There is no pill against poverty

No pill can cure poverty. This is an old truth but one that needs repeating. Again and again. An article in the prestigious American Journal of Public Health (reprints can be ordered at the journal’s website) reminds me of this need. Three co-authors with Ph.D.s, two of whom have nursing experience, have published a “Field Action Report” assessing the affect of the formation of fathers’ clubs on child health in rural Haiti.

The article summary reports the key findings:

“The presence of a fathers’ club in a child’s birth village had a positive effect on vaccination status, growth monitoring and vitamin A supplementation after we controlled for socioeconomic status, time and the quality of the village health agent. Child weights and mortality were not affected by the fathers’ clubs.”

That pretty much says it all, but let’s break it down.

The study is based on detailed and extensive individual and household-level data gathered by the Haitian Health Foundation (HHF). The HHF was established in 1985 and is now operating in 104 villages in southwestern Haiti. The HHF instituted fathers’ clubs in 1994 in response to the discovery that fathers play an important role in child care in this region.

The clubs were meant to enhance child health and welfare. The fathers meet regularly to learn about child and family health from a nurse or village health agent. Education focuses on the 12 key family and community practices identified by the World Health Organization and UNICEF. The model outlines three pathways through which child health should improve.

Focusing on data from 23 villages with fathers’ clubs, the authors used children born before the clubs were established as the control group and children born afterwards as the “intervention group.” While not ideal, this approach is scientifically acceptable.

The presence of fathers’ clubs is associated with children aged one to two years being vaccinated, having their growth measured and taking vitamin A supplements. Here is what the authors say about this finding:

“Actual weights of children and infant mortality — measures that are arguably more important than the more proximal outcomes of growth monitoring, vaccinations and vitamin A supplementation — did not improve with the intervention. Furthermore, child weights remained flat over the years of study. Malnutrition is still a major problem in Haiti and continues to contribute to high morbidity and mortality in the first year of life. Malnutrition appears resistant to HHF efforts and is instead affected by factors well beyond the scope of a public health services program such as the underlying conditions of economic deprivation in rural Haiti and the political upheaval that has endured in Haiti for many years.”

I don’t need to remind you that the article under discussion was written before the earthquakes of January 2010.

So what to do? The authors mention the WHO recommendation to educate parents about feeding supplements for infants through 24 months. But they note, “This recommendation may not be feasible, given the economic constraints …. Further research is needed to develop programs that can be successful within these constraints.”

“Constraints” indeed. The kind of “constraints” that prevent the usual well-meaning educational interventions to work. At all.

How would you feel if you had a malnourished baby and no money, and someone tried to educate you about the importance of providing more food for your baby?

You might, as I was, be surprised to read the upbeat concluding paragraph:

“In conclusion, fathers’ clubs appear to be an effective strategy in child health programs. The success of fathers’ clubs in Haiti may encourage other global efforts to include fathers in a wide range of child health programs that use a community-based participatory approach.”

What? An “effective strategy” if your goals are limited to increasing the rate vaccinations, growth monitoring and vitamin A intake. But for improving children’s health? No success at all.

I’m all for fathers’ clubs. They may work in ways that this study overlooks: social support for parents (notably fathers) through the regular meetings. But they are not going to put food in the mouths of Haitian babies.

Source: Elizabeth Sloand, Nan Marie Astone, and Bette Gebrian. 2010. The Impact of Fathers’ Clubs on Child Health in Rural Haiti. American Journal of Public Health 100(2):201-204.

Image credit: Flickr user shouldbecleaning, licensed by Creative Commons.

Recent sources on Haitian culture and social change

This list is intended to provide a guide to recent resources on culture and society in Haiti for people who wish to be better informed about the context in which the recent earthquake and its devastation are occurring. With apologies, most of the journal articles are not public access.

Furthermore, we really encourage everyone to visit InterAction’s Haiti response page, which includes a variety of ways to help out.

Benoît, C. 2007. “The politics of vodou: AIDS, access to health care and the use of culture in Haiti”. Anthropology in Action 143, 59-68.

Coreil, J. & Mayard, G. 2006. “Indigenization of illness support groups in Haiti”. Human Organization 652, 128-139.

Curci, S. 2008. “Mapping Haitian history: a photo essay”. Journal of Haitian Studies 142, 120-30.

Farmer, P. 2004. “An anthropology of structural violence.” Current Anthropology 453, 305-325.

Farmer, P. E. 2001. “The consumption of the poor: tuberculosis in the 21st century.” Ethnography 12, 183-216.

Farmer, Paul. 1992. AIDS and Accusation: Haiti and the Geography of Blame. Berkeley: University of California Press.

Farmer, P. E. 2008. “Mother courage and the future of war.” Social Analysis 522, 165-184.

Giafferi, N. 2004. The violence of relations in fieldwork: the Haitian example. Terrain 43, 123-40, 159.

Guilbaud, P., & Preston, M. 2006. “Healthcare assessment study in Les Cayes, Haiti: towards a framework for rural capacity development and analysis”. Journal of Haitian Studies 122, 48-69.

Hastings, A. 2007. “Eradicating global poverty: is it really achievable?” Journal of Haitian Studies 132, 120-134.

James, E. C. 2004. “The political economy of “trauma” in Haiti in the democratic era of insecurity”. Culture, Medicine and Psychiatry 282, 127-149.

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Anthro in the news 1/11/10

• Tell it to the Marines
NPR aired an interview with cultural anthropologist Paula Holmes-Eber who teaches “operational culture” at Marine Corps University in Quantico, Virginia. Classes include discussion of cultural sensitivity and the cultural/social consequences of military presence and military actions, such as blowing up a bridge.

• Nacirema craziness goes global
In an article called “The Americanization of Mental Illness” in The New York Times Magazine, Ethan Watters (blog) describes how Western, especially American, globalization includes the spread of Western/American understandings of mental health and illness. He points to some of the negative consequences of this trend.

In discussing why people diagnosed with schizophrenia in developing countries fare better than those in industrialized countries, he draws on the work of medical anthropologist Juli McGruder of the University of Puget Sound. McGruder’s research in Zanzibar shows how Swahili spiritual beliefs and healing practices help the ill person by avoiding stigma and keeping social and family ties intact. Note: Nacirema is “American” spelled backwards.

• Guardians of the nameless dead
The bodies of hundreds of victims of political violence in Colombia are often disposed of by being thrown into rivers. Sometimes the bodies wash up on the river bank. WIS News describes the work of one local civil servant, Maria Ines Mejia, who spends time recovering bodies from the Cauca River and thereby helping authorities record the deaths and chronicle the killings.

Maria Victoria Uribe, an anthropologist with Colombia’s National Commission of Reconciliation and Reparation, names people like Mejia as “unknown heroes.” Michelle Hamilton, an expert in body composition who directs the Forensic Anthropology Center at Texas State University, notes that “…you can imagine trying to grab onto a water-logged body with the skin slipping off. It can come off in your hands.”

• Celebration and warning
Survival International’s “weighty coffee-table book,” We Are One: A Celebration of Tribal Peoples, is reviewed in the Ecologist. The unity and diversity of indigenous peoples around the world is celebrated in beautiful photographs and through the words of tribal and non-tribal people. Given that Survival International commissioned the book, it also expectedly contains a message of deep concern about the dangers to survival that so many indigenous/tribal cultures face.

• Who rules?
Janine Wedel is a cultural anthropologist and professor of public policy at George Mason University. Her book, The Shadow Elite: How the World’s New Power Brokers Undermine Democracy, Government, and the Free Market, was reviewed in the Financial Times and by Arianna Huffington of the Huffington Post. Wedel has appeared at several book launches in D.C.
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Toward a new decade in psychiatry

An editorial in Nature argues that funding is meager for research on psychiatric diseases compared to that for other major diseases. Focusing just on schizophrenia, new directions for the upcoming decade include: considering why the efficacy of medications has not improved other than reducing side effects; changing the focus on diagnosis and drugs in late stages of the disease to identifying biomarkers and environmental factors that put people at risk; devoting more research to deeper understanding of the underlying biology; devoting more research to “environmental” (socio-cultural) factors; bringing together knowledge in various disciplines; deepening the exposure of psychiatrists to biology.

This blogger adds that a deepened exposure of psychiatrists to medical anthropology and its attention to environmental factors including illness labeling, stigma, and non-medical treatment options is even more important than more biology. If it is in fact true that, as the editorial claims, about 80% of the pattern of schizophrenia in populations “seems to be determined by genetics” with an unknown share of that percentage “susceptible” to environmental influences, and if the other 20% is directly determined by “environmental factors,” then the proportion that is purely or directly biological alone may be more like 60%…and the other 40% either directly or indirectly shaped by environmental factors. Who knows – these percentages all “seem” to be guesswork, but even the crudest guesswork leaves a lot of room for social/cultural factors. And it just may be easier to deal with/change/prevent such social/cultural factors than it is to mess around with someone’s genes.

The next decade for psychiatry should be the decade of cultural psychiatry.

Image: “Brains” by Flickr user Curious Expeditions, licensed by Creative Commons.

Please pass the sorghum: big news for paleo-dieters

The downsides of a “modern” Western agro-industrial diet of starchy, sugary, processed foods are well-known thanks to the writings and activism of many food-wise non-scientists such as Michael Pollan, Alice Waters and Jamie Oliver. Their advice to eat fresh, locally grown food whenever possible is nutritionally sound, though not always feasible.

A more extreme rejection of the industrial diet is the so-called paleo-diet. The outlines and benefits of a paleodiet were first proposed by three anthropologists — S. Boyd Eaton, Marjorie Shostak and Melvin Konner — in their 1988 book, The Paleolithic Prescription. In 2002, Loren Cordain hit pay dirt with his best-selling book, The Paleo Diet.

Proponents of a paleodiet point out that 99 percent of human evolution occurred when we were foragers (a.k.a. hunter-gatherers) and ate only lean meats, fish and seafood, nuts, fresh fruits and fresh vegetables. Our bodies have adapted to these foods over several million years. The agro-industrial diet goes against our biological base, in this view, and causes a host of health problems such as heart disease and obesity.

An article in today’s Washington Post style section, “Hunter-Gatherer Gourmet” (alternatively titled “Paleolithic diet is so easy, cavemen actually did it“) profiles a young D.C. woman who follows a paleo-diet along with a rigorous exercise plan. She eats no grains, salt, sugar, legumes or dairy products (her one concession is dark chocolate from time to time). In nine months, she has lost 10 pounds, no longer gets migraines, sleeps better, is allergy-free and her mood has improved.

A recent archaeological discovery in sub-Saharan Africa has major significance for paleo-dieters.

Julio Mercader, Canada research chair in tropical archaeology in the University of Calgary and Mozambican colleagues have discovered that stone age hunter-gatherers at one site in Mozambique were harvesting, processing and eating wild sorghum by 100,000 years ago (see this PDF article from Science magazine, which requires a login).

So it’s time to revise the paleo-diet books and welcome whole grains to the neo-paleo-table!

Image: “Paleolithic Food” by Flickr user Roberta Maria, licensed by Creative Commons.

#1 cultural anthropologist of the decade

As any cultural anthropologist will tell you, a decade is an arbitrary cultural construction with no inherent meaning. I agree. But it does offer a potentially interesting way to bracket a period of time within which a lot happens but not too much — at least not too much for my memory to handle.

On Morning Joe today, some commentators were going through a list of top 10 events of the decade, with the 9/11 attacks ranked as number one, the most significant. As I watched, I wondered if it would make sense to compile a ranked list of the most important cultural anthropologists of the decade. It seemed impossibly difficult, especially the ranking part. But then it hit me that I could reasonably make a case for a number one cultural anthropologist of the decade.

I hereby, with all the authority of a lone blogger, name Paul Farmer (Wiki, bio) as #1 Cultural Anthropologist of the Decade.

Here’s why, in case you do not already agree with me. He has published many important scholarly works, beginning with his groundbreaking exposure of the politics and racism that led to blaming Haiti for the origin and spread of HIV/AIDS.

In addition to his many scholarly publications, Farmer is an influential global health practitioner and activist and co-founder of Partners in Health. Tracy Kidder’s book about him and his health work in Haiti, Mountains beyond Mountains, is widely read. CBS did a documentary on him in 2008. The Skoll Foundation named him “Entrepreneur of the Year” in 2008. In 2009, he was a top contender for the position of head of the U.S. Agency for International Development, and in the same year he was named U.S. deputy special envoy to Haiti.

Within the discipline of anthropology, Farmer has placed consideration of poverty, social inequality and social justice in the mainstream of research and writing. His use of the term “structural violence” has ensured its significance well beyond medical anthropology. His insistence on taking poverty and social inequality seriously as primary causes of health problems worldwide has helped shake the foundations of western biomedicine. He has helped forge importance links between health and human rights.

Rich anecdotal evidence from my experience teaching at GW also supports my naming of Farmer as #1 Cultural Anthropologist of the Decade. In my undergraduate cultural anthropology class, when I ask who has heard of him, many hands shoot up. Of these students, most have read Mountains Beyond Mountains. A few have heard him speak. In my upper level class on medical anthropology, an even larger proportion of students is aware of his work, and many have read one of his books in another class (they will in my class as well). In my graduate seminars, most students have read at least one of his books and perhaps also an article or two.

Beyond the impressive level of awareness among my students of Farmer’s contributions to health and anthropology, however, is what I refer to as The Paul Farmer Effect (PFE). I created this term to refer to the Pied Piper role he plays: I keep hearing from students that want to be a Paul Farmer. And they are choosing courses, majors and minors, to help achieve that goal.

Thus enrollments at GW in classes in medical anthropology, culture and human rights and cultural anthropology generally are booming. Increasing numbers of B.A. students are combining majors in anthropology, global health and/or international affairs, and adding a minor or two if they cannot fit in a double major. At the graduate level, our dual M.A. degree in international development studies and public health is very popular, and there is strong demand for a similar dual master’s degree in anthropology and public health. Every year, I receive inquiries from medical students about how they can include anthropology in their training.

The Paul Farmer Effect.

At GW, I began to notice it five years ago or so. Since then, the PFE has not abated. It is growing. Because of the PFE, more students each year combine their academic interests in anthropology, global health and international affairs. These students are beginning to graduate and go on to pursue humanitarian careers. Thanks to Paul Farmer and the PFE, they are more powerfully informed and more motivated to make the world a better place than would otherwise be the case.

Chagas disease on the move in Peru

Chagas disease affects 8 – 10 million people in the Americas. Previously limited to the rural poor, it is spreading to the poor of urban areas. A qualitative, interview-based study (PDF file) of five per-urban communities of Arequipa shows that men who have recently migrated to the city’s “new shantytowns” from the countryside are most at risk of contracting Chagas. But the migrants tend to come from Chagas-free areas and therefore do not bring the vector with them. Instead, it appears likely that they become infected through short-term migration to the Chagas-endemic valleys west of the city for seasonal agricultural labor.

Thus migration is involved in the spread of Chagas but the causal chain involves more than simply rural to urban migration. First, poverty in the rural areas prompts people, even young children on their own, to migrate to the city to seek work. Once there, limited employment options force many migrants to take on seasonal work in Chagas-endemic areas. They return to the shantytowns bringing the vectors with them. The disease then spreads rapidly in the new shantytowns, given their suboptimal housing, population crowding and high density of animals. Suggested methods for improving vector control include: focusing vector surveillance on mobile populations, motivating the Arequipa Ministry of Health and Ministry of Housing to work together to include new shantytowns in their vector surveillance and launching education campaigns for migrant workers who go to Chagas-endemic areas.

Improving vector control is certainly important, and I hope it proves successful in keep Chagas out of Peru’s cities. But what about programs in rural areas directed at protecting livelihoods and entitlements so that fewer people are compelled to migrate to cities in the first place? And how about focusing intense poverty alleviation efforts in Chagas-endemic areas? Such endeavors would help reduce the need for surveillance. If the conditions that foster Chagas were reduced and Chagas eventually eradicated, then education campaigns could focus on other, more productive kinds of learning.

Image: “Chagas” by Flickr user Clonny, licensed through Creative Commons.

Death (sticks) & taxes

Local governments in the Republic of Korea that earn the most local revenue from the tobacco consumption tax (TCT) are less likely to participate in the central government’s anti-smoking campaign. Statistical analysis of data on 163 municipalities revealed a clear policy conflict and points to the need to reduce local governments’ dependence on TCT revenue by supporting alternative sources of revenue.

The authors mention the need for further research to investigate local policy environments and changing social and regional patterns of smoking, and comparative studies of tobacco tax policy.

Let’s not leave out attention to advertising campaigns sponsored by tobacco companies and who they are targeting as well as public health education programs that need to target the same groups as the tobacco companies in order to counteract the lure of the ads.

The world needs more anthro-doctors

by Barbara Miller

Dr. Lewis Wall is dedicating his life to repairing obstetric fistulas of women in Africa. Nicholas Kristof, who has been writing about fistulas since 2002, lauds him for his work, as we all should.

Dr. Wall is an ob-gyn at Washington University. When not in St. Louis, he has done many fistula repairs for women in Africa: “You take a human being who has been in the abyss of despair and –boom! — you have a transformed woman. She has her life back.”

A fistula is a hole. An obstetric fistula is a hole due to the birthing process either between the vagina and the rectum or between the between the vagina and the bladder. Because of the fistula, the woman becomes incontinent, with either urine or faeces coming out of her vagina. She is typically abandoned by her husband and becomes a social outcast.

Obstetric fistulas are common throughout much of the developing world for a variety of reasons: childbirth of very young and/or malnourished women, poverty, female genital cutting and infibulation, lack of access to prenatal and delivery care and to emergency obstetric services. Related to many of these factors is a culture of patriarchy which devalues and disempowers women and girls, offering them little say in when and how to bear a child and whether or not they can access medical care when a problem arises.

Kristof has been writing about fistulas and the heroic efforts of many to repair them, including Dr. Catherine Simpson. He is delighted that Dr. Wall will also be opening a fistula hospital soon in Niger.

Kristof tells us that Dr. Wall started out as an anthropologist working in West Africa where he learned to speak Hausa. “But he concluded that the world needed doctors more than it needed anthropologists.” So he went to medical school at age 27.

Sorry, but the world doesn’t need just “more doctors.” Starting with the great tradition launched by anthropologist/psychiatrist Arthur Kleinman, medical anthropologists have for long pointed out the limitations of western biomedicine including what its scope allows it to treat and the related narrow training of doctors. In treatment and training, technology rules. Medical students are systematically sleep deprived and distanced from their patients. Melvin Konner’s book Becoming a Doctor convincingly recounts these processes. Konner is a biocultural anthropologist with field experience among foragers of the Kalahari desert. He decided to attend medical school, and then wrote about it as a dehumanizing rite of passage. He does not practice medicine but continues to teach anthropology and comment in the public media from time to time about how to reform medical school in the U.S.

If Dr. Wall had gone straight to medical school, chances are slim to nonexistent that he would have repaired a single obstetric fistula in Africa. Instead, being first an anthropologist first afforded Dr. Wall the contextual awareness and humanitarian spirit that medical school training totally bypasses.

The anthro-doc combo has become an increasingly valued option by many young people in the U.S. (if my students are a good sample, and I believe they are), popularized especially by Paul Farmer. Farmer is the only anthropologist I know who has inspired a documentary book while still living: Tracy Kidder’s Mountain beyond Mountain. Many of my students have read this book and want to become some version of Paul Farmer, combining anthropology with a profession that helps people who are resource-poor and ill. Our classes in medical anthropology and global health are always oversubscribed. I call it the “Farmer effect.”

So Dr. Wall was only partially correct. The world doesn’t need more doctors. The world needs more anthro-doctors. As well as people who combine anthropology with other healing/health-related professions such as public health, nursing, midwifery, and more. As Dr. Wall might admit: you do need to know something about “the people.”

Pills against poverty: Easterly speaks power to Farmer

by Barbara Miller

Paul Farmer walks on water for a lot of people around the world, from Haitian villagers he has treated in his clinic to my GW students who he has inspired with his writings. So what to think when one of my favorite economists, Bill Easterly, zaps him in an opinion piece in The Financial Times for promoting programs that have helped the middle and upper classes and bypassed the poor?

Answer: Easterly has a point. International “health rights” cannot only be about providing ARDs (anti-retroviral drugs). Especially if, as Easterly claims, international aid-supported programs are giving access to these life-saving and costly drugs differentially to better-off people in Africa.

This is an ugly thought but one worth pondering. It would not be the first time in international aid that benefits bypassed the poor and landed with the better-off.

If you read Farmer’s books, and I do every year since I assign his writings in my undergraduate and graduate medical anthropology classes, you will see the interplay between Farmer the anthropologist and Farmer the doctor. The doctor wins. Farmer the doctor is interested in treating, not preventing, illness. Treatment, through drugs, wins out over more anthropological concerns about social inequality, causes of poverty, and “solutions” such as empowerment, employment and other ways to reduce inequality.

Farmer has walked the walk in the hard scrabble hills of Haiti (to get a sense of Farmer the humanitarian healer, read Tracy Kidder’s docu-ography of him, Mountain Beyond Mountain). He has seen countless AIDS victims living in extreme poverty. He has been in Russian prisons and seen the ravages of XMDRTB. He has seen the work of structural violence. His medical political activism: He prescribes ARDs and lobbies in Washington for more funding for ARDs.

Pills alleviate pain and suffering and can extend life. A health rights position says that access to such pills should be equal for all. But in the end, pills don’t cure the diseases called poverty and inequality. Easterly offers a corrective view.

Photo, “Pills & Container (Landscape)”, from Flickr via Creative Commons.