Loomnie

A couple of weekends ago we hosted a friend who had just returned from Nigeria. She mentioned that penises were currently being ‘disappeared’ in the country. We smiled, we laughed, and I told the story of how I first learnt about disappearing penises. Like a good, self-respecting, PhD-holding anthropologist, I concluded by insisting that I really couldn’t say much else until someone did an ethnographic study of the topic.

I hadn’t thought about it since then until this evening when Teju Cole, during one of the times he breaks character as a writer of Small Fates, tweeted a link to the closest thing to an ethnographic study of disappearing penis – a Frank Bures article titled A mind dismembered: In search of the magical penis thieves. It is a well nuanced piece whose quality does not derive only from the fact that it wounds my Nigerian pride by showing that  we are neither the originators of, nor the exclusive owners of the rights to, disappearing membrum virile.

Much like how a very quick look in the literature, as I was thinking of starting a research project on the study of internet fraud, showed that we cannot claim to have founded – or even be the greatest practioners of – the confidence trick, even though it is now known almost exclusively by its Nigerian name, 419. Bummer.

From the Bures article:

Nigeria was not the first site of mysterious genital disappearance. As with so many other things, its invention can be claimed by the Chinese. The first known reports of “genital retraction” date to around 300 B.C., when the mortal dangers of suo-yang, or “shrinking penis,” were briefly sketched in the Nei Ching, the Yellow Emperor’s Classic Text of Internal Medicine. Also in China, the first full description of the condition was recorded in 1835, in Pao Siaw-Ow’s collection of medical remedies, which describes suo-yang as a “ying type of fever” (meaning it arises from too much cold) and recommends that the patient get a little “heaty” yang for balance.

Fears of magical penis loss were not limited to the Orient. The Malleus Maleficarum, medieval Europeans’ primary guidebook to witches and their ways, warned that witches could cause one’s membrum virile to vanish, and indeed several chapters were dedicated to this topic. Likewise the Compendium Maleficarum warned that witches had many ways to affect one’s potency, the seventh of which included “a retraction, hiding or actual removal of the male genitals.” (This could be either a temporary or a permanent condition.) Even in the 1960s, there were reports of Italian migrant workers in Switzerland panicking over a loss of virility caused by witchcraft.

Read it all here.

Seye Abimbola, a research fellow at the National Primary Health Care Development Agency, Abuja, Nigeria, uses the case of a country without a proper health system (Nigeria) to reflect on how one might build a health system for the 21st century:

The world is at a watershed, on the brink of monumental change in what constitutes health care and life in general so much that the absence of health systems may even be desirable. To combat the challenge of non-communicable diseases (NCDs), we may even want to wish away current health systems altogether. Factors that are changing the way we perceive life and health include communication with internet and mobile connectivity, population ageing, the shift from acute and inpatient care to long-term care, and management of risk factors instead of disease states in themselves.

The new paradigm for service delivery, a shift from infectious disease of earlier centuries, will be self-management, risk factor management (hypertension, diet, inactivity, tobacco, alcohol), chronic disease and comorbidity. The question then arises as to how we may  build a health system for the 21st century. This makes the thought experiment of a country without a health system necessary: it sets the mind free for uncluttered imagination and allows one to think as if one is building afresh.

Read the article in full at the BMJ group blog.

I just started reading Sidhartha Mukherjee’s biography of cancer, The Emperor of All Maladies. I am still in the first part but I can already see that it is a very well-written and nicely-paced book. This is how a New York Times review describes it:

“The Emperor of All Maladies” is a history of eureka moments and decades of despair. Mukherjee describes vividly the horrors of the radical mastectomy, which got more and more radical, until it arrived at “an extraordinarily morbid, disfiguring procedure in which surgeons removed the breast, the pectoral muscles, the axillary nodes, the chest wall and occasionally the ribs, parts of the sternum, the clavicle and the lymph nodes inside the chest.” Cancer surgeons thought, mistakenly, that each radicalization of the procedure was progress. “Pumped up with self-confidence, bristling with conceit and hypnotized by the potency of medicine, oncologists pushed their patients — and their discipline — to the brink of disaster,” Mukherjee writes. In this army, “lumpectomy” was originally a term of abuse.

For me, reading a biography of the disease is very personal: just over a year ago, my mother died of a particularly virulent form of cancer.

Keith Hart writes:

The contrast between Zuma and Mbeki could hardly be greater, a tribal chieftain in the mould of Bolingbroke or Henry Tudor against Mbeki’s Othello, a man happy to be photographed dancing in Zulu warrior gear versus the austere western intellectual with his stiff suits and goatee beard. The number of Zuma’s wives, lovers and children is uncountable. He was once tried for raping an HIV-positive woman who was the daughter of a trusted political aide; claimed that it was his duty to satisfy any woman who appeared to want him; and took a shower after the act so as not to catch the disease. Jacob Zuma epitomises the image of African male sexuality that Thabo Mbeki tried so desperately to counter. Yet Zuma appointed a leading progressive medic as Minister of Health; and he has pushed through drastic changes in government AIDS policy, winning singular praise from AIDS social movements for having committed state resources to the fight. Only recently Zuma made public his own HIV status (negative after four tests). Political leaders like this make nonsense of the stereotypes that pass for analysis of South Africa’s trajectory.

Now at last many more South Africans have access to the most effective sources of prevention and treatment known to normal science, although this is still highly unequal and plagued by Christian and traditional beliefs affecting the use of condoms, for example. The whole story is mind-boggling. You couldn’t make it up. Because of or despite all this, South Africa has stimulated a number of compelling book-length studies by leading anthropologists which, taken individually and together, offer a remarkable chance to reflect on how our discipline might illuminate a tragedy that has implications for how we all live in today’s world. Here I will briefly consider three: Didier Fassin’s When Bodies Remember (2007), Robert Thornton’s Unimagined Community (2008) and Ida Susser’s AIDS, Sex, and Culture (2009).

Read the whole article, including his review of the three books, here.

The list of podcasts I download just increased by one. Last week’s edition of This American Life, really great podcast, had a story about how hookworms helped someone overcome allergies (Chris Blattman blogged it here). Since the story is taken from a Radiolab episode, I decided to try Radiolab out. Just finished listening to the current episode, on limits, and it is really good stuff.

Still on the topic of hookworms. My mother said that she never gave any of her children boiled water when we were growing up; just water straight from the tap. According to her, that is one of the reasons we have really strong immune system. None of us has ever had typhoid, for instance.  This would seem to support the hookworm guy’s claim. You can listen to the edition of This American Life here. In case you are wondering, I grew up in a small, Nigerian town.

Links on how to subscribe to Radiolab podcasts is here.

was published a couple of weeks ago. It is here, but I have pasted the full text below.

Thinking through kids
Olumide Abimbola

Act One
A couple of days ago I joined one of my friends to pick up his daughter at the kindergarten. This was the first time I was seeing her in close to two years; the last time I saw and carried her she was just about 4 months old. Of course, she didn’t remember me, so I had to find a way to charm myself into her favour. The first steps involved me smiling sheepishly, talking gently and offering my arms to her. She refused all the advances, despite the very hearty encouragement from her father.

We left the kindergarten and headed for a café, where my friend pulled out a lunch box filled with grapes. It was obviously something she loves very much. Still trying to get her attention, I took one of the grapes and offered it to her. She, as I suspected, refused. But then, something else happened that got me thinking about reciprocity and economic exchange. As I was trying to ingratiate myself in her favour without much success, her father gave her a grape to give to me. She collected the grape and passed it on. Then he gave me a grape to offer her; this time, she accepted it. From then on things went pretty smoothly.

What I took away from this has nothing to do with trust and child psychology, at least not directly. I realized that I just witnessed, from a child, one of the most cardinal things in human economic relations: reciprocity. At that moment, with that little girl, I realized that I was witnessing the early traces of that social characteristic of the human. I could not help but wonder – and this is the part where I need the help of child psychologists – when kids start putting a value to things, what values mean to them and how they relate to values.

Act Two
Another friend’s daughter made her parents promise to get her a Spider-man cake for her third birthday. But all these were to change just shortly before the birthday. Sometime between the day she elicited the promise from her parents and shortly before her birthday she changed her mind. She had just joined a kindergarten, where she learnt about the differences between what a boy should want and what a girl should want.

She learnt that she liked pink – something she did not know until she joined the kindergarten. She also found out that she wanted to be a princess. Her mother started getting requests concerning pink dresses for princesses. Boys were supposed to be knights. In fact, one of her male friends was waving a sword, slicing the air, when I met him. Of course, her relationship with Spider-man changed; she wanted a princess cake instead. She had learnt that Spider-man is for boys and princess for girls.

This got me thinking about how children are socialised by each other. Someone mentioned to me that children are very serious conformists, and that kids always strive to be like their mates, never wanting to unduly stand out. How many kids have quickly forgotten languages they acquired while living abroad because they are afraid that their mates would make fun of their difference? How many kids have joined in making fun of other kids who look like they might not ‘belong’? Of course, prejudices that kids display are picked from adults; and it is presumable that the children who are the first to bring the idea of gender roles and differences into the kindergarten somehow got it from adults.

It is interesting to watch kids learn from their parents and from each other. But perhaps the most important thing is what one learns from watching them learn: the importance of socialisation, and of being social.

by SEYE ABIMBOLA*

Lately, I have inundated myself with a series of incredibly enlightening dispatches from TED Talks. Listening to them, especially those related to international health and development has been a wonderful respite from my undesirably excessive clinical workload. The one by University of Chicago economist, Emily Oster, who shared her work and ideas on HIV/AIDS in Africa at last year’s TED, however struck me as particularly, if unwittingly, poorly conceived. Her theoretical abstractions reveal in shameful detail how easily tainted the lens through which the developing world is seen from the outside, and the kind of thinking that underlie the misconceptions that inform the largely skewed global health priorities.

Emily Oster based her first argument on a shaky, if not completely false premise, justifying a claim that there was no behavioural change in response to the HIV pandemic in Africa by juxtaposing data from two radically different cohorts — homosexuals in the US and heterosexuals in Africa. High HIV prevalence within a population where there is widespread awareness of heterosexual sex as the predominant mode of transmission will result in increased rate of abstinence from sex or at least a modification of sexual behaviour as an evolutionary compulsion to preserve the species. Without elaborate public health campaign to promote abstinence, HIV prevalence would have reduced on its own. That is what you would expect, but Oster says it was not so in Africa. She compares data from gay men in the US in the eighties, (where the men that had more than 1 unprotected sexual partner within a month reduced from 85% to 55% in 4 years) with data from single men having premarital sex and married men having extramarital sex in Africa dropped by only 2%.

There are obvious flaws in Oster’s argument apart from cohort mismatch. Her homosexual cohort had a reduction in the number of unprotected sexual partners, whereas there was no specification as to the nature of sex amongst the African cohort: protected or not, homosexual or heterosexual. She did not give any idea of the HIV prevalence amongst the said African population(s), so we cannot possibly estimate the cost of sex among the population, and arrive at any predictable behavioural change based on that. We know though, that HIV prevalence among gay men was about the highest in America in the early and mid eighties.

However, even if Emily Oster’s two cohorts were by any chance or twist of logic comparable, and if there was indeed no behavioural change in response to HIV in Africa, her explanation for this — the cost of abstinence is so high that in the presence of low life expectancy, people would rather not bother to live healthy lifestyles, they’d rather prefer to expose themselves to the risk of contracting HIV/AIDS since they’re gonna die early anyway — is as unconvincing and implausible. Oster demonstrated that in places and within populations in Africa with high prevalence of malaria and high maternal mortality, there was no positive change in sexual behaviour in response to HIV. She did this, totally ignoring two huge, glaringly obvious confounding variables, poverty and lack of basic health services, leading causes of low life expectancy in Africa, together with lack of adequate sanitation and good water supply, which promote the presence and spread of diseases, and in themselves, inextricably linked to poverty.

This is actually where Oster’s greatest mistake lies, and unfortunately, it is what forms the main thrust of her thesis. M. Khan and colleagues in Burkina Faso, found that even within a developing country, the sex network within rural areas is denser, more closely interlinked than in urban areas, and the percentage of those who receive goods for sex is far greater in the semi-rural border area (45%) and urban area (31%) than in the rural areas (12%). This is easily explained. There is far greater homogeneity in relation to poverty in rural areas compared to urban or semi-rural areas, and so there are fewer people who are prepared to offer money or goods for sex. Poverty too breeds idleness, and it is easy to imagine that an idle man will easily have multiple sexual partners in a community where money is not given in return for sex. This explains why poverty may be associated with high levels of sexual activity. In these settings, there is high maternal mortality both from unsafe abortion, and because maternity care is not available. Where poverty abounds and basic health services are not there, mortality from malaria will be high. Where there is no access to basic health services like STI prevention and treatment and modern contraception, there will be poor awareness of the presence, reality and prevalence of HIV. Illness and death from HIV is attributed to other diseases, witchcraft, the will of God et cetera, hence diagnostic, prevention and treatment services, even if available will suffer low uptake in the absence of these basic health services.

Emily Oster however asserts that HIV prevalence rises with increase in economic activity and urbanization. She evokes the oft-quoted high HIV prevalence amongst truck drivers and migrants to support this claim. She also showed that the fall in HIV prevalence in Uganda was closely associated with a fall in the export price of tobacco, Uganda’s main export commodity. All of these are true, if only in part, but yet again, she misses the point. It is not wealth as an absolute quantity that encourages increase in sexual activity, hence HIV prevalence; rather it is the widening of the gap between the rich and the poor, increased contact between the rich and the poor, and the attendant dynamics, the differential power gradient, that characterises the relationships between the two classes. Much of extramarital and premarital sex is facilitated by an economic advantage of one party, often the male, over the other. With a fall in export price of tobacco in Uganda for example, the gap between the rich and the poor is less, there is less money available to maintain multiple sexual partners and visit commercial sex workers, thereby reducing the sexual network, and also, predictably, HIV prevalence, at least in part.

Marjolein Gysels and colleagues at the Medical Research Council Programme on AIDS observed and interviewed truck drivers and commercial sex workers at a roadside town in southwest Uganda. Truck drivers are a high-risk group for HIV due to their sexual networking and long periods away from home. They stop at towns along major routes to eat, sleep, sell goods and 94% of those interviewed would regularly have sex when they spend the night at the truck stop. Commercial sex work was found to be common but quite hidden and implicit in this setting and is centered around roadside bars; hence intermediaries are often involved in negotiations between drivers and commercial sex workers. However, in the wake of HIV/AIDS, the middlemen on whom truck drivers rely to find women have had an additional role, which is to identify HIV-negative women, and in spite of this, condom use was reportedly high, at 95%, in marked contrast to local men. HIV prevalence used to be very high among drivers and at truck stops. In the study town it was 40% in 1991; in the surrounding district it was 8% in 2001. The demand for casual sex however appears not to have decreased among truck drivers in the era of HIV, but there is a general awareness that this lifestyle carries the risk of infection. This shows indeed, that there has been behaviour change in response to the HIV pandemic in Africa; contrary to what Emily Oster will have us believe.

In 2004, 12% of children with malaria died as inpatients at the national hospital in Guinea-Bissau. Special drug kits for children with severe and complicated malaria were introduced, but this did not reduce mortality. In an award winning BMJ study in 2007, Sidu Biai and colleagues tested in a randomised trial of under-5 children admitted with malaria, whether removal of prescription charges, strict monitoring of patients, and financial incentives for doctors and nurses could reduce mortality. Mortality indeed came down to 5% in the intervention group and 10% in controls, reflecting the crucial role of poverty in mortality from malaria. The only difference between the two groups was that doctors and nurses were given financial incentives in one group and they were not in the other, which alone reduced the mortality by as much as 5%. Given, the drugs were free in both groups; maybe that explains a fall in mortality from 12% pre trial to 10% in the control group. Weigh this against the 5% reduction, when health workers were given added incentives. From this, it is clear that with just three simple interventions — i.e. if we could make basic health services available, if patients could afford the drugs and other services and if health workers were well remunerated — we could cut under-5 mortality from malaria by more than half.

It is much the same story with maternal mortality. Obstructed labour and ruptured uterus, eclampsia and other forms of hypertensive disease in pregnancy, obstetric haemorrhage mostly postpartum, puerperal sepsis, and unsafe abortion are still the main causes of maternal mortality. However, in the presence of accessible basic health services, they disappear as in Sri Lanka where maternal mortality ratio dropped from 550 per 100,000 live births in 1950-55 to 80 per 100,000 live births in 1975-80, and 58 per 100,000 live births in 2005. This was achieved by introducing a system of health centres all over Sri Lanka, and making quality maternal care services available and accessible to all including in rural areas. In Sri Lanka, 94% (1993) of deliveries are assisted by a skilled attendant, compared to 42% (1999) in Nigeria, with one of the worst maternal mortality ratios in the world (1,100 per 100,000 live births). This has been replicated in Cuba, where in 1970, the maternal mortality ratio was 73 per 100,000 live births, and in 2000, it had more than halved to 33 per 100,000 live births. In 1999, skilled attendants assisted every (100%) delivery in Cuba, after maternity care services were made available and free including accessible referral centres for complications.

Hospital wards in many developing countries are a heartbreaking, pathetic sight. The most basic and common place of materials, things you would otherwise take for granted, the most routine of investigations are often procured at great cost, from private pharmacies and laboratories that have clustered around government run hospitals over the years owing to the ineptitude of the hospitals to run efficient services. Worse still, these hospitals stock the drugs and have those equipments, but the regular story is that the equipment stopped working after a few months, the model is outdated, there are no staff to man them because they are off moonlighting or do not work during call hours or take weekend shifts, or even the bureaucracy of getting to buy the drugs or get the investigations done in the hospital is enough to push them outside. No matter how bad a patient is, no matter the emergency, the family usually has to pay for services and procure materials for treatment at the point of service. Usually, there are no provisions for emergency. These patients are also seen by poorly motivated health workers, who themselves are poorly paid. The distance from access, the prohibitive costs of hospital treatment and admission keep patients away, all contribute heavily to low life expectancy.

In sharp contrast to this, some new structures are also sprouting in hospitals or around them. They are highly efficient units, dedicated to single disease programmes, often HIV/AIDS, provided and funded by external donors. An AIDS orphan who lives with siblings in squalor without access to insecticide treated nets and artemisinin based combination therapy for malaria, whose sister does not have access to specialised obstetric care in pregnancy, gets antiretrovirals for free at these units. Those with more rou¬tine diseases receive poor care and still have to pay. Hospital staff who are supposed to be at their duty posts seeing patients that they were trained and being paid salaries and allowances to see are often busy running those units, with extra remuneration often in hard currency, often surpassing their salaries, at great expense of the system. This is the newest brand of internal brain drain in sub-Saharan Africa.

Single disease priorities generally weaken health systems. Of all, spending on HIV research, treatment and prevention activities is the most notorious example of this prodigality. In 2006, although Zambia’s entire Ministry of Health budget was only $136m, the President’s Emergency Plan for AIDS Relief provided the country with an HIV targeted budget of $150m. This unbalanced distribution of health funding occurs across sub-Saharan Africa. Making HIV into a pivot, raising it to the status of the zeitgeist of the times has indeed skewed health priorities at both national – in many developing countries – and, most importantly at global levels. There is only so much we can achieve, with HIV at the centre of our planning and initiatives. We cannot move ahead while we ignore so much. What more evidence do we need, than that with all the spending on HIV, much too little is being achieved.

Healthcare and development are so interlinked that it would be grossly wrong to interpret data without due consideration for the whole picture and connections that are not immediately apparent. It is not enough to have epidemiological data, without the insight to interpret them and discern underlying trends. Poverty and the lack of basic social and health services is at the centre of what defines developing countries, and that is really where our attention should be focussed in trying to find solutions to problems in these countries; any thinking that as much as puts these as second to any other priority is ultimately bound to fail. Until these form the crux of both local and global public health interest and policy, much of our effort will only continue to result in the proverbial one step forward, two steps backward.

*This is the first in a series of posts from guest bloggers.

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Seye Abimbola is a medical doctor in Nigeria. This article is an abridged version of an article that will be published in the Spring edition of Perspectives on Global Issues.

Early this morning I listened to a technology podcast from PRI’s The World. Chris Carrol, a National Geographic writer, had been travelling around the world, looking at the way e-waste is managed. He wrote an article about it; an interview with him took a portion of the podcast. He first talked about how most e-waste is disposed in the US: A random recycler in the USA sell used computers to brokers who have connections in developing countries. These brokers load them in containers and send them to developing countries. He then went on to describe what he saw in Accra. He describes how he saw children smash up old computers and pull them apart in order to reveal the wirings. These wires are piled on top of old tires, set on fire and left to burn for about 15 or 20 minutes, with the boys standing close by the fire, in the smoke, making sure that all the covering on the wire is burned off. At the end of the burning session they pick up about 50 cents worth of copper wire from the burnt off wires. These are sold to metal buyers.

Headaches and Nausea
Those who grew up in Nigeria can probably remember the nauseous smell that comes off burning things this way. Chris said he had a headache and a general feeling of mild nausea for weeks after watching the children do this for only a couple of days. He also said that the kids said that when they first started they got sick everyday, vomited, had headaches, but after a few weeks or months their bodies got used to this. He said that a large percentage of the e-waste also end up in China. When asked whether there are reports that say whether people who are exposed to this kind of toxicity are facing health problems he replies that in a town in China, a test of the air and soil revealed that there are persistent toxins in the soil and the plants. They refused to comment on the effects on humans.

And Maybe Cancer Too
Listening to this story made me think about a discussion I recently had with Professor Francis Egbokhare of the Distance Learning Centre, University of Ibadan. We were talking about the rise in reported cases of cancer. He wondered about health problems in Nigeria, and about the possibility that this might be linked to the time of the World Bank/IMF sponsored Structural Adjustment Programme. During that period, people werenmaking their own soaps by mixing all sorts of chemicals together. Other household items were made locally and under unmonitored circumstances. He wondered about the possibility that there were carcinogenous agents in some of the chemicals used to make say toothpastes during the period. We also talked about the sachets of Pure Water and the problem that most of the ones on the streets today are not even approved by the National Foods and Drugs Administration and Control, NAFDAC.

The point of the Pure Water comes home closer when one considers Lagos. There was a time I used to joke that I would easily know that I am in Lagos by the horrible stench that meets me when the window of the car is wound down. Those who stay close to Ojota/Ketu must be very familiar with the smell that comes from the refuse dump along the road. The open incinerator burns everything, from decomposing food items to electronics. These kinds of garbage are also always burnt on almost every street in Lagos. If it can be found that soil and plant contain toxins it would be safe to assume that water from wells in these places also contain toxins. That is the kind of water that we often buy as Pure Water on the streets.

The Issues
There is a serious increase in cases of cancer diagnosed in China, and it is increasingly pressed to pay attention to it. At least tests are being carried out to find out the level of toxins in soils, plants and persons, even if the reports of the tests are never publicly available. I wonder whether our governments in Africa are paying attention to these issues. If anyone knows about any organisation or government agency – in any African country – that work on this they should please leave the name and address of such agency in a comment. And if there is nothing happening I wonder when we will, and how we can, start making the government pay attention to the issues. I am also interested in the position of African countries on e-waste management. I think it is time we started talking about things that may not appear now, but that might end up complicating our future and that of later generations.