"To make money, we lose our health and then to restore our health we lose our money."

            I’m back! I’ve actually been home from Botswana for about two weeks, but I’m just now getting the chance to post a blog entry. This is going to be really short, but I just wanted to highlight a few things I learned about the U.S. while in Botswana. I don’t know who said the quote in the title, but I think it sums up something important I learned in Botswana: in the U.S., we seem to take our health for granted, when in reality it is the most valuable thing we have.

            Botswana had a very large Ministry of Health (MOH), and as a result, I think the entire country was pretty health-conscious. The mindset there seemed to be that prevention is the best option, and the next option is treatment. In the U.S., I think that culturally there is a norm to just assume that if you fall ill, the doctor will be able to fix it. Taking steps to improve health and prevent disease is often considered something that only “health nuts” do. However, the reality of the situation is that chronic disease, which includes heart disease, stroke, cancer, diabetes, and arthritis, is the leading cause of disability and death in the U.S. And the four most common causes of chronic disease are what the CDC describes as “modifiable health behavior”—lack of physical activity, poor nutrition, tobacco use, and excessive alcohol consumption (http://www.cdc.gov/chronicdisease/overview/index.htm). Making healthier choices could prevent or prolong the advent of chronic disease for many Americans.

            I think this is the area in which having a strong public health body could truly benefit the U.S. I’m not calling for universal healthcare or socialized healthcare (that’s an entirely different discussion). I just feel that the government sees health as something that pertains to individuals rather than populations, which is simply not the case. Public health is a unique sector of the medical community because it aims to improve the health outcomes of many individuals at once. Because, at the end of the day, we are not as unique as we think we are. The majority of us, and I’m certainly guilty of us, don’t always take care of ourselves as well as we should. And this creates a vicious cycle. Disease takes its toll on the body and the mind. How can someone with constant pain due to arthritis be productive at work? How can someone who is addicted to cigarettes focus when the only thing they can think about is their next smoke break?

            This is where public health, specifically the field of behavioral epidemiology, comes in. Behavioral Epidemiology focuses on public health issues that stem from the practice of certain behaviors. As I learned in Botswana, behavior change in a population is very difficult to accomplish. In the 1990s, when Botswana had the highest HIV prevalence in the world, the government began implementing education and prevention initiatives throughout the nation. Then, once anti-retroviral (ARV) medications became available, the government invested in those medications, providing them for free to all HIV-positive citizens. Although the introduction of ARVs did cause a significant decrease in Botswana’s HIV prevalence, the numbers have now hit a plateau. This is because, for the majority of the population, awareness about HIV has not translated into behavioral and lifestyle changes in sexual behavior. Botswana’s Ministry of Health is aggressively promoting behavior change through many initiatives.

            Behavior change is induced by the creation of persuasive health messages, which is the focus of many of my communication classes. When a message is effective, it disseminates information in a way that causes cognitive dissonance for the person receiving the message, forcing that person to reframe previous beliefs and ideas into a new paradigm that incorporates the message presented. In Botswana, I was able to see firsthand how the use of convincing health messages induced behavior change, especially among the youth, which is now the subgroup with the lowest rate of new HIV infections. I believe what I learned in Botswana can be directly applied at home. As a physician, I will have to promote behavioral change in order to improve the health of my patients, especially since chronic disease, is best dealt with by changing behaviors. However, my individual efforts are not enough. The U.S. needs to experience a cultural shift which puts health at the forefront of our lives. And, I think the U.S. government should be instrumental in creating that shift. The government should invest in public health because it is an investment that extends the life and enhances the productivity of the nation. Healthy people are simply able to do more and be more effective in their work.

            I think that ultimately, my experience in Botswana has taught me the importance of communication within the realm of public health. While learning effective ways to communicate with my patients is vital to my future career, I now recognize the importance of learning to communicate health information to the public in a way that will induce the behavior changes necessary to improve health at the macro level. As Paul Rusesabagina, the man who inspired the film Hotel Rwanda, states in his memoir, An Ordinary Man: “Words are the most effective weapons of death in man’s arsenal. But they can also be powerful tools of life. They may be the only ones.”

P.S. In the next few days, I’m going to be posting my journal entries from each day in Botswana, so you can read about what we did there, so keep checking for that! Happy April!

Can't Get Out From Under a Sky that is Falling

The title of this blog entry is a line from the song “Vegas” by Sara Bareilles (http://www.youtube.com/watch?v=HZBxCsuV2F0&feature=BF&list=QL&index=2). Although her song has nothing to do with alternative energy, I think the image of becoming trapped as the sky falls on top of you seems to fit perfectly with this week’s reading. The theme of the reading for this week was how Botswana is incorporating alternative energy use into governmental policy and development programs, and the effectiveness of those implementations.

As I read about these programs the strong influence of neo-colonialism struck me. Using funding from the UN, NGOs, and other foreign aid sources, Botswana (and Africa in general) has made great strides in introducing alternative energy technologies, particularly solar panels, or photovoltaic (PV) cells. However, as evidenced by HIV education, prevention, and training programs, these programs were executed based on Western models. The people of Botswana, their feelings on the subject, and their cultural views were not taken into account.

Cognizant of their own errors in environmental preservation, developed nations have descended on Africa, much like helicopter parents, in their intensive efforts to ensure that Africa doesn’t make those same errors throughout its development trajectory—largely disregarding the feelings and opinions of the African people. I find it very sad that the developed world is descending upon Africa to create a prototype of the distant future world in which alternative energy will be the norm.

As activists, scientists, and international officials descend upon Africa, they essentially paint an image of doom for African leaders—a world where they won’t be able to get out from under a sky that is falling. And so, African leaders attempt to make the best of a bad situation. This is especially the case in Botswana, where the government is pouring millions into sustainable development programs, with the hope that the country will become an international hub for the alternative energy industry.

And the idea makes sense. As African nations like Botswana enter the international market, they need to produce a good or provide a service that no one else does. Since diamonds aren’t actually forever—at least not in terms of Botswana’s booming diamond industry—the government needs to invest in an industry in which the nation will be able to be successfully compete. That’s the only way to ensure that Botswana’s economy remains viable and secure. And, the largely untapped area of alternative technology seems like a great industry where Botswana can build an international niche. This would provide a major advantage in the future, catapulting the country to a seat at the global “dinner table.” Unfortunately, right now, Botswana (and much of Africa) is perceived to be stuck at the “kiddie table” in terms of global contributions.

However, I really believe that Botswana’s approaching this entire venture in the wrong way. After all, Botswana has a resource that no one else has—the Bushmen. These are a group of people who have survived in the harsh dessert for eons. Surely, the survival methods they employed can be developed into useful alternative energy technologies. I can’t imagine a better way to utilize the expertise of the Bushmen, and ensure that their way of lives on as they transition into mainstream society. I know that the Bushmen are a very controversial issue in Botswana, and that there has been outrage from within and from outside the country with regards to how the Government allows them to live on the Central Kalahari Game Reserve, as though they are a tourist attraction. So, it’s entirely possible that I’m completely wrong about this, but I feel that environmental preservation may be an area where the entire world can learn from and benefit from the teachings of the Bushmen.

I understand a desire to make sure that the mistakes of Western development aren’t repeated in Africa, but in the process of doing so, the Western world is preventing Africa from developing independently. It makes me wonder: is doing what we perceive to be in Africa’s best interests, really in the best interests of the African people? After all, they say the road to hell is paved with good intentions. I don’t know if there is any actual opposition to alternative energy technologies in Botswana at present, but I do believe it is something that should be thoroughly explored.

Our study of HIV taught us that it is vital to include the people of a country and to account for culture when implementing programs such as this.  None of the articles from this week’s reading seem to talk about cultural influences on sustainable energy or about opinions the Tswana people have on the topic. I find this disturbing—based on the HIV campaign, we know that Western education mechanisms are not fully effective in non-Western societies. So, rather than going gung-ho into Botswana with the idea of turning it into a country operating on alternative and renewable energy, maybe we should pause and figure out how to get the Tswana people on board. This process will only work if the people there are committed to it.

After all, it’s a lot easier find your way to the top of Cloud Nine when the sky is falling.

P.S. Since music was part of the inspiration for this post, I think it's appropriate to end with a terrific song about environmental degradation. Originally written and performed by Joni Mitchell in the Seventies, I much prefer the version by the Counting Crows, featuring Vanessa Carlton: http://www.youtube.com/watch?v=tvtJPs8IDgU . I recommend scrolling through the pictures of Bushmen on Flickr as you listen: http://www.flickr.com/photos/deepblue66/5434645194/in/photostream/ .

Destruction = Growth

Over four years ago, I remember reading a short African myth in English class. I don’t remember which region of Africa the myth came from, and I don’t remember the details of the myth. All I remember is its moral: destruction is necessary. The myth exemplified that fact that destruction of the current system or current situation, allows effective change to occur. This idea isn’t unique to Africa, gods and goddesses of “destruction” are a part of Hindu, Gaelic, Greek, Egyptian, and Roman mythologies and religions. The idea of destruction spawning growth is an antithetical concept, and I have difficulty grasping it, but the basic idea is that in certain circumstances, the only way to create improvement is to get rid of the old and make room for the new.

                                                 

I remember my English teacher at the time used that analogy of a forest fire. Forest fires occur naturally (often due to lightning strikes) every few years, completely razing parts of the forest in its wake. Why does Mother Nature repeatedly cause this mass, violent destruction? It’s a regulation mechanism—keeping the forest from growing to a point that is out of control. It also promotes plant adaptations that resist fires, growth of new vegetation that provides the forest with more biodiversity, and clears dead wood. Of course, in today’s day and age, far too many forest fires result from mankind’s influence, and this excess of fire is damaging to the forest and the ecosystem.

This idea of the interplay between destruction and renewal seemed to be a theme of the reading this week. My class is now shifting gears in its study of Botswana, exploring the other focus of the trip—Sustainable Energy. So rather than reading about HIV/AIDS, this week we were asked to read about renewable energy, alternative energy, industry, and community gardens. I have to say my initial response to this was rather disimpassioned. Unlike the topic of HIV, it is difficult to relate to issues of environmental awareness and activism. I can imagine putting myself in the shoes of someone with HIV, but I can’t imagine putting myself in Mother Nature’s shoes.

But, as the reading continued, I realized that I needed to regroup. HIV is something that impacts very few people. Of course, it doesn’t just impact those who have the condition, but also their families, their communities, and their societies—and it has devastating ramifications. But, overall, it impacts only a fraction of the world population. In contrast, issues of environmental decay impact everyone. And, I literally mean everyone. Every single man, woman, and child that is alive right at this very instant, and probably even an entire generation that isn’t born yet.

What’s my point? Our resources are limited. We cannot live the way we are currently living forever. If we do, we will face dire consequences, which will result in death and travesty. Change is not only necessary, it is long overdue. And, the responsibility to channel change lies with each and every one of us. In essence, we have already started a raging forest fire, fueled by our wasteful habits and apathy towards Mother Nature, which is systematically and strategically destroying our planet so thoroughly that it will eventually be beyond repair. It is time for all of us to allow social, cultural, and national boundaries to blur, put on our firemen’s hat, and put out the fire. It’s time to rebuild, so that Mother Earth can burgeon and blossom anew. So that humanity can grow, becoming more inventive, more resourceful, and more mindful of the consequences of our actions. So that we still have a home.

P.S. I’m rather ambivalent to the House’s recent vote to cut federal funding for Planned Parenthood, in terms of my personal political views. However, I am interested to know how badly this would impact Detroit, knowing the city’s high incidence of HIV and given the fact that Planned Parenthood is one of the largest testing and education agencies around. I’d be really interested to know whether or not Detroit’s Planned Parenthood uses federal funding to finance its HIV prevention and testing programs, whether or not it will be able to survive without federal funding, and just how big of an impact a shutdown of the agency will have in Detroit. I know that there are broader issues involving the federal budget and abortion at play here, but learning all that I know now about the HIV epidemic in Detroit, I can’t help but wonder how this will play out at the local level. And the Senate hasn't voted yet, so this may end up becoming a moot point. I guess we’ll all just have to wait and see.

For more info, this is the least biased article I could find: http://www.nytimes.com/2011/02/18/us/politics/18parenthood.html?_r=1&scp=1&sq=planned%20parenthood&st=cse .

Ambiguous

This week, our reading focused on HIV/AIDS in America, with a cursory look at the epidemics in the Caribbean and Latin America. However, with the focus on the USA, I find myself wading through a lot of vague ideas and questions. Needless to say, this week I feel very confused and overwhelmed. I’m not sure what my role is as a student researcher, studying HIV/AIDS in Botswana and Detroit. And, I’m not even sure if I have the skills, the tools, and the ability to do that kind of research correctly—without negatively impacting the groups that I aim to help. I find that when it comes to HIV and AIDS there is simply too much ambiguity.

First of all, there are far too many labels. In Africa, the HIV epidemic is branded as one that is affecting heteronormative heterosexual people—although the truth of that can possibly be disputed. In contrast, in the USA, HIV is considered a disease of drug users and people of non-heteronormative sexuality. These people may self-identify themselves with any number of labels, including homosexual, gay, lesbian, bisexual, transgender men, transgender women, hermaphrodite, intersex, asexual, questioning, queer, butch queen, femme queen, drag queens, MSM, WSW, MSMW, WSWM, etc. None of these labels are very clearly defined, and there is considerable overlap between them. However, there are still subgroups within each label that are dependent on race. The experience of an African American lesbian is very different from the experience of an Asian lesbian. This further confounds these groupings, which are often considered fluid, changing depending on context. For the purposes of these blogs, I will refer to these various groups as alternative sexualities or non-heteronormative sexualities. I hope those terms don’t offend or marginalize anyone, I’m just trying to simplify things a bit.

The major problem I have with the ambiguity of all these labels is that I can’t put a face to any of these groups. How do I, as a student researcher, approach these groups when I have no knowledge or understanding of them? How do I prevent myself from oversimplifying their complex lives and the complex issues they face when I have no way of conceptualizing those lives or issues? The scholarly articles we read and discuss in class are not enough—I want to actually see and talk to some of these people or to researchers who interact with them so I have a better idea of what to expect and how to conduct myself.

I can’t even begin to imagine what it’s like to be an African American person, much less an African person. I’m not sure that I’ve ever met an adult who is a member of the LGBTQ community. How could I possible understand what it’s like to be someone who is both African American and a part of the LGBTQ community? Or Hispanic and part of the LGBTQ community? Or African or Asian or Native American? I wouldn’t even know how to begin. I can’t help but wonder if my attempts to analyze the current state of affairs regarding HIV and  my attempts to commentate on strategies being used to help these groups and identify ideas that need to be put into action, I am inadvertently passing judgment and engaging in the marginalization of these groups of people myself.

I’m pretty sure that everything I write (and everything I have written) in this blog entry will probably be stereotyped, colored by my own personal biases. I don’t intend to, but I am most likely going to oversimplify some very complex, multi-faceted issues. And I am probably going to make assumptions of similarity among certain groups of people, even though the views and lifestyles of the people in those groups are probably very varied. With that being said, here are my thoughts on marginalization, stigma, and politics, based on the reading for this week. Hopefully, I’m doing some justice to the experiences and the discrimination faced by those who are marginalized. If not, I’m truly sorry, but I suppose I won’t ever be able to completely understand where my thoughts have gone wrong.

In essence, marginalization occurs because the mainstream group can identify and label one group of people as the “other.” The “others” are usually isolated because they engage in what is seen as immoral behavior. It seems to me that marginalization and the attachment of stigma has happened to people with HIV/AIDS in American and in Africa, especially to drug users and to those who aren’t heteronormative. In America, race plays a strong role in marginalization, ultimately affecting funding. I feel that this has been extrapolated to a large extent to the entire continent of Africa, which has experienced marginalization to some extent by the international community.

In many cases, the entire African experience is considered to be identical across the board. People forget to account for the plethora of cultural, social, economic, and political differences across the continent. The HIV epidemic is considered a heterosexual one in Africa, even though it is clearly a problem among non-heteronormative sexualities. In order to get funding, the “outliers” or “others” in Africa have been marginalized—including non-heterosexuals, women, and drug users.

This is the same pattern of what has happened in America. While the White LGBTQ community is relatively well-funded, minority groups aren’t. And few people are paying attention to the unique risks faced by minority women. Many of the people affected by HIV are disenfranchised from mainstream society in the USA to the point that they no longer attempt to access any sort of healthcare. Sound familiar? This is very similar to people choosing alternative healers in Botswana over modern medicine when it comes to care for HIV. In the USA, certain groups are innately distrustful of government for fear or persecution, racism, and discrimination. Many Africans feel that HIV is a “white” or “Western” disease, and so they fear the advice of NGOs, modern healthcare, and sometimes even their own governments. African Americans and Africans have both made claims that HIV was designed by white people to kill them.

Ultimately, this marginalization has a strong affect on how these groups represent themselves to the mainstream group, particularly in the political sphere. The marginalized group seeks to present itself as having a singular experience and agenda, inducing secondary marginalization of those is subsets of that group that don’t identify with that experience or with that agenda. African American women whose life experience doesn’t mirror that of the quintessential African American man with little choice but to turn to crime for sustenance, or African American women who are considered to be engage in immoral behavior, such as teen pregnancy have no voice in African American politics. Those who are impoverished or uneducated may not have time, resources, or ability to wade through the paperwork to get services they need from Medicaid, Medicare, and the Ryan White Program. The culture of certain facets of LGBTQ community, such as Ballroom culture, is completely ignored, rather than being used as a way to prevent HIV transmission.

Similarly in Africa, the existence of non-heteronormative sexualities is completely ignored, and often criminalized. This is because Africa relies heavily on the Western world for funding, research, and infrastructure to reduce HIV incidence and transmission. If the African HIV epidemic is no longer a heterosexual epidemic, some of this funding, support, and research may be withdrawn. So, the experiences of Africans who have non-heteronormative sexualities, are sex workers, or are victims of sexual abuse are ignored. In fact, in many cases, these people aren’t even factored into the equation. How can research and services properly address the situation if entire groups of people are being ignored? How is that an effective use of funds?

Can all of these issues be any more confounded and ambiguous? What's the right course of action to take--help the majority or help the minority? Honestly, I don't know if doing what is for the "common good" is really for the common good.

I know this blog post has become very long-winded. And, I think my frustration with the cyclic, caustic process of marginalization has become evident. But, I’d like to end with a few things I discovered as a result of my new StumbleUpon account. I most definitely recommend that site to anyone who hasn’t used it—there’s some fantastic stuff. First of all, I wanted to share the 2010 World AIDS Day Video: http://www.avert.org/world-aids-day.htm . I think it does a great job of highlighting the need for universal access to HIV treatment. It also illustrates much of what I felt about the HIV epidemic before taking this class. Now, watching this video, I wonder, does it truly reflect the experiences and needs of all individuals living with HIV? Is it overstating certain aspects of the disease to appeal to a certain demographic—namely, Western heteronormative people concerned with global health? Is this video a vehicle of marginalization?

I’d also like to draw attention to inSpot: http://www.inspot.org/About/tabid/64/language/en-US/Default.aspx. This is a service that allows anyone to send a e-card or e-message to a sexual partner that they may have exposed to an STD. The message can be sent anonymously or not, and is accompanied by information and resources for that person, so that he or she can get tested and treated. While some of the e-cards on the site are insensitive and maybe even crass, and most of the e-cards seemed to be designed with the idea that they would be sent by a man to a woman, I think this site is a very interesting concept. Obviously, it has some major design flaws. And, it can only be used by people who regularly use the internet and social networking media, and have sexual partners that also do so regularly. But, if reworked, I think it could be an effective tool to help people inform partners of STD exposure, while eliminating stigma, discrimination, and marginalization in that that may stem in that interpersonal relationship from direct conversation. I definitely think it’s an option worth exploring.

A Lion Cannot Hear Its Own Roar

            The title showed up in a listing of common proverbs from Botswana from a Google search. I don’t know whether or not it is a real proverb in Botswana, or what it’s supposed to mean, but I think it communicates the theme of this entry effectively. Just as a lion can’t hear its own roar, people often have a tendency to get tunnel vision, and become so lost in their own thoughts—their own roaring, if you will—that they forget to consider perspectives different from their own.

            I think that this happened to me last week. When I was asked to read a bunch of literature stating that HIV/AIDS prevention and testing of patients should be referred to traditional healers, since mainstream medicine’s approach wasn’t effective in reducing the incidence rate, I dug my heels in and refused to accept that idea.

           To me, the use of scientific inquiry to answer questions about our health is fundamental. As a pre-med student, that is what I aspire to spend the rest of my life doing. So, I couldn’t fathom the idea of having this usurped by a practice that wasn’t based on evidence, but on something that is indiscernible and immeasurable. However, after I heard my classmates speak on the issue, I realized that I was overreacting. The idea of incorporating traditional practices of health care in the mainstream modern system may be vital to reducing the incidence rate of HIV in Botswana.

This is in large part because, even with the current advent of modern medicine, most people in Botswana turn to traditional healers first when they are ill. There is a wide mistrust of medical professionals, especially since all of them are foreign-educated because Botswana is just now building its first medical school (which we will get to visit while there!). So, it isn’t physicians who are the first line of defense and treatment for those with HIV—it is traditional healers. By incorporating these healers, whose opinions are widely respected and whose advice is followed, into the system of support for those with HIV, it will be possible to convince more people to get tested and to get treatment earlier. Furthermore, prevention techniques may be more readily employed by individuals who put more stock in the counsel of traditional healers than they do of government officials and physicians.

Last week, I was too busy hearing my own roaring to stop and hear what others had to say—and to recognize that they had valid points.

This week, the reading focused on the topic of identity, especially as it relates to gender and sexuality. There are two very important points that struck me from this reading: the HIV/AIDS epidemic in Botswana is not just a heterosexual phenomenon, and gender roles are deeply ingrained in the Tswana society, in a way that is difficult to comprehend as an outsider.

First, this week was the first time I’d heard anyone mention homosexuality in Africa. Researchers commonly use the term “Men who have Sex with Men” (MSM) for this group when discussing HIV transmission. However, it should be noted that HIV can be transmitted from one woman to another during sex. For my purposes, I am going to call it homosexuality, although it could be any number of labels. What resonated with me most about this reading is that while in America, HIV/AIDS is considered a disease that is basically a problem of the LGBT community (as horribly insensitive as that sounds). Yet, in Africa, and specifically in Botswana, there has been great reluctance to have it associated with anything other than heterosexuality. The MSM cohort is not at all accepted socially in Africa, and many of these men have to hide this aspect of their lifestyle from others for fear of discrimination, blackmail, or abuse. The same applies to women who sleep with other women.

In fact, this entire group of people is completely invisible. They aren’t publicly ridiculed or harassed for leading “unacceptable” lifestyles. They aren’t purposely ignored or ostracized. It seems to me no one is willing to admit that they exist. As a result, the African LGBT community essentially has no label—at least not a mainstream one. In fact, one African Man of the MSM group even stated that he belonged to a third gender. He did not consider himself a man, but he also didn’t consider himself a woman. He felt he was something else entirely. This is a very different conceptualization of self than can be seen in the West with regards to homosexuality. As such, I think this is another case of roaring too loudly. Until people in Africa recognize that they have an entire group of people that they are ignoring, they won’t be able to accomplish many of their goals with regards to HIV incidence.

Secondly, this week’s reading questioned my personal conceptualization of STDs. Personally, I have always felt that STDs, especially HIV, are conditions framed by choices—the choice to have unprotected sex, the choice to inform sexual partners about one’s HIV-positive status, and the choice to get tested and treated. At least in America, making smart choices can help you avoid HIV to a large extent. However, after reading many interviews and accounts of teens and young adults in Botswana, it is clear to me now, that choices aren’t always available there, especially not for women.

Based on these readings, it is clear that men in Botswana hold all the power. Whether it is during a school project or in a marriage, women defer to men in all aspects of life. There was one particularly powerful image where schoolchildren were asked to pose in a stance that conveys power. All the boys looked straight at the camera with their arms crossed over their chests or in a pose imitating Rodin’s Thinker. In stark contrast, all the girls posed with their heads down, and posture slightly hunched over. To them, a powerful woman was submissive.

In the context of sexual experiences, this submission means that women don’t always have the choice to ask a partner to use protection. Far too often, they don’t even have the choice to consent to sex at all. Furthermore, this power dynamic isn’t simply a psychological barrier for women. Young men firmly believe that they must have the power in relationships with women, especially those of a sexual nature, and that they can even use violence to get what they want if they feel it is warranted.

Personally, I think HIV/AIDS will continue to be a problem until the playing field is leveled. As long as women don’t have power over their lives, especially over their own bodies, they won’t be able to protect themselves. And, as long as men aren’t checked in any way, they won’t feel the need to use protection. I don’t mean to say that men are the problem here and that the oppressed women have all the answers. I just mean that until men are taught to respect women and respect their wishes, there won’t be any respect for the act of intercourse.

In essence, a lion cannot hear its own roar.

Is it me or is it you?

            For the first time this week, I’ll admit that I had some difficulty with the reading for this week, which focused on the idea that Botswana has not seen a drop in HIV incidence, in spite its aggressive ARV program, because education campaigns were too “Western” in their nature. My discussion of the reading will be very brief in this entry, simply because I feel that I haven’t completely grasped the concepts at hand as of yet. Hopefully, after the in-class discussion today, I will have a better understanding of the material. I plan to post another blog entry post-discussion. That should be a bit more insightful.

For now, I’m just going to summarize the a few issues presented in this week’s readings. Many scholars believe that these education campaigns, which were often in English, and were based on education campaigns in the U.S. and Europe, did not have the intended widespread effects, because these initiatives did not properly account for Botswana’s culture and value systems.

            Prior to the advent of modern medicine, for centuries the Tswana people have gone to “witch doctors” and other “healers” to cure their illnesses. These healers are still widely consulted today, and many are well-respected in their communities. One of the foundations of this alternative medicine is that all ills in one’s life can be traced back to a clear source in that person’s life—often the illness or suffering of the patient is considered to be a function of that individual mistreating someone else. For example, a healer may attribute an individual’s bad headaches to his or her jealousy of a colleague. Many scholars contend that the education campaigns put forth in Botswana, simply state that the cause for HIV is unknown, and this is problematic because it is culturally not sound. Another major contention by the scholars in the readings for this week is that topics about sex, such as condoms, are taboo in public forum in Botswana, and that HIV campaigns that bring such issues to the forefront are difficult for people to accept.

            While I understand how campaigns put forth in Setswana would be more effective than those in English, I am not sure what these scholars believe these campaigns should say. Of course every culture and every group has its own system for interpreting the suffering that befalls it, but I don’t understand how else a campaign for HIV awareness and education can be made.

            Perhaps, my personal bias as a pre-med student, and as someone who strongly values scientific inquiry is clouding my judgement here, but I feel that these scholarly articles are marginalizing the Tswana culture. In essence, it seems like these scholars don’t think the Tswana people can handle the cold, hard facts about HIV. As a future doctor, I believe it will be my responsibility to arm my patient’s with as much knowledge about their health as possible—even if I have to bring up topics that are uncomfortable or admit to the limitations of science. I simply don’t understand how laying down the facts is so problematic.

            Am I the one who’s marginalizing the Tswana culture by putting it to the side? Or is there more merit in the scholarly argument that the Western way of doing things isn’t always right than I am able to see?

Ignorance Isn’t Always Bliss, but Knowledge is Always Power

        

HIV/AIDS is an equal opportunity ailment. It crosses every boundary imaginable to afflict adversity on thousands upon thousands of people from all walks of life while continuing to confound doctors and researchers from around the globe. It is the mystery in medicine, like the one of the HIV/AIDS epidemic, that initially drew me to pursue a career in medicine. As a doctor, I hope to be able to develop the skills necessary to help others lead healthy lives and also to confront the medical maladies that cause so many to suffer.

I seek knowledge so that I will have the power to alleviate the pain of others to the greatest extent possible. My patients will come to me seeking knowledge about their health and how it can be improved. (I guess we’ll see how successful I am at actually convincing people to trust me with their health.)

From Unity Dow and Max Essex’s Saturday is for Funerals, it is clear that knowledge was key in giving the people of Botswana the tools to fight the AIDS epidemic there. Although the incidence and prevalence rates remain high, Botswana is one of the only nations providing anti-retroviral (ARV) medication to all citizens. Such a system ensures that those who are sick will get treatment. Although in certain cases treatment is complicated due to drug resistance, in general the ARV cocktail widely used in Botswana, called HAART is highly effective in prolonging the lives of patients with HIV, and a similar cocktail is also highly effective in combating the transmission of HIV from mother to infant.

The government program of providing ARV medications is accompanied by intensive education and counseling services, so that patients do not only get a second shot at life with an improved bill of health, but they can also understand what having HIV entails and what they must do to protect others from transmission. When just south of Botswana, in South Africa, many leaders, including President Mbeki, many denialists are spreading fallacies about how HIV does not exist and was made up in the West, it is especially remarkable that the government has responded in such a decisive and unified way. South Africa continues to have one of the highest HIV rates in the world, with low quality of treatment. Ignorance and bliss, diametrically opposed.

            This book is an eye-opening account of how Botswana went from a nation where in one year, Unity’s mother attended at least one funeral every week, in which AIDS was often hidden as the cause of the deceased’s death due to stigma, to a land where the epidemic is now spoken of much more openly and where friends and coworkers band together and convince each other to get tested and get treatment.

The bottom line: knowledge about the diesease will help everyone—not just those who are HIV-positive or have a loved one who is. Effective treatment, counseling, and education about prevention is vital to the economy. Instead of losing many of its young adults to HIV/AIDS, Botswana is able to keep those individuals in the workforce longer, reduce the number of orphans (who are unfortunately more fiscally demanding since their parents generally don’t leave much behind to help care for them), and reduce overall costs of healthcare and childcare, by providing ARV drugs. This also ends up creating a more egalitarian societyl.

In 2006, Michael Ganz, an Assistant Professor at the Harvard School of Public Health, released a study that showed society pays $3.2 million to care for an autistic person over his or her life, citing that this was partly due to the loss of productivity created by autistic people who are unable to hold jobs. The point of his study was that early intervention therapies for autism, which are proven to help autistic individuals function at higher cognitive levels as adults, should be instituted and covered by health insurance, which they are currently not. By doing so, Ganz’s work implies that the initial expenses of these therapies will be cost-effective because it will end up being an investment that pays off, allowing society to reap the benefits.

Obviously, autism and AIDS are two vastly different beasts. But, both are lifelong, and until a cure is available, they never go away. Succumbing to them, hurts everyone in the long run. But, knowledge about how to take early action to keep these conditions under control, and taking smart, well-planned action based on that knowledge helps everyone in the long run.

Many other nations struggling with the AIDS epidemic and with other such medical mysteries should perhaps study Botswana’s model. After all, it is following one of the most basic tenets of medicine, straight from the Hippocratic Oath: “First, do no harm.”