Sustainability of Hope

“Hope” has been the word of the hour since Obama’s campaign adopted it
as a key concept in his concept. While generally in the aid world, we
tend to focus more on the tangible resources, I think that hope has a
great deal of influence on the allocation of funding and attention.
I’m beginning a project focused on large-scale HIV prevention efforts
around the world. With the advent of antiretroviral therapy, access
to treatment has become the rallying cry for the AIDS community. And
indeed, millions of HIV-positive people have received access to
treatment, and often very good, comprehensive services, through the
programs made possible through PEPFAR and Global Fund monies.
Nonetheless, without bringing down the incidence rate significantly,
in a sense all we’re doing in bailing water out of a sinking ship
without addresses the structural problems. That’s easy to say, but
prevention remains an elusive concept—it’s difficult to measure,
difficult to define, and difficult to see, sometimes. As a result,
some narrow interventions, including condom distribution and
counseling have received disproportionate amount of funding without
producing results, while broader-based interventions, such as poverty
reduction, promotion of women’s rights, and increased access to
education, which may not be proximate causes but undoubtedly relate to
vulnerability, struggle to find resources. I am always struck by
this, because I feel that those prevention activities are just another
form of bailing water. Attacking the fundamental causes will require
us to really understand the societal context and dynamics, implement
long-term programs, and be patient as population-level change doesn’t
occur overnight.
I’m sure as I delve into this project, I’ll have more informed
thoughts on these issues and want to share them. Actually, this week
my mind has been in an entirely different realm, that’s elucidated
these issues very clearly. For the past four years, I’ve worked with
Harvard’s Office of Sexual Assault Prevention and Response to educate
freshman women about sexual assault, risk reduction, and resources on
campus. All freshmen are required to attend a presentation that
attempts to use humor to talk about gender norms and how they relate
to sexual assault, and then participate in a one-hour facilitated
discussion. In those discussions, we always share the tragic
statistic that 20-25% of college women will be the victim of an
attempted or completed rape. This number is unbelieveably high—what
would people say if we classified these as hate crimes: the idea that
1 in every five women will suffer a hate crime during college for some
reason may sound much more compelling.
While I was familiar with that statistic, what I did not realize that
is the department of justice has been conducting this survey for over
20 years. And guess what—that statistic has, in their language,
“remained remarkably consistent”. In other words, nothing that has
been done in the past twenty years has improved women’s control of
their sexuality on campus. What has been done is create resources for
victims. At Harvard in particular, the response team, composed of
passionate individuals possessing huge amounts of compassion and
empathy (though not institutional resources), victims who come forward
for support can be expect to met with some of the highest quality
services available anywhere. But I have twenty years worth of data in
front of me now to say that in terms of prevention, we are failing
young women. And no one should be satisfied by simply knowing that
victims now have places to go, because most victims still don’t seek
out services and even though many victims are able lead happy,
productive lives, the road to that recovery is often laden with
disruption and pain. Why do we ignore this issue? Has it been
classified as “hopeless”? I would believe that changing the dynamics
of what goes on in the bedroom would be extremely difficult—in the
critical moments, individuals are making decisions independently and
with no one to exercise any sort of social pressure over them. Which
inherently means that one would have to fundamentally shift the
paradigm of sexual dynamics to reduce or eliminate the incidence of
sexual assault.
You can see the connections to HIV prevention—at the end of the day,
what fuels HIV transmission is inextricably linked to what causes
sexual assault. Perhaps an extreme example of this comes from Rwanda,
where during the genocide, Hutu men with HIV were often encouraged to
rape Tutsi women.
Does is make sense to think about HIV prevention in a separate silo
than sexual assault prevention? Or should it be framed in a positive
way—promotion of safe, healthy sexual practices? How we define the
problem will determine the modes of intervention, and no doubt we’ll
start with the areas where we think (i.e. hope) we’ll have the biggest
impact. I’m not disagreeing with this strategy in principal, but I do
think it’s dangerous to get so focused at piece of puzzle that we lose
sight of the full context. Let’s not let another twenty years pass us
by and have people remarking about how incredibly consistent HIV
and/or sexual assault rates have been.

Updating "us" and "them"

Great TED talk by Hans Rosling, whose work on www.gapminder.org has helped me conceptualize population health around the world in new ways. Here, he explains why the idea of "developed" and "developing" countries fails to capture the complexity of how the world is changing.

He also praises USAID for supporting (financially and technically) the collection of child mortality data internationally and making it available for free online. Without data, it'd be difficult to have any of these conversations or advocate for the expansion of programs that are working. So, while it often seems callous to focus on data collection in the context of people dying from poverty or lack of accessible resources, in the long run there is no substitute for data-informed decision making.

One sees this a bit right now with some of the efforts to promote the collection of patient-level data in HIV facilities in Africa in electronic medical records. Some of the clinics I visited on a recent trip were incredibly understaffed--in one clinic, a mere two NPs and 3 PAs saw 300 patients in an average day, from 9-1, covering all steps from registration including lab, pharmacy, and counseling services. It was difficult for me to justify internally the data requirements put on them by various stakeholders. And yet, when I look at what Dr. Rosling presents here, and think about whether we'll be able to do similar analysis on improvements in combatting HIV, I have to acknowledge that it will require data collection efforts like those being pushed on implementers now. Though, data quality would undoubtedly be higher if dedicated staff were supported. And quality of care data is collected about would undoubtedly be higher with greater clinical resources and support!

http://www.ted.com/talks/hans_rosling_at_state.html

What is the "real" Kenya?

Our time here is drawing to a close--tomorrow we head to Nairobi. On Thursday, Lusaka. Hopefully, on Friday,Victoria Falls! Last night we checked out prices for helicopter rides and ziplines!

After a packed week in Eldoret, on Friday, we went to Webuye, a smaller town about 1 hr away, to learn more about AMPATH's home-based counseling and testing program. For the past two years, AMPATH has been sweeping through the villages hidden on back roads, surrounded by fields and fields of maize, doing rapid diagnosistic tests in people's houses. Some of the technology they use is also pretty cool--the counselor uses a GPS to mark the exact location of the house and conducts a household survey using a PDA. The house that I visited was occupied by a young couple--the wife and her daughter were at home, the husband away as he works in a village nearby. We ask about HIV and she says that they go to the clinic together to get tested every 3 months. I honestly can't fathom that as a routine part of a relationship, but if everyone did there here, it could prevent a lot of HIV. Meanwhile, my colleague accompanied a counselor to a house next door, where a man, his wife, and their 10+ kids had heard of HIV but did not know how one contracted it. They were extremely nervous as the counselor ran the tests for them in their sitting room. Luckily, everyone was negative. The counselors were amazing adept as combining compassion with education with professionalism; they worked in messages about mosquito nets, prevention of mother to child transmission of HIV, and de-worming into their conversation. It was a real eye opener for me--the first time I've been in such a rural place in Africa. We saw guys bringing home-brewed liquor by on a bicycle, ate guava straight off the tree, and came face to face with seriously malnourished children--guava and boiled maize are not enough to live (and thrive) on. Made me wonder how long we can continue to treat HIV with the exceptionalism it receives when hunger, lack of access to family planning, and a host of other issues that stem from poverty continue to ravage the same populations that we fight so hard to protect from HIV.

We headed out to Kisumu for the weekend. Kisumu is Kenya's third largest city--it sits on Lake Victoria and has a much larger city feel (i.e. it has sidewalks and similar luxuries). After throwing our stuff in a bare-bones motel, we walked down to the waterfront to a number of shacks on the beach. They escort you to the back, where you choose the fish you want for lunch--all tlapia, varying sizes (and most likely freshness, but I'm not that much of a fish connesseiur). They steamed it, covered it with stewed tomatoes and onions, and brought it out with sides of collard greens, chapati, and ugali. We washed it down with a Tusker beer and watched the boats out on the lake. Just a day after I decided that global health was too focused on HIV, here I was in a restaurant, observing the vast sea of street children that wander Kisumu, sniffing glue and begging. While Kenya's HIV rate is around 8%, Kisumu's is closer to 15%. The children are often high when they tug at your arm, and hang out around these fish shacks with plastic bags to collect the uneaten food left by customers. While it's heartbreaking to watch now, trying to predict the consequences of what will happen to Kenya (and the world) as these children turn into adults is difficult, but speaks for the need to take the long-term consequences of present (in)actions. But what to do? These problems require the complex, long-term solutions that are difficult to implement and sustain, and its an area no doubt riddled by good intentions and disappointing outcomes.

Not to paint a negative picture of Kisumu! We walked around the city, spending a good portion of the afternoon sitting on the second floor of a bar in the middle of the park, watching a local soccer game and enjoying the breeze off the lake. Saturday night we went to a place playing local music, where we mingled with the locals. The band played Ohangla music--which has a nice, laidback rhythym and fun guitar melodies.

The drive back may have been my favorite part. For the most part, the road is good, though the 90km trip takes about 3 hours in total. We unfortunately were hit by a violent rain storm, and found ourselves crawling along to avoid the numerous potholes (almost more potholes than remaining road), as the dirt side road that has been formed by the numerous cars that prefer dirt to the uneven asphalt had become sticky, treacherous mud (not that it stopped the matatus, the van-like buses, from flying along through them). The silver lining was that the many stops meant that there were many photo opportunities for me, squished in the back of the van on the left side. The landscape was amazing. The hills were so green--many covered with tea plantations. The flatter ground that directly surrounded us was drier--the rain was sorely needed by the maize and sugar cane. The mist and rain only made the greens seem deeper and added a semi-mystical-like quality to the whole countryside. It was not what I would say was typically "African" by western standards, but beautiful and indicative of how not "resource-limited" Kenya is in many ways. My favorite part, of course, was how, out here, when we saw so few people and so few signs of any human habitation other than the huts and small tin-roofed houses that peppered the hills, suddenly we'd come across a pack of lean and fast runners, dressed like they'd just stepped out of a nike commerical, taking the rocky road in stride and climbing the hills as if they weren't there! Best image of the essence of a runner that I can imagine.

As always, I'm honored by how willing the people here have been to let us step into their world, despite our superificial understandings of so many things and as always, regrettably ephemeral presence (at least from my perspective). We've heard first-hand accounts from those who lived through the post-election violence last year, heard former street kids talk about their childhoods, and met many who are HIV positive (including the 4th patient AMPATH started on ART) or who have lost friends and family to the disease. I can only hope that the experience helps open my eyes to the full scope of the world's problems, gives me the courage, humility, and hope to help take over at least some small portion of it. I'm inspired greatly by what I see here, though at times it feels like it's a drop in one very big bucket.

So on that note, I will end. I'm off to Mosoriot today to see the transition of one AMPATH site from just HIV care to primary care (for all). Good stuff.

Releasing the inner kenyan

I feel a little bit like Carmen Sandiego these days--have the sunglasses, just need that red jacket. Greetings from Eldoret, Kenya, which, as the sign on the highway says as you enter, is home to "#1 runners in the world"! Funny thing about Eldoret, Kenya, it's like 9,000 ft above sea level! I didn't quite realize what that would mean until I tried to go running, and found myself gasping like a fish out of water after five minutes and one little hill. I even was thinking about quitting halfway (sometimes loops are a poor choice!), until this teenage guy in nice clothes--leather shoes, jacket, etc.--walking along sees me coming up beside him and decides to run the last two miles with me. I push through the side stitch, struggling not to gasp too loudly for air lest he get worried, and run the last 2 miles. We finish--he is of course not out of breath and barely sweating--we shake hands, and we go our separate ways. Not a run I'll forget soon. Beautiful landscape too--fields of corn and something that I vaguely recognize, milo perhaps--dirt roads, cows and sheep grazing. Semi-hilarious signs (totally unintentional I'm sure). Hard to beat.

I'm studying AMPATH--a medical partnership between Moi Teaching Hospital and Indiana University. If you can imagine a place where a midwestern accent seems totally out of place, this is it! And yet, the program is amazing. They were one of the first to treat HIV in Kenya and have grown into one of the largest providers in the country. Recently they started a home-based counseling and testing program, and I'm going out with a social worker next week to learn more about the community presence. They are also transitioning to primary care--so will start serving the entire catchment area, not just those with HIV. They've built income generating program, provided leadership opportunities for very talented Kenyans, and brought a lot of resources to the area. Not to mention, built a heck of an electronic medical record that they use for just about everything imaginable!!

Not a bad life here. Living in the IU dorms--get up for a breakfast of toast with Nutella every morning; have a nice cup of chai at the hospital mid-morning. If I'm lucky I can get into town for lunch or dinner--they make some mean grilled goat and beef here that one eats with ugali, a sort of white polenta-esque food that you mush into the shape of a spoon and use to scoop up the meat. Mmmmmm. Just finished up a game of soccer--again, the Kenyans that played with us smoked us completely in terms of speed and style. Karaoke is on Tuesday night; I'm very excited to see how this goes down. Given the amount of singing that I've seen on the dance floor the past two nights (my favorite so far was a club full of Kenyans singing Thriller!), I need to do a bit of practicing in front of mirror in the next two days!

The time is going quickly--hard to believe how much has happened in the last two weeks. I've yet to see a McDonald's/KFC/Starbucks/etc, so I'm kind of forgetting my cultural roots. If it weren't for the Obama quotes and pictures everywhere, I would have no grounding. Last tidbit: when obama became senator, a beer came out called Senator. Guess what it's called now :)

Mmmbop, Mbarara

I'm writing from Mbarara, Uganda. I've found probably the only wireless internet point in the whole town--even here the internet still only creeps along. Or shall I say, at the risk of some response from my African friends, it runs on African time!

I'm on a journey to look at electronic medical records across Africa--specifically, OpenMRS, an open-source system developed by Partners in Health and AMPATH--a huge HIV program in Kenya that involves Indiana University and Moi Teaching Hospital. Health Information Technology is all the rage right now--but we've found so far that there's little data to support or refute the claims around how it improves care and efficiency in the developing world. So, that's the mission: bring some light to those issues. And hopefully, from my standpoint, bring a richer perspective to some of the key players in this field (including the large donors) around the potential for high impact investments and how to improve current funding and implementation models. And finally and most importantly, have an amazing time in the process.

We landed in Kampala on Sunday night and were shuttled to a guest house at Makerere University--essentially a house filled with beds occupied by American medical students. The next day, I visited to Mulago Hospital, which is the national referral hospital. The number of people waiting for care in this type of facility never fails to move me. Here, there are very few nurses, one person ballparked 1 nurse per 40 patients, so family members often have to perform many of the duties normally done by nurses. So they sleep outside the wards on the floors when they get kicked out of the patients' rooms at night. I had a chance to talk to a few physicians--all of whom do an amazing amount of work in extremely challenging conditions--and hope that they are able to find the support to pursue some of their very innovative ideas for how to improve Uganda's health system. I got a wish list from one doc for what he'd do with $100 million--if you all know anyone trying to figure out what to do with that kind of cash :) Top of the list was hire residents--here most medical officers (who have just done medical school) have to pay for residency.

We took to bus to Mbarara on Wednesday. The bus park was its own adventure--you tell one of the guys on the perimeter where you want to go, and then they grab you and help you run through the crowd so that you can catch the bus that's about to leave. Then you sit there on the immobile bus for a good 90 minutes while people try to sell you everything from "fresh" yogurt, watches, bibles, etch and sketch. you name it--I did most of my Xmas shopping. The bus ride itself was interesting--it's crammed full of sweaty people--and passes along a semi-paved road past miles (km, more precisely) of banana plantations, billboards, and small villages. We even saw a few impala.

Mbarara is small--maybe 40,000. It's very safe as long as you keep an eye on traffic (it comes from the left, and there are no sidewalks). People are very friendly--if you can think of ways to get out of having someone buy you a beer, please let me know (I usually have half a glass when they ask, so can't involve an excuse that includes full absention). AMAZING pineapple (50 cents for a whole one!) and bananas (75 cents for a full bunch) for breakfast, and avocado at lunch every day. I could REALLY get used to this. The shower on the other hand--sort of a "no pressure" situation. Even tepid water would be improvement. I can see why women have their hair in braids--I may have to more that way! I love the folks working at our hotel--it's a nice place--and I'm growing fond of the goats that seem to use the hotel grounds as a grazing area--I saw them chasing a cat away this morning and that just sealed it!

Took a break from the clinic this morning to go see a local elementary school play that a friend of a friend directed (I've literally met a dozen people from Boston here--so weird how small the world is). It was peter pan, with a michael jackson theme. Amazing acting, but one of the weirder things I've ever seen. Thriller Ugandan style?

Off to Lake MBuro for the weekend--minor game park near the town. This is just the beginning--the voyage continues through the end of August!

Off to forage for more bubble tea!

We made it into China without any issue--I even got to see Confessions of a shopaholic and He's just not that into you on the plane. Thought I was going to kill myself for a few hours there.

Had some fun finding our hotel. Evidently two streets in shanghai translate into the same pinyin (western characters) so we wandered for like two hours only to be on the wrong Shanxi St. Luckily with my Chinese phrasebook, and happening upon someone who spoke english, we were able to get directions to the right one. Had a great dinner of xiao long bao, a shanghainese special dumpling filled with pork and soup. we also took a ritzy train up and down one of the main shopping streets, just because we could.

Met up with one of my bro's friends today and walked through the french concession and old Shanghai. The bund, the famous walkway on the water, is closed as they are renovating for the world expo in 2010, so unfortunately we won't get to that this trip. the city has changed a lot since 2006 when I was here last, a lot more European/American fashion, western banks have moved in, young couples are more amorous in public, and contrary to the etiquette book I read before coming, people do in fact wear flip flops these days. Some things remain amusingly different--I ordered veggie soup at lunch, which evidently had meat and duck blood, which they had neglected to mention in the description. Duck blood has a similar consistency to jello, if you ever wondered. I would take it any day over the fried whole birds, snails, and innards that we saw while walking around the market.

It's a lot of fun being back though harder without the Chinese speakers that I relied on last time. more room for adventure, I guess?

Off to forage for more bubble tea!

Note from Travis: Mangoritas on Cloud 9
We just saw the Orient Pearl Tower light up and enjoyed the view of the skyline and river (and the pollution-fog haze).

The view is even better than the underwater sightseeing tour in the Bund tunnel that took us through "Paradise and Hell" and a "Meteoral Shower".