Freewheel Burning

In lieau of an actual post….

Despite making up only 37% of the state population, African Americans account for 78% of HIV cases[1]. HIV infections nationwide are increasing rapidly among African American women(find ref). In 2000, Rural Mississippi had the second  highest incidence of HIV of any region in the country, and heterosexual transmission of HIV was highest in Mississippi, compared with other states[2].  State policies such as abstinence only education, low access to health services and policies which prevent individuals from entering the system until they have full AIDS are exacerbating transmission[3]. HIV in Mississippi has long been shown to be disproportionately high in rural African-American compared with urban and rural whites[4]. Among HIV infected pregnant women, African-American women far outnumber women of other ethnicities, are less likely to present to clinics and more likely to have co-infections with other STIs[5].  Incarceration has been shown to be associated with HIV/Hep C co-infections[6].

Adherence to treatment regimens is affected by lifestyle factors such as drinking and drug use, individual symptoms of depression and social attitudes which stigmatize HIV infected individuals in rural Southern populations [7]. HIV transmission in rural areas of Mississippi has been shown to occur through heterosexual contact and partnerships largely occur between older men and very young women[8]. In urban areas, HIV transmission among MSM has been well documented. Increases in incidence rates of MSM in the urban South is higher than that of MSM in all other regions combined[9]. Like heterosexual partnerships among African-Americans in rural Mississippi that results in HIV transmission, age disparities among MSM pairings are highly associated with HIV transmission[10]. Rural African American male HIV cases were more likely to report being IDUs, were more likely to report concurrent sexual pairings and to report having exchanged sex for money than urban cases. Urban cases, however, were less likely to use condoms than rural HIV positive individuals. These results suggest vast differences in the nature of sexual pairings and thus opportunities for HIV transmission between urban and rural African American populations[11].

Mississippi has one of the highest incarceration rates in the country, and prison populations tend to be overwhelmingly African American and male[12]. Prisons and crime are known to be associated with HIV transmission[13].  Among formerly incarcerated HIV positive males residing in rural areas, those with larger number of past arrests are associated with more sexual pairings, are less likely to use condoms and more likely to buy or sell sex[14]. Risky sexual behavior among parolees has been shown other contexts to be common[15].

Migration which might affect spatial data quality appears to not coincident with HIV diagnosis. One study concluded that although IDUs were more likely than others to change location of residence following diagnosis of HIV, in general HIV transmission in new HIV cases in rural Mississippi and Alabama appears to be occurring locally[16].

 

1.            Mississippi State Department of Health SHO: Reported cases of HIV disease in Mississippi, 2010. Jackson, MS: Mississippi State Department of Health, STD/HIV Office; 2010.

2.            Hall HI, Li J, McKenna MT: HIV in Predominantly Rural Areas of the United States. The Journal of Rural Health 2005, 21:245-253.

3.            Talha Khan B: State policies worsen HIV/AIDS crisis in Mississippi. The Lancet, 377:1994.

4.            Young RA, Feldman S, Brackin B: HIV SEROPREVALENCE AMONG ADOLESCENT MISSISSIPPI SEXUALLY TRANSMITTED DISEASE (STD) CLINIC ATTENDEES-IS THIS A RURAL EPIDEMIC? Southern Medical Journal 1990, 83:2-103.

5.            Rana AI, Gillani FS, Flanigan TP, Nash BT, Beckwith CG: Follow-up care among HIV-infected pregnant women in Mississippi. Journal of women’s health (2002) 2010, 19:1863-1867.

6.            Burton MJ, Reilly KH, Penman A: Incarceration as a risk factor for hepatitis C virus (HCV) and human immunodeficiency virus (HIV) co-infection in Mississippi. Journal of health care for the poor and underserved 2010, 21:1194.

7.            Amico KR, Konkle-Parker DJ, Cornman DH, Barta WD, Ferrer R, Norton WE, Trayling C, Shuper P, Fisher JD, Fisher WA: Reasons for ART non-adherence in the Deep South: adherence needs of a sample of HIV-positive patients in Mississippi. AIDS care 2007, 19:1210-1218.

8.            Cluster of HIV-Infected Adolescents and Young Adults–Mississippi, 1999. JAMA: The Journal of the American Medical Association 2000, 284:1916-1917.

9.            Mena L, Johnson K, Thompson C, Thomas P, Toledo C, Heffelfinger J, Sutton M, Ellington R, Larkins T, Rynn L, et al: HIV Infection Among Young Black Men Who Have Sex With Men-Jackson, Mississippi, 2006-2008 (Reprinted from MMWR, vol 58, pg 77-81, 2009). JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION 2009, 301:1428-1429.

10.          Oster AM, Dorell CG, Mena LA, Thomas PE, Toledo CA, Heffelfinger JD: HIV risk among young African American men who have sex with men: a case-control study in Mississippi. American journal of public health 2011, 101:137-143.

11.          Williams PB, Sallar AM: HIV/AIDS and African American men: urban-rural differentials in sexual behavior, HIV knowledge, and attitude towards condoms use. Journal of the National Medical Association 2010, 102:1139-1149.

12.          Stemen D, Sorensen J: The Effect of State Sentencing Policies on Incarceration Rates. Crime & Delinquency 2002, 48:456-475.

13.          Okie S: Sex, Drugs, Prisons, and HIV. The New England Journal of Medicine 2007, 356:105-108.

14.          Oser CB, Leukefeld CG, Cosentino-Boehm A, Havens JR: Rural HIV: Brief interventions for felony probationers. American Journal of Criminal Justice 2006, 31:125-143.

15.          Morrow KM: HIV, STD, and hepatitis risk behaviors of young men before and after incarceration. AIDS care 2009, 21:235-243.

16.          Agee BS, Funkhouser E, Roseman JM, Fawall H, Holmberg SD, Vermund SH: Migration patterns following HIV diagnosis among adults residing in the nonurban Deep South. AIDS CARE-PSYCHOLOGICAL AND SOCIO-MEDICAL ASPECTS OF AIDS/HIV 2006, 18:S51-S58.

 

Anyone who has been to a grocery store in the past 2 years can tell you that food prices have increased. Intuitively, one would think that a few key factors have contributed to this rise in food costs.

Rising fuel prices increase the price of delivery. Rising demand for food from an increasing world population, and demand for protein rich foods from a rapidly urbanizing world, specifically from the emerging economies of China, India and Brazil increase demand for grains. A turn toward using biofuels increases competition for grains that would normally go to feed humans and livestock. Climate change and extreme weather events create a volatile agricultural market.

However, despite all these very obvious players, the amount of volatility seen in the food commodity markets is unprecedented. Agricultural production, though regionally volatile, has not experienced the same level of fluctuation as that of prices in the food commodities markets. Energy demand and production, though increasing, also do not exhibit the same behavior. Conflicts have negatively affected market prices in certain commodities, most notably that of cocoa due to recent political conflict in the Ivory Coast, but, the large ag-producing countries of the United States, China, India and Brazil have experienced no such disruptions. In fact, China and Brazil, despite a growing population and experiencing an expansion of the middle class, are still largely able to maintain food security.

In short, demand is rising, though not volatile. Supply also, is rising, though not volatile. One can make the argument that volatility in the oil markets is spilling over into grain commodity markets, but biofuels still only account for a small percentage of energy use. These factors do little to explain the large fluctation of the of the food commodity markets that we are experiencing today.

According to a UN Conference on Trade and Development report

• “these factors (rising food demand, biofuels, climate change) alone are not sufficient to explain recent commodity price developments; another major factor is the financialization of commodity markets. Its importance has increased significantly since about 2004, as reflected in rising volumes of financial investments in commodity derivatives markets – both at exchanges and over the counter (OTC). This phenomenon is a serious concern, because the activities of financial participants tend to drive commodity prices away from levels justified by market fundamentals, with negative effects both on producers and consumers.”-UNCTAD, 2011

Prior to the private equity bubble (remember the dot-com bubble?) of 2000, financial markets relied on investments into stock equities. Following the burst of what was up until then an unheard of rise in the financial markets, investors, speculators and hedge fund managers moved increasingly toward commodities investments outside of the traditional equity markets. Financial investors seeking new opportunities, moved toward to commodities markers, including oil and food, anticipating rising worldwide demand. Commodities of all kinds were financialized and brought into the portfolios of hedge funds and money markets.

I am not an economist. Through my limited understanding of futures markets, I think that what I understand is this: Prices of commodities are usually set on a supply and demand basis, with considerable elasticity. If one wants to buy gold, for example, demand and supply work to set prices. If one wants to take advantage of cheap gold now, all one has to do is buy and store to sell it later. The storage costs must be rolled into the final resale price. With oil and agriculture, the model is similar, but these commodities can only be stored temporarily, before they are unsalable (rot). Thus, as there is little to hedge against future risk, speculators will buy contracts for future, as yet unproduced, goods at set prices. This practice is not uncommon and was originally conceived to protect American and European farmers from risk and to insure consistent supply and price in the market.

What is different now is that interest prices are rolled in based on the length of contract, linking worldwide financial markets with the prices of commodities and distorting the true supply and demand relationship. As futures, by definition, are conceived to protect investors from risk, they are a perfect target for large hedge funds, which protect large investors from long term risk. The tying of interest rates into commodity prices means that end prices will fluctuate wildly with the market, while protecting investors from losing their shirts.

One important way that hedge funds minimize long term risk, is thorugh machine trading. Computers and mathematical models available market information, predict future fluctuations and sell when necessary. What this does is insert an even greater level of volatility into the market. Sudden sales of commodity futures will induce other funds to sell as well, creating a herd effect of commodity sales that has little to do with true supply and demand models. Imagine how flocks of birds or schools of fish move in response to one change in direction by a member of the group and you can get an appreciation for how machine trading works.

We are already see the effects of the financialization of food commodities. There was an unprecedented rise in food prices during the period of 2000-2007. The financial crash of 2007, brought in part by the activities of the very same financial players that are driving food prices up, saw a drop in prices, but as the market rebounds, prices are increasing once again, now higher on average than they were in 2007.

In fact, futures markets in commodities are exploding with the number of contracts rising to never before seen levels over the past decade as can be seen in the figure to the right.

Der Spiegel recently penned an excellent article on the rising price of food. In it, they spotlighted scumbag of the week, Alan Knuckman. Mr. Knuckman and a host of other US and worldwide speculators are unconcerned as long as the money is flowing to them. To Mr. Knuckman, he could be investing in GM, a new chain of box hardware stores, big pharma, copper, oil or food for kids, it’s all the same as long as it brings him a profit. In fact, he is quoted as saying, without a hint of irony, “the age of cheap food is over. Most Americans eat too much, anyway.” Yep, these dirtbags are just like the rest of America, blind to whatever happens outside their own gated communities.

Rising food prices are not a problem for Americans. In fact, we only use, on average, 13% of our income on food. In places like Kenya, however, food can consume nearly 100% of a household’s monthly income. In Kenya, food must be imported to account for shortages due to underdeveloped ag and transportation infrastructure, which prevents Kenyans from protecting themselves against extreme weather events and disruptions in supply. Even a 1% shift in the worldwide price of food can spell death for an Kenyan infant. What we have seen, however, is not a 1% shift, but rather a 71% increase in the worldwide price of grains since 2007. In Kenya, the price of corn meal has shot up 100% in the past five months. To Knuckman, this is just “an undesirable side effect of the market,” kind of like having to drink coffee that sat in the pot too long and turned bitter.

Truthfully, there is little attention paid to that which the US Federal Government gets right. News coverage continually conflates government and politics. Recently they have turned into sounding boards for self-interested groups which unfairly malign public entities and public employees and seek to dismantle all public services from education to environmental protection to parks management. Nearly zero airtime is given to those in the US Government who get it right.

That is why I’d like to introduce my new government hero, Todd Park. Todd is Chief Technology Officer at the Department of Health and Human Services and should be our next head of state.

Todd, through funding under the Affordable Health Care Act, is responsible for helping the HHS leadership “harness the power of data, technology, and innovation to improve the health and welfare of the nation.” Todd vision is simple. Several departments at all levels of government routinely collect data. As an example, the National Oceanic and Atmospheric Administration (NOAA) collects weather data from around the world. This data is not only essential for determining whether you should carry an umbrella to work tomorrow, but also essential to local planners, disaster preparedness, aviation and military planning. NOAA took the extra step of not only making the data available internally, but also has posted all of it on their website for use by anyone at no cost. That’s right, NOAA data is completely free.

The private sector, not willing to let an opportunity to make a buck pass, has siezed the opportunity to capitalize on this tax payer funded system to produce such heavyweights as The Weather Channel, weather.com, AccuWeather and your local news station.

Todd believes that the same model can be applied to the wealth of public health and medical data that the government collects anyway. He, while protecting the privacy of individuals, approaches businesses to develop ways to create new and innovative ways to create profitable opportunities for the private sector, putting people to work AND improving the public health in the process.

He doesn’t just want to offer it to them, he also wants to offer it to the rest of us as well, and wants to make sure that the data is absolutely free. This strategy not only benefits nerdy researchers like myself, but also creates entrepreneurial opportunities for anybody with a good, moneymaking idea.

Todd believes in what he does, and his successes have already been documented. On top of that, he’s an amazing speaker, perpperiong his impassioned sell of government public health data with a litany of Star Wars references. America needs to hear people like Todd Park speak, if only to get them excited about the things that government does right.

In Africa, western medicine often has to compete with it’s indigenous counterpart. Traditional herbalists have long offered medical services to the ill, treating a variety of physical ailments and offering help to the injured and sick. Some merely offer herbal services, but others offer assist in the treatment of spiritual illnesses. Diagnosis of disease however, is a holistic matter, where practitioners look into the spiritual nature of the patient to discover answers to the type of ailment and the strategy of treatment. If ones looks hard enough, one can find herbalists on the outskirts of public markets. Often though, they wait by the entrance to standard hospitals, offering there products to anyone who passes by. Where western medicine fails, herbalists readily provide.

Many readily discredit herbalists and traditional medicine, but its my view that the characterization of fraudsters and hacks are undeserved. Herbalists often come from a long blood line of traditional doctors, and recipes are handed down and modified from father to son. Both of the herbalists I spoke with indicated that they first learned their trades from their parents or relatives.

Herbalists in Malawi are licensed to practice by the Malawian government and their legitimacy formally preserved. The Malawi Medical Practitioners and Dentists Act of 1987 protects the rights of traditional healers and herbalists to practice their trades in Malawi, assuming that life is not threatened:

“Nothing contained in this act will be construed to prohibit or prevent the practice of any African system of therapeutics by such persons in Malawi, provided that nothing in this section shall be construed to authorize performance by a person practising any African system of therapeutics of any act which is dangerous to life.”

Medications are intended for a variety of conditions, a few of which I list here. These were the medications which appeared in the short video I shot below:

1. Kuthenta Mapadzi – Medication for aching joints and feet

2. Mauka – for pain in urination, likely due to urinary tract infections or sexually transmitted infections

3. Konjzela Mphamvu - an aphrodisiac and sexual enhancement medication

4. High blood pressure medication

5. Back pain

6. Burns on the hands or body

7. Any type of problems at all, it appears to be an aspirin like medication

8. Chibayo - for kidney problems

9. Kudya Kanzanza - medication for diarrhea

10. Eye problems

11. Njohka - for cases of intestinal worms

Not surprisingly, most of these medications are for chronic conditions associated with aging. Medical service in Malawi, being as rudimentary as it is, likely cannot accommodate more serious chronic diseases. Thus, herbalists provide some level of relief for desperate patients. I asked the gentleman if he treats malaria, a disease readily treatable with western pharmaceuticals. He readily said no, that when patients come to him with malaria, he sends them to the local health facility. With the exception of basic pain killers and some anti-helminthic meds, none of his treatments were for commonly treatable conditions.

This is not to say that herbalist medications do not work. In fact, I am positive that at least some of them do. In contrast to more ambiguous forms of care, such as spiritual healing, traditional medicines cannot be completley ineffective. The ingredients in at least some of the medications are likely the same ingredients of more expensive factory produced meds. Studies of traditional medicines have been performed in the past, but it has only been recently that western practitioners have begun to take them seriously. The anit-helminthic and anti-diarrheal meds likely work to some level. I know that marijuana is commonly used throughout Malawi as a means of controlling nasuea during malaria episodes in adults. By probably no coincidence at all, traditional herbal meds to treat malaria in Tanzania contain cannabis.

My conversations with both of these men revealed immensely proud and professional medical practitioners. Both of them readily and openly discussed their craft with me as clinicians and not as charlatans. Neither one attempted to sell me any type of medication. Perhaps if I had gone to one complaining of some physical ailment, one might have. As with western doctors, there is no sense in treating those who are not ill.

Interesting to me was the method of packaging and sales, which follows a western paradigm. Medications are packed at pills, given at particular dosages from clearly marked containers. While the methods of pharmaceautical creation and diagnostic strategies may be as they were before Colonialization, the practice has clearly been absorbed into a standard western paradigm of licenses and packaging. In my experience, most things in Africa, from medicine to music to religion, are a fascinating reinvented mix of indigenous and western, producing something new and old at the same time in contrast to merely adapting new ideas to sell to a local population. Malawians, while in some ways very conservative, are in other ways a very curious and inquisitive people, eager to explore and integrate new ideas into everyday life.

Below is a short video I made while conversing with an herbalist in the Limbe Market last month.

Although I know many that go without, anyone travelling to a malaria rich area like Sub-Saharan Africa, should take anti-malarial meds. It’s almost stereotypical, and is seen by many as a symbol of the colossal failure of African economies to create hygienic environments, or an indication of the terrifying blackness of Conrad’s “Dark Continent” spoken to scare privileged white children at night. The truth is, that it’s only been in the past 60 years that the United States successfully eliminated malaria, and even more recently that Europe experienced it’s last indigenous cases. For the rest of the world, malaria is still a fact of life, such as that which has been the norm for all of human history. To this day, the number one killer of children worldwide is malaria.

Meds now have come a long way since the discovery of quinine, a miracle drug which allowed the white man penetrate his parasitic, resource extracting tentacles ever deeper into the African continent. Now, for those of us who were not born in a malarious area, we can safely travel to places which would likely kill us, or leave us incapacitated to the point where we wished we would die. Some medications are more expensive than others, but they all have a similar bizarre side-effect which varies in intensity according to how much you are willing to pay. Anti-malaria meds induce nightmares.

I don’t dream, or, should I say, I don’t remember my dreams, perhaps mostly because I don’t sleep well. However, on malaria meds, I do. These dreams are graphic to the point of being past NC-17, vivid and detailed visions of bloody dissections and exposed bone, of horrid beasts and killings performed with the precision of a scientist. It’s frightening to wake up from one of them, as the thread between dream state and awake state is often thin under the fog of being rustled from mid-sleep. The world is often still tainted with the color of blood red and pristine white bone matter against a back drop of gray tinged blackness that seemingly extends without bound. Fortunately, the details are quickly forgotten.

While the nightmares are reportedly milder on the meds I take (Malarone, $3.00 a pill, taken every day), persons who take cheaper meds such as Doxycycline and Mefloquine report graphic visions, sometimes leading to the point of insanity. Doxycycline prescriptions often recommend a psych evaluation. The suicide rate on Doxy is extremely high, one of the highest of all prescription meds, and the context in which they are taken likely doesn’t help. Women report commonly of graphic sexual assaults, almost as if the drug plays on the individuals greatest fears. During waking hours, hallucinations on Doxy are common.

For many that come to countries in Sub-Saharan Africa, the reality of actual human suffering, insanity and depravity comes as a shock. Against a back drop of contented smiles and a level of happiness absolutely unknown in the depressed and debilitatingly lonely developed world, one sees evidence of the spoils of disease. Walking TB and HIV cases publicly teeter on the cusp of death. Common are the scars of burns, some perhaps intentional, and mysterious lesions that could be the results of accidents or attacks. Worse yet is the linear gash of a panga knife across a head or face, remaining as a testament to the incredible violence that Africa is famous for.

Conversations with Africans will reveal that incredible 1 in 10 people, who tell tales of seeking refuge after entire witnessing entire families murdered in the midst of conflicts like the 30 year Mozambiquan civil war, of abductions by rebels in Somalia or of witnessing the decomposing results of mass killings by rebel groups. It’s a fucked up thing, and although the US is no stranger to violence, we do a much better job of keeping its victims sequestered silently away. Here, people will smile and casually relate horrific stories of senseless and disgusting violence as if relating any other past memory. In the US, we’re not allowed to talk in real terms about violence, and if we do, we’re considered weak and somehow deserving of our fate. Here, it’s a fact of life.

My feeling is that suicides on Doxy and Mefloquine are fed by this grim and terrible reality and the inability to parse out the apparent contradictions between a continent full of some of the most mild mannered people on the planet, and the incredible capacity for mass insanity and bloodshed. We rationalize things in the west, occupying our own separate compartments at the bottom of a greater hierarchy of powers. The heart is contained within the mind, which is contained in the body which is contained in the family, in the social group on up to the greater order of things. Here, the only order is as much that can be given on a day to day basis, security is only in the preservation of precious friendships and family relations, evidenced in Malawians incredible ability to remember those who even only casually pass through their beautiful country.

 

While everyone is focused on the uprising in Egypt, part way around the world, Thailand and Cambodia are killing each other over a temple and the conflict threatens to kill millions of children on a completely different continent. Last year, UNESCO certified the Preah Vihear a World Heritage Site, and recognized it as rightfully belonging to Cambodia. Thailand across the border, likely in hopes of capitalizing of the vast tourist dollars (bhat?) which flow out of such sites, exploded, triggering a series of border clashes which have resulted in several deaths and the displacement of thousands of residents living along the border areas.

This strong arming of Cambodia over temple sites is not new to Thailand’s pattern of aggression against it’s neighbors. Angkor Wat, an internationally famous temple site, despite lying more than 150 miles from the Thai border, has long been claimed by Thailand. Conservative voices within Thailand have called for the Thai government to forcibly take Angkor Wat as a bargaining chip against Preah Vihear which would undoubtedly lead to an all out war between Thailand and Cambodia.

This not only poses a threat to regional and local stability and presents a danger to an important historical landmark, but also threatens efforts to contain a strain of drug-resistant malaria. After vast selective adaptation of P. falciparum malaria to standard malarial medications, Artemisinin Combination Therapy, a cocktail of malaria medications is the end of the line for effective treatments that prevent death from one of the world’s biggest killers. Recently, artemisenin resistant strains of malaria have been found in southeast Asia along the Thai-Cambodian border. Vast efforts are being undertaken to contain it’s spread.

It is widely feared that the strain will reach Sub-Saharan Africa, where ACTs are being successfully used to prevent mortality in children. If it does reach SSA, treatment efforts will be undermined and clinicians expect incredible spikes in childhood deaths. ACTs are expensive compared to other medications, but effective. Unfortunately, they are thought to be the last of effective treatments against malaria for the near future. If an artemisinin resistant strain of P. falciparum spread out of the border regions, it will likely reach sub-Saharan Africa in months. If this comes to pass, it is thought that millions more children will die than do already.

Border regions in any country are hot beds of poverty, violence and infectious disease which does much to explain why deadly strain of malaria are able to propagate along the Thai-Cambodian border. Containment efforts by public health groups are now undermined due to the senseless violence. Clinics are no longer able to effectively operate in the area. Displacement and instability forces residents to live in conditions conducive to the transmission of malaria, making a bad situation even worse, exacerbating the spread of dangerous strains of the disease.

All this over a single temple.

It what was a landmark triumph of science over warfare, Dr. Louise Reiss single-handedly put an end to nuclear testing in the United States in 1959. Collecting more than 300,000 baby teeth from the St. Louis, Reiss was able to demonstrate that the levels of radioactive agents in teeth post nuclear testing were significantly higher than before. The implication was that fallout from nuclear testing was entering the food supply and placing the American population at elevated risk for a host of negative health outcomes. President Kennedy, recognized the results of the study and successfully worked in a worldwide ban on atmospheric nuclear testing with the cooperation of the Soviet Union.

One can only assume that Reiss’ study, had it been performed in 2011, would have been widely discredited and decried as fabricated science and a threat to national security. Thankfully, the powers on both sides of the Cold War saw fit to put human health above the ability to wipe out all life on earth. The data and samples collected from her study, continue to this day.

I don’t know where this graphic came from, but it’s reportedly an anti-smoking sign from the town of Zion, Illinois, erected in 1915. The second sentence is classic.

Clearly, it was well known that cigarettes caused cancer and strokes, even back in 1915, despite the tobacco industry’s fight against scientific claims that carried well into the 60′s and 70′s.

Zion, apparently, was founded as a Christian oasis in a country fraught with sin by a Mr. John Alexander Dowie. In addition to regular (and popular) faith healings, he was also known for waging a “Prayer Duel” with self-appointed Muslim prophet, Hadhrat Mirza Ghulam Ahmad. Ahmad was a complicated figure himself.

It was said that whoever died first during the duel would be exposed as a fraud. Dowie died a year before Ahmad of alcoholism.

Afghanistan’s health profile could be considered to be the worst in the entire world. Infant (1.65/10 births) and maternal mortality (1.4/100 births) are high and life expectancy short (46 years) (World Bank) After years of warfare, an anti-woman Taliban regime, it can be said that even the most basic of health needs have remained unattended to, largely ignored and out of the public discourse.

In 2002, post invasion, the Afghan Ministry of Public Health along with the World Health Organization, UNICEF and United Nations Population Fund established a framework of basic services, which included essential mother-child health care, basic vaccinations, control of TB and malaria, nutrition and basic mental health services. Tuberculosis and malaria (largely vivax) run rampant throughout Afghanistan. Through the proactive efforts of Rural Expansion of Afghanistan’s Community Based Health Care, health care access in Afghanistan has gone from 40 to 77 percent in the past 8 years, but that still leaves more than 7 million people without any access to even the most basic of care. To put it in perspective, this would be equivalent to the entire population of Michigan having no access to any type of health care at all.

While pictures we see of Afghanistan here are largely from the large population center of Kabul, it is forgotten that Afghanistan is roughly the size of Texas and provides home to nearly 30 million people. Afghan residents are spread in nearly every quarter of Afghanistan and largely have little access to basics such as electricity and schools. One of the poorest countries and lagely inaccessible places on the planet, it is no surprise that the country has massive internal challenges to surpass.

Afghan Health Services

The Afghan MoPH maintains a listing of all Basic Package of Health Services facilities throughout the country and has made a database freely available online. There are nearly 800 facilities spread throughout Afghanistan, consisting of District Hospitals, Basic Health Centers and Mother Child Health Clinics. Kabul has the largest number of facilities at 79. Assuming the 115 District Hospitals accept any Afghani seeking care, the average catchment of an Afghan District Hospital would include nearly 270,000 people. To put this into perspective, Michigan, with a population of approximately 10 million people, has nearly 1,320 hospitals. That’s one hospital for 8000 people. Accounting for population and potential catchment areas, there are hospitals (that are likely understaffed and underfunded) which serve more than 1.7 million potential patients (Chahar Burjak Hospital), whereas hospitals near Kabul and Kandahar which serve less than 200,000 people, still an incredible number when placed against the United States.

Hospital Catchment Areas and Civilian Casualties

It is doubtful that local small health facilities are equipped to handle seriously injured individuals. Thus, civilians wounded in conflict events must either make their way to a district hospital, hope for the best from the local facility or do nothing and potentially die. Thus, it would be of interest which facilities potentially serve the largest number of civilian casualties and where they might be located. The map on the right shows the number of civilian casualties as a function of the underlying catchment population. The units in the legend are odd due the the catchments being in millions, but the relative color scales not. Facilities in the southern districts are disproportionately overloaded due the high number of civilian casualties within their respective catchments.

Geographic Access to Health Services
Hospital access, in addition to overburdend by the sheer numbers of the surrounding population are mostly inaccessible to the Afghan population, as the figure on the left confirms. Accounting for elevation, slope and the rudimentary road system, the brunt of Afghanistan has no access to health services. Most areas of Afghanistan are located more than 300 or more kilometers from the nearest hospital.in developing country contexts, 5 km or more is considered to be a market of lack of access to health services. As in all developing countries, facility utilization is strongly related to proximity to services (O’Donnell 2007).

Conflict Events at Health Facilities

Although completely reprehensible, conflict events do occur at health facilities, particularly those which are located in urban areas. The recent “Afghan War Diary”, unfortunately, confirms that they not only have occurred, but are fairly commonplace. For the purpose of this analysis, I considered any event within 100 meters of a health facility to be at the facility itself. Summing over all the events within the 100m buffer, I discovered that none to as many as 25 events occur at facilities, specifically at the Hilmand District Hospital.As many as 31 people have died in attacks on health facilities, and as many as 13 have been wounded in events on or directly proximal to a hospital or clinic. It is well worth noting, that the largest numbers of attacks on health facilities occurs not within crowded Kabul, but rather in the rural northern areas.

Relationship of Distance from Health Facility to Civilian Casualties

Calculating the mean number of casualties per facility by deciles of distance to health facility from the conflict event, I found that the most casualties occur near facilities. Facilities are often located near infrastructure and market centers, raising the likelihood of civilian casualty should a conflict event occur. yet, this calculation is restricted to actual events. Although the mean difference is only slight, the pattern of decreasing death and injury with distance is striking. However, without data on the distribution of households in relation to health facilities, true effects are difficult to determine.

Environmental Determinants of Civilian Casualties

Using available data from GIS sources, such as elevation, distance to water, distance to roadways and distance to nearest health facility, I was able to relate the number of wounded civilians in a conflict event to environmental variables. Using a negative binomial model to determine the statistical significance of possible predictive covariates, I found a best model included only distance to road and distance to the nearest health facility. In fact, both variables required a quadratic term, and both distance to road and distance to health facilities were related to a sharp decrease in civilian casualties as distance increased. Analyzing the estimated coefficients, I found that civilian deaths were at a minimum at 20 km from the nearest health facility, and 7 kilometers from the nearest road. Both were at a maximum directly at the facility, and at the road. This result is, or course, hardly surprising, as people most often reside close to road and close to infrastructure. Still, the pattern of these two variables was interesting, and more interesting was that both retained significance even when included in the same model.

Call:
glm.nb(formula = CivilianCasu ~ DisttoHF + DisttoHF2 + DisttoRoad + DisttoRoad2,
data = subx, init.theta = 0.05989177641, link = log)

Coefficients:

	Estimate	Std. Error	z value	Pr(>|z|)
(Intercept)	-0.8944109	0.0708122	-12.631	< 2e-16 ***
Distance to health facility	-0.0806837	0.0116815	-6.907	4.95e-12 ***
Distance to health facility^2	0.0023833	0.0003205	7.437	1.03e-13 ***
Distance to Road	-7.7975250	2.0432720	-3.816	0.000136 ***
Distance to Road^2	24.6081933	9.8147377	2.507	0.012167 *

—
Signif. codes: 0 ‘***’ 0.001 ‘**’ 0.01 ‘*’ 0.05 ‘.’ 0.1 ‘ ’ 1

AIC: 14192

Conclusions

The Afghani health system, already strained to the gills with immense public health challenges, suffers under the brunt of a lack of public funds in a non-existent economy, warfare, a dearth of trained physicians and the massive populations which they must serve. That conflict events which result in civilian casualties occur in the proximity to health facilities is unforgiveable and all parties in this senseless conflict would do well to respect the safety of the Afghani civilian population. While the outlook under the present government is miles above that which existed (or didn’t) under the Taliban, there is still much to do.

References

O’DONNELL, Owen. Access to health care in developing countries: breaking down demand side barriers. Cad. Saúde Pública [online]. 2007, vol.23, n.12 [cited 2010-11-23], pp. 2820-2834 . Available from: . ISSN 0102-311X. doi: 10.1590/S0102-311X2007001200003.

Zwarenstein, M., D. Krige, and B. Wolff. 1991. The use of a geographical information system for hospital catchment area research in Natal/KwaZulu. South African Medical Journal 80: 497-500.

Most people who know me know that I grew up in Mississippi. Everyone who knows that I grew up in Mississippi knows the extent of my disdain for the place. However, I’m thankful for having had the experience, as it has informed much of the kind of person I’ve become, for better or worse. It’s a place filled with incredible challenges and problems, economic inequality is incredible and those on top aren’t interested in the problems of those on bottom. Compound this with a bloody and inexcusable history of slavery, human trafficking, lynchings and hate motivated violence that extended even to my lifetime and you might conclude that Mississippi is an extension of Africa. All of this lined along a background Muzak of Jesus, hellfire and unattainable moral standards that few people actually adhere to. My assessments might seem unfair, but it’s worth mentioning that they are largely fueled through my childhood and high school eyes, rather than adult reason.

Mississippi is already a hotspot for STI’s, with infection rates dwarfing many other states in the union, often on par with those of developing countries. People still die of syphilis in Mississippi in 2010. Low insurance coverage among the largely African American poor, distrust in medical professionals through the fault of exploitative and unforgivable events such as the famed Tuskegee syphilis study, lack of education, lack of political will and political representation create conditions that fuel the spread of a host of infectious diseases, not the least of which is HIV.

HIV is hitting the American South at levels not seen in any other part of the country, outside of Washington, D.C. Most people living with HIV are heterosexual African American men, and African American women aren’t far behind. Mississippi jails more people per capita than any other state besides Louisiana, Georgia and Texas. Incarcerations among African American men are common in the South, often under reprehensible conditions that facilitate HIV transmission. Couple that with social conditions that are unfathomable in other parts of the country (outside of Native American reservations), and it’s easy to see why it’s so bad.

I pulled a table of county level HIV data for Mississippi of of the Mississippi State Department of Health website and fed it into ArcGIS to produce the map above. Logically, population centers produce the largest number of overall cases. However, adjusted rates indicate that the large urban centers (of which there aren’t that many), are not the places facing the highest overall spread of the disease, but rather areas along the Mississippi Delta and traditionally African American counties proximal to Hinds (where Jackson is) are.

A Getis-Ord hot spot analysis finds areas that deviate greatly from the overall mean, both above and below. Basically, it points out areas where the outcome is extreme, relative to everyone else. An analysis of HIV rates for Mississippi counties confirms the existence of areas of extreme concern, when accounting for neighbor effects and overall mean rates. From this, we conclude that rural Holmes and Leflore counties in the middle of the state are by far the worst. While counties in the north and northeast are disproportionately low, these counties west and north of Hinds are of incredible concern. I’ve been to these places. I don’t find this results surprising. I also don’t find it surprising that very few people care.