The sun's radiance

I took two weeks off blogging, but not by design. It's good to be back. Since I'm recovering from a week in Providence and since I'm still living out of a box while I move apartments, I'm not ready to post anything substantial. But something is coming. I've been thinking about the campaign to make medicines available to the destitute poor, and how this campaign collides with intellectual property rights. I've been getting excited for the ultimate frisbee tournament I'm staffing this weekend. And I've been treating myself to fancy dinners - nutritious but no less indulgent.

I'm lucky to have a job where my duties include surveying incoming journals. So I saw that the Journal of the American Medical Association devoted an entire issue to the fight against malaria, which still kills a million people a year. What a great imperative for the research agenda and for the rest of us: Malaria "can be controlled everywhere the disease still exists, no matter how poor or remote the location or population." Besides reading JAMA, I spent part of the afternoon with the New England Journal of Medicine, the Annals of Internal Medicine, the American Journal of Bioethics, the Chronicle of Higher Education, and the New York Review of Books. Not a bad day.

For one professor here at the bioethics center, I've been compiling an annotated bibliography on issues of disability, genetics, and law, focusing especially on reproductive choice and genetic discrimination. For another professor, I've been digging through recent reports of the IPCC to understand how climate change is impacting the economies of developing countries. Yes, there are days when my job is simply my job. But on other days, there's nothing I'd rather be doing.

I moved in this week with a friend who recently purchased a house. For several hours last night I schlepped over everything I own, finishing around 3:00 AM, utterly exhausted. To my dismay, I woke a few hours later when the radiance of the sun flooded the naked windows. Note to self: Buy window shades ASAP. I hadn't anticipated that moving apartments would take so long, but over the last year in Syracuse, I seem to have acquired kitchen supplies, nonessential furniture, and other household amenities that are generally associated with adulthood. In this new house, I feel quite grown-up - pleased that I will no longer have to drown quarter after quarter in public laundry machines. Then I remember that starting a fifteen hour day on just three hours of sleep is exactly the kind of feckless, youthful indiscretion I quietly adore. Oh, be still my heart.

An Indiana Jones Moment

The stacks in the library basement stretch from floor to ceiling. I've long found these quiet aisles a trusted refuge, perhaps because the books have a permanence - and a smell - that the internet can never match. The volumes are endless: Neurobiology, Neurological Clinics, Neurology - bound in dark blues, violets, and greens. The article I'm seeking - I check over my notes - was published in 1982, vol. 1204, pg. 634. I know these journals well: I run my fingers over the spines, pull out a heavy volume, and shuffle through the pages. It's second-nature, as if I'm tying my shoes.

Then I hear a soft rumble. Behind me, the massive wall begins to move. The aisle is thinning.

Interesting, I think. I should leave.

I look up one way, then down the other, then back to the first.

Like I'm Buridan's famous ass.

Oh screw it, I realize. RUUUUUNN!

I dash out, tripping over myself. The stacks heave closed behind me. I've sometimes wondered whether these electronic sliding stacks have movement sensors. Judging from the narrowness of my escape, I'm guessing they do not. The person who absently pressed the close-button is now standing beside me. She's as startled to see me as I was to find myself in the meat grinder.

"OhmygoshyouweresoquietIswearIlookedohmygoshohmygosh..."

I spend the next five minutes calming her.

Such are the perils of being a research assistant.

Arabs are full of stem cells

President Bush has threatened to veto any pro-choice legislation, or in his words, any measures that “allow taxpayer dollars to be used for the destruction of human life.”

A letter-writer pointed out the irony of that statement, made by a man who's burned trillions of taxpayer dollars to wage a war that's claimed thousands upon thousands of Iraqi lives.

It reminded me of a political cartoon from last summer's Israel-Hezbollah war.

The blackness of the black market

The black market in organs is proliferating in places like Tsunami Nagar, a refugee camp in India's Tamil Nadu province. The residents are people left homeless after the tsunami two years ago. Here's what Maria Selvam, the camp's only elected official, told a reporter:

"In other parts of India, people say that they are going to Malaysia or the United States with a glimmer of hope in their eyes... In Tsunami Nagar people speak that way about selling their kidneys."

Rani (pictured) was once such a person. She sold her kidney to pay her daughter's medical bills. Due to complications from the surgery, she is now unable to work. The brokers paid her only $900 of the $3,500 they promised - a common swindle in this trade. She and her husband make less than $2 a day.


She's not the only one. Thirty residents of this five-story municipal project (pictured) sold their kidneys last year. The municipal project was nicknamed kidneyvakkam, or Kidneyville.

I have frustration, bewilderment, and pain for the way people so ruthlessly exploit other people. The black market in organs is a new kind of rape, another forced link between poverty and prostitution, the latest maneuver in a tradition of profiting off the world's poorest people.

That's all I have to say. Nothing insightful, just a cry of despair.

Lolita, loneliness, longing, love

I’ve been reading Vladimir Nabokov’s famous novel Lolita, a book so erotic that four American publishers once declined to publish it. Enchanting as it is, I put it down and removed it from my book list because the 1972 binding was breaking. And I have no acid-free tape to fix it. Of course, I’m in no hurry to get acid-free tape. That book was making me so love-sick that I was quite happy to find an excuse to bury it – at least, hopefully, just temporarily.

It begins: "Lolita, light of my life, fire of my loins. My sin, my soul. Lo-lee-ta: the tip of the tongue taking a trip of three steps down the palate to tap, at three, on the teeth. Lo. Lee. Ta" (11).

It continues: "All at once we were madly, clumsily, shamelessly, agonizingly in love with each other; hopelessly, I should add, because that frenzy of mutual possession might have been assuaged only by our actually imbibing and assimilating every particle of each other's soul and flesh..." (14).

If my life were a movie, a future girlfriend would read this post and buy me a roll of acid-free tape. Alas, “bioethicist by day, blogger by night” doesn't generate enough drama to merit Hollywood.

What "abstinence-only" really means

News flash: The director of Bush's HIV/AIDS program, which emphasizes abstinence, regularly used an 'escort service' which is now being investigated for prostitution. He abruptly resigned.

Randall L. Tobias (pictured) headed the U.S. Agency of International Development (USAID), a post he acquired in January 2006. He oversaw all foreign assistance granted by the U.S. government. In 2003, somewhat out of the blue, Bush appointed him to lead the $15 billion President's Emergency Plan for AIDS Relief (PEPFAR). Before that, he was CEO of the pharmaceutical giant Eli Lilly and had little background in AIDS policy or international development.

As director of PEPFAR in 2004, Tobias asserted that "condoms really have not been very effective." His reasoning: "It's been the principal prevention device for the last 20 years, and I think one needs only to look at what's happening with the infection rates in the world to recognize that has not been working." His preferred approach to HIV/AIDS prevention was to promote the well-known ABC strategy - be abstinent, be faithful, use a condom - except leaving off the c. Nevermind that abstinence education doesn't work. Under Tobias, PEPFAR required that grantees sign an "anti-prostitution" pledge that prevented them from reaching out to sex workers and undermined their prevention efforts, as this 13-minute video featuring sex workers from Bangladesh, Brazil, Cambodia, Mali, and Thailand attests.

Now the man who embodied the abstinence-only agenda is caught with his pants down. For his part, Tobias said he used the escort service "only to have gals come over to the condo to give me a massage." (Nothing suspicious there...) The head of the escort service, Deborah Jeane Palfrey, told reporters that her business disallows prostitution and offers only legal, sexual game-playing - at a cost, by the way, of $275 per 90-minute session. But absolutely no sex. So maybe Tobias wasn't being hypocritical. Maybe all he wanted was to prove that abstinence can be sexy after all.

The social justice sisterhood

I'm part of an advisory group for a new 'global health office' at the medical school. The office will help med students make contacts abroad and will sponsor a lecture series on issues such as refugees, sex trafficking, HIV/AIDS, and migrant labor. The group - which includes both students and professors - met a week ago. Of the 12 people around the conference table, 2 of us were men.

This imbalance isn't exceptional. My public health courses in college were brimming with women; they outnumbered the men 10 to 1. I didn't complain much. I'd joke that I studied public health for romantic reasons. Plus, it was quite exciting to bring diversity to a group - which as a white male I don't often get to do - though it meant I was often looked upon as a curious XY specimen. But the imbalance always bothered me. Really, where were all the men? I don't have any studies about it, just anecdotal evidence. In Providence, I spent a week with a Brown program exploring issues of homelessness and affordable housing - with 25 women and 5 men. In Syracuse, I've been tutoring through the city's literacy corps, a group that teaches adults how to read and write. In my training class of 17 people, 3 were men. I tell ya, it sure is hard to be a man in this world...

So when did social justice work become an old girls network? Here's a hypothesis:

In both developed and developing countries, women disproportionately suffer from economic and social inequalities. In the United States, women earn 77 cents to a man's dollar, occupy fewer CEO positions, can't take time from work to breastfeed, and may even get kicked off a plane for it. Sexual violence, meanwhile, is as frequent as it is perverse. A 2007 study published in last month's Journal of American College Health found that only 2 percent of victims of sexual or physical abuse (that's 1 in 50!) contacted the police. Many women don't report such abuse because they feel ashamed or embarrassed or somehow at fault or because they see the abuse as an isolated incident and not as part of a larger epidemic. We evidently have a fairly vacuous sense of sexual violence.

Inequalities in developing countries also disproportionately affect women. Complications from pregnancy kill half a million women a year. It's safer to donate a liver lobe in New York than to give birth in Afghanistan. In some African countries, women can't insist on condoms or refuse sex and may contract HIV from their husbands. In Muslim countries, no man is killed for raping a women, but women are sometimes killed for 'losing their honor' - or otherwise beaten. On the economic front, we know that the whole family benefits when women achieve financial independence. In fact, UNICEF's 2007 State of the World's Children Report went as far as to say that expanding women's opportunities in South Asia would save 13.4 million children from malnutrition.

I would bet that the pervasiveness of women's victimization - and women's awareness of it - is a key reason why women disproportionately gravitate toward work in public health and social justice. Perhaps women seek to rectify injustice because they tend to bear the brunt of it. Another idea is that women - because they have been marginalized - have great sympathy for fellow sufferers. Both help explain why women greatly outnumber men in public health - a field with a very wide social justice purview - but don't outnumber men in medicine. I also bet (though I have no stats) that female medical students are more likely to see their medical training as part of an overall effort to promote social and economic opportunity and reform 'the system.' The radical conclusion, of course, is that if medical schools want to foster social justice, they should admit more women.

That, anyway, is my preferred explanation. An alternate explanation maintains that women are simply more caring than men - an explanation that's always smacked of reductionism to me and begs the very question it purports to answer: why are women (supposedly) more caring?

News Round-Up: Incarceration

Since last October, I’ve been tutoring inmates who are studying for a G.E.D. Some want it to impress their parole boards, some to get work upon their release, some as a personal goal. My time in this maximum-security prison, which amounts to 2.5 hours a week, has spawned a general interest in incarceration and the so-called “criminal justice” system. It may be odd to think of "convicts" or "felons" as vulnerable people, but I think they deserve our attention as such. Throughout these snippets, I hear "structural violence" beating like a tell-tale heart. 1. The United States, “the land of the free,” will have 1.7 million people (1 in every 178) behind bars in 2011 (an increase of 192,000 from 2006 numbers). Altogether, there are currently 2.2 million people in the U.S. criminal justice system. This increase will cost $27.5 billion more than what the system currently costs. For details, see the 52-page report of the Public Safety Performance Project at the Pew Charitable Trusts. It doesn’t take much imagination to wonder whether we’d need to build additional prisons if we spent the money on poverty relief and education. 2. Treating violent juvenile offenders as adults actually increases the odds they’ll be back in prison. A special Task Force on Community Preventive Services found that juvenile offenders tried and imprisoned in the adult system are re-arrested 34 percent more frequently than their peers in juvenile courts and facilities. The full report of the task force was published in the April issue of the American Journal of Preventive Medicine. At least one organization, The Campaign for Youth Justice, is trying to reform this system that turns juvenile delinquents into life-long inmates. 3. Dozens of prisoners kill themselves every year, and mentally ill prisoners held in segregated cells are especially at risk. Several of the inmates I tutor report spending as long as a year in these segregated cells – what the correction officers call the “special housing unit” and what the inmates call “the box.” As one might imagine, being locked up for 23 hours a day can have horrific effects. In Michigan last August, a “floridly psychotic” inmate “died in his segregation cell, naked, shackled to a concrete slab, lying in his own urine, scheduled for a mental health transfer that never happened.” A 2006 study from the Justice Department’s Bureau of Justice Statistics found that 56 percent of state prisoners and 45 percent of federal prisoners report mental health problems. Proposed regulations in New York would expand inmates' access to mental health services. 4. The Federal Bureau of Prisons claims to house its inmates in “facilities that are safe, humane, cost-efficient, and appropriately secure.” But that doesn't always happen. Some inmates in Philadelphia sleep on concrete, their heads next to the toilets. On the west coast, California faces similar problems of overcrowding. From 1980 to 2006, its prison population increased 600 percent. The state’s 33 prisons were designed to hold 81,000 inmates, but hold 174,000. 16,000 of them have to sleep in hallways and classrooms. California’s “tough-on-crime” laws, combined with the system’s poor success at rehabilitation, generates a constant flow of young men. About 70 percent of the 120,000 California inmates released each year return within two years. 5. A new bill (HR 1943) before Congress would require federal prisons to offer HIV testing to inmates at the beginning and end of their sentences. Inmates could opt-out. Unlike some state prisons, federal prisons do not test for HIV unless such testing is specifically requested. Another new bill (HR 178) would allow community organizations to provide condoms and HIV prevention education in federal prisons. With some 20,000 to 40,000 inmates raped each year (on lower-end estimates), transparency about HIV - and active prevention - is all the more important. 6. A 2007 study (NEJM 356(2)) of 30,237 former inmates found that they have a higher risk of death than the average person, 3.5 times in the first two years and 12.7 times in the first two weeks. The leading causes of death were drug overdose, cardiovascular disease, homicide, and suicide. 7. A 2007 study (PLoS Med 4(4)) questions whether lethal injection is as painless as it's purported to be. The authors found that some executed inmates suffocated while still conscious, rather than first being sedated by the anesthetic. They noted that the protocol for lethal injection does not account for the inmate’s weight, sometimes requiring repeated doses. Lethal injection is legal in 37 states, and was used in 52 of the U.S.’s 53 executions in 2006. On a different note, because I can't resist editorializing: Killing people because they've killed people is, at best, bizarre. 8. A riot took over Indiana’s New Castle Correctional Facility last month, involving 500 of the facility's 1,668 inmates. The riot lasted several hours while fires raged in the prison yard. A group of inmates sparked the riot by taking off their shirts to defy orders. I don't think it's a coincidence that the instigating inmates came from Arizona - way out-of-state, far from family and friends. The inmates I tutor regularly lament that their families can’t afford the five-hour bus-ride from New York City (ten hours round-trip) to visit. Arizona contracted with Indiana to relieve its overcrowded prisons. Indiana in turn contracted with a company based out of Florida. Public reaction to the riot was as interesting as riot itself. The news reported that inmates “commandeered radios and key controls that open doors and fences but never broke through the outer fence.” In response, a county prosecutor commented, “The point is, the system worked.” The system worked? When 500 inmates riot (imagine! these guys aren’t small!), it's hard to say that the system is working. In the riot's wake, (Democratic) legislators blamed Indiana's (Republican) governor for privatizing the system. The governor, Mitch Daniels, defended the state’s contract with the Florida company: “This (idea) is not particularly new. Lots of states do it.” 9. Also on prison violence, Philip Zimbardo revisits the “the power of situation” and hierarchies in the infamous Stanford Prison Experiment he conducted three decades ago.