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Today is Jonas Salk’s 100th birthday

100 years ago today, Jonas Salk was born. As the creator of the inactivated polio vaccine, he not only changed the course of human history, he also ushered changed the field of public health forever. We can count the polio vaccines and the elimination of smallpox as probably the two great success of public health.

In its mildest form, polio causes a mild bout of diarrhea. In its worst form, the virus migrates to the spine, impedes development and causes debilitating long term paralysis. My grandfather was struck with the disease and had one of his legs stunted and weakened (though he managed to serve in WWII anyway as a Marine). A carpenter who worked for me a while back died due to long term respiratory complications from a childhood polio infection.

Polio is mostly foreign to anyone born in my generation. We were nearly all vaccinated, and the high levels of vaccination have destroyed opportunities for the virus to persist in the environment, protecting everyone, even those who don’t get the vaccine.

Unfortunately, though Salk’s achievements were great, medical care and attention to polio was hardly equitable and tainted by the racism of the time.

During the 1930s the systematic neglect of Black polio victims had become publicly visible and politically embarrassing. Most conspicuously, the polio rehabilitation center in Warm Springs, Ga, which Roosevelt, himself a polio survivor, had founded, accepted only White patients. This policy, reflecting the ubiquitous norm of race-segregated health facilities, was sustained by a persuasive scientific argument about polio itself. Blacks, medical experts insisted, were not susceptible to this disease, and therefore research and treatment efforts that focused on Black patients were neither medically necessary nor fiscally justified.[1]

It is likely true that African Americans experienced a lower burden of disease than white children. We now know that polio’s worst effect arise from the lack of acquired immunity to the disease. Repeated infections from infancy, most importantly during the first six months, when babies still have maternal antibodies to fight for them. Improvements to sanitation delayed exposure to the virus, so that children were not immune and thus more susceptible to the disease’s worst effects.

In short, polio is a disease of development, not underdevelopment. The horrible racism of the pre-civil rights medical system can’t be denied, but the observed disparities in disease incidence might have not been imagined given the disparities in sanitation and access to clean water.

Presently, we are fighting a battle to insure that all kids in Sub-Saharan Africa are vaccinated. However, there still exist pockets where the medical system so dysfunctional and the politics so chaotic, that vaccination rates are low and disease continues to flourish. In places like Afghanistan and Northern Nigeria, the hope of polio elimination is almost non-existent

 

1.    Rogers N: Race and the Politics of Polio: Warm Springs, Tuskegee, and the March of Dimes. American Journal of Public Health 2007, 97(5):784.

 

Ngugi wa Thiong’o and the language of NGOs

I just finished reading “Decolonizing the Mind,” a short book from perhaps Kenya’s greatest living writer, Ngugi wa Thiong’o. Ngugi is an interesting figure. Born into a peasant Kikuyu family in the fabricated colonial village of Kamiriithu in Central Province, he managed to take advantage of new educational opportunities during the colonial period and attended Makere University in Uganda and eventually Leeds in the UK. He returned to Kenya and eventually became Chairman of University of Nairobi’s Literature Department.

Though highly critical of colonialism, having been in the heart of the worst of Kenya’s experience with it, he was even more critical of Kenya’s post-colonial trajectory. He started a political theater in his hometown and was eventually jailed under the dictator Daniel Arap Moi.

In “Decolonizing the Mind,” Thiongo seeks to dissociate Kenya’s literature from that of the colonialists. He seeks to create a new African literature, by and for Africans. He would eventually abandon writing in English, choosing instead to write works in his native Gikuyu. Despite Thiongo’s call for an African literature, his European pedigree can’t be denied. He is Brechtian in both rhetoric and action. Hs politics are wholly Marxist and it can even be noted that his medium itself (the novel) is decidedly un-African. Moreover, despite his clear hostility to Europe and the United States, it is interesting the he would be jailed by his own countrymen and then would receive asylum and employment from the US.

I found his ideas of language, however, quite interesting. The colonialists, like the Americans, worked to debase indigenous cultural practices to further an imperialist agenda. Locals were weakened through the apparent dominance of English as a language for communication and business, and the language itself was presented in such a way that social hierarchies were reinforced.

This phenomenon continues to this day. Children are taught from an early age, to greet white people on the street with a scripted “How are you?” “I’m fine, and you?” The formal distance between the stilted Kenyan English spoken in Palirament and the guttural Sheng spoken on the streets of Nairobi is hardly an accident. English the language of oppression, control and government exploitation, and Sheng the language of resistance.

Given my recent experiences at Governmental and NGO meetings, however, what strikes me is how language continues to be used as a tool of control, but hat this vocabulary has been internalized by Kenyans themselves. I grit my teeth now when I head the term “capacity building,” which basically implies that people lack the capacity to help themselves without the good graces of NGOs and governmental organizations. It implies that people are helpless without the assistance of formal authoritarian structures. This is, of course, untrue (though one has to allow for the possibility that people often do things that run counter to their long term self-interest).

People may argue that the term is innocuous, but in my experience “capacity building” is often used in place of “training.” To me, words matter, and where “capacity building” carries with it the implications that there is an inherent defect to be rectified, training implies that the capability exists, but the knowledge not yet there. To put this in perspective, I don’t think that anyone would call any of my academic degrees to have been an exercise in “capacity building.” I can’t help but think that white people are trained, while black people are “capacity built.”

Worse yet is “gender empowerment,” which implies that women weren’t sufficiently capable of managing their own affairs prior to the arrival of some dubious microloan project. Again, in my experience, women all of the world are sufficiently empowered. It’s the men who need to be de-powered. The term is condescending and fails to appropriately recognize the inherent capabilities of individuals while at the same time avoids challenging the paternalistic structures which created economic disparities reprehensible practices like FGM, the buying and selling of women and the inability for women to hold men accountable for violence. In essence, the term blames the victim.

Both “capacity building” and “gender empowerment” reinforce the weakness of the individual and offer that the poor of Africa’s only hope lie in international organizations and their own authoritarian though wholly inept governments. It’s worth noting that the strategy is very similar to that of Christianity, which requires followers to believe themselves powerless and to blame for whatever awful fate has befallen them.

Sadly, both of these terms have worked themselves so deeply into the consciousness of people in SSA, that questioning their validity is futile, which is exactly the nightmare that Thiong’o writes of in “Decolonizing the Mind”. Pointing out that “training” is a more appropriate term than “capacity building” to locals will be met with black stares.

Who pays for development?

I was just reading this on the Guardian’s Poverty Matters blog:

First, identify the most important issues. One of the main problems of the MDGs, as noted in countless analyses, was their failure to bring the major structural issues to the table. I know of no one who thinks that aid is the most important contribution that wealthier countries can make to development, but the vague terms of MDG eight allowed politicians to get away with aid promises (which in some cases they didn’t keep) rather than setting a bold agenda for transformational change in global financial governance, dealing with illicit financial flows, for example, taking bold steps towards international tax reform, and introducing fairer mechanisms for working out debt repayments.

Well, yeah, very true, but again this type of reporting skirts the issue of where those illicit flows are coming from and who took out the loans. The problem with the MDGs was that it failed to put any pressure on leaders of developing countries to stop being parasites. Worse yet, they didn’t allow for the provision and protection of basic individual rights to free expression, judicial rights and economic freedom, instead opting for a few vague and unverifiable targets which failed to address structural problems WITHIN developing countries.

In Kenya, at least, the government is bleeding the populace dry. Evidence from countries such as Botswana and Korea has shown that countries who want to develop can. The biggest obstacle (among all the other obstacles) to development is a lack of political will to do it.

To its credit, the article goes on to point out that domestic ag subsidies in wealthy countries are distorting the world market and preventing developing countries from being competitive on the world market. Eliminating these subsidies will be a real challenge, at least in the US. First, subsidies control price and market volatilities. The US electorate would go bonkers if the price of food went up and down like the price of corn does in developing countries. Second, Americans simply like subsidies and enjoy protecting agricultural interests at all levels. The right likes to pander to farmers for the rural vote while the left is somewhat bummed out because their favorite organic farms don’t have access to them. Though the left loves to pay lip service to ending ag subsidies, I can’t imagine they’d be all that sad if they were offered to their local hippie farmers. That’s speculation for another day, however, and I’m no expert on ag matters.

I hate to be pessimistic about development, but the barriers to progress are hobbled by forces both within and without developing countries and no one seems to be tackling the right issues to improve matters.

The need to look for more than just malaria

I was just reading a comment in the new Journal of the American Society of Tropical Medicine and Hygiene “After Malaria is controlled, what next?”

Fortunately for all of our jobs, there is little to worry about. Malaria, as a complex environmental/political/economic public health problem, won’t be controlled anytime soon. As there’s no indication that many sub-Saharan countries will effectively ameliorate their political problems and also no sign that, despite the “Rising Africa” narrative, African countries will develop in such a way that economic rewards will trickle down to the poorest of the poor, malaria transmission will continue unabated. This is a horribly unfortunate outcome for the people, particularly small children, who have to live with malaria in their daily lives.

In all of the places it occurs, malaria is merely a symptom of a greater political and economic failure.

Indeed, we really know less about the causes of suffering and death in the tropics than many believe. Even vital statistics of birth and death are unrecorded in many areas of the world, much less the accurate causes of disease and death. Some diagnoses, such as malaria, dengue fever, and typhoid fever, are often ascribed to patients’ illnesses without laboratory confirmation. Under the shadow of the umbrella of these diagnoses, other diseases are lurking. I have found significant incidences of spotted fever and typhus group rickettsioses and ehrlichiosis among series of diagnostic samples of patients suspected to have malaria, typhoid, and dengue in tropical geographic locations, where these rickettsial and ehrlichial diseases were previously not even considered by physicians to exist.4–8 Control of malaria or dengue would reveal the presence and magnitude of other currently hidden diseases and stimulate studies to identify the etiologic agents.

This is the problem with our public health fascination with malaria. We are missing all of the other pathogens and conditions which case untold suffering in the poorest and most isolated communities. It can’t be the case that malaria acts in a box. In fact, it could be the case, that multiple pathogens coordinate their efforts to extract as many human biological and behavioral resources as possible to obtain maximum opportunities for reproduction and sustenance. A public health system only designed to look for and treat a limited window of diseases misses the opportunity to disrupt what is probably a vast ecological complex.

First, we have a problem of poor diagnostics. Facilities traditionally treat most fevers presumptively as malaria, dispensing drugs appropriate to that condition. However, conditions like dengue fever exhibit similar symptoms. While is it extremely likely that dengue is all over the African continent, particularly in urban areas, there is little ability to identify true dengue cases in the public health sector, and thus, in addition to mistreating patients, the extent of the disease burden is unknown. We cannot tackle large public health issues without proper data.

Second, we have the problem of all of the “known unknowns,” that is, we know for a fact that there’s more out there than we have data for but we also know (or at least I do) that there is a greater disease ecology out there. We know that many pathogens interact with one another for their mutual advantage or to haplessly effect significantly worse outcomes. The awful synergy of HIV and TB is just one example.

OK, I’m going to go and deal with my own pathogenic tenant which I think I’ve identified as an enteric pathogen of the genus Pseudomonas, which might have taken hold opportunistically through an influenza infection. This is complete speculation, however. Data quality issues prevent a reliable diagnosis!

Terror in Kenya and pathological domestic politics: a recipe for disaster

From the Guardian

From the Guardian

I’ve fucking had it. I recommend that all Americans live in a country where terror attacks are a common occurrence. 9/11 was a huge wake-up call for the States, but the daily threat of terror, with all of its unpredictability impacts every aspect of life, even in ways which may not be immediately obvious.

I’m not stupid. I know that I’m much more likely to be hit by a car in Nairobi than to be killed in a terror attack, but I can at least minimize the risks of being hit by an automobile. Terror attacks, on the other hand, come from nowhere.

The Kenyatta administration has proven itself completely incapable of dealing with issues of security. It’s pathetic appropriation of the Mpeketoni attacks for petty domestic squabbles is at least as embarrassing as it is dangerous.

From Think Africa Press:

Initially, al-Shabaab claimed responsibility for Mpeketoni killings through a spokesperson, declaring that Kenya was now “officially a war zone.” However, in a speech to the nation the next day, Kenya’s President Uhuru Kenyatta dismissed the notion that the Islamist militants were behind the attack, maintaining instead that it was “politically motivated ethnic violence.”

Though he did not explicitly mention names, local media outlets interpreted Kenyatta’s allegations as being aimed at the leader of the opposition, Raila Odinga. In response to these apparent accusations, Odinga in turn blamed the Kenyatta administration for failing to address the security situation since Westgate and called for the resignation of Joseph ole Lenku, Kenya’s Cabinet Secretary for the Ministry of Interior and Coordination of National Government.

Opposition leader Raila Odinga, a seasoned Luo politician affiliated with the Orange Democratic Party, has been rattling the cage for the past few months, demanding a “dialogue” with the Presidential office. Kenyatta, who ran on a platform of unity, appears uninterested in engaging the Luo stalwart.

If he doesn’t engage Raila, we’re guaranteed a day of demonstrations and inevitable rioting on July 7th, the day celebrating the birth (return to?) multipartyism in Kenya during Moi’s disastrous Presidency. It’s going to be a bloodbath, and Kenyatta will be watching in the safety of the State House. Most likely, though, he’ll be quietly watching football. Regular folks will be blaming this or that tribe for the fallout and we’ll slowly return to the bad old days of tribal violence.

Most troubling is Kenyatta’s refusal to engage the West, instead trying to curry short-term favors from China. A new road to allow Kenyan elites to move around the outskirts of Nairobi is worth more than solid security assistance from the West. Even more troubling is the seeming lack of interest from the Obama admin to a spreading terror threat in East Africa. Recruitment among Kenyans has become even easier given Kenya’s growing political divide, providing a ripe breeding ground for violence which could spread far beyond Kenya’s borders and potentially destabilize the most important economy in East Africa.

From Think Africa Press:

A domestic threat
So far this year, there have been 14 attacks in Nairobi, Mombasa and the nearby coastal tourist area, according to data from Terrorism Tracker. By contrast, there were just eight such incidents in these areas in the whole of 2013. This also marks a geographical shift in the threat, with attacks now being more common in Nairobi, Mombasa and the coast than in the northeastern region bordering Somalia. Although al-Shabaab continues to mount infrequent mass casualty operations inside Kenya, it seems to be Kenyan militant groups operating from Nairobi and Mombasa that now pose the greatest threat.

So the line between Al Shabab and local “militant groups,” the nature of which is mostly unknown, the credit for which goes to a policy of non-communication from the Kenyan Government itself. The Americans are quite good at identifying the nature of the threats, though also quite adept at defining it thereby giving militant groups an opportunity to mold their images in the shape of how the West perceives it. Here, that opportunity doesn’t exist. On the surface, this seems like a destabilizing strategy for militant groups, but in reality, it merely exacerbates the threat by giving it no ideological boundaries to operate in. The violence becomes random, and hobbles the ability to politically engage these groups.

Thoughts on an ISIS propaganda video “The End of Sykes-Picot”

These days, I’m pretty sensitive to the idea of Islamic militants, given that Al-Shabab seems to be successfully killing people not a stones throw from where I live and work. Honestly, as much as it pains me to say, I’d be more than happy to see some American humvees rolling into Kenya’s coast right now since the Kenyan government seems pretty useless when it comes to issues of security.

ISIS’s crusade, however, lies far from here, though ISIS’s successes could embolden Islamist groups elsewhere, though it’s difficult for me to gauge how deep the connections are between Islamist groups.

The video, however, was quite interesting. The first thing that strikes me is that the presenter is Chilean, speaking American English, representing the international nature of ISIS itself. It is not a home grown ethnic Islamist movement, struggling for historical territory and self-determination. Like it’s arch enemy Israel, it is an international movement of foreigners seeking to establish and ideological state in a foreign, based upon a self-created narrative of religious entitlement.

There are various scenes which show the host talking with other members of the group, who are clearly a hodge-podge of ethnicities and nationalities. The common language appears to be, in many cases, English, though at times it’s hard to tell.

The production values, outside of the sound, are excellent. Most striking is the use of symbols. Throughout the video, the host walks through a number of symbolic points, starting at the border of Iraq and Syria itself, to symbols of border checkpoints, military patches and signs. The message is that ISIS is exposing these symbols as empty illusions, positioning itself as the harbingers of Islam in a corrupt and empty landscape.

What’s interesting is that a young Chilean, likely raised in the US or Canada, is seen mocking much older and obviously local prisoners. He calls the Kurds Satan worshipers and mocks the Iraqi soldiers as cowards and fools.

So, how is ISIS, as an international terror group with roots in the West, any different from the corrupting Westerners they so hate? The video repeatedly appeals to Western sentiments that Sykes-Picot was the great destabilizing factor in the middle east, but it’s unclear as to how ISIS provides an avenue of self-determination to the ethnic groups who were broken up or forced to tolerate one another. Does taking the borders away liberate Sunnis and Shiites? Does ISIS respect the right of self-determination for Kurds? Clearly not.

Check out the video. It’s pretty surreal.

On the way back from Kwale

Spent the week in Kwale, a sleepy town on near the Mombasa coast. The security situation prevents me from spending a whole lot of time there. I find this to be incredibly saddening but its unavoidable. Some people brave it out and stick with it, but I just can’t justify the awful risks.

The Japanese folks are mostly oblivious to it all, or maybe just indifferent. I’m convinced that they have no real concept of threat, given the relative safety of Japan itself. It’s a horribly dangerous situation but fortunately they stay locked inside. Japanese people love to sit at desks, even when they don’t really have to. Japan has yet to appropriate the concept of the mobile office. (Sorry, generalizations abound….)

I’ve caught some infection, but it’s hard to say exactly what it is. At first, it looked a lot like malaria, but then everything looks like malaria. Now, I’m just in a general state of not feeling well. It’s not responding to antibiotics, which makes me suspect that it’s not bacterial in nature. I started a round of ACTs just in case. They leave me a bit loopy, but I’m improving somewhat. A malaria test turned out faintly negative, but it’s possible the antibiotics are skewing the result or that the guy doing the test spilled to much assay onto the test. So, I’m not sure. I have a somewhat better appreciation for why the tests are treated with suspicion by the locals.

In any case, I feel like total hell, but thankfully have a normal appetite and digestion. I deeply crave red meat though, which leads me to suspect that the dizziness is anemia and thus, the cause could be malaria. This might be wishful thinking though. I could simply be exhausted.

Kenyatta is universally hated on the Coast, which explains a lot of the violence here. Though people apt to disregard domestic politics when talking of terrorism here, it’s hard to rule it out given the vast resentment toward the Jubilee party here on the coast. In fact, the lack of attention to security by the Kenyatta administration is likely fueling even more resentment, which might be fueling even more violence or at least, helping improve recruiting numbers for Al Shabab. As crazy as I think Luo politics are, Raila Odinga would have made a far better president.

People here are convinced that Kenyatta is a weed-head. “He is smoking the mari-ju-a-na.”

I spent the last two days convalescing in a hotel located within the Shimba Hills Nature Reserve. As much as I wanted to tough out the guest house in Kwale (which really isn’t so bad at all), I really needed a decent few hours of rest in a somewhat pleasant environment. It was worth it. A real hot shower and a set of clean sheets is worth the extra cash every now and again. The only wildlife to be seen were bush babies and squirrels, who seem to have worked out a deal where one begs for food in the day, and the other at night.

Malaria transmission here is low and it shows. Malaria endemic areas are characterized by low levels of education, part of which may be attributable to the inhibited cognitive development of children due to repeated malaria infections. Even if educational opportunities are available, kids in malaria endemic areas appear to have worse outcomes. It’s somewhat staggering at times, after having worked in Western. Part of it also could be the influence of Islam.

I’m now flying back to Nairobi where I’ll crawl into my bed. If I’m lucky, I’ll not come out for a few days.

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