Just the Facts Jack

On the last day of the DTMH course the course director had a feedback session. Routinely and yearly he has discovered it necessary to determine if any particular area of the world has been offended by any of the presentations. Commonly those from Africa and the U.S. experience some difficulties for different reasons.
The DTMH is African-centric with no apologies on the basis of the scale of problems and the experience of the LSHTM faculty. During some of the presentations of the problems presented by HIV, tuberculosis, malaria and neglected diseases in an environment that suffers from poverty, the situation can seem overwhelming. My colleagues from Africa shared mixed feelings of sadness, shame and frustration during these presentations. Some expressed that the picture presented left a skewed impression with those not first-hand experienced with their countries.
My take home message was that a presentation of facts is never simply a presentation of facts. There are other messages delivered with one's choice of "facts", methods of presenting the "facts" and messenger of the "facts".
It generates within me a profound sense of caution as I begin the process of sharing the "facts" of my experiences along with my subjective impressions. Nevertheless the story is worth telling, thus this blog. But I have been thinking about the message delivered with the story and I want to be as intentional with that message as I am with the story. So I need a bit more time to think about what I want to say about my first trip to Mwanza and why I want to say it.

Perspectives

Apparently in Northern Nigeria, polio cases are still actively occurring. One of the reasons is that the polio vaccine is suspected of causing harm. Vaccination coverage otherwise is not out of the norm. Why is this? Kebir believes local politicians have benefitted politically by frightening the local population with fears the US is purposely tainting the vaccines to harm Islamic people. I wondered how the US could successfully be suspected of this degree of nastiness. This was not a unique example. A physician from Botswanna told us of his efforts in HIV education when local people held the condoms up in the sunlight and the visible streams of lubricant flowing down were perceived as worms the Americans had placed within. Where does the fault lie for these suspicions? Interestingly, Kebir tends to place responsibility on local, Nigerian politicians. I, on the otherhand, place responsibility on my country for its international activities in recent history. With this perspective I would be cannon fodder in a presidential debate. The truth is somewhere within my and Kebir's perspectives and would be better understood with many other perspectives. It frightens me for our leadership to refrain from international dialogue. There is limited understanding and a markedly diminished understanding of the truth when multiple perspectives are not solicited.

I have made an initial visit to Mwanza, Tanzania to meet with hospital leadership and Touch Foundation folks. I plan on sharing my initial impressions in a posting to follow.

Soapbox

Today was family planning day at the DTM course. Two speakers spent the morning making the case for the need for family planning in the developing world. No argument really. Yes, there is a need. One of the difficulties in speaking about the needs in poverty stricken areas of the world is not so much making the case that the need exists but how you go about making the case. Because the intent should extend beyond educating people to inspiring them to act on the presented need. Our speakers today failed. I have shared the success' of other speakers.
There is a role that individuals play in the creation of the current world situation. It is an art to communicate this role with the appropriate degree of discomfort and personal ownership absent strident blame-mongering. There needs to be some discomfort mixed with inspiration to alter behavior and encourage positive action. Once the data of inequality is presented is the truth of inequity understood? What do we do once we are convinced of the inequity? Hopefully we find little disagreement that we should strive for equity in the world.

Inspiration

August Stitch spoke to our class on Friday February 1st.
A German physician who has worked with Medecins San Frontieres(MSF), he described some of his experiences since graduating from the Diploma Course in Tropical Medicine(DTM).
He combined scientific expertise about schistosomiasis(a common tropical, water-born, parasitic disease afflicting primarily the rural poor in Africa, Asia and parts of South America) with a captivating story of his venture into the Khmer Rouge dominated area of Cambodia to establish a hospital. This followed a time he had spent working with a Trypanosomiasis(tse tse fly carried parasitic disease in Africa) project in central Africa. His multi-media presentation was well organized and masterfully presented. He shared his frustrations with big pharma as some of the few drugs for trypanasomiasis were discontinued from production in the early 2000s for financial reasons until one of the drugs was included in some cosmetic creams for facial hair reduction and deals were struck with these companies, the World Health Organization(WHO) and MSF. He admitted his mistakes in attempting to tackle HIV with the same tactics used in the schistosomiasis effort.
Friday was a day that met my lofty expectations of the DTM.
In medicine and in life, we are inspired by mentors(or heroes, though these individuals might object to this descriptor). Friday I was inspired.

The City

I like London. The humor, the tube, the diversity, the briskness, the futbol, the history, the squares..... My morning reading from Richard Rohr's Daily Meditations seems timely enough to share in its entirety.
"In America we don't have anything even close to Europe's great cities with fountains, cathedrals, promenades and parks. I know we've had two hundred years to work at it, but the point is, Americans don't dream of building a great city. The American dream is having one's own house. In America, we have moved from the Catholic consciousness of the community, of building the city of God, a great people, to taking care of our houses, protecting our neighborhoods, so that handicapped people and people of other skin colors don't move into it and kill property values. We have got to call this what it is: narcissism.
There's a world bigger than our families. The only way we can ultimately protect our family is to create and protect the entire human family."
Well said.
Once again to rail against narcissism on a blog is quite ironic. Nevertheless Father Rohr in a clear and concise way expresses a reason for us to think and feel globally.
And if you are so inclined and practical...
explore ready to use formulas(RTUF) to address malnutrition at validinternational.org and insecticide treated nets(ITN) to address malaria at theglobalfund.org/en/

Initial lessons

KB is my Nigerian housemate. He rents a room in Mrs Finch's house and attends the diploma course in tropical medicine with me. He is primarily interested in malaria because he directs a malaria control project in Nigeria. We have some discussion over breakfast and hit the road walking at 0800 to make our 0900 first class. The weather here is chilly and wet. He normally drives to work at home where he says the roads are hot and dusty. If he is walking, then a countryman will stop and say"Here doctor, please ride with me." We talk about the salaries of doctors in our countries and how much it costs to buy a car or send your children to college.

The day after I arrived, I bought an Oyster card for a month of unlimited travel on London's tube system. But once we'd settled in our routine, I had the card changed to "pay as you go" and placed 50 pounds on my card. About a week after we had been walking, I developed swelling and pain above my left ankle with crepitance(a squeaky feeling when I moved my foot up and down). Pitiful I know. The treatment is rest and anti-inflammatory medicine. I am taking the ibuprofen but I am continuing my 45 minute concrete surfaced, wet and chilly walks. Doesn't seem right somehow to use my oyster card though I'm sure KB wouldn't mind and probably insist I take the tube should I ask him. I doubt he'd allow me to purchase his tube ticket to accompany me though again I've not asked.

Sometimes it's about the "us" not the "me" or the "you". Tiny, trivial but tangible and a bit of a taste of things to come.

Questions

Questions generally begin with a what, why,how, when, where or who? Though I find "why" questions most intriguing and the answers multi-layered, the what questions are the starting point and require clear, concrete explanation. So to answer "What are you doing?"...

Until I complete exams on April 1st 2008, I am attending the diploma in tropical medicine course offered by the London School of Hygiene and Tropical Medicine. Class begins in the morning at 0900 after a brisk and sometimes wet 45 minute walk from north London to the All Souls Clubhouse classroom(temporary housing while construction occurs at the LSHTM). I walk with my housemate Kebir Ibrahim(KB) a Nigerian physician who works at home in a malaria control program. Class ends at 1700 followed by our walk home. To date the quiet evenings have entailed some reading and British TV watching in the room I rent from Mrs Finch.

Wednesdays are spent in discussion of cases or on rounds at London's Hospital of Tropical Medicine. Thursday afternoons are spent in the laboratory peering through microscopes at malaria infected blood smears or parasite cysts.

Perhaps more interesting is the question "What is tropical medicine?" Two professors have had a go at that question. Eldryd Parry co-author of Principles of Medicine in Africa and impressively experienced in the field, founding multiple African medical schools described it as a blend of poverty medicine and the medicine of climate. Tom Doherty, our course director, also emphasized poverty medicine and added that the patient population tended to be young, otherwise healthy people with reversible medical problems, often an infectious disease.

David Hilfiker MD author of Not All of Us are Saints describes his experience working with the poor of Washington DC and offers that his medical training did not specifically address poverty medicine. Though poverty medicine became his specialty as he worked with his homeless patients. He and my professors here emphasize that poverty medicine must consider more than the bio-medical problems. There are political, social and psychological considerations often under emphasized in traditional medical training.

I am fortunate to be learning from experts in the field teaching me poverty medicine.