health care professionals forget this. As Dr. Gawande puts it, we often get swept up in their whims, making ourselves salespeople and our patients consumers. After all, this is America, and the customer is always right.

At the end of the day, it IS the patient that calls the shots. The gentleman who passed away last week had every right to demand mechanical ventilation in his last days. Or did he?

My dad always used to say that when you live in a society, whether you like it or not, you have to conform to certain societal laws. As taxpayers, whether we like it or not, we pay for certain civil services that we ourselves may or may not make use of. One of these services is government-issued health insurance for the destitute and the elderly.

In America, we are at odds. We buy into this sense of shared existence, but we also defy it by protecting our personal rights to all kinds of things. End-of-life care is the perfect example. We spend billions of dollars on one person's last week of existence, fighting the inevitable and throwing quality of life to the dogs. Meanwhile, somewhere else in the country, whole neighborhoods of children with potentially bright futures go unvaccinated, undernourished, underdoctored. Where's the justice?

When will things change? If history is our guide, only when they get so bad there's no choice but to make it better. Some would say, hasn't that already happened? Isn't medical spending sufficiently out of control to warrant acute efforts? Isn't health care access abhorrent enough? I'm not sure. What I do know is that the new crop of doctors entering the workforce should grow enough cynicism to be hungry for change, and enough idealism to fight for it. If the most salient thing we provide is hope, there is no place for apathy in this profession.

You can't run, you can't hide

2010-11-11T22:23:00.000-08:00

I'm on my second month of visiting rotations in surgical specialties, and while the experience has been mentally and physically demanding (as my family can tell you from all my complaining), it has also been tremendously rewarding. I truly love surgery, and just like most other milestones in life, what was initially a pipe dream is shaping into something more perfect than I could have ever anticipated.

I was always drawn to the surgical field, but it's only after several weeks of being on service that I'm starting to realize why I love it so much. Surgery, particularly vascular surgery, is intense. It's like a sport: you train for it, hone your skills, go out to battle, and continually analyze your performance to improve. Every doctor develops the practice of introspection to increase his competence. However, in surgery, it's not only knowledge but technical excellence. And the course of events for a patient changes so acutely with the surgeon's involvement that perfect action is even more crucial.

I'm on vascular surgery right now, and we've just had a couple of tough cases with major complications, including death. Each of these times, the patient had a potentially fatal, surgically curable disease (both, in fact, were AAA's). One of those patients is no longer alive (iliac vein injury), and the other does not have a duodenum (we cut through it). Both of these are major, predictable complications of AAA surgery. However, at the end of the day, they walked into the hospital well, and in our hands, suffered more than they were helped. The transaction is clear; we hurt those patients more than we helped them. Nowhere to hide.

One of those cases will certainly be discussed at Morbidity and Mortality conference next week. The chief resident will stand up in front of the entire surgery housestaff to go over the case with a fine-tooth comb and offer up our actions to critical minds. We will bear witness against ourselves and take responsibility for ourselves. This is what I love about surgery: nowhere to hide.

In surgery, you can't help but be honest. You can't help but be compulsive, hardworking, caring. If you see a little bleeding before you close the fascia, you don't wave it away assuming it will stop on its own. You go back and explore, you remove hard-earned sutures if you need to, because you know that bleed will declare itself as a hematoma later on if you don't. On an exploratory laparotomy, you run the bowel meticulously looking for injury, knowing that if you don't, the patient will develop colonic necrosis and decline rapidly. There's no way around doing your very best for the patient.

That's what I love.

2010-06-15T08:54:00.000-07:00

Each year, the AMA has an essay contest on a burning question in ethics. There's a handsome prize for the winner: $5,000. I'm not really a fan of the field of ethics; while I recognize its usefulness in medicine, I don't enjoy arguing about heated topics with opinionated people when there's no right answer except the one you feel in your heart. But I have to admit, the prize money was a draw.

The topic was whether or not medical schools should use social networking sites like Facebook as criteria for making admission decisions on applicants. And while I didn't write the essay, I thought it was an interesting question because, at its core, it asks a deeper question about a physician's role in society.

As much as I used to roll my eyes at people who claimed this, I now understand why good medicine is not just another 9-5. We all want to believe we are special, putting ourselves out there for the world to appreciate. It's not a terrible thing; it's the human condition. If we don't believe we are special, what's the point of living?

But a good physician IS special. A good physician spends extra time with anxiously waiting family members to explain how the surgery went. A good physician translates the pathophysiology of disease processes into more digestible elements so his patients can participate in their own care. A good physician listens patiently to her patients' worries, even when they are unfounded. A good physician struggles to suppress judgment and objectively advise a patient whose health problems are clearly attributable to his own poor choices.

A good physician is someone who, after interacting with her, leaves you feeling better. It requires going above and beyond the call of duty. Doing the right thing, all the time, not because someone is looking over your shoulder, but because you are taking the responsibility of someone else's health in your hands.

This kind of person is not acting from 9-5. This kind of person just is.

What does this have to do with Facebook? I don't know the answer to the AMA's ethics question. I know many golden-hearted people who have what would likely be considered character-compromising material on their social networking pages. They are professional when they need to be, and unprofessional when they want to be. What's the problem?

My dilemma is a little different. I'm a nondrinker, so you won't find pictures of me on Facebook in various states of drunken revelry or undress. But as a medical student who, this time next year, will have an MD behind my name (God willing), I find myself wondering how I am going to be a good person and a good physician at the same time. Yes, one necessitates the other. But they also conflict.

My sister, unlike me, is in the family-making phase of her life. She just had a beautiful baby boy, a little brother to her other beautiful 20-month old child. My parents, who came to this country at my age for medical residency, worked harder than I can imagine and made their wealth by God's grace, are growing older. I play an important role in my family's life, and that role is only growing. Not in a duty-bound sort of way, but in a loving, part-of-the-fold way. We are a nuclear family and stick together, helping each other solve problems, be good, and do good for ourselves, each other and when possible, others. When I was growing up, my parents always emphasized my studies. My job in life, as I understood it, was to go to an Ivy League school, attain a graduate degree, and become a working professional making lots of money (not for the sake of greed, but for the sake of respect) and living an honest life.

Well, three out of four ain't bad.

I went to Cal, got my graduate degree (x 2, almost), and am, I pray, living an honest life. I don't care how much money I make but as a physician, it will most likely be a respectable amount. But even though I am still a student, there's one criterion my parents forgot to emphasize when I was growing up: I am a person first, and a student second. Yes, my studies will get me that contributing role in society. But I cannot respect myself unless I am a contributing member of my family.

And that is a tall order. As I develop my personality as a physician, I have taken pride in actively listening to patients, involving myself emotionally enough to go the extra mile for them, but not so much that I incapacitate myself to give good care. I want to be a resource, a giver, a source of hope for my patients, God willing. But what about my family?

A person has only so much to give. A good physician gives a lot to her patients and their families. But what about their own? Are a professional giver's priorities skewed? How is it ok to spend those extra ten minutes at the end of a long day with a patient's family rather than your own?

So it seems that I don't have the answer to my own moral dilemma, either. All I know is that I'm incredibly grateful for the opportunity to be a physician, but also that it is only one role I play in life. I can only pray that my role as a good family member will make my role as a physician more complete. That the two will be synergistic in some way, perhaps in the preservation of some sense of humanity that seems to be buried in weathered professionals. And weathered people.

And that I have the wisdom to leave it entirely up to God.

Reflections on the psych ward

2010-06-10T05:43:00.000-07:00

As I come up on the last few of days of my psych rotation I find myself already missing it. Tomorrow I will write my last soap note on a psychotic patient. My subjectives will go back to being dull and uninspired, recording bowel movement consistency and skin turgor rather than colorful quotes or behavioral quirks. My morning rounds will involve conversations about passing gas instead of the latest visual hallucination. That is not to say that the field of psychiatry is one big party--on the contrary, some of the most dramatic, challenging and emotionally charged moments of my third year occurred on thus rotation. But when you are dealing with human behavior as your disease, the neat line between black and white that other fields draw so meticulously to protect their scientific practice often blurs to a chaotic gray. I would argue that this happens in other fields, too; it is just that psychiatrists are necessarily more comfortable navigating the nebulous territory of raw humanity.

I never thought that I would leave this rotation filled with, of all things, hope. Nowhere in my life have I witnessed in such detail the utter unravelling of an otherwise functional human being. However, also nowhere else have I participated so intimately in the process of healing the mind, and, or so it often seemed, the soul. Of course, I would be as deluded as my first schizophrenic patient if I thought we fix people. We play a brief role in a tiny sliver of their lives; for a moment in the grand scheme of things we share our existence and the goal of finding truth and clarity. Then the patients go on their way, back to mobile homes, group homes, or, rarely, families. And we move on, too, to the next crisis. Our next learning experience.

Daisy was a middle aged, stocky woman with piercing blue eyes and heavy features. When I first met her, her face was locked in a resolute grimace. She was muttering to herself and could barely acknowledge my existence, let alone carry on a conversation. How am I supposed to report on this patient’s status if I can’t even communicate with her, I wondered. For the first few days of her stay, my daily report went something like this: “Daisy is a 52-year-old Caucasian female with a long history of chronic paranoid-type schizophrenia brought in by police after she was found running away from her parents’ home convinced there was a bomb on the porch. Collateral information was obtained from her parents who state that the patient was stable on her treatment regimen until she was found catatonic in her apartment after calling 911. No known significant events or stressors preceded this episode. Overnight, there were no acute events. The patient slept three hours, anxious about a bomb under her bed. This morning, she continues to mumble to herself, responding to internal stimuli. She exhibits thought blocking and paranoid ideation, unable to complete sentences and perseverating over a knife she believes was placed in her abdomen against her will. The patient endorses abdominal pain secondary to the knife and requests a pelvic ultrasound. Legal status: she is on a 14-day hold for grave disability. Overall, her thought processes, hallucinations and delusions have improved from admission but she still exhibits debilitating symptoms and would benefit from continued inpatient care at this time. Disposition planning: the patient will be discharged to her apartment where she lives alone. Her son, who previously lived with her, refuses to participate in her care after receiving a disturbing call from her in which she pleaded with him to release her from the hospital because "Hell's angels are raping me here." Her parents are elderly and unable to provide support at this time but are willing to call Daisy each day for phone support."

This same distant patient, whose personality was initially such an enigma to me, slowly emerged from her psychosis to reveal a sweet, pleasant woman with a bright smile who loved to go on walks and listen to music. In her second week on the ward, Daisy began to style her dirty blonde bob and wear her own clothes. She looked lovely. One day, she came up to me and tugged on her shirt. “You like it?” she asked, her words slightly slurring together. “My parents brought it for me. The color’s called rust. It looks good on me. It’s hard to find.” I looked at her, amazed. It was one of the first conversations we had had about anything other than the voices in her head, the bomb under her bed, or the comb in her belly. It was Daisy, unplugged. Or plugged, rather. Another afternoon, I found her swaying in front of the radio to a Frank Sinatra tune. “You like music?” I asked her. “Yeah”, she said, her eyes glued to the radio. “Sometimes, when I’m at home, I turn on some oldies but goodies, close the curtains and dance.” She leaned towards me, shrugged her shoulders and smiled like a child indulging in guilty pleasure. Again: meet Daisy.

Another patient of mine, Lenny, had his first manic episode ever while I was on the ward. Lenny was a 33-year-old stockbroker with no prior psychiatric history who recently lost his job and was experiencing severe psychosocial stress. He had four children under the age of 5 and one on the way, as evidenced by his wife’s very pregnant belly the night of his admission. He was deeply religious, and in the past few weeks had become convinced that there was a bloody battle between good and evil being fought, and that the end of the world was near. He was so convinced of this fact that he initially eloped from the emergency room, anxious an earthquake was about to occur marking what he called “the end of times.” The first few days on the ward, Lenny kept to himself. On the surface, he appeared normal; he smiled appropriately, followed the rules, and was never agitated. I would learn of his delusions from the nurses, from my daily conversations with his wife--only occasionally did he let his anxiety loose with me. When I asked him if he missed home, he politely inquired whether I was asking about his home in Orange County, or his home in heaven. He refused to do yoga because he suspected it was a form of pagan worship. Several days after admission, when he was coming out of his manic episode (an occurrence that automatically earned him the diagnosis of bipolar disorder), he told me that he initially refused to let the phlebotomists blood drawn from his right arm because he was afraid it would leave the “mark of Satan.” Over his ten days of inpatient care I was able to witness Lenny lose nothing short of body, mind, and soul, and then slowly collect the pieces of his shattered self. Each day, just as Daisy’s delightful personality awakened just a shade more, so did Lenny’s insight into his delusions about the devil. “I don’t know how things got so intense”, he told me one morning during rounds. “It seemed so real. I really thought the world was gonna end.” This was the same man that sat in front of a judge during his 52/50 hearing and swore beyond a shadow of doubt in front of his wife, family friends, physician and me that he was right about his apocalyptic predictions. Who, as his colleagues were doing their pagan yoga stretches, launched a self-imposed 20-minute run around the milieu as “penitence for my sins”. By discharge, Lenny was asking about therapy to help him deal with stressors in a more productive way. He acknowledged that he had been depressed for months, maybe even years. He planned to change careers as he was finally able to admit that he had never felt comfortable playing the stock market. His wife filed for short-term disability for him so he could fully recover and help with the new baby. He understood the importance of taking his antipsychotic medications. He was in it for the long haul. Broken, yes. But in a brave, strong way. The way that forces you to reach into your insides and see what they’re made of. And then decide what you want them to be made of. I had faith that was Lenny’s path when he walked out of our ward, carrying his few belongings in plastic bags, wife in tow, eager to get home to his children and reinhabit his world.

Not every patient has a happy ending. My last patient Gina was in isolation when I first met her. She was crouched on all fours in the corner of the room, picking at invisible objects on the ground in front of her. She would occasionally try to lift herself up, only to flop back onto the floor. This would prompt her nurse to enter the room, trying to coax her back onto the bed. “34509!” she would scream, or some other combination of numbers. She complained of thirst, biting her lips until they bled. We offered her water; she opted to mold her hand into a shaking fist and bring it up to her mouth as if it were a glass. This was delirium.

Delirium tremens (DT), more accurately. Gina had a long-standing history of polysubstance dependence. She was a binge drinker brought in by her father after he found her walking naked on a street near their home. It was unclear whether her psychiatric disorder was organic or substance-related; she had never been sober long enough to figure it out. We sent her immediately to the main hospital for alcohol detox; she needed IV fluids, soft restraints, and Librium. 24 hours later, she came back to us, sensorium clear, personality disorder in full swing. She yelled, cried, sneered, blamed, and pleaded. It was disturbing behavior, but nothing even remotely resembling her delirious state on admission. She was unapologetic for her condition. “Why am I in here? I’m confused 24/7,” she would sneer, as if to say that crawling around the floor on all fours was all in a day’s work for her. Classic borderline: past suicide attempts, difficulty forming or maintaining any relationships, splitting (people were either the best or the worst, and her judgment changed on a whim), deliberate manipulation. She alternately kicked you away and drew you in: “You think this is a joke? Do you enjoy seeing me like this? Leave me in peace!” and literally two seconds later, when you walked away to give her (and yourself) a break, “See? You always just walk away! You don’t even care about me!” Despite Gina’s nasty behavior once she came out of DT, I found myself rooting for her. She would show flashes of kindness interspersted with her outbursts of agitation, thanking me profusely for my help while the tears from her last tantrum were still rolling down her cheeks. Drawing me in.
Gina left the hospital in this state, as there is nothing a hospital can do for a personality disorder except manage acute episodes. But what is fascinating to me I s how different a person she was from the Gina who was admitted five days ago, licking the furniture and trying to climb the padded walls in solitary confinement. The power of the human mind over the body and soul is overwhelming. As the delirium melted away, the real Gina came back, demanding the right to live her life. I knew well that alcohol would probably get the best of her again, and that she might end up in our ward or somewhere similar soon enough. But the transformation was amazing to witness nonetheless.

The power of the human mind. During a manic episode, patients feel like there is nothing they can’t do. They are up for days, minds racing, deluded into thinking they can solve the world’s latest crisis. Depressed patients won’t leave the house, incapable of experiencing any pleasure. Addicts mold their whole lives around their next hit, letting families, friends, jobs and hobbies fall by the wayside. Schizophrenics are tormented by voices often taunting them, or commanding them to hurt themselves or others. I know this now not because I read it in a book, but because I’ve gotten to know people with these illnesses.

Some people say that psychiatry should be an optional rotation in med school. The field has a reputation for being laid-back, so much so that many students and physicians in other fields don’t treat it as a medical specialty. I was one of those people until my rotation. But I was wrong. If there is an organic disease out there with medications that work to ameliorate its symptoms, a physician must know about it. I’m grateful for what my patients taught me, and for those precious moments where we met minds in their time of crisis to come to a better place.

Hands

2010-04-28T08:10:00.000-07:00

I believe without a doubt that we all have a path in life, and that path is to God. In that respect, my future career as a surgeon was always inevitable, literature major or not. But as far as this worldly life is concerned, it's fair to say that I am in medicine in large part because of my father's hands.

My father's hands. Big, gentle, gracious, useful. Just like the person.

I cannot express the kind of security a child--particularly a young girl--feels growing up in a world tethered by a father's love. 27 years into my life, I am still coming to appreciate how my father's support has buoyed and shaped me. Forget the early morning coffee sessions, the bailing me out of trouble in high school (ok, and long after high school), the countless hours philosophizing about life. That's all extra. I'm just talking about the sheer knowledge, every day of my life, that I have a dad. My dad.

And what is a dad, anyway? Problem-solver, answer-giver, plumber, doctor, builder, you name it, my dad will do it. He can fix a car, a toilet, a TV, a table. He can build a fountain, pave a road. He can coax a lamb out of a sheep's womb, cajole peppers out of well-toiled soil. He diffuses tense situation with thoughtfully placed words, makes you feel at home whether you have business here or not, and treats you like you're human according to your humanity, not your wealth.

And that's not even the half of it.

My father is a surgeon. A vascular surgeon, which I never thought made much of a difference until my vascular surgery rotation this past month. I thought the specialty was all about old people who smoke and have bad arteries or varicose veins and multiple medical problems. And a lot of it, to be honest, is about that. But there is also a terribly elegant art to it.

In its simplest description, the human body is a 5-liter bag of pipes filled with blood. Of course, there are also the airway apparatus and the plumbing systems, but without the sheer volume of liquid pumping through this bag of skin (thanks, heart), all the rest would be functionally nonexistent.

So when you're talking about giving someone blood thinners for peripheral arterial disease, or obliterating someone's veins for varicosities, or, more dramatically, reinforcing an aneurysmal aorta (literally the lifeblood to the lower half of the body bag), it's kind of a big deal.

Of course, the fact that my dad does surgeries that tinker with this lifeblood in astonishing ways never mattered to me. He's just my dad. For me, he's never been a hero for repairing an aorta or saving a limb. He's special for many other reasons. The kind of reasons you keep to yourself sometimes because they're so ardently pure, so defiantly unaffected that you ache to keep it that way.

A picture tells a thousand words, but I'm not a photographer--paragraphs are my snapshots. So here goes:

One: I'm standing outside the house near our makeshift barn in the freezing cold at 5:30 am. My dad is with me, kneeling to inspect Catarina's mangled foot. She is shifting her hind legs, unable to bear weight after a run-in with some barbed-wire fencing. It's a bad sign. My dad cleans up the wound with the garden hose, putting his thumb over the spout to deflect the force. He pulls out a tube of betadine he always keeps in the house in case anyone gets hurt. While he cleans, he talks. "You see," he starts off, "horses are very sensitive animals." Catarina shuffles her feet in discomfort, lending quiet agreement. He waits patiently, then wraps the foot up in gauze and goes back to stroking her, continuing his lecture on horse psychology. We do this until the wound heals.

Two: On another visit home, I wake up early to go to Starbucks and hit the gym. I feel a guilty twinge as I see my dad, up early too, sipping coffee from a mug and tending to his grape vines. I should be spending time with him. I get my coffee fix, do my forty minutes on the treadmill, and go home to join him. By now he's moved on from the vines to the vegetable garden. It's a humble effort, historically threatened by gophers and infection, but my dad insists on growing food as part of an experiment in sustainability. Most people would give up and go to Costco. Not my dad. Instead, he tilled and fertilized a plot of land and planted cauliflower, eggplant, broccoli and lettuce. A few years later, our first successful harvest yielded two fistfuls of buttery greens and a single crown of broccoli. Ever thoughtful, he triple-washed them and gave the whole lot to my brother-in-law to take to his mom.

Three: It's the last week of my surgery rotation. I'm at the VA cutting out devitalized tissue from a veteran's gangrenous foot as he lays in his bed watching Maury Povich. He's almost deaf, so when I enter the room, I yell into his ear, "It's time for our date, Mr. Miller! We gotta stop meeting like this!" He smiles pleasantly in my general direction. I tell myself we have a special relationship, though I'm not sure he comprehends much of what's going on. I take off his protective boot and unwrap the dressing to expose our putrid villain. His ulcer is so severe the entire heel bone is exposed, but he can't feel a thing. I take my scissors and forceps and slice away. Something makes me remember my dad, perhaps Catarina's injury or a more distant memory. I kneel next to the malodorous wound, thinking of my dad nudging his glasses up the bridge of his nose to examine the health of a rosebush. "You have to remove all the dead leaves," he'd tell me as I watched him purposefully snip away hard-earned branches. "It will grow better this way." I return to the task at hand, thinking of the fresh pink tissue that will appear tomorrow if I do my job well.

When you say you want to be a surgeon, people take notice. Like every other profession, there are preconceived notions about what it means to be someone who cuts people up and puts them back together. But the rules of engagement are the same no matter what endeavor you choose to pursue. An unwavering commitment to the preservation of life and dignity is required, whether your subject is a horse, a rosebush or a human being. It's not something you can learn from reading a book or hearing a lecture. It's something that comes from the heart. I learned this from my dad. Not in the OR, but in the garden; not as a surgeon, but as a veterinarian; not by his lectures, but by his living example.

I hope my hands do justice to their precedent, wherever they find themselves.

Labor and delivery

2010-03-31T16:41:00.000-07:00

Labor and delivery—what a ward. It’s the happiest and saddest place in the hospital. When things go right, a new person is welcomed into the world. When things go wrong, lives are devastated. Always, always, two healthy lives are at stake, hanging in the balance. Anything can happen to either at any moment. For the patient and her family, it’s one of the biggest days of their lives. For the physician, it’s another stressful, restless day or night.

I am not a mother. I do, however, have 27 years of personal experience with a mother’s love—my own. For 27 years, I have been on the receiving end of pure, undying, unconditional, unrequited, undeserved love—this is a mother’s love. I am awed, humbled, perplexed, overwhelmed by this love. If God’s love is more than a mother’s—and I know it is—my mind cannot even begin to fathom it. A topic for another time.

Flashback to a couple months ago. As a treat after two stress-filled weeks of labor and delivery, I treated myself to a pedicure to soothe my raw, blistered feet. The pedicurist, a friendly young woman with a heavy Vietnamese accent and perfect English, chatted me up. She asked me what I was reading, where I lived, where my family was from. I put my Case Files down and decided to have a human conversation for a change. I asked her where she lived, where she was from. She had arrived in Orange County just 9 months ago with her husband and two children, 4 and 5 years old. Why did she come, I wondered? She had a good job back in Vietnam, she told me. She was manager of a department of a prominent software company. I asked her why she didn’t apply for a similar job here? I did, she said. They’re not hiring people with no work experience. Apparently, her Vietnamese corporate experience didn’t count. So she went to beauty school and started doing pedicures and manicures full-time, 6 days a week. But again, I asked, if her family was doing so well in Vietnam, why did they give it all up to come here and start over? The education is better here, she said. I lost my opportunity, but my kids will find theirs here.

I wondered if her kids, who were probably now waiting for her to come home for dinner, could ever fully grasp what she had given up for them. Would they ever work hard enough at school to do justice to her sacrifice? To make her days full of scrubbing strangers’ calluses and painting flowers on their toes worth it? How could they possibly understand?

And what about me? Sure, my parents came to this country with residency positions already secured, ready to be molded into surgeons. They forged a new path purely for themselves, not for their parents or children. But sacrifices come in different packages that are no more and no less poignant for their differences. The force behind them is one and the same.

My mother always used to tell me that I could never love her the way she loves me. That it was virtually impossible for me to reciprocate her love. That I would only understand it when I had my own children. I hated hearing this, and always vowed that she was wrong. I couldn’t bear the thought of her being right, because the imbalance seemed so unfair. But after 27 years, I have come to realize that as much as it shames me to admit it, she’s right. A mother’s love is inexplicable, unmatched; deep and complex yet, at the same time, simple and naked.

I guess that’s one of the things that amazes me the most about labor and delivery. The raw humanity of hope, expectation, joy, love and pain are all mixed up together in those moments of laboring. There is the mother who in excruciating pain screams "voy a matar a mi bebe!"--(i'm going to kill my child!)--and is, minutes later, cooing happily at her newborn as we suture an angry perineal tear. The pregnant teenager who comes to the ER pathetic, crying and vomiting, and leaves days later, proud and strong, body language transformed by her ordeal. It's a mother's love: exquisitely simple and impenetrably deep, and bears testament to the incredible relationship between parent and child.

Brief musings on a weekend off

2010-03-31T16:21:00.000-07:00

It’s a gorgeous sunny So Cal day today. The air is sweet and there’s a slight breeze. It’s perfect tennis weather, reminding me of the old summer days when I would wake up in the morning, swing my racket bag over my shoulder and mentally prepare myself for a day on the courts. It’s been years since my last official tennis match, but I still can’t step on a court without remembering the sweat, the nerves, the excitement, the churning stomach.

These days I get my kicks not with topsin, angles and deftly placed serves (or so I liked to think), but with battling disease. Now it’s a pager, a stethoscope and a scalpel (on a good OR day) replacing my racket. Now I fidget by popping my pager in and out of its holder on my hip rather than rearrange my strings between points. The smell of a fresh can of tennis balls is replaced by the odor of cauterized flesh. But the sweat, joy, devastation and nerves are all too familiar, and after years of being holed up with basic science textbooks, I revel in the nostalgia.

It happened one night (call)

2009-11-11T09:25:00.000-08:00

It was the third day of night call at 1 am, and the ED was slow. Our team was killing time in the workroom, half hoping for a patient to give us something to do and half ready to quit waiting around and just go to sleep. I was tired of wasting time, incapable of studying or resting, but I wanted a patient both for the experience and to have something to show for myself at rounds with our attending the next morning.

An hour later, there was still no patient, so I decided to throw in the towel. I went to bed wearing my pager, expecting that the night was over. I climbed onto the top bunk in one of the call rooms and passed out. 45 minutes later, I was awoken by my bunkmate to let me know that my pager had been going off for 15 minutes. I slid off the bed clumsily and made my way back to the workroom.

To my relief, my intern had been waiting for me to go see our patient. The new charge was a 10 year old boy named Miguel with upper respiratory symptoms, severe autism and a known seizure disorder. He was presenting with fever, productive cough and two recent seizures. We went down to visit him in the ED. I was flustered and groggy, and had to work hard to muster up my usual excitement at meeting a new family.

When we got to the patient’s holding room, we found a sweet-looking child asleep with his mom at bedside. Mom was clearly worn, with unbrushed hair and circles under her eyes. She was leaning over her son's listless figure, hands propped on the bed frame protectively. A teenage girl wearing a college sweatshirt and Uggs was curled up in a chair on the other side of the room.

We introduced ourselves, took a complete history and did a basic physical exam complicated by the fact that Miguel was both fast asleep and also developmentally delayed. He was definitely congested, and the X-ray confirmed pneumonia. This was his second ER visit in 24 hours, and on the car ride home from the first trip, he had his second seizure of the day. His mom, Anita, was clearly drained but determined to help him get well. She spoke quietly, and her body language made her seem timid, but all that was misleading. She was the mother of a sick child.

Before leaving the ED to put in orders, we had to inquire about Miguel’s behavioral issues—is he violent? Does he bite or kick? Does he ever need to be restrained? No parent of a developmentally delayed child enjoys this line of questioning, but it's our job to anticipate special needs and challenges. At this point in the interview, his sister woke up, uncurled herself in her chair and addressed us for the first time. "You know, he does bite sometimes, but it’s actually just his way of giving a kiss. He doesn’t even know he’s doing it and it doesn’t hurt at all.” She insisted that there was nothing to worry about. I was moved by her protective instinct for her little brother, and remember thinking how much she must love him to interpret a bite as a kiss from a child who’s likely incapable of showing affection. We left the family to put in orders for Miguel’s hospital stay. Satisfied that I'd finally gotten to see a patient, I went back to my bunk to catch an hour of sleep before morning rounds.

On night call, you don’t follow the patients you admit, so a couple of days passed before I went back to visit Anita and Miguel. As I walked in the room, I saw Anita struggling to hold her son up as he tried to stumble across the hospital room floor, dragging his IV pole with him. She looked up at me, tangled up in his limbs and wires, and laughed nervously. “He feels better so he wants to move around. He doesn’t understand that he’ll fall.” Together, we carried him to a chair. He had a blank expression on his face, the only look I’d ever seen from him. I spent some time chatting with Anita and tried to answer her questions. I left mother and son on the couch together, feeling overwhelmed by her love for him. It was the same way I felt that night in the ED with Miguel’s sister.

The next morning, we visited the family as a team during rounds, piling into his room and surrounding his bed. It was discharge day for Miguel, so the mood was light. He was sitting up in his bed and moving his wiry body from side to side, looking off in the distance. Anita was at his side as always, patting his matted hair. She told us he was happy today, and her spirits seemed lifted too. Then she bent down to offer him her cheek, and to my utter surprise, he turned his head to her and kissed it.

I was happy to be wrong.

Questions in the ER

2009-09-13T12:01:00.000-07:00

The ER is, not surprisingly, a hectic place. When I'm evaluating a patient, it's often hard to have a conversation what with all the traffic and talking and monitors beeping, pagers going off, and phones ringing. It's also an undignified place-most people lying on the gurneys didn't plan to be there, so they didn't have the luxury of wearing something comfortable, bringing things they would need for the 8 or 9 hours they might be waiting, or calling someone who loves them to keep them company.

Most people who visit the ER are on the patient end of things. Here's how it is from the other side: our team, on call for the day, gets paged that we have a new admit. Most of the time, we're either sitting around in the team room waiting for this call, or we're in the middle of taking care of the last call. When we're free, we look the patient up in the computer to see if he/she's ever been to this hospital before. We build up our clinical suspicion based on previous record: if she was in for liver disease last time, we're going to bring drugs and alcohol up. If she's an asthmatic, we're going to ask about compliance with controller meds. If we have no prior history to go on, we look at the ER questionnaire to form a picture in our heads.

Once we've gleaned all we can, we go down to visit our new charge. We pepper them with rapid fire questions. Are you experiencing any chest pain, sir? Palpitations? Shortness of breath? How about nausea, vomiting, diarrhea, or constipation? Does it hurt when you pee? And how about when you poop? What did your mom die of? Your dad? Cancer in the family? Oh, I'm sorry. What kind? Where do you live? Where do you work? In the event that you were incapacitated and could not make decisions for yourself, who would you like to make medical decisions for you? Would you like to have chest compressions or a tube put down your throat to help you breathe if you suddenly stopped doing so on your own?

All this, and we met five minutes ago.

Then we move on to the physical exam: Can I unbutton your shirt? Roll up your pants? Take off your shoes and socks? Does this hurt? Can you feel that?

It is a whirlwind 20 minute conversation, after which we leave the patient as promptly as we arrived, go back to our computers to write the official admission note and put in our orders, and wait for the patient to get a bed on the floor. In the meantime, we think of questions we forgot to ask that will help us figure things out.

What all too often forgets to be asked:

How are you holding up? Do you understand the plan? What questions can I answer for you? Not do you have any questions, but what questions do you have. Did anyone tell you the results of your blood test/X-ray/MRI? You'd be surprised. And what do those results mean to you? From a 5-year-old kid in need of a tonsillectomy: you're going to cut my head off and take out my tonsils and then sew it back on. From a patient with pneumonia found to have a pleural effusion, or fluid in the lungs, on chest X-ray: this happened because i drank too much water.

At the end of the day, sure, it could be more elegant. But nothing about this process is elegant. When you are sick enough to show up to the ER, you are stripped to your very core. When you are on call for 18-30 hours, sometimes into the wee hours of the night, you are also stripped to your core. And for the most part, decorum aside, patients are simply glad to answer any question they think will help you solve what's happening to them.

We just need to remember to return the favor.

Back in Nairobi

2009-05-30T20:44:00.001-07:00

I just got back from Juba yesterday, so now I can blog in real time. This adventure is almost over and I'm really grateful for it. I am satisfied that we did the right thing by coming in with the Wharton team to do a careful assessment, asking some hard questions before jumping right in. Sure, you walk away wondering if this trip did any good, but you have to think long-term. It's not always just about feeling good.

And what feels better than practicing medicine? Seeing patients, prescribing medicine after a 15-minute interview, and doing surgeries is very rewarding, from what little experience I have. In Malek, another thing we did was set up a makeshift clinic with the small pharmacy of drugs we brought with us. People came in droves with health problems of every kind. It was uncontrolled madness and we definitely could have organized ourselves and our patients better. My mom and I interviewed and examined the patients with the help of translators, and Orin, Grace and John filled "prescriptions". Sush went to distribute vitamins to the women, and was apparently nearly accused of poisoning them (one of the women told him to swallow a pill himself so they'd know he wasn't trying to kill them all).

It wasn't that we didn't do any good that afternoon. I think we did. We de-parasitized, killed fungal infections, cleaned abscesses, and treated diarrhea. We tried to give clear instructions on how to take the meds, although communication is the most overlooked, most important factor in doctor-patient interactions (and is 100 times harder when you're being ambushed by mothers pushing their kiddos toward you). I can only pray that we did some good. But I am more convinced than ever now that medicine is NOT the answer for rural health, at least not in Malek.

Those kids need clean water to drink, and they need protein. Their bellies are obviously swollen with kwashiorkor. What good will pylotrip do for their ulcers without a proper diet? They need latrines, and they need sewage. They need vaccinations. They need to go to school. They need better housing to shield them from the elements, of which there are many in East Africa, home to a billion bugs and all those cool safari animals.

When we got back to Juba from Bor, we had a debriefing where the Warton team gave my mom and I their impressions of where Universal Unity should go next. They were all against building a clinic, as am I. Not because it's not needed, but because so much more, and so much more basic things, are needed more desperately. And because as a growing organization in its beginning stages, we don't have the know-how, the funds, the time commitment, or the managerial skills to make this happen. We're talking about a location where CRS, a behemoth of an aid organization with 10-year commitments to its subjects, is pulling out. What makes UU's chances better?

I'm not saying we should pull out too. Not at all. I think we should partner with Michael Lear from Real Medicine Foundation and send nurses to his nursing program at Juba Teaching Hospital. We can also help revise the curriculum and bring doctors and nurses in to help train for short periods of time (which is what we have to offer, since no one has stepped up to move to Africa permanently). I think we should refine our "Educate Refugees" project, which needs a lot of help before we take on something new (I knew this before we left for Sudan, and meeting former students in Nairobi only confirms it). In short, I think we should build capacity. In a few years, our students will be engineers and agriculturalists. We just met two high school graduates, Natalina and Mercy, who are hanging around Juba after sitting for the KCSE -- they would be perfect candidates for nursing school. In time, UU will be able to complete our promise to our students that we would help them find their way in life through education. It will be a more complete promise than simply paying their fees, and it would help us do what we've wanted to do all along: help Southern Sudan.

I'm mentioning this on the side, but the current peace agreement between the ever-warring North and South Sudan ends in 2011, at which time there will be a referendum. Kwai thinks the North will never agree to let the South be free for good, and I don't see why they would. He seems to think 2011 will bring war, at which time "you will see Kwai in uniform". With peace this fragile, building a clinic now makes even less sense. Better build capacity in a place where there is none, waiting for 2011 and its aftermath while continuing to educate students in Nairobi and hopefully soon in Juba.

Tour of Bor and assessment in Malek

2009-05-30T20:42:00.001-07:00

The next day was our only full day in Bor, so we had to make the most of it. We started by meeting IMA's team leader in Jonglei, Dr. Makina, and the state level minister of health, whose name I honestly don't recall. Dr. Makina is an MD/MPH, and the IMA (International Medical Agency) is the most important health care player in SS right now (the Government of SS, or GOSS as the cool kids call it, is broken and broke, and a multi-donor trust fund is the only money available for public services). It was a very informative meeting, and we got a lot of historical and
current information about Jonglei, Bor and Malek. The census data is shaky at best. But they were able to outline the biggest challenges they face, and where they think opportunities for aid might lie. It was a useful meeting.

Aware of our tight schedule, we first set out with Dr. Benjamin to tour Bor Town Hospital. The hospital is a converted barracks, staggering to meet the needs of its population. The buildings are dilapidated, and a few have been abandoned due to asbestos or massive bat invasions. There are makeshift buildings, such as the surgical ward, which is literally a tent donated by MSF. Inside, the heat and stuffiness are sweltering. I was shocked that either surgeon or patient could survive an operation under such conditions, but Dr. Benjamin said nothing. As in almost all other resource poor medical settings, they do almost all operations under spinal anesthesia.

Just as the conditions of Juba Hospital made me understand the dire need for health care in the capital city of SS, so did the conditions of Bor Town Hospital. But I was also struck by the distinct recognition that these people are doing the best they can with the resources available to them. There is no funding for salaries, yet they have four midwives. Their budget is hardly worth mentioning, yet they have an x-ray machine and an ultrasound. They do antenatal care. They have a lab where they run tests, and they treat patients based on the results. They do the best they can with what they've got.

After the hospital tour, we set off for Malek, a half hour drive from Bor Town. In Malek, we surveyed a couple of potential building sites. The team favorite was hands-down the site near the Nile with the open grass field, where Deng envisions planting crops to feed the patients of our proposed clinic. We then had to introduce ourselves to the village elders, which was a drawn-out affair of seeking to understand and to be understood. From our side, Orin did an excellent job of
being gracious and diplomatic. On their side, it was helpful (if not encouraging) to hear their reservations about our promises (and whether we would fulfill them, or disappear). It was also nice to know that they acknowledge our work educating their refugee relatives in Kenya.

Finally on our way to Bor

2009-05-30T20:41:00.001-07:00

After a few eventful days in Juba, we were ready to make the 200-km, 7 hour long trip to Bor Town on May 26. However, we were told that the police commissioner would not allow travel and that the roads would be blocked. Apparently, we had the good fortune of being in town for SPLA Day. While SPLA Day (SS Independence Day) actually falls on May 16, the celebrations are staggered across cities in SS to allow the president to be present for all the festivities. I thought it was strange that the capital of SS should have its SPLA Day ten days after the real thing, but whatever.

So on May 26, we pushed back our plans to travel and decided to celebrate the national holiday by going to the festivities. We saw some lively performances by men and women, singing and dancing in circles with colorful costumes and noisemakers of every kind. Older women sang about their days as female soldiers during the wars, and others marched and danced in rows, celebrating freedom. SPLA soldiers lined the field, their guns inexplicably pointed at the crowds. It was definitely a sight to see. Afterward, we got ourselves out of the blazing sun and ate lunch at a cute British sandwich shop (Juba is a place of utter social contradiction) where we saw some of the prime missionary/aid glitterati (Lebanese, American, Anglo, Japanese, Arab, you name it). Then, we drove home to Samaritan's Purse, rested until the sun let up, and went for a gorgeous hike in the mountains with Lori. Great way to spend a national holiday, Juba or not!

The next morning, we set out for Bor. We were traveling with police escort to ensure our safety, so we had to wait six extremely frustrating hours for our entire entourage to assemble itself. We had 21 armed soldiers with us. It was a bit ridiculous.

By nightfall, we were in Bor, which is more of a shanty than a town, despite being the capital of Jonglei State. We were taken to the Freedom Hotel, where Mach and many others had suggested we stay for our short trip (two days). My mom was horrified at the thought of sleeping in tents and found the communal bathrooms and showers equally horrendous, but with Sushant and I leaning heavily toward setting up camp as soon as possible, we decided to make Freedom our new base. It was a good decision, I think, and by the second night, we hardly noticed all the bugs in our tent!

Juba

2009-05-30T20:39:00.001-07:00

Our trip started out in Nairobi, after a nice layover in London (during which time Orin, John, my mom and I visited Sushant's family's home in Kensington Gardens!). We arrived to Nairobi the night of the 20th and stayed at the AIM Guesthouse, which houses humanitarian workers for $30 a night. It's a nice place with a lived-in feel. The only complaint I have is that the culture is distinctly missionary, and I am distinctly (vehemently) not. More on that later...this post is about our trip, not my soapbox!

We spent the next day in Nairobi (Friday) getting tickets to Sudan, which cost an arm and a leg ($550 roundtrip each). We also picked up more medicines to distribute in Malek, our proposed clinic site.

The next day, we finally arrived in Juba. Our flight was delayed four hours, and we were greeted by Dr. Benjamin Malek, known to us as the only doctor in Bor Town, the capital of Jonglei State, where the vast majority of our sponsored SS students are from. (Malek, and apparently all Dinka names, are words for cattle. Malek means brown and yellow spotted bull). We were also greeted by Kwai, who we worked with extensively last year, and who was instrumental in helping us implement the sponsorship program. It was good to see them again. We were also reunited with Mach, a strong-willed student who we interviewed last year but could not support. Mach ended up being extremely helpful to us throughout the trip, at every leg of our journey, whether it was car problems, police trouble, or the endless Jonglei cow herds blocking the roads. His left hand was burned at 6
months by a bomb during the war; he was rescued by his father and operated upon to salvage his thumb. Mach is one of the most determined people I've met, and he gets things done.

Once in Juba, we settled into our new accomodations at Samaritan's Purse, another hostel for missionaries. We spent a few days meeting with key contacts in the city who gave us invaluable information. My favorite meeting was with Michael Lear, who is launching a nationwide health care capacity-building project in partnership with the UN. I and the whole team envision a great fit between our interest in training nurses and doctors, and his desire to expand health care services. I quickly realized that Juba is a city whose presence is dominated by aid workers, whether they are NGOs or UN workers. SS relies heavily on this shaky support to get anything done.

We also visited Juba Teaching Hospital, which serves the estimated population of 300,000 with shockingly few resources. It has a program that trains nurses in basic care, but my mom and I flipped through their exams, and the curriculum is not at all up to par. Some of their textbooks date back to 1937! We were shown around by Magda, a fierce and stylish aid worker who clearly has a vision for the hospital and the people it serves.

As the clinic we are envisioning would most likely resemble what in SS would be called a PHCC (primary health care clinic), we went to visit one in a place called Kator to see what it looks like. The building itself was impressive; the structure was donated by an Italian NGO. However, what the place lacked was human resources; there were only two personnel there, and the rest of the place was totally empty. It was, of course, a Sunday. But in the capital city of SS, in a country where malaria is endemic and maternal and child mortality is the highest in the world, Sunday is no excuse for an empty clinic. The doctor who was there told us he sees about 1000 cases of malaria a month, and receives only 60 treatments from the government. They expect those 60 treatments to last three months. It's a joke.

Malaria nets are also a tricky business. In the cities, it is easier to implement net use. But in the villages, many people live in cattle camps. The tribal way of life is wholly centered around cattle. It is their wealth, their religion, their ideology. They sleep near their cattle in tents of their own making, and are suspicious of people who advise them to drape strange netting over their shelter. It's not impossible to implement change, but often here in SS it seems pretty
close.

Universal Unity in South Sudan!

2009-05-30T20:34:00.000-07:00

I haven't blogged for awhile, but I'm on a trip to South Sudan right now so it's a good time to resume. I just finished my second year of med school, survived the boards (I think) and have two weeks before third year starts (the advent of a professional life...sort of). Since I'll be journalling our trip periodically, and we won't have much internet access for the greater part of the trip, I'm going to lump everything together :).

This year's Universal Unity trip to East Africa is very different from previous ones. Last year, we went to Kenya and interviewed Southern Sudanese (SS) refugees living in and around Kakuma camp. It was a very good project for an NGO in its incipient stages--it allowed us to come for brief periods, to manage the program remotely when we were not in country, and to feel satisfied that we were making a difference.

This year, the NGO's leader (and my mom) had the vision of taking UU's involvement with the SS cause a step or two or a million further: she wants to build a clinic in the village of Malek, where many of our SS refugee contacts are from. Enlivened by the Lost Boys' passion for helping their people, she wanted to bring quality health care to people who have no idea what that phrase even means. Naturally, since we've never even been to Sudan, we had to travel their first to do an assessment. That is what our two-week trip now is about.

Because of our desire to do a thorough assessment before investing in what's sure to be a large-scale project, we are partnering with business students who recently graduated from Wharton. Orin, Sushant, John and Grace are a vibrant, intelligent, seasoned bunch who are well-versed in international development, logistics and strategy...all of which we at UU are lacking. It's been great so far, and we are learning a lot from each other.

"It's the education, stupid"

2009-02-05T07:40:00.000-08:00

I was recently reading a magazine article (it might have been Cosmo at the gym, don't judge) that cited education as one of the most important predictors of health and long life. My thoughts immediately drifted to the hundreds of Southern Sudanese kids who I communicate with daily as they plead for money to attend school. The emails are desperate, often in all capital letters with scanned documents to legitimize their requests. They address me as sister, and my mom as mum.

It's all about education.

That's exactly what I think in the very different but distantly related context of the soda wars in the highlands of Chiapas. Traipsing through the mountains for our interventional stove study last year, my classmates and I were awed to find that Pepsi and Coca-Cola were duking it out in literally every community in the mountains. It was cheaper to buy a bottle of soda than a bottle of purified water. And it wasn't just soda, but all kinds of processed foods, including chips, cookies and other diabetes-inducing goodies. Considering my personal history as a Berkeley grad, an MPH, a med student and a (closet) hippie enthusiast, it may seem surprising that what bothered me most about the whole situation was not the presence of big business in the communities, but the poverty of health education that rendered the Chiapanecos unable to make healthy choices.

Big business can bring a lot of good, but it has to be consumer-driven, and to drive consumption, consumers need information. WIthout education, how can they make healthy choices? By shielding them from the evils of a cool, crisp, wonderful bottle of Coke? Why is it that they can't handle the responsibility of junk food, and we can? I don't even want to know what inhabitants of developed countries like the US and Britain would do without carbonated beverages and convenience foods. Besides, if we protect underdeveloped communities from consumer goods that happen to bring them diabetes, what else will we deprive them of? Antibiotics that kill shigella, because they create resistance? That doesn't make much sense.

Back to the Southern Sudanese. I always thought of education as important because it allows you to buy things that you need to be healthy: a place to live, a balanced diet, clean water, soap, etc. But that isn't the only reason education is healthy. Studies show unequivocally that educated women are not only healthier themselves, but also nurture healthier families, than their uneducated counterparts. And by education I refer to more than knowledge about boiling drinking water or washing hands after using the latrine. I am talking about the sort of education that opens your eyes and your mind to different spaces, whether they are social, physical or entirely abstract.

It's obvious how important health is to a community. My dad always says if you don't have your health-physical AND mental health-you don't have anything. And if education is a great predictor of health, then it's a very worthy and economically sound goal to focus resources on improving access to and quality of education.

Obama has already signed off on long-awaited SCHIP expansion plans. That's great. In our current health system, people need insurance to get care. But I didn't have to go as far as Southern Sudan or the highlands of Chiapas to prove how desperately we need to meet a basic standard of education right now. I don't have to look much further than a 10-mile radius from my current home at UC Irvine. The quality of public education in America is appallingly poor. And in other countries, it's often a combination of poor quality, poor access, and high expense.

So while health is a vital resource for living, let's not forget about the things that lead to health. Education is one of those things, and it's an investment whose return is more profitable than we apparently realize.

Lobby Day 2009: CA Health Professional Students for Single-Payer Health Care

2009-01-14T06:28:00.000-08:00

Early this week, about 500 health professional students from all over California gathered in Sacramento to urge senators and assemblymen to vote yes on Senator Sheila Kuehl's bill for universal health care, SB840 (HR676). After a day of student-led training on how to talk to legislators, we formed groups to create streamlined presentations, marched up to the Capitol for a rally, and set off to our various appointments in the Capitol building. I have lobbied before, several times, but it's always good to remind myself that as a health professional student, I have a political voice and I should make that voice heard.

The only problem is I hate politics.

My dad always says that you can't hate politics because it's ubiquitous: wherever you have two people, you have politics. I can't deny that. Yet, it is so frustrating because reason and logic are either absent or so abstract that their relation to humanity is tenuous.

Our first legislative meeting was with a Republican senator from the Riverside area. We met with his aide, who explained to us kindly and patiently that there was a Political Divide between the Republicans and Democrats on the issue of single-payer health care (in case we hadn't heard). So, if there ever came about a bill that would fix the health care financing crisis (he clearly didn't think SB 840 was a candidate), the Democrats would oppose it purely because it isn't single-payer. And likewise, the Republicans will vote against anything that overhauls our current system. They would rather just plug up the holes.

Now, what about economic efficiency? What about hypertensive patients and diabetics showing up at ER's with blindness and gangrene What about babies dying? What about ranking the lowest of industrialized nations in something so wholesome and universally important as child safety and security?

None of those points, as salient as they are, had a fighting chance in our conversation, because the truth is that they don't matter. Political realities are what matter.

Our next legislative visit was more promising, as it was with an Assemblyman who had not yet voted on the bill. We got to inform his aide that the bill was being reintroduced with Senator Mark Leno (he thought it died with Kuehl), and he listened to our arguments, showed his concern for the issue, and said he would present it to Assemblymember Dutton. He was dubious about Dutton's support for a single-payer solution, but it was the best we could hope for.

The march and rally was overall successful. It was an empowering experience. My only complaint was that a big deal was made of the fact that both Kuehl and Leno are the first openly gay Senators. There was a lot of cheering when that point was made, and it made me angry on a personal level, as well as on a professional level. I came to support SB 840 and health care justice. Insofar as that is a Democratic cause, fine, lump me with the left. But I am NOT in support of every leftist cause, and was offended to be associated with something I don't believe in. Furthermore, I think it hurts our cause as lobbyists to introduce unrelated topics. It makes us seem like nonspecific liberal/hippie protestors who are against The Man, as opposed to future health professionals serious about changing the broken system we're about to inherit.

Was the event a success? Depends on how you measure it. We got 6 more co-authors of SB 840, and educated dozens more legislators about the issues. But Lobby Day is also about empowering students to engage in the political process. A couple of classmates and I are conducting a survey to assess changes in knowledge, attitudes and skills as a result of participating in the two-day experience. Despite my criticism, I am glad I went for the impact it had on me and my future career. I will probably never become a physician-politician, but my involvement in Lobby Day has made me recognize the respect and responsibility of my professional voice.

Post-Int'l Health Project Musings

2008-12-29T07:49:00.001-08:00

I just got back from a whirlwind trip to Chiapas to "finish up" a public health project I and three of my classmates at UCI "carried out" over the past six months in three Tzotzil communities. We were first there this past July, but for so many reasons, it was especially difficult to go back this time. We have our own collective blog.

We went to Chiapas to bring ecological stoves to 40 families in the highlands and to measure changes in pulmonary function (via spirometry) and air quality (via PM measurements) after 5 months of stove use. The project was messy in and of itself because that's how international health projects are. We went back to Chiapas to measure (hopefully) a reduction in particulate matter; however, we did not expect that open fires would be blazing all day long (worse than in the summer when we took pre-stove installment measurements) because of the cold season. Oops. We also could not have predicted vast political changes in Las Abejas, the civil society that we are partnering with to carry out the project. The social climate had changed dramatically, and it affected relationships among the health promoters, families and communities we worked with, as well as our relationship to all of them as outsiders.

Also troubling is the notion of us "executing" a "project". I hate it when people write in quotation marks as if the punctuation alone imbues your words with the hidden meaning you hope to convey. I hesitate to say we have finished our project because completing a finite project with a beginning, middle and end was never my intention. In fact, having done similar things in the past, that was exactly what I wanted to avoid. As a future public health professional (God willing), I'm looking to establish relationships and make lifelong investments in international health. I want to lay down roots. When I signed up for Chiapas, I saw that potential. Looking back on our interactions with the communities, however, I don't think we built relationships so much as we completed a study.

Why do I say that? Months ago, I would have said that we were doing a good job building the relationship with Las Abejas health promoters. We were building bridges, hanging particulate matter machines in homes, making stoves together, making people breathe into tubes over and over again...together. We went to a health promoter meeting to announce our arrival and plan, went to church to introduce ourselves to communities, dined with families, celebrated a local festival. We bathed with rainwater, used the latrine, ate twice a day, walked up and down mountains.

But we also called all the shots. We brought these mysterious machines and collected all the filters to take back to our fancy laboratory with our fancy weighing machine to run sophisticated statistical tests to come up with Significant Data to publish in a fancy journal that the health promoters and their families will never see or understand or care about, it's that irrelevant to their daily existence. If that is true, did we truly collaborate the way we set out to do? It was a big part of our project's self-image that we had community buy-in to ensure the sustainability of our project. True, it's a huge challenge to achieve true collaboration, but if we don't have that, then what do we have? Yes, we installed 40 stoves. But do they like them? Did they make a positive impact on their health? Their quality of life? Did we gain their trust in a way that makes future cooperation likely? My head is full of these questions.

Whether they use the stoves we installed or not is a fair, honest question that deserves our evaluation, and I think that we did justice to that problem by carrying out a follow-up study of past stove recipients (last year's UCI-Chiapas cohort also installed stoves in similar communities). Whether or not the stoves improve health outcomes is another fair question we have and are continuing to evaluate through our study. But whether or not we and the health promoters of Las Abejas (and the communities they represent) have invested in a truly collaborative relationship working toward the betterment of health and quality of life in the highlands of Chiapas is another question that I don't think we gave enough thought to. And in the long run, I think it's a far more important facet of our "project" than the simple delivery of 40 ecological stoves that may (or may not) improve respiratory health.

I was talking to John Rose, the founder of UCI's relationship with Las Abejas, on the way back to San Cristobal from the community one day when we thought of a way to really work on the collaborative relationship aspect of our project versus the service aspect. The service aspect is undoubtedly important, but it gets in the way of the collaboration and two-way learning, as it did in our case. When you're running around trying to get a spirometer donated to you, designing a study, writing grants and stretching money, worrying about how to pay for 40 stoves and endless other logistical details, it's hard to concentrate on the philosophy of health promotion, the rich history of indigenous rights and resistance in Chiapas, and the intricacies of binational communication as it applies to international public health projects. We need to strike a balance between service and learning.

What we came up with is an idea that may or may not end up happening: a series of workshops next summer in which students work with health promoters to design comprehensive projects addressing their top five or so community health concerns. They can learn how to define a health problem, write a grant, gather data, and present findings. We med students can learn how health promotion works and focus more on building relationships and communicating ideas. At the end of it, UCI med students will come out having had a fulfilling experience a) learning about how health promotion works in Chiapas, and b) having shared knowledge and know-how regarding how to go about convincing the people with the money to give you funding to carry out a health project. The health promoters will be invested, too, because they will pick the health problems that will be addressed in the workshops. At the end of it, they will have several of their biggest health concerns fleshed out in a language that funding organizations understand, and whether it is in collaboration with UCI or independently, they (or together, we?) will be primed and ready to present a convincing case to attract funds.

It's an exciting prospect. I only hope I can be a part of it next year, too. Because as much as I love stoves and my experience in Chiapas this year, the idea of investing further in our relationship excites me even more.

Happy holidays!

Prop 4: Abortion Waiting Period and Parental Notification Initiative

2008-10-17T23:08:00.000-07:00

For those of you who haven't read up on the propositions yet, Proposition 4 is on the ballot this year in California.

The initiative prohibits abortion for unemancipated minors until 48 hours after physician notifies minor’s parent, legal guardian or, if parental abuse has been reported, an alternative adult family member.

It's also called "Sarah's Law" after a 13-year-old girl who passed away from a botched abortion after having a relationship with a 39-year-old sexual predator, Gary Cross. When she became pregnant, he took her to an abortion clinic and then resumed sexual relations with her, all without her parents' knowledge. Sarah's mom found out about the abortion after coming across related paperwork in her daughter's room.

Anti-Prop 4 arguments include the very realistic fear that more minors will opt for illegal and dangerous abortions. Communication between minors and their parents/guardians is never uncomplicated; teens probably fear that their parents would react irrationally and/or hurt them. Whether that fear is real or perceived, it affects a minor's behavior at such a crucial, traumatic moment. Another argument cited is that no law can mandate family communication; rather, it's something that has to come naturally. And what if it doesn't? Then take the lesser evil, because a safe abortion is better than an illegal one.

I am against abortion. I think it's killing an innocent being that was meant for life, if not for our intervention (ie, abortive procedure). Does this mean that I don't care about the poor minor in this traumatic situation?

Of course I care. But I think instead of figuring out ways to deal with the symptom of the problem, such as rules regarding abortion among minors, we need to concentrate really hard on figuring out ways to reduce unwanted pregnancies. Of course, they will still happen. But when they do, we need a plan. A plan that supports life--both the life of the baby and the life of its young parents (who are kids themselves). Two wrongs don't make a right; there's no real way to undo a pregnancy. Does having an abortion make a minor whose had a sexual relationship mentally sound and "over it"? I don't think so, having been through a pretty rocky decade myself at that age. It's short term relief, but the emotional wounds leave big scars you have to deal with sooner or later.

I don't have a real answer. I just know that what needs to be done is to focus on prevention, and on building a society where support systems are in place for minors who would be at risk for this kind of behavior. And when sex and unwanted pregnancy happen, there should be support for that, too. There are plenty of young people who DO choose to carry their babies to term. What makes them different? Probably less hopelessness, more of a support system, more emotional maturity. Doesn't every minor deserve that, pregnant or not?

In a way, maybe Prop 4 will help some families. I agree that it will backfire in many ways, particularly in families where communication isn't possible. I know in my own family, when I was a minor, communication definitely didn't feel AT ALL possible, so I can only imagine what it's like in families with more diverse challenges. But in those families where parents or guardians are ready to reach out and help their minor, maybe it will force-foster some needed healing. Because when a teen is pregnant and wants an abortion, clearly something isn't going right.

Ramblings, on becoming a doctor

2008-10-10T07:33:00.000-07:00

“When we come to you
Our rags are torn off us
And you listen all over our naked body.
As to the cause of our illness
One glance at our rags would
Tell you more. Tis the same cause that wears out
Our bodies and our clothes”

From Bertoit Brecht's A Worker's Speech to a Doctor

I'm visiting home this weekend and am fascinated watching my sister interact with her newborn child. He is such a helpless little thing. As my sister said, anyone can do anything to him, and all he can do is cry. It's an obvious point, but I guess that degree of fragility is something we don't often encounter in daily life.

It got me thinking about the above excerpt from Brecht's poem. One of the reasons I love medicine as a profession is that people come to you with their problems, and you get to fix them. Anyone reading this will probably immediately think, "Oh yeah? Is that how it works? Because that isn't how it's been working!" Nevertheless, it is that idea(l) that attracts me to the field.

It's a scary thought, not to be taken lightly. As a physician, you are asking someone to come to you in their most vulnerable state, helpless as a baby (let's leave litigiousness aside for the moment). You have powerful drugs at your disposal, compounds that can wreak havoc on the body, or fix it instantly, or some compromise thereof.

Small things make a huge difference. Maybe your marriage is in trouble, or your teenager is a nightmare. Maybe you're depressed. Maybe your finances are suffering. Maybe you don't want to talk about it. Maybe you do. Maybe you shouldn't, but maybe you should.

How will I know if I don't ask?

Sometimes I frankly cannot believe that they let me into medical school. That assuming all goes according to plan, I will be a doctor and I will have this huge responsibility of someone's life in my hands. That I will have a pad on which I write treatments that could do a lot of damage to another human being. Or if I become a surgeon, that I will be fiddling around inside a fellow person.

But wasn't that the dream? Isn't this what I've been striving for, that very responsibility? Didn't I write in my medical school applications that there was nothing I wanted more than to be in this position?

And it's true, it is still true. There's nothing I want more. I don't know how this sounds, but I want to be a resource, a beacon for people. I want to be a giver like a tree that bears fruit. You pluck the fruit and it grows more, no problem, no questions asked. It bears so much fruit, in fact, that sometimes the tree bends over with the weight of its bounty. I want to be like that, if God wills it.

I pray I never forget what Brecht is referring to. The exquisite vulnerability of that moment with a patient. Eventually, it will be up to me: I can treat their symptoms (or what I perceive to be their symptoms), or I can treat them whole.

I'm sure I have no idea what I'm talking about right now, but I'm also sure that what I'm saying is true.

Food for thought from Infidel

2008-08-14T15:51:00.000-07:00

I’ve read quite a few novels this summer, but Ayaan Hirsi Ali’s Infidel has probably been the most provocative. While I oppose with her fundamental conclusions about Islam, I do agree with some of her injunctions against traditional Muslim culture.

That fundamental point of disagreement is this: I think she fatally misinterprets Islamic tradition as being part of the Quran—the word of God is NOT the same as what your imam or Quran school teacher tells you, necessarily, nor is the word of the Prophet in Hadith. She’s had some seriously crooked people/institutions rear her in their seriously crooked (mis)interpretation of Islam.

Anyway, while I think she takes her frustration out on the Quran when she should be directing that energy against opportunist, backwards interpreters of the scripture, I found her account of refugee camp life and her criticism of faith-based schools particularly interesting, especially as I was interacting with kids who had been through this unfathomable experience. I wanted to share some excerpts:

“The UN began to distribute food; basically they handed rations to people who claimed to be clan leaders, and these people either kept it for their own families or sold it.”

“It began happening al the time: Kenyan soldiers came at night to rape Somali women who were alone without protectors. And then all these women would be shunned and left to die.

This is what my grandmother had meant when she warned me: if you are a Somali woman alone, you are like a piece of sheep fat in the sun. Ants and insects crawl all over you, and you cannot move or hide; you will be eaten and melted until nothing is left but a thin smear of grease. And she also warned us that if this happened, it would be our fault.

It was horrible. Everyone in the camp called themselves Muslims and yet nobody helped these women in the name of Allah. Everyone was praying…but no one showed compassion.”

And on Muslim schools (this is the author’s opinion; I personally know nothing about Muslim schools but imagine it’s similar to Islamic tradition/culture):

“Muslim schools reject the values of universal human rights. All humans are not equal in a Muslim school. Moreover, there can be no freedom of expression or conscience. These schools fail to develop creativity—art, drama, music—and they suppress the critical faculties that can lead children to question their beliefs. They neglect subjects that conflict with Islamic teachings, such as evolution and sexuality. They teach by rote, not question, and they instill subservience in girls. They also fail to socialize children to the wider community.”

I believe strongly in gender equity, like Hirsi Ali, but I also think men and women were created to fill different roles in life (I’m thinking particularly about family life). Different, but equal. I also believe in creationism—to me, evolution is an undeniable truth, but within a species—but I agree with the author in that whether you believe it’s true or not, children need to be educated about the ideas that exist in the world they’re living in. That’s the only way they can make real choices and be intellectually and spiritually strong enough to believe in something worth standing up for.

A new outlook on my future in global health

2008-08-12T10:37:00.001-07:00

Yesterday I had lunch with my dad, and we got to talking about global health. He's not against aid to Africa; on the contrary, he was the one who accompanied my mom to Kenya last year, when the project was in its incipient stages. But he always seems to ask, "Why not India?" Considering that we are definitely Indian, and speak Indian languages, and eat Indian food, and know Indian culture, and have family there, it's a more than legitimate question. Why Africa?

Until I really got to know all these students and delve into their personal histories and, more importantly, the history of their place of origin (Southern Sudan, specifically Bor Town), this was my question too. I love India. I may not speak the languages my parents do, but something happens to me when I go there, oddly: I feel at home.

Anyway, if it's language we're talking about, why not Mexico? I speak pretty good Spanish and have grown up around Latino culture. Why not the urban poor of San Francisco, for that matter? The needy communities of Santa Ana?

Those are all legitimate questions, no doubt. How did we become all about Southern Sudan?

Sudan is not a cause (if I can momentarily reduce it to that) that we sought out, it's something that just happened. We weren't looking to work in this particular part of the world, necessarily. Most of my global health experience is in Central and South America. And last year I did a project in India.

But there's something about Africa's need that is staggering right now. I know well that the indigenous in Chiapas have suffered unspeakable violence in the highlands--I'm thinking of the 1994 Acteal Massacre that earned the Pillar of Shame. I know that Hindus, Muslims and castes and subcastes (the Gujjars and Meenas, when I was last there) have been at it for centuries.

But right now, I feel that Africa is in a crisis mode we as members of the human race cannot ignore. Particularly, Sudan right now is in crisis. A whole nation is utterly torn apart, and at its heels are Ethiopia and Somalia and Rwanda. The instability is staggering. This extent of civil upheaval, of human cost, is among the greatest of international atrocities. Yes, the Acteal Massacre was horrific. It almost took our breath away to hear Manuelito's account of it (a survivor who lost both parents and several family members, including babies). But what about the 1991 Bor Massacre no one talks about? Yes, the social and political drivers are not comparable. But I'm talking about human suffering and consequent human need. So for me, and for my mom, that is why Africa.

(Banner from the film "Not Lost" on the Lost Boys of Sudan)

Faith-based schooling in East Africa

2008-08-12T01:30:00.000-07:00

State House Girl's High School in Nairobi

Osama bin Laden once said, “You are either with the Crusade, or Islam.” This summer, that definitely seems true—in Mexico, it was the Crusade, and in East Africa, it’s Islam (and the Crusades, too).

In my two-week crash course on Kenyan secondary schools, I learned that almost all (if not all) schools incorporate religious education as a required part of the curriculum. There simply are no secular secondary schools (or so few that choosing to go to one is not an option for most students). In the fee structure for each term or year (3 terms in a year, 4 years total), the Bible is included as a necessary expense. Masses are held, and religious classes are mandatory. You even get a grade that factors into your point total. A part of the national exam administered at the end of high school, called the KCSE (Kenyan certificate of secondary education), is devoted to religion—if you are Muslim, you take the Muslim version, if Christian, likewise. You have two or three choices—I think Hindu is now a choice, according to Kwai, What if you decline? It is rare, but possible. Most people don’t decline—they already have their tidy social designation.

Anyone who knows me can predict where I’m going with this: why not let people think for themselves? Why make religion part of the curriculum at all? What are you going to teach, anyway? Piety 101? Charity, modesty, honoring your parents? Those are life lessons. You have to choose them all by yourself.

But there’s more to it than that. Everyone is so neatly categorized. In Southern Sudan there’s the Dinka, the Nuer and the Murlee, and more that I don’t know about. In Kenya there are clear lines between Somalis, Ethiopians, and other expatriates. Within each nationality, clans and subclans exist. You should know your family’s ancestry; it’ll help you in case you need to stay at a distant relative’s home, or if your people are at war. A relative won’t turn you down or leave you hanging; it would look bad. Clan/tribe/family ties are so strong in places like East Africa (eg Sudan, Somalia, Rwanda)—no coincidence that these are nations utterly torn apart by civil war.

Of course, they’ve had help from outsiders, no doubt about that. Khartoum in Northern Sudan is the #1 slave trade spot. Egyptians have historically come there to steal human beings—particular Southern Sudanese—for bondage. The discovery of oil has drawn often destructive, purely self-interested international attention (like China’s). But the fact remains that the Hutus and the Tutsis tore each other apart on their own, as did the Hawiye and Darod in Ethiopia, and the Nuer and Dinka in the Bor Massacre in Southern Sudan (in 1991). They didn’t need any help.

Nor did they receive any. Yeah, it’s true that civil strive had to do with internal tribal/clan conflict, but it’s much more complex and much larger than I’m pretending for the purpose of this post. And regardless, for wealthy nations to stand by when the chips are down, and step in when they eye something shiny, is in some ways more abominable than the civil unrest itself.

If You Knew

2008-08-11T08:36:00.000-07:00

If you knew what my life has been like, you wouldn’t look at me this way when I ask you for a thousand more shillings, call you three times to see if you got my email, take up half an hour of your time outside your hotel even though I wasn’t on the list of “accepted students” you posted outside the office. With the note saying how hard it was to choose, how you wished us all well with our pursuit of education.

If you knew I only eat a meal a day, and that’s why I called you to ask for more money, after you’d already made a check out to my school to pay my fees, you wouldn’t lose your patience with me.

If you knew my only motivator growing up was fear, maybe you would understand why I didn’t tell you in the interview I had an outstanding balance at my school.

If you knew this scholarship means I’ll finally be able to go to boarding school and get out of my uncle’s house where I work all day to earn my keep, with no time to study, maybe you’d pick me even though I get C’s and D’s.

If you knew I could get 3 masters degrees for the price of your 1, maybe you’d see it’s worth it to put me through medical school.

If you knew I have no idea where my parents are, whether they’re dead or alive, maybe you’d be as shocked as I am to see how you talk to your mom sometimes.

If you knew I’ve seen a man almost shot over a jerry can of water in the refugee camp, you’d see that it’s not just a bottle of water to me.

If you knew that my features are typical Southern Sudanese, and that this fact is grounds for a life of discrimination, both in Kenya and in my own country, you’d understand how much more fighting needs to be done to be able to say that “everyone is equal”.

If you knew I’ve seen hyenas too, eating dead bodies while I was fleeing civil war, you’d realize wild animals are not just “beautiful” and “peaceful” they way they look on safari.

If you knew the only reason I showed up to your hotel was to say it’s okay you didn’t pick me, I’m happy for those you did pick—they’re my brothers.

If you knew that if you don’t pay my school fees now, my mom says I have to go back to the cattle camp in Sudan next month.

If you knew my ulcers make it impossible to eat whatever food is available to me, let alone study.

If you knew I look nice and presentable because I wore my very best clothes to come to meet you.

If you knew this chance to study means the difference between a wasted life and a future full of hope.

If you knew. If you knew. If you knew.

Tutaonana!

2008-08-09T00:58:00.000-07:00

It's our last day in Nairobi and I'm really sad to leave, for so many reasons. Hence the title; tutaonana means goodbye/we'll see each other again in Kiswahili. One of the reasons I'm sad involves the fact that I'm two and a half weeks away from life in med school in Irvine. It has it's positives, but I'd much rather be here in Kenya talking to kids about how to complete their education and get ahead in life. But God has a plan and I can't be anything less than excited about it, because it always ends up better than I ever could have imagined. And that's the truth.

Anyway, there's so much to write, but the last week has been a whirlwind of paperwork and phone calls and haggling over school fees (yes, haggling, my mom is a genius by God's grace) and tying up loose ends. Running to the bank to make out banker's cheques to pay term fees for the upcoming school term. Converting between kenyan shillings and dollars, and withdrawing from the ATM, which is very stingy with letting us access our own money. We've also met with all the students, and had a real, delicious Sudanese meal at Kwai's house. That was probably one of my favorite things that happened here, actually. To eat traditional Sudanese food with some of the accepted students who we've been working with to sort out all their school and personal information was really nice. We'd been all business before, but this was purely a social event. It was a definite highlight. Even some of the very gracious applicants who weren't accepted came to share the meal, which I appreciated so much.

We are in the process of scanning all the life histories and photos of the students who applied but were not accepted this year, so that we can put them up on a yet-to-be-created website. God willing, the plan is to connect these students with donors other than the ones already involved in Universal Unity, Kiva-style. We'll keep everyone posted as this unfolds; there were a LOT of applicants so it will take a few weeks to sort everything out online.

There's so much to write about and think about, thankfully I have a whole 24 hour journey ahead of me to do all of that :).

More later.

A Few Photos

2008-08-02T10:17:00.000-07:00

The first day in Nakuru, introducing ourselves. Mario is to my left, Panchol to my right. We held the interviews in a church at an orphanage.

At the Sudanese community office discussing applications today.

Agou Jon and Mayen. I really love working with them!

Mom and Kwai. Indispensable!

Eliza and me after an interview. She is just starting secondary school and is disabled. She was so shy, but put her arm around me for the photo. A very sweet, determined girl.

We finally have our list!

2008-08-02T10:13:00.000-07:00

Today was another crazy work day in Nairobi. We had finalized the students we picked for the scholarships for university, pre-university (certificates, diplomas) and high school (boys and girls) last night in another long meeting with lots of good-natured arguing. This morning, we did more of the same, and then went to the community office to meet with the many students who were, sure enough, waiting for us. (They often show up to the hotel we are staying at, too. In fact, today we had to deal with that and it was unpleasant).

Anyway, so we got to the office and met with the students, finally able to give them the news of whether they’d been accepted or not. It was really difficult and I have to admit to shedding a few private tears (no one noticed, otherwise it would have been mortifying). It was a lot harder than I expected, partly because there have been so many logistical things to take care of, that I didn’t dwell on this particular moment, aside from the practical aspects like explaining exactly how we decided. I didn’t prepare for how they’d react, the raw emotion of it all. For instance, the first guy we had to let down said that he didn’t have any bad feeling, because even though he really wanted the scholarship, he was happy we were helping Sudanese, because they were all his brothers. Another person apologized for his low grades (I explained that even though his mean grade of B- was decent, we had no choice but to pick others with higher grades like A or B+), but told us that it was life was really hard and there were other circumstances that got in the way. Ulcers? Fatherlessness? Lack of food? Being chased away from school because of arrears? Ten students to a textbook in Kakuma refugee camp? Yeah, I bet. Life is hard.

Anyway, so we had some good meetings and some tough ones. Thank God we are working in a team. Because we are all working together and we want to fight for the truth and pick the absolute best students (we have to defend the fairness of our choices, to ourselves, to each other, to the students, and to a higher power), it’s great that there are so many eyes looking at all the applications. This morning, Mayen fished out an application that my mom had looked over, and asked us why this boy was not on the finalized high school list. Indeed, he had better grades than a couple of boys we’d chosen. We had had reasons for picking other students, but in the end, we felt we had to swap another with him. It was an important decision. Two similar other decisions were made through the course of the day. Imagine, because of God’s help and our due diligence, three people who otherwise would not have gotten funded, finally did.

At the end of a long, lunchless day (sadly, one or two meals per day is how too many people usually operate here), we finally left the community office to eat. We ended up at an Ethiopian restaurant where we had a delicious, buttery, meat-filled meal, eating injera and curry with our hands. It was amazing!

Tomorrow, we are going to the Nairobi museum in the morning with Mayen. In the afternoon, we’ll meet with Kwai and Jon to discuss strategy since not all the students who were accepted showed up to the office today. We have to call them all and get all their official school documents together to start making payments. A few don’t have schools to go to yet, so we have to place them. We also have to open a bank account here in Nairobi to deal with all our new financial commitments. But that will have to wait until Monday.

Takwenyo/Sopa! Backlog from Masai Mara.

2008-07-31T03:43:00.000-07:00

Last weekend my mom and I got back from a short trip to Masai Mara, the southern part of the Serengeti here in Kenya. Masai refers to the Masai tribe (more on that later) and Mara refers to the Masai tribe (more on that later!). Takwenyo and Sopa are Masai greetings for females and males, respectively. If someone greets you in this manner, you say Iko or Ipa. Other words in my paltry Masai vocabulary: Asheoling means thank you; Ijo a means how are you; and Olesere means goodbye.

Masai Mara comprises 1/50 of the Serengeti, and features one of the highest concentrations of natural wildlife on the planet. Now is the season for the famed migration of the wildebeest, so we saw a lot of wildebeests crossing the Mara river. The animals start migrating from Tanzania to Kenya in June, so by August, the highest concentrations can be found. There are between 1.6 and 2 million of them! We saw lots of lions, elephants, giraffes, crocodiles, gazelles, antelopes (diktiks, topis, and elands), and a few buffalo, warthogs and hyenas. Cheetahs, hippos and finally, a rhino. Evidence of a leopard in the form of a baby wildebeest carcass strung on a tree branch.

I learned a lot from Samuel, our guide who seems to love offroading in his Jeep and watching animals do their thing. He excitedly taught us about the difference between giraffe "horns" and real horns (like male antelopes have)--horns are bony, and "horns" are keratinous. He also taught us some anthropology: lions engage in community breastfeeding; male wildebeests have harems (they are forever running around defending their females and babies from being stolen, or pursuing other males' "property"); hyenas are predators of lion cubs; cheetahs can jump 10 feet high and 30 feet long; and elephants live up to 60 or 70 years old and are dangerous predators of Masai people (as are buffalos). Samuel is also a fan of The Lion King and the circle of life/the food chain. As thousands of wildebeests risked their lives crossing the river full of crocodiles, he told us, "So many wildebeests! No wonder the crocs and lions eat them up! If not, there would be no grass left, even the roots would be eaten." The man makes a point.

The whole thing was amazing. I'd never seen anything like it, it was right out of the Discovery Channel or National Geographic. The only thing I didn't like at all was how close up we got to the animals. Tour guide jeeps were so eager to get up close to the wildebeests crossing the river that they'd park on the banks, with tourists getting out of the car or sitting on top of it. It throws the animals off; when this happens, the wildebeests wait or turn back, unable to cross in the presence of people on foot (they are ok with people inside the cars, apparently). We also drove right up to the lions, so close we didn't need to zoom in to get an incredible photo. Yeah, it was amazing to be that close, but it was also very disconcerting, especially when you see eight Jeeps surrounding cubs and their mother, eating the morning kill. Kind of like watching a movie scene being filmed, rather than nature unfolding itself.

It made me reflect: 1) how different are we from animals, and 2) what right do we have to be so intrusively curious about them? and 3) what gives us the ability to pursue that curiosity? I bet wildebeests don't have maps they've drawn up of our migrations, or hold tours showing their fellow beests how we mate in social groups. Something from our trip to Masai Mara tells me, in a way that is distinct from my other ways of knowing (faith, logic, scripture) that I am not just any other animal "evolved" from natural history. The height of my emotions; my ability to reason, to calculate; my capacity for guilt, remorse, shame; and even just the mere fact that I was sitting in that Jeep watching a pride of lions eat a zebra carcass, taking pictures and learning about their way of life as we humans have discerned it, reinforce my intuition that I have a deeper purpose in my existence, and that is to uphold good and stand up against bad, to be grateful to whatever awesome Power made me what I am right now, and to correct myself when I misstep, because I will be called to account for it. This is really inarticulate (and with extremely poor grammar) but it was just a fleeting moment of profound clarity.

Anyway, we also went on a nature walk. Our guide was Daniel (that’s his Christian name, I forgot his Masai name). Daniel taught us about the history of the Masai tribe’s relationship with the Kenyan government since the 1940s. It was at that time that the government independently decided to make Masai Mara a national conservatory (a part of the Serengeti where the Masai live—Mara means spotted in Masai, referring to the spots of bush dotting the flatlands). They drove the Masai out with excess force, as Daniel put it. The Masai retaliated indirectly by burning grassland (endangering herbivores) and killing wild animals, particularly endangered species. Finally, the government called a meeting with the Masai chief to reach some sort of accord. After almost two years of talks, an agreement was reached whereby the government would lease the Masai Mara land from the tribe, and give 19% of park entrance fee profits to the Masai people. With their profit, the 300,000 Masai here in the south Serengeti do things to benefit their villages, like build water dams to ensure their cows have enough water in case of drought. Interesting.

Some other things about Masai Mara I found intriguing/worrisome: the Jeeps drive over croton bushes and through herds of wildebeests, which I thought was really disruptive and disrespectful of the natural habitat. Rangers carry out controlled burning of grassland for the gazelles--they like flatland because they're able to see prey more easily, but burning grassland is bad for trees and birds that nest on the ground. (Do they do this for the tourists, because tourists will find gazelles more pleasing to the eye than birds/trees? You gotta wonder.) There are also excavations in certain places, and the introduction of (I think man-made) gravel so the dirt roads are less slippery for tourist vehicles. And tour guides regularly off-road, and allow tourists to step outside their cars. Sure, off-roading sometimes allows you to see that amazing animal you would not have otherwise reached, but the fact remains, you're an intrusion.

I'll post pictures when I can!

A random thought on 'charity'

2008-07-31T03:41:00.001-07:00

One of the dilemmas we’re running into with the high school applicants—particularly the girls—is that many of them, as orphans, are staying with benefactors or distant relatives. These guardians often strike a deal with their charges: clean the house, and we’ll take you in (and sometimes also pay for school). Of the girls we interviewed, several were concerned that going to day school rather than boarding school, and relying on the kindness of benefactors, would result in their spending too much time doing housework and chores to focus adequately on their studies.

This is problematic for the students, but it’s also a symptom of a larger social issue. Sure, that benefactor wants to spread around his/her good fortune to the needy orphan. Yet, he/she still wants to get something out of the deal—perhaps to keep the orphan accountable, or perhaps because he/she has unmet needs that a poor girl with few options in life could fulfill. (What is an unmet need, anyway? A cleaner toilet? Fresh cut fruit for breakfast?) Perhaps this benefactor would hire a real servant otherwise, if not this orphan Sudanese refugee student. He/she might think, I’m helping this child change her life. And it’s partly true, no? But not if she can’t get good grades because she is doing chores with the greater part of her free time, in order to earn her keep.

Why is this problematic on a social level? Because while many of the haves will always be ready to give charity to the have-nots, it’s also true that many of those same charitable haves (the so-called well-off) will also always want there to be a ready pool of people to hire for menial jobs like cooking, cleaning, and raising their kids. They want this workforce to be readily available for them while they do other things with their time: travel, make money, or do whatever. They want this workforce to work long and hard, sometimes for fair compensation, sometimes for a bargain. So how can these well-off, well-meaning individuals expect to bring up the poor classes who they profess to want to educate? How can they give them a hand up in life while simultaneously requesting that they stand at attention, ready to sweep the floor or cook the family’s evening meal? By supporting the idea of the orphan girl’s education while (perhaps) resenting the notion of her spending the greater part of her time and energy not in polishing wood banisters but in learning English and math?

I don’t hold the well-meaning well-off in contempt for their wealth, or for their desire to help the needy. I have no right. I think our Creator has a good reason for providing each of us with whatever means we have; I believe in a divine plan. But at some point, I think we all need to look around and take stock of where we are and what got us to where we are. And then I think we need to think about how we can be part of affording others the luxury and the freedom of making the choices we are able to make as a result of what has been afforded to us.

Meet the Team...pictures soon!

2008-07-30T03:37:00.000-07:00

I've mentioned in earlier posts the names of team members I'm working with on this refugee scholarship project, but I wanted to introduce them properly, because theyare phenomenally capable people whose dedication astounds me as much as the hardship they have survived and continue to overcome every day.

It is approprate to start with Mario, as he is the first of the so-called Lost Boys we came to know back in California. Mario is a graduate of University of San Francisco, and my mom was introduced to him by a Christian missionary, Ursula. My mom traveled to Somalia and Haiti with Ursula before realizing that she could accomplish more on humanitarian trips if she ventured out on her own, unfettered by organized religious/bureaucratic organizations. She continued to keep in touch with Mario and his Sudanese friends-Deng, Mamer, and a lot of others who knew each other either from refugee camps or after coming to the US. They were almost all involved in NGO work for Sudan, so my mom and I got involved through them. Last year, she went to Kenya with my dad to meet some of the students who she was introduced to by Mario and who she now sponsors. As I wrote before, this year, our aim is to expand the program, God willing. We haven't gotten any outside funding yet (grants, etc) but to continue to see the project grow (and there is a desperate need for that!), we plan to actively pursue other sources of funding.

Anyway, another member of the team is Deng, also studying in the US. Deng is a softspoken but adamantly just man who plans to get his masters in public health at Touro Univ. in Vallejo, CA. He is a college graduate. He is with us in Kenya right now, but just returned from his marriage in Sudan to a young woman he met in Kakuma refugee camp. They have two kids. He is forever arguing for us to make the most fair decisions regarding students: for instance, not discriminating against Ugandan applicants just because they are in Uganda (and thus harder to keep track of), and not discriminating against students who seem to look better off (what, do we need them to look dirty and bad to sponsor them? he asked last Sunday).

Kwai is another member, but I think I devoted plenty of time to him in my last post. A blessing to the project and more importantly, to SUdanese refugees in Kenya, period.

Then there's Mayen. He's also a refugee who was kidnapped by the SPLA but escaped with Chol, another one in Sudan right now for a school project (Chol did a lot of the organizational work for the project here in Nairobi while me and my mom were in Mexico and at home in CA, respectively). Mayen has two brothers, both of whom are in the US/Canada. They won the lottery like Mario did. He should have gone too, but his paperwork was lost. He's studying catering in college. He's a loyal, hardworking, resourceful, honest, accountable guy, always ready to help his people and their cause. As he told us in Nakuru: I don't care if I have to sleep under a tree, as long as the work gets done. I am learning from his example. He also likes rap music, so I'm going to make him some CD's once I have access to my laptop again.

And finally, there’s Agou Jon. He goes by Agou but I’ve only known him as Jon. I met him over email last year when he wrote to me, telling me about his studies. He had gotten admission to Moi University to study medicine. Moi is a prestigious public university here in Kenya. It’s even harder to get into med school here than in the US, which is saying a LOT (trust me). But he had no money to pay (like everywhere else in the world, studying to be an MD is extremely costly). So he gave it up, and decided to study communications instead. Of course, he excels at it, and USAID is doing creative projects using the radio to bring education to Sudanese, but I can’t help thinking that he would be of much greater service to his people as a doctor. And at least equally as importantly, I believe he’d get more satisfaction from it. Just my .02. Personally, I hope he finishes his current degree and then pursues funding (maybe a Universal Unity scholarship?) next year for medicine. The cost is $7,000 per year for four years. Anyone have any ideas? He is just so capable and dedicated. For instance, on Sunday in Nakuru, we divided up the labor of drawing up cost estimates for each candidate we’d narrowed the list down to. He took university students and I did high school boys and girls. He had class on Monday, but still came at 6pm with a neat Excel spreadsheet detailing everything. Knowing how prepared he would be, I did the same by hand (no laptop), calling all the schools I could in order to find out term costs in each school (each term is priced differently, and there are four forms in high school, three terms per form). I am inspired by his work ethic, as I am by Chol’s, Mayen’s, Kwai’s and Deng’s.

As I mentioned before, some of these students knew each other long before we got to know them as individuals. Mayen told us about how they all knew each other before this, back in Ethiopia and Sudan. Apparently, Chol snuck Mayen out of the SPLA camp at one point, and then himself escaped. In Kenya, Mayen met Mario. They were refugees trying to survive. Mario would bring food, Mayen and others would search for water, and still others would bring firewood back to the bush. Everyone knew Mario because he would bring the food and then distribute it, first to the little ones (like Mayen, back then) and then to the adults. Hearing this made me realize that there’s a whole history I know nothing about, and I have to be humble and keep my eyes, ears and brain wide open to learn as much as possible as I insert myself into this social network.

Back in Nairobi!

2008-07-28T12:12:00.000-07:00

It occurred to me that I didn't exactly introduce what me and my mom are here in Kenya to do. Basically, we have accrued through my mom's non-profit organization a sum of money that we would like to now invest in Sudanese refugee children's education here in Kenya. My mom got to know some of the "Lost Boys of Sudan"; students who won a lottery established in the U.S. to bring Sudanese boys living in refugee camps to study in American universities. She developed a relationship with them and as they graduated from universities like San Jose State and University of San Francisco, she realized that they were determined to go back to Kenya and work for change for Sudan. And she wanted to be a part of it. She is already sponsoring 5 or so Sudanese students going to college in Kenya, so this was an extension of a network that was already in place, by God's grace.

So Mario, Deng, and other students from the U.S. (who come back to Kenya when grant money and other means are available) put the word out to the Sudanese refugees studying here, some of whom are my mom's students. They were happy to put up fliers in refugee camps like Kakuma, and schools where Sudanese refugees study. In this way, by the time we got here on Thursday, there were over a hundred secondary school and university students (or hopeful students) waiting for us with their biographies, life stories, and copies of their grades and other documents that might help us make a decision.

Over the weekend, we were in Nakuru, a two hour drive from Nairobi. There are lots of Sudanese refugee students there and we had an even longer day of interviewing than we had in Nairobi the day before. But it was great to meet all the students. My heart broke for the ones who were very nervous, as well as for the ones who had lost a parent (or both). So many have no idea where their parents are. So many have lost their parents to the war. So many woke up from hiding in the bushes from bombs at night, to find that family members were missing in the morning.

So many walked to Ethiopia, then out of Ethiopia and back to Sudan when war broke out in 1991, and then Kenya when life in Sudan became too dangerous to continue. They didn't know they were en route to Kenya. They were just following the masses of refugees.

We spoke more with Kwai, who I mentioned in my first post: he's the coordinator of the donated Sudanese community office in Nairobi. It's called PARAD: Penkyou Agency for Relief and Development. He's an awesome guy, and a great resource for the students. He went with us to Nakuru and was one of our greatest assets. We didn't know much about him until we finally shared a couple of meals together. He was a former SPLA fighter (Sudanese People's Liberation Army; we met others who were kidnapped as children by the SPLA and then taken to Ethiopia before the Ethiopian war, and fed and clothed until they were old enough to either escape or be sent out to fight with AK-47's). He fought for the SPLA and then somehow got to Kenya as a refugee, where he was a teacher in Kakuma camp. Then he got to this post at PARAD, where he helps anyone and everyone in the Sudanese community.

Kwai was deployed by the U.N. (last year? can't remember) on a peace mission tothe Murlee tribe of Sudan. I am finding from interviewing students that one of the most commmon reasons for poverty and refugee status is the Murlee warriors. The Dinka and the Nueri tribes are frequently attacked by the Murlees, who steal children and cattle. Apparently, they suffer from STD's and some of them are left barren; Kwai says he hasn't seen any Murlee boys in their community, only Dinka and Nueri (perhaps stolen or bought). They even wanted to buy him when he was a young boy!

Anyway, so he was deployed with a team of 7 other Dinka and 2 Kenyans to Sudan. Their mission was public health: they didn't want to hold the Murlee accountable, they only wanted to give them what they obviously lacked: food and water (probably the reason for their reliance on thievery to subsist). They came expressing their desire to help with finding water, and drilled holes to 100 meters searching for a water source, with no luck. The Murlee got angry, starting to mistrust the team, and Kwai said he was truly afraid they'd attack. So he called the U.N. and got permission to drill to 120 meters, and a plane dropped more supplies so that they could continue their mission. They found water and drilled a lot of holes, and the Murlee celebrated with their tribal dances and by smearing cow dung, blood and saliva on Kwai and his team.

Despite their portrayal as guerrilla warriors and terrorists (as far as I know), the SPLA doesn't seem to be held in contempt by the Sudanese people I've been talking to. They steal kids and give them AK-47's, but I think in Sudan, where you have the Murlee and the Arabs terrorizing peaceful tribes, the SPLA stands against them, and is probably not too badly received. In fact, they seem to be somewhat well-received; in another moment of danger, when leaving the Murlees, Kwai had to call for emergency protection and the SPLA came to his rescue, surrounding the area with troops while a U.N. plane came to airlift his team out of Sudan.

Yesterday and today were devoted to compiling all the students’ information, including grades, schools, family status (Which is an indication of need…orphan? One parent? Father or mother? Who currently pays school fees, if anyone?), how many terms they have left (there are three terms per year for a high school student), and all sorts of other helpful information. We also narrowed down the list to about 12 university candidates, 12 high school boys, and 10 high school girls. It was definitely a two-day job, with me on the phone to all the high schools I could reach to confirm fees, and Jon making an excel sheet of estimated costs for all the university candidates. Yesterday, we also visited three girls’ schools, as educating girls is a priority of ours. We were not impressed with any, but got a lot of insight into what life is like for a student. You’re not allowed to go to your room anytime you want (as a boarder); they lock the rooms from 6am to 9pm because otherwise people steal from the rooms. Crime is such a danger in schools that you can’t even keep any pocket money with you; you have to leave it in the main office and take it out as you need it.

Today, we had two more last minute interviews, one for high school and one for college. One of the candidates was a 17 year old boy whose mom currently works for the SPLA and earns $100USD a month (the reason for her joining). She tries to support her son, but she has four kids. They are all in Kakuma refugee camp, and she is back in Sudan. Their father was killed. He is a straight-A student. The only hindrance to his studies is his ulcers. I think he’s so afraid to eat because of the grinding pain that he simply doesn’t eat except for the sake of survival (in fact, most Sudanese I meet only eat twice a day, or even just once, just something to keep them alive, even in Kenya). He is so thin! I talked to him at length about food at schools, and it’s hard because the schools have a set menu and his ulcers make it impossible to eat some of what they give. I asked him to buy bread with some money, but he can’t take any outside food to his boarding school; if he does, the administration will search him and take it away! Why? For fear of stealing. Yes, even a loaf of bread.

Sudanese are definitely treated differently in society. Today I was reminded of this fact yet again. We had borrowed a stapler at the motel we did most of our work at yesterday. Today, we borrowed another stapler. It looked very similar to the one we were using yesterday, and I wondered if one of us had mistakenly taken it from the motel in Nakuru. It turned out that we hadn’t, it was just a very similar-looking stapler (broken in the same way). But Mayen, one of the boys on our team, then mentioned to us that yesterday, someone called the police and told them that two Sudanese boys had stolen a stapler from the front desk. The truth is, we were all using that stapler! I had borrowed it earlier in the morning and returned it; he had come back because we needed it again. I was so angry…how unfair. The things they have to deal with in terms of discrimination, on top of lack of food and having gone through so much.

Ok this is the longest blog ever, so I’ll have to save some of this for later.

Kenya, so far

2008-07-26T08:20:00.000-07:00

so we had a whilrwind first two days in kenya, starting early morning friday to see all the college students we had lined up to select for scholarships. lots of students came to the donated sudanese "office" in nairobi, and we ended up splitting up into two teams with me and mom working separately, so we could see everyone in a timely fashion both for the students' sake and ours. some of these kids came from really far so we had to see them, no matter whether they were promising or not.

to hear them describe what they go through as you try to figure out how they live, how they study, what their plans are, is really something else. another post.

after a hectic first day, this morning we woke up super early (like 2am) because we couldn't sleep. late night i had been compiling all the student information into one coherent master list, so at 3 or 4 mom and i decided to work on it together as neither of us could sleep anyway. so we ate the emergency quaker granola bars and finished the list, two separate ones, one for college and one for high school candidates.

then at 6 we started to get ready to check out of the hotel already for nakuru, where we are now. nakuru is a couple hours away from nairobi, and it is where a lot of high school candidates are. so we came here. there were lots more high school students waiting for us than college. we ended up seeing 35 yesterday, not sure yet how many today. we just got done and went to eat food, and then came here. we are restless but zombielike because of the jet lag.

on the way to nakuru we were told we'd have to stop and vacate the car and be inspected by police because there have been recent cases of people with guns in buses like ours, but it didn't happen.

the sudanese are definitely treated differently here. you can tell they are different by their facial features and they are a lot blacker than kenyans. we don't understand swahili but we understand they are called by their nationality "sudanese" sometimes and this evening one of the students claimed he needed 3,000 kenyan shillings (conversion: 67 KSh = 1 dollar) to get home because the police stop him and take money from him, and he's in trouble if he doesn't have the cash.

there are lots of stories like this going around. i tend to believe them despite how awful they sound because they are so alike among sudanese refugees, and because they tell you the truth even when they don't have to (for instance we ask, what are your grades? they will tell you B- or whatever they are even when they didn't bring their documents. they could just say A, right?). anyway.

i am surprised to find who i like working with and who i almost cannot tolerate. i really like john agou, and deng, and chol, and mayen. i am on a short string with mario, who is from the US and got 8,000 through Univ Unity to check things out in Sudan. i just lost my patience after awhile. and after the 30th interview you're just like please...but mayen is really honest and hardworking, and chol always has a smile on his face, and john has a cool head but he notices a lot of things, and kwai is another one who is coordinating everything behind the scenes. we couldn't do this without them. they made the lists and told everyone when and where to come, and had staplers to staple documents, and gave us the applications as the students came in to ensure steady flow to get things done efficiently, etc. etc. we really have to be grateful.

now we have the even more daunting task of going through all this information and selecting the students. we wanted 5 girls and 5 boys for college and 15 high school students in roughly the same gender proportions. it's tough to find college girls, easier to find female high school candidates. but we have so much information on so many candidates, and because we split up into two groups over two full interview days, we have to communicate so everyone is up to date on every candidate and we can all make a fair, informed decision. not to mention that we haven't done proper justice to the essays of each applicant, so we have to do that.

we are also taking photos of each applicant to put together with their scanned autobiographies and other school documents, to create a profile online of each of these students, so that their efforts in applying to Universal Unity scholarships will not be in vain, God willing. our hope is to put each of their profiles up on the internet, and publicize it so that donors can be connected with these students and can put money toward their tuition, kind of like kiva.org. this was reshma's idea and i think it is an excellent one. we want to show appreciation for the fact that they came all this way and overcame so much hardship to pursue their desire to study, jumping through our hoops of paperwork, essay, and face-to-face interview. none of this could have been easy.

tomorrow we are going to see lake nakuru, apparently there are flamingoes there so we will hopefully visit for awhile. nakuru is not a big city, but it is definitely a town and not a village, so there is a lot of commerce and traffic here. i want to walk the streets more and get more of a feel of what life is like here before we leave on monday morning. and of course, we have a LOT to talk about regarding the candidates we have interviewed!

Liberation Theology

2008-07-22T08:30:00.000-07:00

I'm writing this post fresh off the beginning of what I hope will be a lifelong commitment to the betterment of public health in the rural highlands of Chiapas, Mexico. Sounds like a lofty statement. That's probably because it is.

Anyway, it was an amazing experience, meriting its own blog (estufasenchiapas.blogspot.com). I got back a couple days ago, ate my weight in junk food, and am leaving for Kenya tonight. Hey, they said it was our last summer and I believed them, so I figured I better do it big.

Chiapas was about getting stoves to families that cook with open fires, and Kenya is about educating Sudanese refugee kids. Disparate projects, but they seem to have one disturbing theme in common, the topic of which is this blog entry: liberation theology.

It's no surprise that religious groups are doing good work in resource-poor areas. After all, one of the basic tenets of any religious faith is to help those in need. It's not disturbing to me that Christians (or Muslims or Jews, for that matter) are putting Sudanese orphans through school or contributing to the empowerment of native Mexicans in Chiapas. What is disturbing (to me, that is) is that an undeniable byproduct of their aid is the conversion of the disenfranchised to the faith of their benefactors.

Now, it may well be the case that I am the only one bothered by this observation. Perhaps the recipients of faith-based organizational aid are unfettered by, or even grateful for, the importation of institutional religion into their cultures and communities. That's not for me to say, and there has been such a profound interweaving of ideas since as far back as the 16th century that the complexities are pretty great.

I believe in God, but inseparable from my faith is my conviction that everyone should use their own eyes, ears and brains to figure out what makes sense for themselves. For some reason, the disenfranchised of this world have endured the structural violence of hegemonic relationships for so long now that some of them seem more apt to accept what they are told (even by those who created those hegemonies) than to think for themselves. As Jaime from Medicos del Mundo told me and my crew in Chiapas a couple weeks ago, if you tell an indigenous man that this piece of paper is worth $1,000 pesos, he will believe you. This observation, to me, is potentially almost as disturbing and destructive as Hernan Cortes was to the Aztecs, or as NAFTA has been to the campesino. I'm exaggerating, but you get the idea.

So how do we empower the have-nots to think for themselves? How do we get to the point where as we objectify them by talking about them as the "have-nots", they too are creating social constructs in which we are pinned as the "haves", creating a way of seeing the world that makes sense to them and in which they have agency and can affect change?

Health and education are the only things I can come up with.

Health + education = agency. Health and education = object --> subject.

This post was supposed to be about liberation theology, so I guess I should say things about that now.

Mainly, I am concerned about the mixing of charitable work and religion. I think it's perfectly fine to share your religious beliefs with others. I definitely do. But sharing beliefs is different from building a church in the local community and tying aid (whether it's education, medicines, housing) to evangelism. In my opinion, it creates in people an unnecessary association between a hand up in life, and a particular way of thinking about the world (ie, Christ is going to save me). It creates in someone whose needs are so great that they don't have the luxury of choice, particular ideas about reality that ought to be his or her decision to make. And in fact, in many of these communities, despite big churches and crosses, people maintain their native ideas about life. And they are often in direct conflict with European religious constructs.

Case in point: I receive emails from Sudanese refugees living in Kenya trying to scrape money together to go to university. One of them wrote to me addressing me as his "sister in Christ". I don't believe that Christ is going to save me, I just believe in God alone, so I mentioned that to him. He wrote me back, and it was a worried email in which he apologized for having "misspoken" and written about Christ. He reassured me that he believed in God alone. And then he asked me again about school fees.

Am I to hold him in contempt for verbally conforming to my own beliefs in the hopes that it will secure some financial stability for his schooling? Definitely not. But I know that there is a strong Christian presence in Sudanese refugee aid efforts, and I am frankly suspicious that it has directly resulted in a large number of "Christian" refugees. What they want/need is a hand up in life, and there isn't much they are not willing to say or do to get it. I would, too, in their shoes.

Nor, however, do I hold religious NGOs in contempt. They are not force-feeding their beneficiaries with their own brand of theology. One can even see the conversion of native Mexicans to Christianity during aid efforts (ie, liberation theology) as an inevitable byproduct of such charitable projects. But I strongly believe that those spearheading these projects should be aware that instead of urging their own religious beliefs (voice them, yes, but voicing is different from evangelizing), they should exhort their charges to use their brains and think for themselves, and then give them the freedom to make their own choices.

And what is freedom? How do you give it to a person? By fighting to increase their access to health and education, I think.

2008-03-28T11:40:00.000-07:00

Last night, after a week of studying for a couple of brutal national exams (whose sole purpose was evidently to convince us first-years that we still know nothing about medicine), I went to the Santa Ana armory to see patients with doctors, residents and other medical students. It was a good experience, as it made me reflect on my choice of profession more than anything else had in a long time.

First, some background: the armory is a seasonal night-time shelter in Santa Ana, California that runs only during the winter months. It opens its doors every evening around 6pm, and closes at 5am (the homeless are woken up at 4:30am to gather their belongings). It is located in a big warehouse stocked with 200+ four-by-six mattresses that accommodate its nightly patrons.

However, despite the lack of a kitchen, a child-care area, and other basic necessities of a shelter for people who have nothing (such as being open year-round, perhaps), the armory is generally well-run. It does its best to provide the services its clients need most: health care, legal aid, toiletries, and a hot meal.

My experience, of course, was in the clinic. MD's, DO's, residents, nurses, social workers and students are all part of the team providing care for 24-30 patients in a two hour time slot--no small feat. I've seen a lot of volunteer clinics, and this one worked well. Everyone had a role to play (even us first-years!) and things went fairly smoothly, the only worry (and it's a big one) being that homelessness is a disease too complex to cure in a twenty-minute visit. No matter how good a triage system you have.

I was paired with a family physician from Kaiser, a soft-spoken guy who (thankfully) was happy to have me around. He seemed like a natural teacher, and was eager to explain the intricacies of each case and field my endless string of questions. He was impressed that I knew what Barrett's esophagus was (he didn't know it might be the only thing I learned in histology) and that I was able to come up with differential diagnoses (even though much of the time, my differentials were longshots). In short, he was a kind man.

We saw several patients, and all of them reminded me of how my interests in literature, doctoring and people are the very reason I sit on my butt all day reading about the human body. I met an elderly German who shared his name with a film star from his country and chastised me for my poor geography. A Santa Ana native who came in for infected abscesses from heroine use and told us he spoke three languages: "English, Spanish and obscene." A jittery lady who "got out of prison on February 28th and lost all my teeth by the first of March." (I didn't ask how, despite wanting to know, because her chronic acid reflux was a much more pressing concern). "This homeless thing really gets in the way of eating properly and not stressing out," she told us. No kidding. We met a slight African American gentleman who hobbled into our station so fatigued he spoke in a whisper and had to rest on a cane. He was suffering from congestive heart failure, high blood pressure, peripheral neuropathy, and a really bad case of athlete's foot (which I noticed!). "Try to keep your feet as dry as possible, buddy," the doctor advised, despite all three of us knowing that his feet were the least of his worries. It was hard not to feel a little overwhelmed by the daily struggles the patients obviously face.

The night reminded me that everyone has a story. Not just homeless people, for that matter, but everyone. When we see standardized patients with our teachers and peers at school, or even when we practice interviewing with community doctors, I never get the feeling that I'm truly listening to a patient. I'm worried about whether my history-taking is orderly, or whether I'm asking all the right questions, or whether I'm projecting professionalism. But last night, in a real clinical setting, I felt more natural than ever before. And it didn't make me a worse clinician-in-training...in fact, I think it made me a better one. I was truly listening to the patients, trying to understand the evolution of their chief complaint from their point of view. Questions popped up in their logical progression; their answers led me down various paths. Some were right, others were clearly wrong. Either way, I felt a true connection with the patients, and I can't wait to volunteer again. Being a doctor is bearing witness to people's private life stories, and there is nothing I'd rather do than be the person who gets to hear them (and hopefully, one day, do something about it).

Bush, SCHIP, and Med School

2007-10-03T12:10:00.000-07:00

From a NYT article today, this is Bush's explanation for why he vetoed a SCHIP expansion bill supported even by his own Republican contingency:

“It is estimated that if this program were to become law, one out of every three persons that would subscribe to the new expanded Schip would leave private insurance,” the president said. “The policies of the government ought to be to help poor children and to focus on poor children, and the policies of the government ought to be to help people find private insurance, not federal coverage. And that’s where the philosophical divide comes in.”

Well, he got that last part right. It is definitely a philosophical divide. Between him, and sane people. Because that's what insanity is: when things don't make sense and they aren't getting better, but we keep on ignoring intelligent stimuli because we're...not sane.

Stop Trying To 'Save' Africa

2007-09-03T16:45:00.001-07:00

By Uzodinma Iweala
The Washington Post
Sunday, July 15, 2007; B07

Last fall, shortly after I returned from Nigeria, I was accosted by a
perky blond college student whose blue eyes seemed to match the
"African" beads around her wrists.

"Save Darfur!" she shouted from behind a table covered with pamphlets
urging students to TAKE ACTION NOW! STOP GENOCIDE IN DARFUR!

My aversion to college kids jumping onto fashionable social causes
nearly caused me to walk on, but her next shout stopped me.

"Don't you want to help us save Africa?" she yelled.

It seems that these days, wracked by guilt at the humanitarian crisis
it has created in the Middle East, the West has turned to Africa for
redemption. Idealistic college students, celebrities such as Bob
Geldof and politicians such as Tony Blair have all made bringing light
to the dark continent their mission. They fly in for internships and
fact-finding missions or to pick out children to adopt in much the
same way my friends and I in New York take the subway to the pound to
adopt stray dogs.

This is the West's new image of itself: a sexy, politically active
generation whose preferred means of spreading the word are magazine
spreads with celebrities pictured in the foreground, forlorn Africans
in the back. Never mind that the stars sent to bring succor to the
natives often are, willingly, as emaciated as those they want to help.

Perhaps most interesting is the language used to describe the Africa
being saved. For example, the Keep a Child Alive/" I am African" ad
campaign features portraits of primarily white, Western celebrities
with painted "tribal markings" on their faces above "I AM AFRICAN" in
bold letters. Below, smaller print says, "help us stop the dying."

Such campaigns, however well intentioned, promote the stereotype of
Africa as a black hole of disease and death. News reports constantly
focus on the continent's corrupt leaders, warlords, "tribal"
conflicts, child laborers, and women disfigured by abuse and genital
mutilation. These descriptions run under headlines like "Can Bono Save
Africa?" or "Will Brangelina Save Africa?" The relationship between
the West and Africa is no longer based on openly racist beliefs, but
such articles are reminiscent of reports from the heyday of European
colonialism, when missionaries were sent to Africa to introduce us to
education, Jesus Christ and "civilization."

There is no African, myself included, who does not appreciate the
help of the wider world, but we do question whether aid is genuine or
given in the spirit of affirming one's cultural superiority. My mood
is dampened every time I attend a benefit whose host runs through a
litany of African disasters before presenting a (usually) wealthy,
white person, who often proceeds to list the things he or she has done
for the poor, starving Africans. Every time a well-meaning college
student speaks of villagers dancing because they were so grateful for
her help, I cringe. Every time a Hollywood director shoots a film
about Africa that features a Western protagonist, I shake my head --
because Africans, real people though we may be, are used as props in
the West's fantasy of itself. And not only do such depictions tend to
ignore the West's prominent role in creating many of the unfortunate
situations on the continent, they also ignore the incredible work
Africans have done and continue to do to fix those problems.

Why do the media frequently refer to African countries as having been
"granted independence from their colonial masters," as opposed to
having fought and shed blood for their freedom? Why do Angelina Jolie
and Bono receive overwhelming attention for their work in Africa while
Nwankwo Kanu or Dikembe Mutombo, Africans both, are hardly ever
mentioned? How is it that a former mid-level U.S. diplomat receives
more attention for his cowboy antics in Sudan than do the numerous
African Union countries that have sent food and troops and spent
countless hours trying to negotiate a settlement among all parties in
that crisis?

Two years ago I worked in a camp for internally displaced people in
Nigeria, survivors of an uprising that killed about 1,000 people and
displaced 200,000. True to form, the Western media reported on the
violence but not on the humanitarian work the state and local
governments -- without much international help -- did for the
survivors. Social workers spent their time and in many cases their own
salaries to care for their compatriots. These are the people saving
Africa, and others like them across the continent get no credit for
their work.

Last month the Group of Eight industrialized nations and a host of
celebrities met in Germany to discuss, among other things, how to save
Africa. Before the next such summit, I hope people will realize Africa
doesn't want to be saved. Africa wants the world to acknowledge that
through fair partnerships with other members of the global community,
we ourselves are capable of unprecedented growth.

Uzodinma Iweala is the author of "Beasts of No Nation," a novel about
child soldiers.

A Global Health Celebrity in the Family

2007-06-29T10:33:00.001-07:00

I've been updating mostly on my other blog since I'm in India this summer, but this piece of news really belongs here. My cousin, Kavitha Narra (who I still remember in diapers), just returned from a visit to Germany for 2007's G8 summit. As you all know, the G8 summit is an annual meeting of the 8 most powerful countries in the world. They have instituted a (new?) feature of the G8 called the J8, wherein young representatives from each G8 country apply (via the United Nations) to participate in the history-making conference. Among other activities, J8 leaders sit with presidents from these 8 superpowers and discuss global issues like health care, the environment, peace and conflict, and other relevant topics.

Kavitha was not only a part of J8, she was the US team leader. She handpicked teammates and teachers, all from The Harker School in Saratoga, CA, to form the J8 team that represented the US this year. She spoke to world leaders along with her teammates, urging them to set small, measurable, achievable goals and calling out politicians who make empty promises just to borrow goodwill. Makes sense, no? She's fifteen.

Now, Kavitha's in Hyderabad, India, learning about female empowerment through business enterprise with ALEAP. She's visiting a lot of sites with her friend and J8 teammate, Rachel.

As you know, political and social apathy among the younger generation has been a definite concern in the past few decades. Some say that US youth haven't been motivated to contribute actively to better their country since the 1960s. I think that creating the J8, and encouraging motivated teenagers like Kavitha, not only shows that youth are starting to play a more active role; it also indicates how important it is for the future of global public welfare to engage these bright young voices.

All about Ayush

2007-06-20T22:36:00.000-07:00

This week has been all about Ayush, the alternative system of medicine in India. As I’ve already mentioned, it’s much more widely accepted by the general public than its equivalent in the U.S., and it’s even recognized by the official government of India. Because of its cultural, historical, social and health care importance, I’m glad we got the chance to learn about it.

Ayush stands for Ayurveda, Yoga and naturopathy, Unani, Siddha, and Homeopathy. We didn’t go into much detail about unani, siddha and homeopathic cures; most of our time was spent learning about ayurveda, yoga and naturopathy. But these are all drugless therapies, so some version of hot/cold manipulation, physiotherapy, and herbal treatment is probably incorporated into each one of these. Meditation and breathing exercises also have healing properties in this system.

The basic principles of Ayush are that the body has five great elements: earth, water, air, ether (space), and fire. Health is defined as the harmonious vibrations of all the elements and forces composing the human entity.

The body is said to heal itself if it is given proper scope, or nourishment. We are what we eat. An acute disease is considered to be the healing and cleansing effort of nature, while a chronic disease is the suppression of an acute disease with drugs. There is also something called the unity of disease, which is the accumulation of foreign matter or toxins inside our system. Unity of cure is defined as the elimination of accumulated toxins from the body.

Interestingly, bacteria and germs are considered secondary causes of disease, which I agree with…they are not primary causes. This is an important distinction. Sanitation, improper diet, and other causes that will be discussed below are delineated as causes of disease.

The stomach is the origin of disease, and so it is to be treated first. 99% of diseases, according to our lecturer, Dr. Nair, start in the stomach.

And the last tenet is that the cause of all diseases is one, and their treatment is also one. Dr. Nair did not specify what that one cause was, but I think it’s meant to get patients thinking holistically instead of treating each specific ailment as it comes.

On to the causes of disease. Diseases are defined as violations of nature’s laws. This seems to mean that humans cause disease by going against nature. The causes are: a) ignorance; b) indulgence; c) indifference (high ego). Dr. Nair forgot one that I think is vitally important, and that is d) poverty. It is interesting that she did not include that. Poverty is lack of access to nutritious food, clean water, etc…before many people get the chance to be ignorant, indulgent or indifferent, they are simply poor.

Obviously, modern medicine could have a field day with some of these descriptions, but the traditional system in India is simply a theory. On its side are centuries of experience, so it can’t be easily dismissed.

There are many treatments that Ayush offers for various ailments. They are best for chronic conditions such as arthritis, obesity, diabetes, asthma, migraines, sinusitis, and depression. They do massage therapy, hydrotherapy, mud treatments, nutritional counseling (and fasting), chromotherapy (color therapy), yoga, acupressure, magnetotheraphy, electrotherapy, aromatherapy and acupuncture (the last two are widely practiced but are not officially Ayush, because they aren’t traditional Indian healing methods).

A few words on ayurveda (this is basic info that can be gotten anywhere): ayurveda is literally the science of life. Veda is science, and ayur means life. There are three main aims to it: 1) the prevention of disease by adopting a healthy lifestyle; 2) the cure of ailments through treatments, medicine and surgery (yes, surgery!); and 3) rejuvenation. The two major works of literature composing ayurvedic thought are the Charaka Samhita and the Sushruta Samhita. The first is a book on general medicine, and the second is on surgery. These were written by ancient physicians as early as the 7th century, though ayurveda was undoubtedly practiced even earlier. Ayurvedic medicine has a large scope; it was shocking to hear that it includes surgery. It also has branches in ophthalmology, ENT (ear, nose and throat), pediatrics, botany, and more. I’m fascinated to learn more about it.

Another highlight of our week at Bapu was the dance lesson we got yesterday. It was just Linda and I who wanted an Odissi lesson, but in the end, several others came to watch the guruji teach us the history, culture and movements of Odissi dance. I was deemed (by myself first, and more definitively by Dr. Nair) to have both the interest and physique, but not the talent and grace, for traditional dance. I hope it’s not true, but I suspect this ordinance holds true for other types of dance, too. I guess I should stick to athletics.

Oh yes, and there has been a change in travel plans! Tomorrow is our last day of CFHI fun…we are traveling to the village of Mewat, which I’m really looking forward to. If you remember, we postponed this trip a few weeks due to Gujjar uprisings. After tomorrow, Emma goes home and Sejal and I are planning a trip to Dehradun, a hill station in the Himalayas. Then we are (theoretically, God willing) off to Mumbai, where we will stash our bags at an Aunty’s house and go on to explore Goa. Let’s see how it all works out though, God only knows!

Until Mid-July....

2007-06-20T22:29:00.000-07:00

...check out my Delhi blog, because that's where I'll be! I've been in Delhi for a month, but now it's time to pick up and travel around India some more. Mini-trips to the Himalayas, Bollywood and Goa are in the works (of course, God willing!). I came to India through an NGO called CFHI, to learn about HIV and public health challenges in this country of one billion people. Check it out!

Learning from the Acumen Fund: A strategic plan for international aid

2007-05-21T23:04:00.000-07:00

I recently read an article on the Acumen Fund in the Stanford Business magazine, which I'm fond of. It was an appropriate piece to include in the publication, considering that the founder of Acumen, CEO Jacqueline Novogratz, is a graduate of the business school.

What struck me about her strategy is how simple it is. Basically, Acumen collects money from philanthropists and corporate investors, identifies businesses in developing countries that need assistance, gives loans to those business owners, and provides managerial assistance to ensure that improvements are made and that profits are eventually turned.

Loans, coupled with the business acumen provided by lenders, force small business owners to ferret out destructive elements like underperforming and pilfering. When a third party is scrutinizing all aspects of production (remember, they are now major stakeholders in the proposition), business owners become more efficient and more accountable. These are two crucial qualities sorely lacking in small businesses in developing countries.

How can this strategy be appropriated for use in the public health sector? For developing countries struggling to set up infrastructure, loans must come not only with instructions for use, but with built-in guidance and accountability. One of the keys to Jacqueline's success with business owners is that she constantly asks her customers what they think of Acumen's services. If they are unhappy, the company isn't doing its job. Likewise, if international lenders don't work with developing countries to find sustainable plans to use much-needed funds, little will be gained. Remember, we live in a world where 25,000 people die of hunger every day for reasons that have less to do with lack of resources than poor governance.

Acumen is an interesting example of market-driven solutions for human development. As it says on its website, the Fund aims to "provid[e] a product or a service that can be sold directly to out target market or to a small-scale entrepreneur, not only to government or donors who may be out of touch with the demands of low income consumers or their willingness to pay for what they value."

So there you have it. An example of the private sector not only being at the epicenter of global public health, but showing mistrust for other major stakeholders--governments and NGOs. To quote my sister, a current Stanford GSB student, "The quickest way to solve a problem is through business." Those of us in the field of public health and medicine will do well to heed those words.

The other side of the coin

2007-05-14T12:02:00.000-07:00

This is the story of another homeless man I interviewed on Skid Row, Pablo. The post's title refers to my previous entry and immigration issues as considered by the major stakeholders--the people. Obviously, this is anything but a homogenous stakeholder group.

Just like Severiano, I met Pablo at the Downtown Drop-in Center in L.A. He was sitting on a boulder at the Center, looking peacefully the street where a prostitute, a policeman, and a man in a wheelchair were gathered. He is staying temporarily at the nearby L.A. Mission, which he describes as “a living hell.” “The slop they give you isn’t sufficient to survive,” he says. “The guards search you three or four times a day. At Salvation Army, they kick you out after a few days, or start charging you ten bucks a night.”

Pablo was born in 1944 in Puerto Rico. He moved to New York in 1948 with his parents and three sisters, and attended primary school there.

“I’ve been working since I was eight years old,” he says. “I started selling fruits and vegetables on the street when I was ten or eleven.”

Pablo remembers Los Angeles thirty years ago, when he first came from the east coast to work in agriculture.

“L.A. was a lot better back then,” he claims. “There were a lot more job opportunities. Nowadays, there’s no work.”

When asked why he thinks there are fewer and fewer jobs in L.A., Pablo—like many politicians in the country—cites the increasing influx of immigrants.

“They’re willing to work for less,” he says. “If I go in asking for a living wage, employers don’t care because they know they can get the job done for less by an immigrant. They’ll find someone else who’ll sacrifice what they need to get money.”

According to Pablo, this is not a new phenomenon. “I was a union cook at a military academy, and after the [Vietnam] war, they told me, ‘We can get it done cheaper.’ They terminated a lot of Americans to bring the Vietnamese in. They brought them to [Fort] Indiantown Gap for cheap labor.”

Pablo also worked in the oil industry, delivering oil to Panama in the late 1980s when citizens went on strike against then-President Noriega. “The U.S. has a lot to do with the pollution of oceans,” he notes. He also worked in Boston, Texas, Washington and Tennessee, doing everything from coffee roasting to waste management. He likes the adventure of travel and the camaraderie that grows from working with fellow men. “You don’t have to look behind your back,” he reflects. “The guy next to you is your father, your brother, your mother. You don’t have time to argue.”

How long has Pablo been homeless? “I’ve been here three weeks,” he tells me. “I’m getting old, I need the sunny weather.” He then goes on to explain his battle to get financial support from the government. “I won it in court,” he claims. “They owe me disability. I can’t work no more after my bypass. I’ve worked all my life. But the government would rather die than give you any money. They never answer the phone and when you go in to see them, they treat you like garbage.”

I ask about Pablo’s plans for the future. “I’m just waiting for my social security to come in,” he says. “821 dollars.” Considering how often he moves around, I wonder how the check will make it to him. “Oh, I have direct deposit.” Once he gets his check, he’ll rent a room for $280 at a nearby hotel.

Pablo isn’t worried about drugs deals and other criminal activity on Skid Row—despite acknowledging rampant drug use, he seems to think it’s pretty safe. “But the government could take care of this if they wanted to. [The police] lock up 30 or 40 people every day for drugs. Nowhere in the world is [the culture of homelessness] as bad as it is here in L.A.”

A tale of two countries

2007-05-14T06:45:00.000-07:00

I met Severiano O. at the Downtown Drop-in Center on Skid Row during L.A.’s Big Sunday 2007 event. He’s 26 years old, tan, tired and unkempt—they offer showers at the Drop-in Center, but from his appearance, that doesn’t seem to be a priority for him right now.

He is quick to tell me that the reason he is currently homeless is because of a restraining order placed against him by his girlfriend, with whom he was sharing an apartment in downtown L.A.

Growing up in the town of Colima near Guadalajara, Mexico, Severiano had four brothers and four sisters. It was a big brood, and when asked about family dynamics, he doesn’t hesitate to tell me that his family life was unproblematic.

“We didn’t have too many issues. My parents are still together,” he says.

Like so many Mexicans, Severiano came to the U.S. for job opportunities, and has had no trouble finding work in his chosen profession—construction. His friend, also in the construction business, helped pay his way from Mexico and even gave him a place to live and found him his first job. Severiano likes construction work; his only complaint is that employers are often unwilling to pay his going rate of $250 per day.

He tells me that has worked in various cities in Southern California, and even traveled to the city of Pasco in Washington state to build houses. However, in Pasco, the construction job fell through and he ended up working in the field, picking apples. When winter came, there was no more work, so in 2001 he came back to L.A.

After a one-month stint at an L.A. construction company, Severiano began “esquiñando,” literally, “cornering,” an activity many Californians are particularly familiar with. He would sit on the corner of a Home Depot, waiting for people to pick him up for a day’s work. Once, he found a “patron” who gave him steady work for eight months. He doesn’t mention why the job ended; he just tells me he went back to sitting on the corner.

I ask him if he has ever had trouble finding work. “No, I can find work easily. I can make an entire house from start to finish. They don’t want to pay $250, they’d rather pay $80 or $150.” Has he ever had a problem with wage arrears? “Sometimes they don’t want to pay what they promised,” he concedes. “They’re not happy with my work, or they just want to pay less.”

Like many homeless young men living on Skid Row, Severiano has both a drug problem and a police record. He was deported twice in 2006, after being incarcerated on separate occasions for domestic violence and driving under the influence. He was dumped at the border town of Tijuana only to return soon afterward.

“It’s very hard not to fall into drugs here,” he says, alluding to the rampant dealing of drugs that mark Skid Row’s decrepit atmosphere. Is he clean now? “Now, yes.”

Unlike many other immigrants, however, Severiano has family members in the area. As close as San Pedro, his cousin has a home, a job, and a growing family. A brother lives in Las Vegas, and a sister lives nearby in Los Angeles. Why doesn’t he stay there while he gets back on his feet? “I feel like a burden when I’m there. I want to make it on my own. What I get in my life, I want to earn with my own two hands.”

On the other hand, Severiano notices fundamental cultural differences in the way Mexicans and Americans live. “I’m not used to living alone. I’ve never been alone,” he tells me. Unconcerned with his familial relationships, Severiano just wants to make things right with his girlfriend. “I’ve let her down many times. But everything happens in its own time. With tranquility, calmness.”

And finally, I ask about the issue of documentation. How does Severiano feel about the politics surrounding migrant labor? His answer is apolitical—rather, it is simple, humane and reflective. “Leave that topic alone. There are many people who are good and honest, yet they don’t have their papers. There’s a lot of racism.”

“This country is ours too,” he declares. “Our own government is very corrupt. All are. There are mafia, trafficking of drugs, and many things.”

But the challenges for an illegal immigrant like Severiano are profound. “You can’t even say anything, or protect yourself,” he says. “You have no voice. You are boxed in. Some people rob, and do other things. I don’t.”

Above all, Severiano believes in humanity, self-improvement and fate. “All of us have problems. That guy has his, and I have mine. It’s just that I have some unruliness in me. I want to get rid of that. One has to resign oneself to life’s losses and gains. You don’t know your destiny.”

~As told to Farah K.

Conditional welfare: Is provisional aid really a threat to democracy?

2007-05-07T22:58:00.000-07:00

In our very last class meeting, Dr Shahi urged us to think about the future of public health. Future directions have been a part of all our discussions in the past few months, but some interesting ideas come out of dedicating an entire class period to the topic.

We’ve talked about PPPs, SMART cards, diffusion of innovation, and community mobilization.

This post is dedicated to another acronym, CCTs: conditional cash transfers. CCTs refer to a government-based program whereby stipends are issued to poor families. It’s not the dole, though—in return for these stipends, families must pledge to immunize and school their kids, and comply with other basic measures designed to stem the vicious cycle of poverty.

Countries like Peru and Brazil (Bolsa Familia) have piloted CCT programs with great success. New York is unveiling a similar scheme, but as a recent NPR segment indicated, the idea has met with some opposition from critics concerned that CCTs are a form of coercion.

My take? I can understand why those suspicious of socialism oppose the idea of CCTs. There are lots of reasons why the program could go horribly wrong. It could be an ethics nightmare. What if no one wants to comply? Does the government deny those families their stipends, leaving them in poverty and without the freedom to choose what is best for their kids?

Peruvian officials deny these concerns, claiming that families are rarely dropped from CCTs, whether they end up complying with the stipulations or not.

But I think the critics are missing the point. There is such a thing as too much democracy. Are we, as a country, really wealthy enough all around to entirely shun socialist ideals? Or is there still a real need for these kinds of programs? As a collective society, I don’t think we’re as modern as we think we are. There’s a lot of room for improvement, and if designed and implemented with public health goals at the forefront, CCTs could really encourage people to access better opportunities for their kids. If we want to see some real changes in the inequalities we keep referring to, we need to get off our democratic high horses and experiment with a little of what appears to be working in other countries—whether you want to call it socialism or common sense.

Read more about CCTs in New York here. And then check out the Peruvian approach. Catch NPR’s coverage of both here.

STOP THE RAIDS AND DEPORTATIONS!!!

2007-05-01T09:38:00.000-07:00

Today is the National May 1st Movement for Worker and Immigrant Rights. Visit the Mayday Movement Blogspot to find out more about events going on around California, Arizona, Nevada, Tijuana among other places.

The movement calls for a "Great American Boycott": NO economic activity, NO shopping, NO work and NO school for immigrants and their children, to show "what a day without immigrants in the economy signifies."

This can be considered a fight for human rights, but it is also more personal than that. It's a fight to keep families together. Children born in the U.S. are marching for the security of having their parents by their side. Immigrant parents are fighting for the right to raise their kids in peace in a country with which they've built a mutually beneficial relationship. Below is a photo from today's New York Times article of a father and a son whose mother was deported to Honduras two weeks ago in the early hours of the morning.

It's not easy to know exactly what to do, but what not to do--such as sudden deportation and raids--should be easy for public officials to figure out by now. For my thoughts on 21st century global immigration and to read other papers discussing various global health issues, check out our collection of essays on Emerging Trends in Global Health.

Mobilizing communities: How far would you go?

2007-04-26T00:25:00.001-07:00

First, check out this video about Treatment Action Campaign (TAC), South Africa's HIV movement led by HIV-positive citizens to demand ARV's and accountability from their government and transnational pharmaceutical companies.

It is so moving to see these people fighting for their rights. It reminds me of the quote by Margaret Mead that was brought to our attention by Dr. Shahi in class last week:

Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it's the only thing that ever has.

I believe that mobilizing communities is going to make the biggest difference in our reaching the Millenium Development goals. After all, excluding select groups from centralized processes is the very reason there is so much "unfinished business" in human development. Then we went and made it worse by telling them exactly what they need to do to make it better. Now, we seem to have finally come to the realization that involving (and hopefully, empowering) disenfranchised communities is the only way to truly make a difference.

The above picture, from the TAC website, is another dramatic example of community mobilization efforts. We can get lost discussing the merits of PPPs, cost-benefit analyses, global data systems and stakeholder summits. There are other ways to get things done.

What lessons can future health professionals take from this? It goes back to the title of this post: How far would you go? How far would we be willing to go to fight for ARVs, for polio eradication, for universal health care? Would we be willing to dance on a stage to rile people up against the injustice of a black infant mortality twice as high as that of whites? Would that be too unprofessional, too personal, too close to home?

After watching the TAC video, I really don't think so.

Ethics & Global Public Health

2007-04-19T23:01:00.001-07:00

M.Lakshman, AP Photo / healthystartokawalton.org

Last week we discussed the role of ethics in emerging trends in global public health. Dr. Shahi asked an important question: Are we really confronting a new era in ethics, or are the challenges we face today the same as those faced by previous generations?

Like most of the class, I agree that the questions we must ask ourselves now, with regard to ethics, are more important than ever before. The impact of technology on our lives is immeasurable, and it's advancing and impacting society on a greater scale than we can quantify. In the face of persistent disparities (rich/poor, north/south, white/ethnic, urban/rural, male/female), there could be a scramble to end the shame that accompanies the fact that the two children pictured above exist in the same era, in the same global community.

To be fair, scientific and technological developments are not always a scramble, nor do they necessarily present ethical dilemmas. But products like ready-to-use therapeutic foods (RUTFs), labs-on-a-chip (LOCs), GM foods (such as Golden Rice), bioremediation techniques and many other recent and imminent advancements do pose ethical questions, particularly when thinking about long-term development. For instance, as my colleague Liyan Moghadam mentioned several weeks ago, one of the pitfalls of RUTFs is the fact that it is designed to nourish those in immediate danger of starving to death. What do we do after the peanut butter? Pat ourselves on the back??? And what about GM foods? Some independent studies have found links between GM potatoes cancer in lab rats. Do we really know what its impact will be on the beneficiaries/victims of (fortified) GM foods?

But we also have to ask ourselves: is this all rich man's talk? Even in our own community, there are populations that can't really afford to talk about ethics the way we do. Living a moral, honest, insulated life is much easier when all your primal needs are met (and then some). Does this mean we should consider different ethical standards for different populations? RUTF factories in Uganda bring jobs to people desperately in need of livelihoods. Inexpensive LOCs give the power of knowledge to people suffering from treatable illnesses they didn't even know existed (but will they get those inexpensive drugs that cure them? the food? the clean water?).

If you ask the people who would benefit, I don't think they would ever say no to a new technology that gives them more tools for life. But I think the developers of these exciting tools (who obviously have some knowledge of their importance to society) have a responsibility to think of not only the benefits but some of the challenges that their innovations present. They should work with organizations like the Institute for Global Ethics to ensure that those worldwide north/south, white/ethnic, urban/rural, educated/uneducated disparities we're seeing are not exacerbated--and are perhaps even diminished--by new technologies.

Because with regard to equality, our track record with science and tech so far raises some serious red flags (eg, read this poem on the global digital divide).

Public-Private Partnerships for Global Poverty Alleviation

2007-04-11T12:12:00.001-07:00

In a previous post I explored the possibilities of public-public partnerships (PUPs) in establishing vital infrastructure (e.g., water, electricity, city planning) to combat poverty.

This entry is all about public-private partnerships (PPPs), and the case for their potential to alleviate global poverty is unequivocal. PUPs simply cannot compete with the powerful combination of yin and yang that results from public-private collaboration.

First off, for a great list of various PPP models and a diagram of where each lies on the spectrum of public/private risk involvement, see the Canadian Council for PPPs website.

We all know what the public and private sectors stand for. The public sector is concerned with meeting basic needs and ensuring social justice. The private sector is innovative and profit-driven. Inherent in both sectors are problems that endanger human welfare. What happens when you put the two together? With the right leadership, you could have an integrated mechanism for sustained human development.

A little background: in the late 1990s, the IMF and the World Bank implemented the now heavily criticized Structural Adjustment Programs (SAPs) in developing countries to manage debt and reduce poverty. The SAPs emphasized trade liberalization, which, in the way it was implemented, might be described as mutton dressed as lamb...developed nations open up their markets for trade with less developed countries (LDCs), and then heavily subsidize exports so that LDCs with newly open market policies cannot compete. SAPs have been replaced by another acronym, PRSPs (Poverty Reduction Strategy Papers), which are required by the IMF for a country to qualify for aid.

Ugandan President Musevani put it poignantly when he said, "We are asking for the opportunity to compete, to sell our goods in western markets. In short, we want to trade our way out of poverty."

Trade liberalization can do that, but most LDCs are not at the point yet where they can compete with developed nations' subsidies. PPPs could be useful here. What is needed is federal government stewardship over "free" trade. LDC governments must seize back ownership of their economies, develop criteria for collaborating with international partners in the private sector, pick those partners wisely, and ease into financial mechanisms that work toward Musevani's plea.

"Our job is not to give people fish. It's not to teach them how to fish. It's to build a new and better fishing industry."
-Bill Drayton of Ashoka Alliance

On a side note: Where do you and I come in? We can be social entrepreneurs, who seem to be able to harness the yin and yang and everything in between. See these videos of successful innovators for inspiration:

Ashoka Alliance founder Bill Drayton
Grameen Bank founder Muhammad Yunus

On the Future of U.S. Health Care Financing

2007-03-29T11:25:00.000-07:00

No matter how much we talk about global health issues like infectious disease, maternal health, and the role of education, at the heart of every problem we are facing is the question of financing health care initiatives. Perhaps the only other variable so crucial to population health is stewardship, and a large part of stewardship concerns judicious management of funding.

Two videos recommended for this week brought up provocative issues on the future of health care financing in the U.S.: Uwe Reinhardt's lecture and the California OneCare initiative. California OneCare lobbies for universal health insurance, calling for swift steps instead of small changes. The biggest issues we face are administrative costs and lack of access to care for a staggering chunk of the population. Also disturbing are inequities in the quality of care people receive, a measure closely linked to SES and race.

Many other countries use a single-payer system to control administrative costs. Canada and the UK are just two examples. Health care investigators in these countries would be quick to tell us that the single-payer system is no panacea...it has its own disadvantages, like everything else. However, at the heart of the current health care crisis is a civil rights issue that the single-payer system might address: unquestionable inequity in the ability to attain something that is, at least ideologically, universally considered to be a basic human right.

Even developing countries understand (and act on the understanding) that the way we do health care doesn't cover the most vulnerable people. In this country, over half of family bankruptcies filed are a direct result of medical expenses. 3/4 of these people have jobs. They are productive individuals of society crippled by a health care system that's supposed to increase their productivity. Instead, it's leeching it.

If that's not convincing enough, consider this: a 1% decline in income in the U.S. translates into an increase in mortality rate of 22 deaths per 1000. In Canada, no association is found between income inequality and mortality rates. Infant mortality rates show similar results, with the world superpower ranking in the 40's on the list of country-specific rates.

Fundamentally, health is more important than money. Anyone who's ever experienced a serious illness, even a bout of flu, can tell you that without your health, your money doesn't mean much.

Unfortunately, that piece of wisdom is no longer true, and it's least true in places like the U.S., where both health and money are available, but money is infinitely more important than health. Here, money buys health and happiness. What is wrong with this picture???

Back to that paradigm shift we talked about. Sure, we'll have to iron out some kinks in a single payer system to adapt to our needs as a country. But what we're doing right now--taking those kinks and calling them reasons not to act in the best interests of human beings--can't continue. We must first accept that inequality of some sort may always exist, and then go about decreasing it as surely as we can, as other nations--even less developed ones like Korea, Brazil, and India--have done.

And one more thing: an equality of opportunity, as the U.S. has historically been praised for having, is not the same thing as equality. There are several forces, some known and others unknown, working against equality. For instance, racism and SES interact additively to produce poorer health outcomes for certain groups of people. This holds true even when patient characteristics are held constant. What does this mean? It means that somewhere among health care providers and institutions, inequality is being perpetuated. It means that addressing individuals is not enough; the entire establishment must be examined. We must ask important questions: Are doctors giving every patient the same quality of care? Are there good hospitals in largely ethnic areas? Good schools? What are the differences? Our country likes to believe that racial segregation was so long ago that its effects are no longer profound. We have made great strides (remember, in the late 18th century an African-American slave was only roughly 3/5 of a human being). But vigorously addressing contemporary manifestations of these issues will greatly aid a successful reworking of health care financing in this country.

In order to treat some persons equally, we must treat them differently.
-Harry Blackmun

Internet Access and Health Outcomes

2007-03-24T07:12:00.001-07:00

my Grandma:
one of the smartest people I know!

I recently went back to my hometown for a visit and realized that some of my dearest friends and family do not have access to the internet. This may seem obvious and acceptable, but to me it is neither.

Who are these people in my life who are so archaic they don't have internet access even though they can afford it? Well, 1) my grandma and 2) dear family friends who are not-so-recent migrants.

I was studying at my aunt's house the other day when I decided to see what my grandmother thinks of YouTube.com. (This post is supposed to be about health outcomes...we'll get there). I typed in 'Andhra Pradesh' (our home state in India) into the search bar, and six pages worth of videos came up. We watched a few videos on Indian freedom fighters during the time of Gandhi. My grandma was a little girl during India's freedom fight--she recalls witnessing her elder brother being beaten by British-hired Indian law enforcement officers for his revolutionary activities. The videos, which were even narrated in her native Telugu, brought back all sorts of memories for her. She even talked about writing a book about her brother's role in the fight for Indian independence. She was jazzed.

My aforementioned migrant friends could benefit from internet access too. Some of them don't speak English at all. They make enough money to afford a computer and the internet, so the barriers are not financial. They just don't have the freedom to do things like take time off from work to do something frivolous like educate themselves. But there is a crucial point to make here--just as we discussed in the first weeks of class, and just as UK & Netherlands authors Wagstaff and Van Doorslaer (gold standard researchers on poverty and health) point out, the effects (i.e. the cost) of not having things like the internet are much more significant for disadvantaged people. In other words, it would mean a great deal more to my grandma, or to my migrant friends, to have internet access, than it means for someone like me to have it.

What would it mean? The possibilities are endless. For my grandma, maybe it means delayed onset of dementia. Less depression, anxiety and social isolation (she can connect with others and entertain herself as she gets older and cannot move around as much). Fewer medical episodes. For migrants, it also means access to empowering information that may well give them the freedom to see education as a basic right/need rather than a peripheral idea. It would mean access to services that they would otherwise have no way of knowing exist. Faced with all this new technology, it seems that education is more important than ever. Increasing access and utilization are key.

I spent some time teaching my grandma how to use my aunt's PC. She's a quick and eager learner in her mid-80's. Her biggest challenges were learning how to operate the mouse and focusing her eyes on the screen. I wonder why the local senior citizen center offers arts and crafts, but not computer classes? There's so much human potential out there, sometimes in the most surprising places. From that perspective, the field of public health would do something incredible if it focused on ways to give people the tools they need to live productive lives. Because for many (if not most) people, feeling productive = feeling truly happy.

Biotech for Development: A promising solution or a pipe dream?

2007-03-06T12:10:00.000-08:00

There is no easy answer to the debates over where pro-poor development funds should go. As part of the whole paradigm shift we keep referring to, I think every field has to redefine its priorities. Biotech was the topic last week, and one of the controversies surrounding pro-poor biotechnology is the question of whether the vast amount of funding required to develop a new diagnostic, a new vaccine or a new drug is really worth it. Rich countries can argue that drugs already developed are very poorly distributed. Why fuel new innovations that will only widen the gap?

While committees concern themselves with that, paradigm shifters in the field have showed some promising advances, including new vaccines and low-cost treatments that are showing promise in advanced-level trials (anti-malaria vaccine, paromomycin treatment for kala azar). In a
New York Times article posted by Dr. Shahi awhile ago, Tina Rosenberg points out that vaccines have only been around for 20 years. In 20 years, they've made an enormous difference in a child's ability to survive the first five years of life! Who would have thought that such a labor-intensive project, which requires hunting people down in all corners of the world one by one, could be so successful? Who could have predicted that wars would be halted for vaccination campaigns? And yet it happened, and it changed everything.

Another example: The human genome was discovered two years ahead of time, and well under budget. According to one account I recently read, these unexpected outcomes were largely attributed to competitive cooperation among investigators. Again, it would seem impossible to unravel something as complicated as the human genome ahead of schedule simply because someone wanted to beat everyone else to it. And to do it more cheaply than expected, to boot. But that also happened, and it changed everything.

But we seem to forget history. Or maybe we're unaware that we're the ones making it. It's ironic, but one of crucial ways of achieving a paradigm shift is, I think, examining history in an attempt to understand just how we got to where we are now. There's an astonishingly accurate (and somewhat grim) picture of human nature buried in there, and confronting it proactively may provide some rationale, motivation, and clues to shifting that paradigm.

To learn more about biotech's role in global health, check out this article on the ten most promising biotechnologies for human development.

Water Democracy vs. Globalization & Public-Public Partnerships

2007-02-22T16:08:00.000-08:00

First off, watch this shocking video to learn more about the impact of the global water crisis:

Beyond Scarcity: Power, Poverty, and the Global Water Crisis

I just read an interesting article written by Dr. Vandana Shiva, author of the book Water Wars. The article exposes water theft (hydropiracy) by large corporations like Coca-Cola, water privatization by the World Bank (in an effort to shift from "social to commercial value"), and other scandals like rerouting rivers to maximize land use (consider the World Bank-supported River Linking Project in India). I never thought of water as a commodity subject to theft! But theft is indeed occurring, and it reminds me of a poignant point made by presenters in our last class who compared our current battle over oil to the possibility of a war over water rights & access. Facing the prospect of water scarcity makes the oil crisis seem laughable.

The article also discusses public-public partnerships (PUP's). Private multinational corporations like the Suez Group--which made over a billion dollars in profit last year--have unfortunately failed to deliver improvements in water access in countries worldwide (e.g Argentina, Bolivia & Tanzania). Public-private partnerships can apparently leave a country with less water and more debt than they had to begin with. The concept behind PUP's is simply to shut out the for-profit sector by forming partnerships that include public authorities, donor governments, international organizations, NGO's, trade unions, and communities/local actors.

As we talked about in class, water is a basic human right, and when that's the case, the onus falls on the public sector. Privatization can indeed help, but in the case of water, taking into account the private sector's failures and the extreme urgency of water needs in developing countries, should PUP's be considered instead?

Check out this article on PUP's worldwide to learn more about their current role and possibilities for the future: "Public Water For All"

Among currently employed, successful PUP's in national water distribution (taken from the above article, and originally described in the book Reclaiming Public Water):

-Public-collective partnership in Cochabamba (Bolivia): democratic control over the public utility SEMAPA (via citizens elected onto the company’s board) and a strong role for local water committees in distributing bulk water supplied by SEMAPA to the unconnected periurban areas.

- Community-utility partnership in Savelugu (Ghana): Ghana Water Company delivers bulk water to the community, who run the next stages of water delivery; planning, tariff setting, new connections, maintenance and billing.

- Public-Workers Partnerships in the province of Buenos Aires (Argentina): a worker’s cooperative manages the public water utility ABSA, consulting closely with public authorities and water users.

- Communitarian water delivery in Venezuela: local communities, the water utility and elected officials co-operate in communal water councils to identify needs and priorities for improvements, allocate available funds and develop joint work plans.

There are definitely barriers to implementing PUP's, but it seems like there is also strong evidence that they could be the answer to establishing water democracies.

Public health in Palestine

2007-02-15T09:41:00.000-08:00

Watch the video "This Is Not Your War" on American nurse Lynn Gras' humanitarian trips to Gaza, Bethlehem, Ramallah and Hezbollah to work with local health care workers. The photo was taken from Palestine Children's Relief Fund.

It's becoming increasingly evident that the topic of global health has a lot to do with issues that don't fit neatly into the sphere of health as we know it. Lynn's video is a testament to that. As a pro-peace Muslim, it is interesting to see how, as the narrator puts it, Western Europe imported its religious strife and racism in the early 1900's to the otherwise neutral "Islamic world" that Muslims, Jews and Christians were cohabiting. Many people don't know that the Quran, the book of the Muslims, urges people of all scriptures to unite peacefully under monotheism. Instead, we're fighting world wars and oppressing each other (and the people behind it are actually portrayed as the most religious). And to make matters worse, vast inequalities mean that the rich always win.

When the political issues are so heavy, can we even talk about public health? This is one of the worst human rights issues in the last century. It seems like there is a lack of political will to do the right thing. And how do we define the right thing? I guess for one thing, it'd be to achieve an environment where kids grow up safe and healthy, in that order.

Micro-gardening...another creative food security option

2007-02-12T12:57:00.000-08:00

Landlessness is becoming an increasingly common problem in some rural areas, as governments take over subsistence farmers' land for large-scale development projects. Micro-agriculture is another potential answer for food-insecure communities with limited capacity to grow their own foods. Oxfam is teaching these techniques to inhabitants of the Sahel region. It's not a widely disseminated tool yet, but I think it could have exciting potential, especially in developmentally hopeless situations (e.g. Sudanese refugee camps, perhaps).

It's not about what you know..

2007-02-08T15:14:00.000-08:00

...it's about what you do with what you know. We are a highly privileged group of people. Obviously, we aren't completely homogenous, but as Dr. Shahi said the very fact that we're graduate students at USC says that we all have access to the same level of education at a specific kind of institution. It seems to me that historically, knowledge has always been revered--the recognition goes to the person who knows the most stuff. That's one of the reasons physicians command such respect (in some countries more than others). But nowadays, most of us have access to the internet, and there's not a tremendous difference between your knowing, say, all the letters of the Greek alphabet, and my looking them up in seconds using Google.

What our challenge will be is to figure out how to use all that information. Of course, we have to be knowledgeable; we can't use information without first being aware of its existence and content. But after that, the people who will do the most good, I think, are those that look for--or even just stumble on--the hidden ideas and solutions buried in all that data. Einstein's thought experiments and Muhammad Yunus' bottom-up approach, both brought to our attention by Dr. Shahi, are two great examples of people who changed the way we think by keeping their eyes and ears wide open to what others took for granted. Hopefully, we can learn from their approach and remember that the solutions are out there--we just have to tease them out and bring them to life.

Some of the world's greatest feats were accomplished by people not smart enough to know they were impossible. -Doug Larson

An Argument for CVD

2007-02-01T22:23:00.000-08:00

So in class this week we talked about chronic diseases. I know what you're thinking: why should gung-ho global development champions care about something like cardiovascular disease, the curse of privileged rich men?

Well, because 17 million people worldwide are dying from it. Sure, when you combine worldwide deaths from AIDS, TB, malaria, malnutrition and diarrhea, you get a figure comparable to 17 million. But in terms of a cost-benefit analysis, a single, multi-faceted intervention (with cultural adaptations) could be developed that would address the elevated number of deaths from this one condition. The same can't be said for HIV/AIDS, TB, malaria and other diseases--to combat that group of diseases, a diverse group of interventions are required to create a positive effect. Disseminating antiretrovirals at a cheap price works great for AIDS, but drug therapies are not going to work for malnutrition. Preventing diarrhea requires better sewage systems and cleaner water--another unique strategy. These interventions are indeed necessary and deserve the attention they receive. BUT, we're also facing a pretty compelling global burden of CVD, and I think that because it's a global problem and is shared by a demonstrably heterogenous mix of nations, it's possible to find a solution that is a)beneficial to most, and b)fairly cost-effective (concentrating solely on CVD could help prevent 17 million deaths, whereas concentrating just on HIV/AIDS would help prevent only 3 million). An obvious counter-argument is that treating diseases like diarrhea, malaria and AIDS would be oh-so-easy with primary and secondary preventive measures, whereas changing people's behaviors is more difficult. But those "easy" solutions are still not being executed, and it's largely because the same old barriers of funding, human resources, infrastructure etc. get in the way. Human behavior can be difficult to influence, but it can't be that difficult--people with monetary incentives (ie, the private sector) do it extremely well.

The point is, chronic disease matters too, and not just to the rich. The countries with the most rapid increases in chronic disease prevalence are, in fact, developing nations (most notably in Asia). And because those countries don't have the resources for preventive measures like screening, drug therapies and surgical procedures, they're dying younger from their conditions than their counterparts in developed nations. Women are taking a hit, too. Tobacco, sedentary jobs, and shifting dietary patterns are some of the culprits. Dr. Shahi urged us to think about what needs to be done in global health after the MDG's are accomplished. If we do end up reaching those targets, it looks like tackling chronic disease will be high on the new list of long-unfinished business.

The behemoth of an article that inspired this post (a very good one from the Earth Institute at Columbia University) is "A Race Against Time."

Check out these excellent videos on the chronic disease epidemic in the U.S., too:

Face to Face With Chronic Disease (WHO video)
Reversing Diabetes With Raw Foods in 30 Days
Community Educators in Oregon Help Prevent Chronic Disease

Power to the People

2007-01-30T10:38:00.000-08:00

Why do aid agencies assume they have to do it all? As we know from our readings on global health initiatives, local people and frontline providers of goods and services must be empowered to distribute any kind of development aid that gets dished out. It's the only way for that development to have any kind of lasting effect.

While researching for my paper I realized just how great a tool information technology would be for developing countries. Information is power. That Chinese baby I mentioned in my last blog? If her parents had the internet, they could have diagnosed her malnutrition themselves, before it was too late. And they would have, except for the fact that people like them, who have access to limited information and sub-par goods and services, don't even know that the internet exists. Many of these poorest of the poor don't even know that they are referred to, by some, as human rights violations.

The internet would be a wonderful tool for people in rural, developing areas to have. It would allow them to communicate suspected infectious disease outbreaks, request needed supplies to uphold quality of care, and put the power of information in the hands of those who have the greatest incentive to use it wisely and well. Access to information in areas where governing bodies are highly corrupted would also force centralized powers to be more transparent, more accountable, and more in-tune with the wants and needs of the people they're supposed to be serving.

At What Cost?

2007-01-28T22:16:00.000-08:00

One of the assigned articles in our class on public health challenges in China recounts the story of Rongrong, a newborn baby whose parents were among villagers sold fake milk powder to feed their infants in 2004. At least 200 infants were severely malnourished as a result of consuming this cheap powder, and village doctors, who aren't rigorously trained or regulated, failed to recognize the signs of malnutrition. Instead, they called it the "big head disease"--a classic indication of malnutrition. Rongrong died in a city hospital. Her parents are responsible not only for the cost of her care prior to her death, but also for the illnesses her mother now suffers.

According to China Daily, rural people are most susceptible to counterfeit food products, where there is very little regulation. Companies wanting to turn a profit have apparently found their target population in China's most precarious citizens. Not only that, what kind of physicians fail to diagnose severe malnutrition?

The original article, published in The Economist, can be found here.

Learn more about the unexpected, adverse outcomes of globalization on the "have-nots": The UN Development Project's report on "Inequality & Development"

Making the case for capitalism: John Norberg video

Compounding the issue: Another video on politics, wealth, and health

An Anthropologic Approach

2007-01-27T18:49:00.000-08:00

I really enjoyed the anthropologic approach to epidemiological transitions in the article assigned last week. The authors seemed to have done a comprehensive review of the current theoretical construct and then re-framed it entirely, just as Dr. Shahi is urging us to do for our topical review papers. The recurring patterns in human history are undeniable and informative--just as hunters and gatherers began to see a spike in infectious disease upon settling into communities, we will likely see new diseases emerge as the rising global population is forced into previously uninhabited areas. The article mentions a history of species jumps from other organisms to humans--as we all know, we're facing this possibility now with H5N1. Migration also has a history of importing disease from one population to another; Columbus may have brought back syphilis from the New World in 1493, and 5 centuries later, a significant percentage of MDR-TB cases are found among immigrants.

It's true that mother nature creates amazing bugs with very interesting properties. Yet, it's also true that we humans have a profound effect on mother nature--our behavior is altering entire ecosystems, which is shocking (e.g., the proliferation of vibrio cholerae due to increased algae blooms from global warming). Better than destroying the entire mosquito population, or pushing for new, stronger, better antibiotics, perhaps we should (also) look for solutions that will last. Whether human behavior changes or not, new bugs will emerge. But changing how we use antibiotics, how we treat the environment, how we live in communities and how we interact globally may determine how well those bugs thrive on us.

Empathetic Solutions

2007-01-24T08:00:00.000-08:00

I was reflecting on Dr. Shahi's urging us to approach global health with empathy, and one of the things that I didn't mention in my first post on the Mondana community in the rainforest is the roadblocks that FUNEDESIN, the founding organization, had to overcome to get children to come to the school. Parents are reluctant to send their children to school, not because they are against education, but for various reasons. Some families live deep inside the forest ("bien adentro") and it would take a good two hours to get to the school. Other families have so many children that they need the older ones to help care for the younger ones. They rely on their older children for help, and can't afford to lose that pair of hands for 8 hours each day. Still others have no way to pay for an education.

FUNEDESIN designed a successful school with full enrollment (and a waiting list to boot) by taking all these factors into consideration. Families don't pay tuition. Instead, they pay with corn, which the teachers actually eat. They are also given nutritious meals (there are much fewer fish in the Napo river due to oil company activity...plantains comprise a large portion of the diet). The school is set up as a boarding school; perhaps surprisingly, parents found this set-up more agreeable than day school. A group of 32 students comes to board at the Yachana School, and stays for two weeks at a time. Then those students go back to their homes to contribute to family life for the next two weeks, and the second group of 32 comes to school. The two groups rotate in two-week blocks.

Yachana students also get free medical care at the Mondana clinic. Their families are often seen waiting in line to get medical care, too. As I mentioned in my earlier post, the students are now eligible for grants to continue their studies in Quito. This opportunity means that a child from a rainforest community and a child born in the capital city might attain the same level of education (although of course there's a long way to go until that's really true).

One of the students I met there had traveled from a small, nearby city to attend Yachana. I wondered why his whole family would come all the way to this little community just for Yachana, when his hometown was more urban and thus probably had more opportunities. But I think that might be an indication that Yachana is providing for its students and its community something that is hard to find in human development efforts: an empathetic solution.

To learn about another empathetic solution for rural development in Bangladesh, watch this video on the Bangladesh Rural Advancement Committee (BRAC).

Learning From History

2007-01-21T11:20:00.000-08:00

In the article"Globalization and Health Viewed From 3 Parts of the World," the author states that international institutions (e.g., UN, WHO, IMF) must re-examine their partnerships to eliminate private interests and to protect international equality.

Is this even possible? If so, how do we achieve it?

The idea of a global health bureau is not new. In fact, the first recorded series of global health meetings was held in 1851 (those of us in PM 566, the China class, are familiar with this). These "International Sanitary Conferences" provided a platform to discuss best practices to control the spread of disease during trade activities. It sounds like a noble goal, but in fact the motivation for seeking global participation was that in an emerging era of international trade, such collaboration was necessary to protect local health interests. 19th century colonialism and imperialism also provided considerable incentive to create global health solutions--Africa, Asia and the Caribbean were seen as exciting European discoveries. So while the Sanitary Conferences symbolized global cooperation, they were at least partially driven by ulterior motives and hegemonic relationships. Sound familiar?

Information is one of the greatest tools for development we have these days, and in terms of global cooperation, transparency is key. Whether the goal is controlling infectious disease, maximizing economic growth, or protecting global security, it is now imperative that information is shared on a global scale. This has not been done, and its effects are perilous (SARS in China, US foreign policy, former Soviet Union's Biopreparat, etc.) and long-lasting. However, enough nations have now united in pursuit of the MDG's to make transparency and accountability in foreign policy matters a logical and necessary next step. Until we, as nations and as international organizations, take that step, personal interest will cloud the proper flow and use of capital toward achieving the MDG's and any significant human development.

Just for reference, the article we were assigned to read in PM 566 is entitled, "International Efforts to Control Infections Diseases, 1851 to the Present" (JAMA, 2004).

The Future is Old

2007-01-17T14:34:00.000-08:00

As developing countries catch up to the Western world in everything from technology to McDonald's to depression, I think one of the most interesting public health issues to discuss is that of the mounting aging population. According to the article posted under week 1, "Global Aging: The Challenge of Success", by 2050, approximately 80% of the expected population aged 65+ (1.2 of 1.5 billion) will reside in today's less developed regions. As global public health professionals, we must keep this in mind when allocating funds and implementing policies. As social entrepreneurs, we might also recognize an opportunity to create innovative solutions to the anticipated costs of the disease burden of the elderly in developing countries.

In the US, UK, and other European nations, the elderly population is indeed expected to grow, but the bulk of the growth is set to happen in countries like India and China. Other countries with large populations of old people (aged 65+) include the US, Japan, Germany and Russia. Ironically, Russia and Japan are also on the list of countries projected to experience the worst decline in total population—12 and 11 million, respectively. So it is the age structure of the population that is changing. This means that the number of productive people (defined as aged 20-64) in these countries is predicted to drop at an alarming rate, seriously affecting the GDP and creating new health challenges.

In places like India, China, Thailand, Colombia and sub-Saharan Africa, a different phenomenon is developing. With increased buying power, better education and more sophisticated technologies than ever before, these nations are experiencing a similar increase in longevity and a surge in the aging population. According to the article, for instance, Malaysia and Colombia are expected to triple their older populations between 2000 and 2030; sub-Saharan Africa should see an increase of nearly 50% between 2000 and 2015. However, these countries are not experiencing as sharp a decline in their working-age population; while many are seeing ever-decreasing fertility rates, the decrease is not yet reflected in the age structure of these populations to the extent that is seen in more developed countries.

The implications? Developing countries will have more human resources—defined here as sheer numbers of working-age people—than developed countries. Yet simultaneously, the disease burden of the elderly, who in any country consume a disproportionate amount of health resources, will be more of an issue in these less developed nations than in places like the US and Europe. As their economies flourish, and their middle classes expand, will they focus on health care for the elderly? Or will they prioritize instead the health of children and workers, who are the promise, the bread and butter of the nation?

If developing nations do not implement health care policies that care for the elderly, entire countries will suffer from the oversight. India is an example of a country that recognizes this, and responded in 1995 with the centrally funded National Old Age Pension Scheme. While this scheme is 100% government-subsidized, it must be noted that each country is different in terms of its culture, beliefs, resources, history, diversity, form of government and much more. What works in India will not work in nearby Malaysia. What works in an Arab country might be totally inefficient in South America. However, as the article stated, we as future professionals should be thinking in terms of 4 pillars of financial support for health care: public pension, occupational pension, personal savings, and “gradual retirement” of the elderly. Playing with these four forms of funding to find the right formula is and will be an exciting challenge in raising developing economies out of poverty so they can pursue health at each stage of life.

For more information, read "Global Aging: The Challenge of Success."

Thinking Past the MDG's

2007-01-14T20:33:00.000-08:00

With the impressive scope of the UN's Millenium Development Goals, it may seem premature to be thinking beyond these eight milestones of global improvement. But to make good on those goals, and to achieve the world vision they represent, that is precisely what needs to be done.

So what do we do after we reach the MDG's? It's 2015. 50% less people (than in 1990) live in hunger and survive on less than $1 a day. There's universal primary education available to every boy and girl in the world. Women are more empowered, mothers and babies are dying less frequently, HIV/malaria/TB infection rates are declining, governments are implementing environmentally sound policies, and the internet is now available to 30% of the world's population (up from 14%).

Have we achieved health for all?

Not yet. Because even if the above is accomplished by 2015--and the verdict is still out on whether it will be--what will those kids do with their primary education? How will women use their newly empowered social status to grow and improve? Will family planning be implemented in time to stave off the surge in population that may result from successfully battling HIV in countries like Africa and India? How will countries steeped in political/social/ethnic conflict be encouraged to collaborate for the wellbeing of their citizens? How will developed countries collaborate with developing countries? These may or may not be poignant issues in 2015, but exploring the path ahead is always useful.

Now, and in 2015, empowered women benefit from group micro-loans, whereby $300 can be invested in a community-based business that manufactures, say, peanut butter. These vendors must be given the freedom to sell their product wherever the demand is. Developing as well as developed countries must recognize the importance of free market economies and lift trade barriers--there are enough money and resources out there for anyone smart enough to figure out how to capture them. Once the MDG's are attained, and the globe is a little more flat (to borrow from Thomas Friedman), it will become increasingly true that this approach can benefit any individual or any country that adopts it.

Technical schools may be another area of focus in another ten years, when the poorest children of the world will (hopefully) be able to take primary education for granted. Literacy, math and geography are useful building blocks, but they are just that--stepping stones to learn professional or technical skills. Developing countries must have quality institutes of higher learning so that it makes sense for the new generation to continue their education in their own nations, and use their skills to build up their own people.

As people start dying less and living longer, efforts must also be made to eliminate urban sprawl and increase city planning. With the advent of the third epidemiological transition, wherein the human race is being revisited by old and new bugs, the disease burden may be doubled. One foreseeable way to limit the spread of infectious disease (apart from better sanitation, part of MDG #7) is through city planning and balancing the urban/suburban population proportions, particularly in places like China, India and Africa. MDG #7 cites improving the lives of at least 100 million slum-dwellers as an objective, yet it doesn't offer any strategies for doing it.

And what about global cooperation? That is, after all, one of the most crucial factors in closing the gap between rich and poor. Debt forgiveness, aid, new loans, incentives for innovation...the degree and quality of international participation will determine how far we can go in making health a resource that is truly available to every human being. Interestingly, it will also determine how important a player each developed nation will be in the world's future.

Sustainable Development

2007-01-13T13:11:00.000-08:00

Our intro class on emerging trends in global health reminded me of an interesting model for sustainable development I saw in the Ecuadorian rainforest in 2006. While I went there to learn about the practice of rural medicine, I was exposed to a promising business model that exploited the tourist industry to bring healthcare, education and buying power to a small region along the Napo River called Mondana.

Like Dr. Shahi said, 90% of healthcare is not accomplished by physicians. What was impressive about Mondana's set-up was not the high level of medical care available to the community. In fact, the clinic lacks any special equipment and must often refer patients to the nearest city, Tena. Many patients are unable to afford the cost of transportation (about $7 U.S.). What was impressive is the establishment of a boarding school that teaches rural children basic education as well as skills in making jewelry, giving tours of the rainforest, and running a hotel. These children get hands-on experience working at the Yachana Lodge as housekeepers, tour guides and boatmen. Proceeds of Yachana go to fund the school and keep the clinic running. The school is now an accredited establishment, and children are receiving grants to study in the capital city of Quito. A few of these kids will go on to acquire professional skills which they can use to improve the status of Mondana and nearby communities.

Along with Yachana, a gourmet chocolate company was established to supplement the lodge's income. Using slow-roasted cacao beans and other ingredients found in the rainforest, locals have created a unique chocolate product that I was very surprised to find in drugstores in Quito, and in fine health food stores here in the U.S. Like Yachana Lodge, the chocolate caters to the palate of developed countries, and that's how a rural rainforest community has (hopefully) begun its way up the ladder of sustainable development.