Thirty

I am thirty now. (As of November 14, 2005.) I feel good about the number. No panic. No tears. In my mind I am at last, inarguably, an adult. There is so much cultural weight put on this number that unlike any other birthday, the over night change from 29 to 30 is one I felt. And, the feeling – spurning a few moments of self-reflection – led to two conclusions, each carrying their own sense of urgency. I imagine this development has much to do with societal expectations but believe it is equally affected by two recent events in my life, I just finished reading “Mountains beyond Mountains” the story of Paul Farmer, and last week I attended an Obstetrics and Gynecology conference in Tanzania. So, here’s my list: (1) If I really want to do something good in the world it is time to be serious and start, and (2) I’m ready for a home. No they are not related but they are both broad and open enough to be achievable.

Paul Farmer is an inspirational character. In short he is a tenured professor at Harvard and a general practitioner whose life story illustrates a deep commitment to the provision of equitable health care. In his early 20s he set out to provide quality health care to Haitians and in the process he achieved what many may consider small miracles, becoming an internationally renowned figure (particularly related to efforts against tuberculosis (TB) and HIV) without losing touch with or devotion to individual patients. He has written numerous articles and books (of which I have only read one so far). This particular biography reads like a novel blending the author’s account of time spent with Farmer with pieces about his family, his philosophies, his life, and his epiphanies along the way.

I want to share my favorite story from the book . . . At one point, early in his career a debate arouse at a clinic in Haiti as to why patients in the catchment area continued to suffer relapses of TB despite the provision of adequate treatment. Most of the clinicians claimed that the relapses resulted from non-compliance, arguing that patients would stop taking the medication because they believed the disease was caused by sorcery. But, one clinician told Farmer that he suspected the relapses were due to malnutrition. Farmer then carried out his own study to resolve the debate. He divided TB patients into two groups, both of which received standard treatment, but the second group also received $5 a month to buy food. Farmer questioned all patients about what they believed to be the cause of their illness. In the end he found that all the patients finished all their medications as prescribed, the vast majority of patients in both groups believed their disease was caused by sorcery, and while several patients in the first group relapsed, not a single patient from the second group relapsed. Farmer distilled two lessons from this experience. First, non-compliance occurs on the clinicians’ end and most often the “non-compliant” patient is not receiving something that is essential for their well-being. And second, we are all complex individuals irrespective of our poverty/wealth/education; our actions and beliefs are not always linear.

I know there are many instances when the first group of clinicians “win”; their argument is regarded as truth and patients are simply lectured more and more fervently about the need to do X-Y-Z but the outcomes fail to improve. This story challenges the paternal-/maternalitstic attitudes we often subconsciously harbor regarding the ill and impoverished. It illustrates, simply and eloquently, that people want what is best for them. They want to care for themselves, they want to care for their children, and they will do everything possible to sustain and protect their own health and that of members of their community. The real problem is that they are voiceless. So, rather than assuming the fault lies with them we must first listen to find out what they need. Great, no?

Reading the book complimented my experience of the conference and provided a supplemental illustration of how individuals can make incredibly differences even in the setting of atrocious health statistics. There were some amazing, shocking, and inspirational presentations, some depressing but not surprising presentations, and many encouraging – simple presentations of research done at sites comparable to Bottom by dedicated clinicians working to improve care in small ways. The overall picture is that the situation of health care in Africa is, at best, holding at deplorable, and more likely worsening. Just to paint a picture of the human resource crisis here are a couple statistics from a recent Harvard Report. Africa has a deficit of one million health workers. Africa has 10% of the world’s population and less than 1% of nurses, MDs, and midwives. Africa trains only 5,000 MDs a year while Europe trains 175,000 per year. To me these statistics scream that the problem of health care in Africa is not one that can be solved by Africa alone. And, the provision of adequate care is not simply a matter of training/retraining and improving skills. (To believe this is a bit paternalistic, Tarek often says that these settings demand a higher standard of excellency and efficiency than settings with adequate resources – I’m not saying that all the clinicians are excellent or that many couldn’t profit from additional training but that this is not a solution). The shortage of human resources is a global problem of distribution demanding true commitment from the international community.

The other major theme was that women in sub-Saharan Africa continue to die and suffer from preventable illnesses and conditions; the same preventable causes that the international community has rallied around for decades, emphatically pledging again and again to eradicate. We know why women are dying, we know what we need to prevent their deaths, so why is nothing changing? Is it a question of finding the appropriate sustainable solution? And what exactly does sustainability mean? Does it mean cost effective? And, what is cost effective? Does that mean that the minimum requirement of any solution is that it should not challenge the standard of living in the developed world? We are entrenched in discourses of blame and power and in the meantime we are accumulating overwhelming proof that the problems are sustainable. While not doing much may be cost effective for the privileged, it is devastating for the poor – as mothers die and breadwinners die. Is the perpetuation of the status quo morally sustainable for global citizens?

I’m not sure what to do with all these questions but I am becoming more and more convinced that the solution requires a radical shift in perspective and must be inclusive of the “best for the whole” concept as well as the capacity to care for those who come to you with all the dedication you would show them if they were your mother or sister or daughter. I am also beginning to believe that individual efforts really can and do make a difference. I have a head full of ideas inspired by many people and many of you who read my blog have repeatedly asked how you can help so, I think it’s time to stop stalling and just start and NGO. My basic idea is to create something with a broad mission, a small organization geared towards improving the health of women and children functioning on a do-and-give-as-you-move-along-and-see-fit basis. Although I’m longing for home I don’t have a specific country in mind and home to me doesn’t necessarily mean a fixed location anyway (it’s more of the feeling that comes when you open the door to the place where you live and see the people within and the objects that form the space). I do imagine that wherever I end up it will be in the developing world in a community with some extra needs, so considering that, I’d like to have an NGO flexible enough to spread around. If any of you have ideas let me know, now is the time for dreaming.