Freewheel Burning

Today I went with one of the survey teams to Sucru, a tiny island of about 200 people on Lake Victoria.

Like other islands, the people make their living almost entirely through fishing. Small scale fisherman capture Nile Perch, Tilapia and catfish, bring them back to community fishing boards, which then sell them to larger brokers, which then take them to the notorious (and mysterious) “factory.” The “factory” then filets the fish and sells them to European and American dealers. The welfare of this tiny island depends entirely on the whims of hungry Europeans. The global economy starts on islands like Sucru.

In contrast with the other islands, however, the locals appear to eat some of what they catch. In fact, I assume that the majority of what they eat comes straight from the water. I could see absolutely no evidence of agriculture of any kind on this tiny island. The result is that the residents of the island appear quite well fed, some are even fat, but clearly lack essential vitamins due to their monotonous diet.

Housing conditions are miserable, and, like many islands here, sanitation is quite poor. About twenty years ago, a group came and installed a septic and well system to try to keep the locals from openly defecating and drinking their own sewage, but the system appears to have never been used. Like most areas around Lake Victoria, people prefer to crap in the bushes over a formal toilet. The result is that diarrheal disease is constant, and children live in states of vastly poor health.

As far as I could tell, school age children have to stay with relatives on the mainland in order to get an education. Healthwise, they might fare better in school.

Though only having a handful of residents, malaria is endemic to the island. Black mambas (considered the most dangerous snake in the world) are also native and live in plentiful numbers. We found a freshly killed one on a rock.

Safari ants are also plentiful. A few crawled up my pant leg and drew blood. I can be seen in one of the pictures picking them off myself. I think everyone had their pants off at some point picking off ants.

Despite all the challenges, the locals are incredibly kind (like many people around the lake), appear quite happy and don’t mind being photographed. They laugh hysterically at my rudimentary (though improving) command of the Luo language.

We’ve started our visits to drug shops in this region of Tanzania, which mostly entails sitting alongside interviews in Swahili and waiting long hours for customers to show up. It’s a national holiday so everyone must be busy attending to children at home, cause noone seems to be interested in buying pharmaceuticals today.

This village sits on the outskirts of Sumbwanga town in Rukwa Region. The local economy is based on agricultural trade and local buying and selling of goods available anywhere in Sub Saharan Africa. The market consists of the usual fare, soap, haircuts, soft drinks and beer, but sports a variety of dried fishes and local fruits. I pass on the dried fish as delectable as it looks. The omelet with French fries is also out, sad to say. The oranges, no problem.

Like most places in Africa, people are very kind and will repeatedly thank you making the long journey to their very small and mostly unknown village. Here, so close to friendly and peaceful hotspots like Malawi and Zambia, extreme kindness is a given.

The only business here is small business. Like everywhere in Africa, businesses are informal, sole proprietorships. The drug shops are no exception. I spoke with two shop owners today, both were trained as nurses, but left public service to open or work at small drug shops.

The relationship of drug shops with the public system is worth noting. As the public system in Tanzania relies completely on government revenue and donor aid to function, drugs are often unavailable. In theory, this opens a market opportunity for private shops but in reality it appears that public employees are funneling drugs to shops they have a stake in, as a recent scandal has unveiled.

I spoke with a gentleman today who may be considered exceptional, but likely isn’t. 20 year old Charles, living in an extremely remote town worked burning charcoal for pennies, saved his earnings and opened a small shop, debt free. Now he sells soap, cooking oil and single cigarettes from a small storefront adjacent to one of the drug shops we visited. He would like to save his money and open a shop which sells lights, generators and electrical goods aimed at other shops.

One common misconception about Africa is that Africans lack an entrepreneurial spirit. Far from it, what they actually lack is capital.

All Africans are entrepreneurs. Americans on the other hand mostly just draw paychecks.

The Lancet recently published the results of a longitudinal study examining resistance by malaria parasite to the latest and most effective treatment for the disease, Artemisinin Combination Therapy (ACT) along the Thai-Myanmar border.

Parasite clearance rates increased from a mean half life of 2.7 hours in 2001 to 3.6 hours in 2010, indicating that resistance is growing. Resistance was originally observed on the western side of Cambodia, but has now either spread geographically to western Thailand or emerged on its own. The latter scenario is actually the more frightening possibility. If resistant strains emerge in Sub-Saharan Africa, it could be a major setback.

Though research to develop new drugs is ongoing, ACTs are presently the most effective treatment and a major part of the arsenal with which to stop transmission and prevent early childhood death. Past treatment strategies are now largely ineffective.

Vaccines are also in development (most notably the RTSS vaccine), though I have little confidence that it will be of much use for long. It is a long series of shots and difficult to deliver in areas where medical delivery is poor or non-existent and efficacy is strain and context specific. Malaria vaccines are nice in the popular press, but impractical on the ground.

That resistance is growing in this particular end of the world, is in itself significant. Both regions are notable for poor health delivery, sporadic armed conflicts and marginalized populations. Efforts to contain the spread of resistance are likely futile. Even in the best of times, adequate delivery of care and prevention strategies are near impossible. Displacement of people due to conflict always provide ample opportunities for infectious agents, poor health and death. Tens of thousands of people languish in refugee camps along the border.

The subject of resistance in this region comes up often in meetings of malaria researchers, though I am always struck at the absence of discussion of social factors and conflict and how they create conditions favorable for the spread of resistant pathogens. It is no accident that malaria occurs in the places it does, and no accident that resistant strains of Plasmodium are able to fester and evade efforts to reign it in. It is almost as if the malaria research world believes that genetic adaptation happens at random, which it does not.

Discussion of malaria eradication cannot proceed without discussion of how to eradicate worldwide conflict, entrenched poverty and proper delivery and access to basic health care and the global forces which create these conditions. Yet it does.

Medications, vaccines and preventative interventions cannot work if there is no way to delivery them, and people cannot access them unless there is a local economy with which to support such a system. Malaria research has to address this fundamental issue or we’re just talking in the wind.

Malawi’s President Bingu, or as he was officially known “His Excellency the President Ngwazi Professor Bingu wa Mutharika” died last Thursday.

His death has left a power vacuum in Malawi. Joyce Banda, the current Vice President constitutionally is expected to take power, but members of Bingu’s Democratic Progressive Party are seeking to block her appointment. Banda, though chosen as a running mate by Bingu himself, increasingly found herself at odds with Bingu’s increasingly autocratic Presidency and ultimately left the DPP to form her own political party. Bingu sought to cancel her vice presidential seat unsuccessfully. The Malawian Supreme Court ruled that she was still entitled to the seat.

Both groups within and outside of Malawi are calling for a swift transfer of power to Banda, including the United States.

Malawi could do worse than Banda. A former educator, Banda has sponsored numerous initiatives to expand educational opportunities for children and to increase female empowerment within Malawi. Since 1990, Banda’s National Association of Business Women has provided support and training for female entrepreneurs, reaching a wide network of approximately 30,000 people. She has sponsored health initiatives in Malawi and won numerous international awards. Most impressive, she quietly sponsored a task force to determine the extent of HIV in MSM populations, a dangerous undertaking in conservative Malawi. Forbes magazine listed Banda as the third most powerful woman in Africa. In short, Banda could be the breath of fresh air that Malawi requires.

Mutharika’s Presidency, though initially lauded due to his successful seed voucher program, which he boldly implemented against the advice of the World Bank and the IMF, fell into disgrace due to widespread fuel shortages and a dearth of foreign exchange. The increasingly dire situation led to mass protests all over Malawi, a state crackdown, and the deaths of 19 people. It is questionable though, as to whether Banda can solve these problems, much of which is due to international market forces out of the control of the domestic Presidency.

Of interest to me were the circumstances of Bingu’s death. Bingu collapsed on Thursday night and was rushed immediately to Kamuzu Central Hospital, a public facility. Upon presentation at the Kamuzu, workers realized that they were lacking epinephrine and had to run to a facility run by University of North Carolina to procure it. Bingu likely died because of problems of drug stocking in Malawian facilities and substandard levels of health delivery. Bingu died due to a problem endemic to all of Malawi. Ironically, the opulent President of Malawi died needlessly like that of even the poorest of Malawians.

It was announced to day that Barack Obama will appoint Dartmouth President and physician Jim Yong Kim to be the next head of the World Bank. This breaks a string of appointments of right wing demagogues including Paul Wolfowitz and Robert Zoellick, both part of the group which orchestrated the invasion of Iraq and the heavy handed response to 9/11 by the Bush admin. I saw Zoellick speak recently and felt kind of gross after it was over.

Jim Yong Kim has an impressive list of publications on global health, notably collaborating with Partners In Health founder and human advocate, Paul Farmer. In fact, Kim was also part of the group that founded PIH and is known for his work on “Social Medicine” (a broad signifier for social determinants of health with a focus on clinical delivery).

Kim is co-founder of The Global Health Delivery Project, a group at Harvard that seeks to improve the health and welfare of population in developing countries by focusing on issues of health care delivery.

Problems of delivery of health care in developing countries has been perhaps my number one interest as of late. In fact, I am even writing a paper on it. As researchers, we can develop effective and radical new clinical techniques and medicines, but they do no good if the systems aren’t in place to deliver them effectively. Issues of delivery will be the primary impediment to controlling and eventually eliminating devastating diseases such as malaria. It is encouraging that Kim has been selected to fill this position.

It is unsurprising that Columbia University development economist Jeff Sachs was not chosen (he has withdrawn his nomination), despite appealing to the world community to pressure the Obama admin to select him. However, it is a relief that the first choice, Larry Summers, has to forego stepping in to a leadership position at the WB. I can think of no WORSE choice. The entire world appeared to agree and it marked the first time that the international community has had a say in who heads the Bank, a welcome departure from past appointments.

Sachs himself even came out in support, likely aware of his role in having Kim picked: “Dr Jim Kim is a superb nominee for the World Bank presidency,” Sachs said in a statement. “I support his nomination 100 percent. I congratulate the administration for nominating a world-class development leader for this position.”

I am interested to learn more about Kim. He may certainly have some ideological skeletons in his closet, though his association with Farmer leads me to think not. Congratulations to the Obama admin for taking the high road on this one.

UPDATE: OK, so it appears that Kim will be the first WB President to ever be caught on film rapping and dancing at a Michael Jackson tribute:

Mechai_Viravaidya, affectionately known as “Mr. Condom” in his native Thailand, has been promoting condom use since the 1970′s. Everywhere he goes, he encourages the use of condoms to prevent disease and unwanted pregnancies. He is at least partially responsible for reducing Thailand’s fertility rate from 7 to 1.5 and almost completely respsonsible for reducing the number of new HIV infections by 90% between the mid 90′s and 2005. It is estimated that his campaigns have saved the lives of more than 7 million people.

Incredibly, he did it in part by giving condoms to elementary school children to take home to their parents. Given the American right’s completely backward and jaw dropping assault on reproductive freedom lately, Mechai might have found himself hanging from a tree had he attempted this in the States.

It doesn’t take a doctor to save lives. Public health activists like Mechai do it every day. In fact, people around me do it every day and receive little credit for it.

Check out Mechai’s video of a TED talk given last year.

Last year, I took a part time job in the UM Business School. At first, I was hesitant. A job in the business school? Isn’t the B-School the heart of all that is evil and wrong with the world? The desperate in me whispered that I needed the money and the academic in me reminded me that I’m intrigued by anything having to do with developing world health delivery. Moving in the circles of business might, at the very least provide insight into how the world of malaria policy works.

Though the details were hazy at first, over time, I’ve come to understand what my employers are trying to do.

In Africa, health care is a premium. What health care is offered is often difficult to access. When accessible, medicinal supplies are limited, stock outs are common, delivery ineffective and, user fees prevent the poorest of households from obtaining affordable medications.

Coca Cola on the other hand is ubiquitous. I may not be able to buy anti-malarials, get on ARTs or even a decent meal, but I can get a bottle of Coke for an affordable price just about anywhere in all of Sub-Saharan Africa, even in conflict ridden corners of the DRC. Better yet, at least for me, this is the old Coke made from cane sugar, not the new, artificial kind we get in the US.

Some folks (who pay me money to do stuff) ask the obvious question: if the multi-national Coca Cola company can get soft drinks in every corner of the globe, why can’t we effectively deliver badly needed medicines to the same people?

My colleagues then examined the nature of private supply chains that deliver Coca Cola and contrasted them with current methods of pharmaceutical delivery. Private supply chains which deliver things like Coca Cola, beer, soap, shampoo and cel phone cards are incredibly efficient.

Soft drink manufacturers, ship concentrates (to protect intellectual property) into developing countries directly to factories which bottle and prepare stocks for delivery. Stocks are then sent by truck to smaller distributors where trucks are able to pass. Distributors then sell to even smaller distributors who deliver stocks to small shops by vehicle, bicycle, or cattle driven cart, delivering to areas inaccessible due to poor roads, seasonal rains or regional insecurity. Every step of the chain is accountable to the link above it, stocks are paid for on delivery and open competition for delivery routes keeps everybody honest. Empty bottles are then returned along the same supply chain for further bottling, saving resources and keeping costs low.

It’s brilliant, really. It keeps people employed, sales generate cash that goes into communities and insures that small shops are open which can sell other types of consumer goods.

Medicines, on the other hand, are distributed through state run warehousers, which then deliver to district level storage facilities, which then are responsible for delivery to smaller clinics and dispensaries. The trouble is that 1) points of distribution are few and often inaccessible for people in rural areas 2) delivery methods often rely on vehicles which can’t pass through many of the most needy of areas, and 3) deep state control prevents competition amongst distributors and fosters corruption and a lack of accountability.

To encourage this distribution model, policy makers have begun subsidizing ACTs (an effective anti-malarial medication) to bring prices to a level where small corner shops can afford them. They are then sold to local wholesalers, who distribute the meds using the same model as that of Coca Cola, penetrating previously unreachable areas. The model works through low cost and the utilization of informal networks of delivery.

Of course, my politics tell me that bolstering an unregulated private market in essential drugs only undermines the overall quality of public health delivery. Indeed problems do exist and the program is not without its critics, but to deny that the role of private markets is essential to health delivery is short sighted and idealistic. In this case, even given potential problems and implications, the benefits far outweigh the costs.

In this week’s Lancet, Christopher Murray published a paper presenting evidence that deaths due to malaria are vastly higher than “official” estimates from the World Health Organization. Specifically, Murray, et al. estimate that worldwide malaria deaths, though declining over time, exceeded 1.24 million compared with the WHO’s estimate of more than 600,000.

Most notably, the Lancet paper speculates that adult deaths from malaria are far higher than previously though, contradicting accepted medical ideas that immunity increases with age, freeing adults from the risk of mortality.

Murray’s paper is not without precedent. In 2010, Dhingra, et al. also called the WHO’s estimates for malaria mortality in India into question, estimating between 125,000 and 277,000 deaths were due to malaria, far exceeding the WHO’s extremely reassuring estimate of 15,000.

That malaria deaths are down worldwide is an uncontroversial notion. The wide discrepancy between published estimates of the worldwide burden of malaria mortality is, however, highly controversial. Overestimating mortality can stream precious monetary donations, most notably from big players such as the Global Fund, needlessly toward malaria, at the expense of other health concerns such as TB and HIV. Underestimating the number of deaths from malaria, can leave countries short changed and unable to fight their own malaria related problems.

Either way, controversy as to the accuracy of reporting dishevels confidence and could provide more fuel to those who advocate for reductions in global aid to fight developing world health problems (read: all of the current Republican candidates) and distract from the creation of efficient policy.

What is needed, of course, is accurate reporting and a reliable flow of health information worldwide. Many developing world governments, however, lack the resources to efficiently provide these numbers. World aid bodies, however, have, to date, missed this essential piece and reporting methods remain antiquated in many areas.

I just visited a facility in Kenya, where records are still kept on paper, and left to mildew in an unused toilet (I kid you not). One could assume that if the records were left in a functioning toilet, the numbers might end up at the bottom of a pit latrine. With the base of the worldwide reporting system in such a shambles, how can we expect accuracy in reporting?

New estimates of malaria deaths: concern and opportunity
[The Lancet, Volume 379, Issue 9814, Page 385, 4 February 2012 doi:10.1016/S0140-6736(12)60169-X] — (English)

This week we publish surprising and, on the face of it, disturbing findings. According to Christopher Murray and colleagues at the Institute for Health Metrics and Evaluation
(IHME) at the University of Washington in Seattle, there were 1·24 million deaths (95% uncertainty interval 0·93—1·69 million) from malaria worldwide in 2010—around twice the figure of 655 000 estimated by WHO for the same year. How should the malaria community
interpret this finding? Before we answer that question, we need to look beneath the surface of this striking overall mortality figure…

Global malaria mortality between 1980 and 2010: a systematic analysis [The
Lancet, Volume 379, Issue 9814, Pages 413 - 431, 4 February 2012 doi:10.1016/S0140-6736(12)60034-8] — (English)

We systematically collected all available data for malaria mortality for the period 1980—2010, correcting for misclassification bias. We developed a range of predictive
models, including ensemble models, to estimate malaria mortality with uncertainty by age, sex, country, and year. We used key predictors of malaria mortality such as Plasmodium falciparum parasite prevalence, first-line antimalarial drug resistance, and vector
control. We used out-of-sample predictive validity to select the final model…

 

WHO Defends Its Numbers On Malaria Deaths [Voice of America (blog)] — (English) The World Health Organization is defending its numbers on global malaria deaths and disputes a new study claiming that nearly twice as many people die of malaria than previously believed……

Malaria death toll disputed [Nature] — (English) Study doubles official estimate, but scientists say its methods are flawed……

Malaria deaths higher than expected, study finds [Deutsche Welle] — (English) The latest findings show that the number of malaria-related deaths is nearly twice as high as previously thought. But other experts have doubts about the methods used to produce these estimates……

Malaria deaths hugely underestimated – Lancet study [BBC News] — (English) Worldwide malaria deaths may be almost twice as high as previously estimated, a study reports……

Malaria kills twice as many as thought: study [Reuters] — (English) Malaria kills more than 1.2 million people worldwide a year, nearly twice as many as previously thought, according to new research published on Friday that questions years of assumptions about the mosquito-borne disease……

Malaria kills more people worldwide than once thought, study says [Los Angeles Times] — (English) In an alarming statistical turn, the number of malaria deaths every year may be vastly underestimated, according to new research re-examining mortality rates from 1980 to 2010……

Malaria deaths may be double WHO estimates [Financial Times] — (English) Worldwide malaria deaths may be almost twice as high as previously estimated, according to a new study that has sharply divided scientists tackling one of the world’s most deadly diseases……

Malaria death toll possibly twice as high as experts estimated [AP via FOX News] — (English) Malaria may be killing around twice as many people as experts previously thought, and it could also be hitting older children and adults – long considered the least susceptible – a new study suggests……

Malaria death toll possibly twice as high [USA Today] — (English) Malaria may be killing around twice as many people as experts previously thought, and it could also be hitting older children and adults – long considered the least susceptible – a new study suggests……

Malaria Kills Nearly Twice as Many People Than Previously Thought, but Deaths Declining Rapidly [Science Daily] — (English) Malaria caused over 1.2 million deaths worldwide in 2010, twice the number found in the most recent comprehensive study of the disease, according to researchers at IHME and the University of Queensland……

Malaria kills more people, older people [Washington Post ] — (English) A new study found that twice as many people die of malaria every year than was previously thought and that it kills many adults as well as young children……

 

 

Kibera is one of the biggest slums on earth. Out of 5 million people in Nairobi, up to 1 million (the number depends on who you ask) live in Kibera making it larger than even supposedly big American cities such as Detroit, MI.

Like slums everywhere, Kibera’s resident flow in from all impoverished areas seeking job opportunities and better lives for their desperate families. Like slums everywhere, Kibera plays an important role in Nairobi’s economy, serving as a source of cheap labor specifically in the manufacture and distribution of hand fabricated goods and migrant agricultural work.
Like slums everywhere, the greater economy depends on keeping the area poor. Public services are sparingly doled out, just enough to keep the residents from rioting, but not so much that the prices of goods coming out of Kibera will rise.

Public sanitation is the greatest challenge in the area. There exists no effective method of handling the large amount of human waste and trash that the area produces. Households will leave waste outside their doorways, where it eventually gets burned or washed away by the rains. One group has created public toilet facilities that composts the waste and uses the methane discharged to allow for cooking by residents. Other public pit latrines are visible in the area, but they are, as yet, too few in numbers to effectively serve the demands of the large numbers of local residents. It is important to note that toilet facilities are not free. If households do not have the money, they will not use them.

Clean water is in plentiful supply, but carefully managed through a system of gouging the public system. The city has run a haphazard series of municipal water pipes through Kibera. Residents either legally or illegally tap into the pipes and then sell the water to other residents. If the tap is legal, the resident must pay a fee to the city. All taps, legal or no, charge for their services. Locals imply that this is merely the market capitalizing on a surrounding demand, but the reality is that the poorest of households cannot afford the water fees. They either illegally procure water from unmanned taps or fetch water from the river which is polluted with human filth. The result of this commercialization of water resources is that poor households have no access to clean drinking water.

Health services are mostly unavailable to resident outside that which is provided by proactive NGOs and private clinics. Though health services are available at low costs from government run clinics, the nearest facility is too far away. I spoke with Elizabeth Akinyi of the “Power Women Group,” a community based organization which supports HIV positive women by selling handmade goods to tourists. She said that anti retrovirals (ARVs) are available from the public clinics, but that the clinics are so far away that even the sickest will not attempt to make the journey. Thus, HIV positive residents depend on the good graces of donor agencies and NGOs to provide medications. Medications, however, are not free so the revenues from the groups store are essential to keeping these women alive and, as they put it, “living positively”.

It should be obvious that the greatest challenge to poor Kenyans is being able to bear the costs of services. As one person told me, “in Kenya, the only thing free is the air.” In addition to water, the city provides power to some parts of Kibera, which also must be paid for. Homemade television antennas can be seen over just about every household. Every once in a while, one can see a satellite dish. Public schools exists, but slots are too few to accommodate all of the children in Kibera, so many go without. Local groups have stepped up to attempt to provide basic education to children but without formal education, the children of Kibera have little future.

All of this, however, should not distract from the incredible resolve of Kiberans to make a better life for themselves. Everyone in Kibera has some kind of business. Street sellers, small fabricators and small businesses are to be seen everywhere. Some follow western models of individual entrepreneurship such as that of the owner of “Apokolipto Cinema” a small DVD theater that runs showing of bootleg horror and action DVDs from morning to night. Many of the larger operations, however, do not. Employee owned fabrication groups produce products for sale in Nairobi, but split profits amongst themselves and provide for school fees of employees’ children such as that of Kibera Jewelry, who make necklaces and other goods from recycled bone products. Kibera tours, the group that allowed me to visit the area, is a mixture. Though owned by one entrepreneur, the success of his tour depends on cooperation with local groups. Profits from his tour group are split between himself and the groups who participate.

It could be said that unemployment is rampant throughout Kibera, but then it could be said that not a day goes by where Kiberans are not doing something to make some money for themselves. A lack of access to capital and dependable city services, however, prevent the area from reaching its true potential.

I’m going to tell a story. My uncle is 52 years old; that’s ten more years than I. When I was a kid he would introduce me to all kinds of amazing 70′s rock and psyche records. My uncle, like much of my family, is mentally ill.

Specifically, he fights severe depression; though through medication, he has been able to maintain a minimal standard of living and assisted my grandfather through his arduously long passing. Like many caregivers, his efforts are little appreciated nor recognized.

After my grandfather passed, my uncle had a job but lost his health benefits. Unable to obtain a new prescription for his depression meds, he started self-medicating through alcohol. Most people in his family are addicts. Little understood is the role that depression plays in addiction. Without anti-depressants, my uncle will drink almost constantly.

Recently, I went to see him. He looked nearly 20 years older than his actual age, was incontinent and hadn’t eaten in nearly two weeks. He subsists off calories from beer. I left heartbroken.

Six weeks ago, I received a call that my uncle had been admitted to the ICU. He had a stroke while buying beer at a local convenience store, fell and fractured his skull. Somehow, he managed to walk home and locked himself in his house. Someone found him and brought him to the hospital, where he was operated on for a brain hemorrhage. He then later had second stroke, fell again, and had to have the surgery once more.

My uncle has since relearned to walk, but has no use of his hands. I must stress again that he has no health insurance. The hospital discharged him since he could not pay. Now, he lives alone in his house, with no power, heat, nor food, he is barely mobile and will never be able to work again.

I tell this story because it fills me with rage. The Republican Party would happily let my uncle die. That we live in a country where basic health care is available only for the rich, and requirements that everyone enter into some kind of health plan are viewed as “Hitleresque” fills me with an indescribable rage. It’s almost cliché to point out that we live in the wealthiest country on the planet (by GDP), yet still can’t seem to figure out how to provide for the health of all of our citizens.

By far, out of all of the Republican candidates, , Ron Paul has the worst suggestions for what to do about the uninsured, let alone what to do about health care in the United States. He believes that insurance companies should be allowed to insure whomever they wish. That no one should be forced to pay for the health care of another individual. That hospitals should be allowed to decide whom to exclude treatment to.

Paradoxically, he believes that the solution to the problem of health care in America is to shift the burden of cost to doctors themselves. He believes that doctors should volunteer their time and resources to assist the poor so that they will stop troubling the rest of us.

Presumably, he’s never asked doctors whether they like working without being paid. Or that most of the cost of health care is for materials and services that do not involve the practitioner. Nurses, for example, are they to work without getting paid as well? Are doctors merely to absorb all the costs of care from their own incomes? If they pass these costs on (as they are now) to other patients, does that not also violate Paul’s ideas of forced remuneration from those who have? Paul, though, waxes nostalgic on health care pre-1965, ignoring the fact that health care was less complicated, less costly, less effective and less accessible in the good old days. But then we should expect no less from bull-headed Ron Paul.

Even worse yet, Paul believes that one of the solutions to health care in the United States is to support “alternative therapies,” such as as vitamin therapy, a movement that believes that massive doses of vitamins can cure cancer. Maybe he also supports aromatherapy?

He even fans the flames of a vast government conspiracy to control the supply of vitamins. What a great idea! It’s cheaper than surgery, and even cheaper than chemo! In Paul’s massively unrealistic world, if the vitamins don’t work, then there will always be a kindly doctor willing to step up and provide multi-million dollar cancer treatments for free to anyone who wants it.

Paul hates the FDA,, who ensure the safety of pharmaceuticals marketed in the US. He hates any hindrance to quackery and the protection of public safety , assuming the free market will weed out dangerous pharmaceuticals. It seems he never considered all of the people that have to die first, or the desperation of the poor who have to balance safety, cost, and the potential for relief.

Paul rightly recognizes that health care is costly, but wrongly believes that the free market will contain costs, assuming that health care is subject to standard models of supply and demand, an assumption that has been repeatedly proven wrong. Have you ever tried to bargain with your emergency room doctor for a better price?

He hates Medicaid, SCHIP, and Medicare. I would venture to assume that he even hates employer-provided health plans, which do not allow individuals to opt-out. In fact, the only insurance plan he seems to support is that of health savings accounts (HSAs).

The math might work out for Paul, but not for my uncle, who skated by on less than $20,000 a year. HSAs are hardly realistic. Even if he were to hypothetically save 2.5% of his income for thirty years (which is nearly impossible, the poor spend everything they earn) and receive a 5% annual interest rate, he would still only end up saving approximately $30,000. He hospital bill well exceeded $30,000 the first night he spent under surgery.

Worse yet, Paul believes that all foreign aid should be rescinded.

This includes successful programs such as the President’s Emergency Plan For AIDS Relief (PEPFAR), which has provided HIV medications for more than 1.2 million people in Africa. Paul believes the private sector should provide these funds and made all kinds of grand predictions about PEPFAR that didn’t come true. Here’s Paul on PEPFAR, spouting the same condescending and borderline racist nonsense that he disavowed from his newsletters:

“I concede it’s very well intended,” Rep. Ron Paul said, “[but] I think if we’re going to be doing any social engineering or social suggestions it ought to be here, and we ought not be naive enough to believe we can change habits that occur in Africa.”

In discussion of foreign aid, he ignores that fact that the Global Fund to Fight HIV, TB, and Malaria is overwhelmingly funded by public sources. The private sector provides a little chump change to improve their sales figures (e.g. the (RED) Campaign) but in reality, nothing substantive in comparison to public funding. Please note that Bill Gates is the exception, not the rule.

A Paul presidency would mean that scores of people around the world would die, simply for the crime of having been born poor and not having a little blue passport. It pains me to laud the health successes of the Bush Presidency, however, the Obama Administration has been embarrassingly lackluster compared to Bush, barely mentioning world health issues in his four years in office. I fear that the rise of extreme right-wingers like Paul signals a general indifference of America—and not only to world health issues—and that the day will come when programs such as PEPFAR are lost to history.

Paul’s attitude toward health care is akin to Jehovah’s witnesses who refuse to provide blood transfusions to dying children. He would let the world suffer and die for the sake of a pig-headed adherence to a limited ideology but what else should we expect form the guy who supports nuclear proliferation?

Václav Havel, the former dissident-turned-President of Czechoslovakia who just passed away this past December, argued in his seminal essay, The Power of the Powerless: Citizens Against the State in Central-Eastern Europe, that, “Ideology, in creating a bridge of excuses between the system and the individual, spans the abyss between the aims of the system and the aims of life. It pretends that the requirements of the system derive from the requirements of life.” Unfortunately for my uncle and millions like him, ideology is a prescription destined to fail each and every time. For Paul, it’s a talking point engineered to sell more newsletters and pad his pockets.

Domestically, the health concerns of the poor are not to be heard on the campaign trail. Republican voters simply don’t want to hear about it. Worse yet, conversations about Paul’s health care policy are absent amongst his youngest supporters, who seem to be more concerned about legalizing weed and the waning wars in Afghanistan and Iraq. The young and healthy, it seems, think little about the sick.

Fortunately, Paul will not become President. His ascendency, however, signals that a large sector of America is comfortable letting people like my uncle die.