One of the best little health books ever published

Few books stay with me for long. I read them and give them away. One has stayed on my bookshelf, now for 26 years. That book is Dr. Stephen Bezruchka’s The Pocket Doctor. First published in 1982 by the Mountaineers, this pocket-size reference, now being published at a bit more than 100 pages, is exactly what its title implies. It is a guide to help a traveler cope with illnesses many people in the developing world face daily. You can buy it online from many vendors, like Powell’s Books.

The Pocket Doctor Cover
Cover of the second edition, 1988 version of Dr. Stephen Bezruchka’s The Pocket Doctor (personal copy).

I credit this book for saving my bacon and mental health on several best-forgotten nights. It helped me cope with medical problems that are normal for hundreds of millions of residents globally, and for me something I did not experience back in the comfort of the United States. But I am not the only writer and traveler who praises Bezruchka and his book.

Why many trust Bezruchka’s work

Bezruchka is a Canadian-born former emergency-room doctor trained at some of the nation’s best universities (Standford, Harvard, Johns Hopkins). He has both an MD and MPH. He has worked with medical specialists in the developing world, notably Nepal for 10 years. He also has written a great guide called Trekking in Nepal, which I used back in 1989. Today he is a lecturer on global health at the University of Washington School of Public Health (UW SPH) and a nationally recognized advocate for health care reform to improve public health outcomes and to eliminate health and income inequality.

I have taken this book with me now to three continents: Asia, Africa, and South America. I just cannot say goodbye to it, even when my developing-nation jaunts seem fewer and fewer.

The advice it provides has helped me to self-diagnose all manners of common gastrointestinal disturbances, such as food poisoning (nasty and scary in a crappy place), dysentery, and common diarrhea. I also used it to help me obtain the necessary medicine for what I still believe was malaria, which I had in Kigali, Rwanda in 1997.

With this book in my hand, I felt I could handle the predicaments that afflict visitors from developed countries to less-developed areas. In my 1988 published version, 13 pages are devoted to common drugs and medicines that address typical maladies, such as the  antibiotic ciprofloxacin, to tackle infections, with information laid out in a table on a drug’s use, likely place of need (city, remote, “third world”), form, and dosage.

Basic health care advice can be fun with good writing

Bezruchka’s writing is straightforward and direct. In his chapter on drugs, he begins his recommendation with a simple message: “Remember that drugs, though valuable, are not a cure all.” He provides advice on assembling a medical kit, working with doctors at home and abroad, and dealing with major sources of health problems—namely, food and water.

Bezruchka also highlights a major global health issue that is more severe than microbial agents, trauma from vehicle accidents. “Trauma, especially that caused by motor vehicle accidents results in the majority of disability acquired in developed countries,” writes Bezruchka. “This is even more true in third world countries. Trauma causes more disabilities to travelers in foreign countries than all the exotic diseases put together.” That observation remains true to this day, as shown in global health data.

Photo courtesy of the University of Washingston School of Public Health faculty photo.
Faculty photo of Dr. Stephen Bezruchka, courtesy of the University of Washingston School of Public Health web site.

But there is much more. Rabies? Check. Animal attacks? Covered. Ticks and leeches, fever, rashes? All addressed. The two-page section, in my old and battered version, on dealing with stress in less-developed nations is a classic summary of what many first-world travellers experience.

“If the culture shock of a third-world setting with its attendant poverty and hopelessness have you in despair, take steps to improve your psyche,” writes Bezruchka. “Seek out help, another traveler, or a religious organization or individuals.”

Bezruchka even has sections on death and how to cope with returning from travels with an illness. I definitely experienced lingering issues when I came back and took this advice to heart.

Meeting Bezruchka later in life

When I first met Bezruchka in person during my studies at the UW SPH, I mentioned how much I enjoyed his book and used it frequently in Nepal. I even mentioned how enterprising Nepalis had published black-market copies of his book they were peddling on the streets in Kathmandu. As I recall, he considered that a compliment to the value of his work.

Sometimes small and perfectly executed creations are ones that have the most impact. In Bezruchka’s case, there is far too much to choose from to say what is best—from published papers to advocacy to mentorship of future health leaders. I will submit this still fine tome as work that stands the test of time and proves that small is often better.

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Public health’s evolving role promoting U.S. military interests

The seal of the U.S. Department of Defense, representing seven branches of the U.S. military.
The seal of the U.S. Department of Defense, representing seven branches of the U.S. military.

The U.S. Department of Defense (DoD) remains one of the most sophisticated media production machines on the planet. Its ubiquitous advertising filters into every aspect of our lives, from public schools to product placement in the lucrative gaming industry to traditional online ads.

In 2007 alone, according to a Rand Corp. study, the total recruiting budget for the Army, Navy, Air Force, and Marine Corps exceeded $3.2 billion. Rand Corp. analysts also deemed those investments as successful as measured by recruitment, even during two ongoing wars in Afghanistan and Iraq.

Events with military personnel always feature sophisticated press and social media coverage. One of the more nuanced and I think effective messages I have seen from the DoD is how the military is not just about defense, but about a more deeply and morally resonant “good.” The U.S. Navy’s very slick videos call the branch a “a global force for good,” and show Navy SEALs in action carrying that message.

This clip from a U.S. Navy recruiting video shows a successful branding effort by the U.S. Department of Defense to promote its global activities as a moral good, including special ops efforts by U.S. special forces
This clip from a U.S. Navy recruiting video shows a successful branding effort by the U.S. Department of Defense to promote its global activities as a moral good, including special ops efforts by U.S. special forces.

Helping to prop up that messaging is the country’s long-standing integration of public health services into the DoD and overall military readiness. The military is successfully integrating public health activities, and it is branding these as part of its global efforts, including on the new battlefield in Africa.

Through contracting opportunities that support these efforts, many U.S. based firms who specialize in development and traditional public health activities are actively supporting these initiatives, in order to monetize their own business models.

Chasing contracts serving two masters: public health and defense

I recently stumbled on a job posted on the American Public Health Association (APHA) LinkedIn page by a company called the QED Group, LLC. The position was similar to ones I see posted on their job site now, for work on a “monitoring and evaluation” project in Africa.

This is one of many government-contracting agencies that chase hundreds of millions of contracts with U.S. government agencies and the major public health funders like the Bill and Melinda Gates Foundation.

In this case, the company was specifically targeting those in the public health community, who are entering the field or currently have positions with backgrounds in public health, economics, science, and health. The 15-year-old company itself actually began as a so-called 8(a) contractor, which means it could win no-bid and lucrative government contracts that are now the center of an ongoing and intense controversy over government waste. (These companies were created by the late Alaska Sen. Ted Stevens, who created the provision to steer billions in government contracting to Alaska Native owned firms that partner with companies like Halliburton and the Blackwater overseas and in the United States.)

QED Project in NorthAfrica
The company QED Group showcases its recent work evaluating anti-terrorism-related efforts in North Africa.

Today, QED Group, LLC claims “it is full-service international consulting firm committed to solving complex global challenges through innovative solutions” by providing clients “with best-value services so they increase their efficiency, learning capacity, and accountability to the public in an ever more complex and interconnected world.” It lists standard international development and public health contract areas of health, economic growth, and democracy and governance.

QED Group is not the only multi-purpose public health and development agency chasing military and global health contracts in Africa.  Another health contracting company called PPD boasts of its “long history of supporting the National Institutes of Health, the nation’s foremost medical research agency,” and that it was “awarded a large contract by the U.S. Army.” It claims its is also a “preferred provider to a consortium of 14 global health Product Development Partners (PDPs), funded in part by the Bill & Melinda Gates Foundation.”

As a public health professional, QED Group looks like a great company to join. However, if one scratches deeper, one learns that this company also uses its public health competencies with the U.S. military, which is spearheaded in Africa by U.S. Africa Command, or AFRICOM.  This raises larger questions of the conflicting ethics of both promoting human health and public health and also serving the U.S. Department of Defense, whose primary mission is to “deter war and to protect the security of our country.”

AFRICOM’s emerging role flexing U.S. power in Africa

AFRICOM’s demonstration of “hard power” is well-documented through its use of lethal firepower in Africa. AFRICOM is reportedly building a drone base in Niger and is expanding an already busy airfield at a Horn of Africa base in the tiny coastal nation of Djibouti. On Oct. 29, 2013, a U.S. drone strike took out an explosives expert with the al-Qaida-linked al-Shabaab terrorist group in Somalia, which had led a deadly assault at a Kenyan shopping center earlier that month.

One blog critical of the United States’ foreign policy, Law in Action, reports that the AFRICOM is involved in the A to Z of Africa.  “They’re involved in Algeria and Angola, Benin and Botswana, Burkina Faso and Burundi, Cameroon and the Cape Verde Islands. And that’s just the ABCs of the situation. Skip to the end of the alphabet and the story remains the same: Senegal and the Seychelles, Togo and Tunisia, Uganda and Zambia. From north to south, east to west, the Horn of Africa to the Sahel, the heart of the continent to the islands off its coasts, the U.S. military is at work.”

U.S. efforts in Africa require health, public health, and development experts. As it turns out the company, QED Group,  won a USAID contract examining U.S. efforts promoting “counter-extremism” programs in the Sahel. That study evaluated work using AFRICOM-commissioned surveys, all designed to promote U.S. national security interests in the unstable area.

The area is deeply divided between Christians and Moslems. It is also home to one of the largest al-Qaida based insurgencies known as al-Qaida in the Islamic Maghreb, which has similar violent aspirations as the ultra-violent Boko Haram Islamic militant movement of violence-wracked northern Nigeria. Al-Qaida in the Islamic Maghreb military seized control of Northern Mali in 2012, which ended when U.S.-supported French military forces invaded the country and routed the Islamic extremists in January 2013.

Public health’s historic role with U.S. defense and national security

“Hard power” and “soft power” are tightly intertwined in U.S. overseas efforts, where health and public health personnel support U.S. interests. This is true in Afghanistan and is certainly true in North Africa. This particular QED-led program used the traditional public health method of a program evaluation of an antiterrorism program to see if a USAID program was changing views in Mali, Niger and Chad—all extremely poor countries that are at the heart of a larger struggle between Islamists and the West.

That research methods used in public health–and which I have used to focus on health equity issues in Seattle–can be used equally well by U.S. development agencies to advance a national security agenda is not itself surprising.

However, faculty certainly did not make that case where I studied public health (the University of Washington School of Public Health). I think courses should be offered on public health’s role in national defense and international security activities, because it is nearly inevitable public health work will overlap with some form of security interests for many public health professionals, whether they want to accept this or not.

U.S. Public Health Service Corps members proudly serve their country and wear its uniforms.
U.S. Public Health Service Commissioned Corps members proudly serve their country and wear its uniforms. This photo published on the corps’ web site demonstrates that pride.

Public health in the United States began as a part of the U.S. armed services, as far back as the late 1700s. It was formalized with the military title of U.S. Surgeon General in 1870. To this day those who enter the U.S. Public Health Service Commissioned Corps wear military uniforms and hold military ranks.

A good friend of mine who spent two decades in the Indian Health Service, one of seven branches in the corps, retired a colonel, or “full bird.” He always experienced bemusement when much larger and far tougher service personnel had to salute him when he showed his ID as he entered Alaska’s Joint Base Elmendorf Fort Richardson looking often like a fashion-challenged bum in his minivan (he frequently had to see patients on base, and was doing his job well).

The U.S. Public Health Corps' web site shows the different uniforms worn by their members.
The U.S. Public Health Service Commission Corps’ web site shows the different uniforms worn by its members.

The U.S. Army’s Public Health Command was launched in WWII, and it remains active today. One of its largest centers is Madigan Army Medical Center at Joint Base Lewis McChord, in Pierce County, Washington. Public Health activities are central to the success of the U.S. Armed Services, who promote population-based measures and recommendations outlined by HealthyPeople 2020 to have a healthy fighting force.

AFRICOM charts likely path for the future integration of public health and defense

Africom photo
This screen snapshot of an AFRICOM media file highlights the public health and health related efforts AFRICOM personnel undertake in the region, where military efforts are also underway to suppress and disrupt Islamic extremist groups.

Today, the U.S. military continues to use the “soft power” of international public health to advance its geopolitical interests in North Africa.  In April 2013, for example, AFRICOM hosted an international malaria partnership conference in Accra, Ghana, with malaria experts and senior medical personnel from eight West African nations to share best practices to address the major public health posed by malaria.

At last count, the disease took an estimated 660,000 lives annually,  mostly among African children.

At the event, Navy Capt. (Dr.) David K. Weiss, command surgeon for AFRICOM, said: “We are excited about partnering with the eight African nations who are participating. We’ll share best practices about how to treat malaria, which adversely impacts all of our forces in West Africa. This is a great opportunity for all of us, and I truly believe that we are stronger together as partners.”

I have reported on this blog before how AFRICOM and the United States will increasingly use global health as a bridge to advance the U.S. agenda in Africa. And global health and public health professionals will remain front and center in those activities, outside of the far messier and controversial use of drone strikes.

It is likely this soft and hard power mission will continue for years to come. Subcontractors like QED Group will likely continue chasing contracts with USAID related to terror threats. Global health experts will meet in another African capital to discuss major diseases afflicting African nations at AFRICOM-hosted events. And drones will continue flying lethal missions over lawless areas like Somalia and the Sahel, launching missiles at suspected terrorist targets.

The crowded, congested, contested road: unsafe at nearly every speed

Seattle traffic
Seattle traffic is among the worst in the nation, and it can be downright deadly, according to those who track road-related fatalities.

Every day that I drive to work, I am literally putting my life on the line. I commute roughly 80 miles daily, round trip, from Seattle to Tacoma, navigating one of the most harrowing urban traffic corridors in the Untied States, on Interstate 5 and two state highways. (My story why I am commuting this way will be for another day, but there are good reasons.)

Routinely, erratic drivers dangerously pass me, putting our lives at risk, in order to gain a few extra minutes by speeding. I have seen many accidents, some fatal, on this route over the years, and I am glad that I have my will and living will in proper order in case a truck jack-knifes near me in the rain—and yes I’ve seen that happen twice before on the freeway system around Seattle.

Seattle Road Kill 2001-2009
How deadly are roads in the Puget Sound–take a look at the roadkill on this data map showing types of mortality by form of transportation for 2001-2009.

Judging by this map, we get a fair share of road kill in the metro area I call home.

The Centers for Disease Control and Prevention (CDC) put the number of road deaths annually in my home state at nearly 500 (2009). Nationally, in 2012, the United States reported that 34,080 people died in motor vehicle traffic crashes in 2012, a 5.3% jump over 2011. This ranks as 10th leading cause of death in the United States, if one pulls this form of death from all accidental deaths, in which it is grouped by the CDC epidemiologists.

So by all counts, getting in one’s car (or on one’s bike or in a bus or other form of transportation) and hitting the road can be deadly business in my country, especially given the proliferation of mobile-device users and drunk drivers.

In 2011, cell phone use in the good ole’ U.S.A. was a contributing factor in more than 3,300 deaths and for the previous year, in 387,000 motor vehicle injuries. These are very sobering numbers, and I actually expected there would be more given that I have seen far too many texters during peak travel times in vehicles moving 70 mph. Normally I move over a lane or lay on my horn to snap them out of it.

But this is nothing compared to the perils that passengers and drivers experience globally. According to the World Health Organization (WHO), road accidents claimed 1.2 million lives globally in 2011, ranking as the No. 10 cause of death, on a list that has some pretty nasty company, including respiratory infections (3.5 million), tuberculosis (1.3 million), and the big killer of children ages 0-5 years, diarrhea (2.5 million).

The Institute for Health Metrics produced this data table showing how road deaths globally compared to other causes of death (it's No. 10); go to: http://www.healthmetricsandevaluation.org/gbd/visualizations/gbd-heatmap
The Institute for Health Metrics produced this data table showing how road injury globally compares to other burdens of disease (it is No. 10); go to: http://www.healthmetricsandevaluation.org/gbd/visualizations/gbd-heatmap

A typical story that one sees with mind-numbing frequency overseas are bus collisions with motorcycles and motor scooters. This November 2012 story, 19-yr-olds crushed to death by bus, notes two aspiring young men were run over by an errant bus driver and dragged 40 feet in Chandigarh, India; the driver then fled the scene. Both of the men’s heads were crushed by the bus’s wheels.

I saw no less than three similar road maulings on the island of Java in 2009, when I visited Indonesia. That island, one of the most densely populated locations in the world, is overwhelmed with low-income and middle-income residents on  scooters competing for space with trucks and army of loosely and unregulated van taxis and buses.

Indonesians who use these highly efficient and inexpensive 100-125cc motor scooters are frequently killed on the island nation's infamously unsafe and crowded roads.
Indonesians who use these highly efficient and inexpensive 100-125cc motor scooters are frequently killed on the island nation’s infamously unsafe and crowded roads.

Road accidents alone in Indonesia account for more than 48,000 deaths annually, the 9th leading cause of death in the world’s largest Muslim nation.

The United States Department of State offers this stern warning to would-be American visitors to Indonesia–a country I really loved by the way: “Air, ferry, and road accidents resulting in fatalities, injuries, and significant damage are common. … While all forms of transportation are ostensibly regulated in Indonesia, oversight is spotty, equipment tends to be less well maintained than that operated in the United States, amenities do not typically meet Western standards, and rescue/emergency response is notably lacking.”

During my two-week visit in 2009 to the island nation, I rode about a dozen different buses and equally as many microbuses, not to mention the country’s crash-prone domestic air carriers once, their local train service (also unsafe at times), and the far less safe inter-island ferry services. I saw about a half dozen crashes from my bus window, most fatal and usually with motor cycle riders as victims, and from my hotel room I heard one multi-vehicle crash in the middle of the night that clearly claimed many lives. I learned the next day it was between a bus and truck. The bus was totaled.

Roads can really kill you overseas, and so can planes, boats, and trains too

Buses like these are cheap in Indonesia, but your life can be as some locals would say, insha-Allah, or at the mercy of God.
Buses like these are cheap in Indonesia, but your life can be as some locals would say, insha-Allah, or at the mercy of God.

The writer Carl Hoffman, author of the book The Lunatic Express: Discovering the World… via Its Most Dangerous Buses, Boats, Trains, and Planes, documents the horrendous conditions of ferries, public transportation, trains, planes, and other forms of transport. The book’s online promotion notes that it offers a “harrowing and insightful look at the world as it is, a planet full of hundreds of millions of people, mostly poor, on the move and seeking their fortunes.”

Anyone who has travelled in developing or “middle-income” countries (like, say, Chile or Turkey) knows their life is literally in the hands of drivers who may have no proper training, in busses with no proper maintenance or even reliable brakes. Worse, the drivers of buses and microbuses in countries from Uganda to India to Mexico may trust their fate to Allah, Saint Christopher, the Virgin Mary, or Krishna. Those who have travelled in such places know this to be true, by the many religious deities dangling at the front of public transportation by the drivers’ seats.

Worse, the drivers will often play chicken with their competitors by speeding into oncoming traffic at high speeds while passing other vehicles or simply to “have fun.” I swear I thought I would die on many occasions in: Mexico, Guatemala, Nepal, Peru, Uganda, Indonesia, Egypt, Turkey, Chile, Argentina, India, and other places that I’d rather forget just now.

accident or more by Birn
When is an accident really an accident, or when it is linked to larger systems issues? This analysis is provided by Anne-Emmanuelle Birn in her description of the social determinants of health (SDOH).

Three separate times, after I lived through the near mishap, I swore I would never, ever take a bus again in a developing nation. Yet I threw caution to the wind, as I needed to get around, and I could not afford to get around any other way. Not seeing the country I was visiting was not an option.

Is it really  “just an accident” or something more?

Anne-Emmanuelle Birn, international health professor at the University of Toronto, and co-author of the widely used global health tome called Textbook of International Health, points out the deeper connections that road-related deaths have to poverty and social inequity in undeveloped and middle-income countries. Birn writes that road traffic accidents are the second-leading cause of death for children between 5 and 14 years of age globally, and that poor and working classes are disproportionately affected in most countries. In high- income countries, most of those killed are drivers and passengers, whereas in low- and middle-income countries pedestrians, cyclists, and public transport passengers make up nine out of every 10 road-related deaths.

In Haiti, for instance, the word for local transport is molue (“moving morgue”) and in southern Nigeria locals say danfo (“flying coffins”).

Duncan Green, an Oxfam policy adviser and development blogger, recently wrote an article asking when road traffic injuries would finally be recognized as a priority by the international development community.

In fact a major report released in June 2013 by the Overseas Development Institute, the United Kingdom’s leading development think tank, notes that transportation is not recognized as a human right like access to water, yet it still is a fundamental factor for many to achieve basic human rights. Well-run transportation systems, for people and for goods and services, promote benefits, while unsafe and weak transportation systems harm the most vulnerable citizens.

Given the debate emerging now for future sustainable development post-2015, the deadline set for the Millennium Development Goals, road safety may finally find a way into the broader public health, development, and environment agenda, as a way to tackle this clearly documented major global killer. Perhaps the threat may finally be treated as the international epidemic that is is, globally or closer to home in the United Sates. For me, this includes the roads in the Puget Sound where I spend more than two hours daily to and from my public health job.

Project Homeless Connect provides ‘disaster relief’ close to home

On May 17, 2013, I participated with other employees in my public health department working at Project Homeless Connect.  This is, at present, a quarterly endeavor to provide a range of medical and social services to the estimated 2,000 homeless individuals of Pierce County, Washington.

However, the people who line up as early as 7 a.m. for a range of needed services are not entirely the homeless. Many have jobs, but lack health and dental insurance. They basically are coming for primary or even emergency care that they cannot access elsewhere.

The Washington State Department of Social and Health Services is one of many organizations participating in Project Homeless Connect.
The Washington State Department of Social and Health Services was one of many organizations participating in Project Homeless Connect, held on May 17, 2013 at Calvary Community Church, in Sumner, Wash.

Project Homeless Connect, in its communications for its volunteer-run event, said it offered the following:

  • Medical and urgent care
  • Urgent dental care
  • Mental health services
  • Social service referrals
  • Vision/glasses
  • Haircuts
  • Child/adult immunizations
  • Veterinary care
  • Legal and financial advice
  • Housing, shelter, employment and education information
  • Tobacco cessation
  • Homeless assistance
  • Veterans services
  • Chemical dependence and assessment

This was no small effort. Months of planning went into pulling off this disaster-relief style engagement that is more associated with hurricanes and tornadoes than with meeting the basic needs of Pierce County, the second most populous (pop. 812,000) in Washington State.

Large, converted vans/trucks lined up providing veterinary services, dental care, and other interventions. Yet, oddly, there was no media present to put the story on the 5 p.m. news or in the daily newspaper the following day. (I checked but found nothing doing Google searches.) Why? Everyone who was homeless in Pierce and most social service and medical service providers likely was aware the event was taking place, for months in advance.

I did see not any elected officials (they may have come, and they may even have volunteered). All of this took place in a county whose hospitals are making profits of $1,000 per patient visit more than the state average and in a county where nonprofit hospitals are earning up to and more than $500 million in profits.

I saw all kinds of people—young, old, white, black, Asian, Latino, Pacific Islander, disabled, able-bodied, veterans, you name it. Volunteers came in all stripes as well. There were military personnel, dental assistant students from Pierce County community colleges (Bates and Pierce ), trained medical providers, church volunteers, hair stylists, and more. The list goes on. What struck me the most was how polite and appreciative the attendees were. Many drove or were driven from remote parts of the county to this somewhat semi-rural area in Pierce, southeast of Tacoma.

One of the providers, Medical Teams International, had one of its full-service converted mobile home vans providing dental care.

Medican Teams International brought one its converted mobile home vans to Project Homeless Connect on May 17, 2013, in Sumner, Wash.
Medical Teams International brought one its converted mobile home vans to Project Homeless Connect on May 17, 2013, in Sumner, Wash.

That program boasts a fleet of 11 mobile dental clinics in Oregon, Washington, and Minnesota that use 38-foot converted motor homes. Each clinic contains has two full medical stations and all necessary equipment, instruments, and supplies. The organization claims it has helped more than 200,000 adults and children with its mobile medical program since 1989.

Medical Teams International defines itself as a christian global health organization “demonstrating the love of Christ to people affected by disaster, conflict, and poverty.” The group works globally, including in Africa, South America, Asia, and North America.

Yet, it was in Pierce, addressing what clearly that organization perceived as akin to disaster and conflict.

In Washington State, 14 percent of all residents are without health insurance, according to the Kaiser Family Foundation. In Pierce County, the percentage is roughly the same.

All of this I find remarkable. Less than five miles from this revolving quarterly circus of human need there was a major shopping center, South Hill Mall, with about every major electronic gadget and consumer good on the market. Truck and car lots were also close by, with products selling from $25,000 and up. The disconnect to me was palpable, particularly the same week the Republican-led U.S. House of Representatives passed its 37th legislative measure to repeal or defund the market-driven health care reform known to its detractors as “Obamacare.”

I recall what one of my University of Washington School of Public Health colleagues—the one I respected more than nearly all others—told me when we talked about our peers who had worked or would work in public health in Africa or in developing nations. My friend asked somewhat ironically, why don’t they work at home. We have plenty of problems here. Given what I saw at Project Homeless Connect in Pierce County in mid-May 2013, I could not agree more.

Africa revisited through the Dark Star Safari

From the comfortable security of my modern cocoon in Seattle, Wash., I am vicariously reliving some long-ago travels I made in Africa during the summer of 1997, which already was 15 years ago. I have the often cynical but always observant and honest Paul Theroux to thank for being lifted out of my quotidian boredom and back to my brief five-week journey in central and East Africa.

Sunrise on the Serengeti, a magnificent sight indeed.

In June 1997, I travelled to Rwanda, just three years after the genocide. I arrived there, hoping to try my hand at freelance journalism and perhaps cover some of the genocide trials that were underway in the aftermath of the horrific crimes against humanity. I lacked two of the most critical elements to pull this off: connections and cash. Maybe I lacked cajones too. I also was floored by malaria once I arrived in Kigali, Rwanda, and I pulled out in two weeks, having lost a lot of weight and having determined I would not have the resources to succeed in my original plan. As to whether I would have succeeded as a freelancer if I stayed longer is hard to say, as Rwanda then was in the throes of an incredibly violent civil war that had claimed thousands of lives. That conflict, which involved the stopping of microbuses—like ones I was riding—and the slaughtering of all passengers, was pitting the Tutsi-led forces of the new post-genocide government of Rwanda against the extremist Hutu militias who had taken hold in then eastern Zaire. This was just before Zaire’s own meltdown into violent civil war, tribal violence, and foreign interventions that remains unresolved to this day.

Passing the time in Moroti, Uganda, on my way to the north of the country in 1997.

Theroux’s book, called Dark Star Safari, is typical and classic Theroux. It recounts a year-long trip he made from Cairo to Capetown in the early 2000s, mostly by land transportation, using local means such as the back of trucks, buses, microbuses, and sometimes rides in Land Rovers and overland safari trucks with the many white Westerners he sees. Theroux is unforgiving in his criticism of both Africans and of outsiders, who are mostly Westerners but occasionally Indians, Japanese, and Chinese. Theroux often savagely skewers this mostly Western crowd as if they were the marabou scavengers, the quite ugly and ubiquitous large storks seen throughout eastern Africa, which lurk about and wait for carrion to devour.

I like Theroux because he attempts to put what he sees into context, with the perspective of a man who spent two years of young adulthood as a Peace Corps volunteer in Malawi in the 1960s and later several years as a lecturer in Kampala, Uganda, before the despot Idi Amin took over and destroyed that nation. To his credit, Theroux’s comments on the failures of aid projects, for instance, are based on his first-hand encounters. He credits foreign aid organizations and Western governments for creating a culture of aid dependency in many African nations. But his biggest target is corruption by African leaders and its military and civilian rulers. Writes Theroux of the large cities he visited and detested on his trip: “Scamming is the survival mode in a city where tribal niceties do not apply and there are no sanctions except those of the police, a class of people who in Africa generally are little more than licensed thieves.“

Traveling by bus in Uganda, rarely a dull moment.

I have exchanged a few emails about this book with a friend of mine who also did a Peace Corps stint in Africa and who thought Theroux was honest about what he observed. I told my friend that Theroux’s description of traveling through a inhospitable, mostly lawless area from Mega, Ethiopia, to Isiolo, Kenya, where two white Westerners refused to give him a ride in their Land Rover, brought back my own memories. Like Theroux, I saw plenty of those same Land Rovers in Kenya, Rwanda, and Uganda and also never got a lift. (Did I deserve one—no, but they could have been offered; I did refuse a ride once too because I wanted to walk, but the driver was African and a decent guy.) I too wondered who are these privileged outsiders anyway? I remember distinctly two haughty U.N. officials—an African and European—sniping like French lords at low-paid Rwandan hotel staff while wearing stylish dark shades and expensive suits, angry dust got on their suitcases, as they disembarked at Milles Colines Hotel, made famous during the genocide where Tutsis hid while surrounded by killers. The cost for a room in 1997 was about $150 a night as I recall, or about half of what a Rwandan then earned in a year. I could not afford the place and luckily found accommodation with a great aid worker I met who I thought was doing good work.

Like Theroux, I travelled by truck to some remote parts in the bush. This trip took about 12 hours and was among my most memorable.

I also remember Italian missionaries in Northern Uganda, near Karamojo, in the deep bush who ran a furniture shop and spoke the local language and seemed completely at ease and in their element — like some of the Italian missionaries Theroux met in Ethiopia and Kenya. And, like Theroux, I remember these “overlanders,” the white tourists on coverted safari trucks crossing Africa, when I stopped at Lake Naivasha, Kenya. In my case, the passengers expressed excitement about seeing mountain gorillas in Rwanda without having a clue about the raging conflict there or another violent uprising that was occurring in southwest Uganda. And one has to wonder about two female aid workers he disparaged for their peddling of a Plumpy’nut type nutritional food product to poor children in person cause they reportedly didn’t trust the mothers to deliver the aid themselves? Is that true? I believe it is. Just this spring I heard an announcement by U.S. AID that the United States is pushing corporate food aid with corporate food giant Pepsico, in Ethiopia. What’s good for Pepsico is also good for U.S. AID and Ethiopians, if I am to believe the facts in this press release.

Anyway, not everyone agrees with Theroux, and here’s one attack, by John Ryle from 2002 in the Guardian, of the book and of the writer himself. Personally, I think Theroux is smart and clearly sees the public health, economic, political, and outsider-driven problems that challenge the countries he visited. I also do not think one sells books being nice or being 100 percent true. Theroux is a strong brand, and you know what you get when you read his brand. And it remains exceptionally enjoyable.

I shot this photo near Mt. Karamojong, a mountain that is home to a rebellious group who were known to rob locals with AK 47s when they were not fighting with other cattle raising tribes in Kenya. Or maybe they are just a tribe trying to survive in a land with few resources and many threats.

Health interventions, the positive face of geopolitical engagement

On June 14, Tom Paulson’s insightful blog, Humanosphere, put the spotlight on U.S. military initiatives underway in Africa as part of a grander strategic focus the U.S. Government is placing on Africa, through the U.S. Africa Command called Africom. He raised concerns about the dual efforts of the U.S. Government. On one hand, it was expanding its covert operations, purportedly to root out so-called terrorism networks and promote and training activities in Africa by building bases stretching from Djibouti to Ouagadougou, Burkina Faso, while at the same time trying to stomp out malaria, which kills about 600,000 Africans a year. According to a U.S. Department of Defense (U.S. DOD) press release, “Africom incorporates malaria prevention into much of its theater engagement, distributing mosquito nets and teaching new diagnostic techniques during training events throughout Africa.”

I think few could argue with the humanitarian goals of this type of health intervention, at least with some basic metrics. But in reality, health-related assistance usually has a broader function. Combining “hard” and “soft” power  is nothing new to geopolitics or the U.S. Government and its diplomatic, development, and military branches. The two often go hand in hand. Closer to home for most Americans, but still far away in the U.S. Arctic in communities along coastal Alaska, the U.S. Coast Guard has spent four years expanding its training activities and capacities in the Arctic to prepare for offshore oil drilling by Shell Oil Co. Production is scheduled to begin in the summer of 2012 in the U.S. portions of the Beaufort Sea, just north of one of America’s largest oilfield, Prudhoe Bay. Oil would then be shipped down the aging and half-empty Trans-Alaska Pipeline System (TAPS).

The Prudhoe Bay oildfield is one of United States richest oil producing areas, but its production is declining leading to offshore development.

The Coast Guard preceded its Arctic ramp-up with a much heralded health and logistics outreach, called Operation Arctic Crossroads, starting in 2009, to Alaska’s western coastal communities, such as Barrow and Kivalina. These were welcomed by the mostly Native residents and received high marks from nearly all quarters in Alaska. The Coast Guard is perhaps one of the most celebrated institutions in Alaska because of its humanitarian work saving countless lives and vessels, year after year, and because of the stellar reputation it has earned, demonstrated by its outstanding safety and rescue record. (I am a huge fan of the Coast Guard, if you cannot tell, having reported on their helicopter rescues numerous times as a reporter in Sitka, Ak., in 1993.) But the Coast Guard also has noted these outreach events in Alaska have been ultimately tied to the much larger issue of energy security and defense. The U.S. DOD reported “the Arctic has economic, energy and environmental implications for national security. Coast Guard missions there are increasing because Shell Oil Co. has permits to drill in Alaska’s Chukchi and Beaufort seas beginning this summer.” The U.S. DOD further notes, “Shell will move 33 ships and 500 people to Alaska’s North Slope, and will helicopter some 250 people a week to drilling platforms.”

Deadhorse is the main landing area for the North Slope oil and gas production facilities in Alaska.
The coast of the Beaufort Sea holds significant oil reserves that Shell Oil Co. will begin tapping in the summer of 2012.

All told, Shell spent some $2.2 billion for offshore leases alone, not to mention millions in legal wrangling, government relations, PR, advocacy in Alaska and in DC, and much more since the mid-2000s. The New York Times estimates Shell spent $4 billion in its quest for one of the biggest oil prizes in North America outside of the Athabascan oil sands of Alberta and shale oil finds in North Dakota. (Shell also is drilling for natural gas in the Chukchi Sea this summer also.) The issues framing a stronger U.S. commitment in the Arctic are natural gas and oil resources and a so-called “race for resources,” as it has been described by some, which concerns rights to those resources on the Arctic Ocean seabed floor.

The U.S. Energy Information Agency claims that nearly a quarter of untapped oil and natural gas resources are in the Arctic basin, which explains the significant interest by the major multinational oil exploration companies in the shallow Arctic waters off Alaska’s North Slope. Companies like Shell and ConocoPhillips and others have been staking out their claims for years by buying controversial offshore drilling leases that have been sharply contested in protracted legal fights with environmental groups and Native Alaskan residents of the North Slope Borough (the Inupiat). The Inupiat residents,  who, while mostly supporting onshore development, are concerned about the threat an oil spill or blowout in pristine Arctic waters, similar to BP’s spill in the Gulf of Mexico in 2010. Some Inupiat resident say that would harm their subsistence hunting of migratory bowhead whales, which have been hunted and eaten by these historic Arctic residents for thousands of years.

A whaling ship rests in the Arctic summer sun in Barrow, on the coast of the Beaufort Sea.

What is clear is that interventions premised on health care will likely be part of a larger strategic framework of  nations as powerful as the United States. Those actions, no matter how well-intentioned to improve health care from Kivalina to Kenya, must be understood in a much larger context of any nation’s political and economic interests. This is particularly true regarding access to and the development of natural resources, wherever those resources may be.

Being SMART about feel-good social media sensations

Like many people, I have very mixed feelings about the media phenomenon that is the super viral video known as Kony 2012. It has a sexy opening line: “Nothing is more powerful than an idea”–something that is a two-edged sword.  This can be terribly awful if applied by those promoting “evil agendas” (explained below). The video is produced by a group called Invisible Children, itself a major recipient of corporate giving (JP Chase Morgan Bank is a huge supporter of this group, according to the company’s web site). This itself gives one pause.

The moment I saw it, I was screaming out loud: “manipulative,” “scam,” “cliche,” “heroic white saviors,” “powerless Africans with only one name,” “exploitative.” I actually have followed this story for more than a decade, and I have been to northern Uganda in 1997, where the Lord’s Resistance Army wrought havoc on innocent Ugandans. This is a long, complex story involving several African nations, ethnic groups, geopolitics, and more. This video, while bringing a horrible human rights offender to the attention of the public, disregarded many historic realities that I found deeply troubling as a former journalist. For instance, the main villain, Joseph Kony, is no longer in Uganda committing crimes; he reportedly was last seen in the Democratic Republic of Congo.

So what are we to do when we see how emotionally manipulative media products can gain one instant notoriety and fame, itself a goal of many scraping to make it in media production, photography, and storytelling.  (Recall “performance artist,” but definitely not a journalist, Mike Daisy and the factually inaccurate story he pushed about Apple’s suppliers in China that compromised his career and brought disgrace to the radio show This American Life.)

I can never disassociate the message from the person. Remember Leni Riefenstahl and her hypnotically seductive Triumph of the Will, a  scary masterpiece of fascist propaganda released in 1935 (when concentration camps were not quite operationalized) that helped the cause of one of the greatest murdering madmen of human history, Adolf Hitler? Riefenstahl latter downplayed her Nazi sympathies and attempted to justify her work as merely the output of an artist doing a job, without moral consideration for the outcome. And she was a brilliant photographer and filmmaker, who even after being associated with a genocidal regime, revitalized her career with images of Sudan (The Last of the Nuba) that many would think of today as “progressive” in its orientation. (See the stunning photo below.)

Leni Riefenstahl’s photos of the Nuba, seen here, are brilliant images in their own right, but should they be viewed as distinct from her ties to a genocidal regime from her more youthful days?

I just stumbled on a promotional page for a group called International League of Conservation Photographers. I immediately smelled the conflict between huge egos involved in their media/photographic work and their worthwhile “cause.” The video creates an image of heroic warriors, backed by their own orchestral score. Or, are they just talented photographers trying to make a living too as photographers. What do you all think?

I am always going to suspect self-promotion if I do not see a clearly defined goal that accompanies the promotion. This organization states what many would believe to be a worthy goal: “The ILCP seeks to empower conservation photographers by creating an organizational structure that allows them to focus on the creative aspects of their work while at the same time finding venues that allow their images to make a significant contribution to the understanding and caring of the environment.” But is this truly a clear roadmap?

In public health, they teach us that the best interventions have SMART objectives because they provide the clearest guidelines for developing measurable, achievable actions. SMART stands for:
-Specific
-Measurable
-Attainable
-Relevant
-Time Bound

Whether SMART objectives actually lead to change, or themselves become watered down by their clever wording, is another topic. But in general, I believe this is a relevant way for looking at groups who promote social change. Is what they are offering SMART, or is something more akin to Triumph of the Will, dressed in clever social media marketing. That really is the job of the viewer, but also those who can also use social media to call attention to Triumph of the Will’s and Kony 2012’s viral step-children.