Tales from Tanzania

Swine flu may expose the “global health apartheid,” as blogger Mike Smith argued this week — but we may have more resources to fight it than we think. According to new research published yesterday in the New England Journal of Medicine, a one-dose vaccine for H1N1 influenza may work much more effectively than researchers initially imagined.

This means that resources currently available for the flu vaccine will go much further than imagined. Twice as far, to be precise. Most experts had predicted that patients would require two doses of an H1N1 vaccine to be protected from the virus, which is now pandemic in 168 countries. It has infected approximately 100 million people in the United States since its arrival in spring of this year, according to the Centers for Disease Control and Prevention.

Dr. Anthony Fauci, head of the U.S. National Institute of Allergy and Infectious Disease, told the New York Times that research currently underway in the United States “corroborates and confirms the exciting data” that protection against H1N1 may require only one vaccine dose, not two.

This is Part II of an interview with epidemiolgoist Elizabeth Pisani, author of The Wisdom of Whores: Bureaucrats, Brothels, and the Business of AIDS. Here, she talks about where she thinks HIV/AIDS funding is headed — and why in the past we’ve refused to spend it in ways that actually work.

Mara Gordon: You spend a good section of your book debunking the “family values first, science-based facts second” global health policies of the Bush Administration. Where do you hope American HIV/AIDS funding — and money for global health in general — will be headed under the Obama administration? Where do you think it is actually headed?

Elizabeth Pisani: I think it is probably headed in the right direction. A lot of very smart people have had to keep a pretty low profile in US institutions such as CDC, USAID and NIH for some time now. But they do know what needs to be done — clean needles for drug users, constructive work with people in the sex trade, effective prevention programmes for men in prison, full information and a very broad range of service options for people who are considering sex outside of the monogamous-from-marriage-as- virgins ideal so beloved of preachers in sermons if not always in practice. Those are some of the things that need to be done now, but as the data change, the needs will change, too.

MG: Your book focuses on HIV/AIDS prevention and treatment. In my experience working in public health in sub-Saharan Africa, earmarked aid money specifically for HIV/AIDS actually weakens health systems; disease-specific funding ignores the way that all health problems, inevitably, are interrelated and intertwined. Do you agree?

EP: Ooooh, this is a big, furious debate right now. Perhaps surprisingly, I don’t have very strong views – the evidence goes both ways. On the one hand, smart governments dedicated to the welfare of their people can use disease-specific funding to build up systems that they can then subvert for use with other diseases and even other development problems. On the other hand, opportunistic, inefficient or corrupt governments can suck at the teat of disease-specific funding very easily, while failing to do anything to address the many other problems that you rightly point out are likely to be linked to that specific disease. (Now, if a government has allowed a fatal, preventable disease to infect a quarter of adults without taking any of the culturally-hard-but-necessary steps it could have taken to prevent it, do you think it is more likely to fall into the smart category or the corrupt category?)

Sometimes, the only way you can get funding is to take disease-specific funding. If you use it right, that’s fine by me. That includes using whatever proportion of it you do spend on the disease in question effectively. But I think it is particularly difficult to use it right (and particularly likely to undermine health systems) where the disease you are taking funding for exists only in sub-populations that no-one gives a damn about. And that’s the truth of it in most countries outside sub-Saharan Africa.

MG: Another interesting tension I observed in your book relates to the way HIV prevention programs target different populations. In Thailand, we should work with sex workers. In South Africa, truckers. In Uganda, the successful “zero grazing” partner-reduction campaign argued that everyone in Ugandan society is affected by HIV/AIDS. When are population-specific strategies successful, and when are they not?

EP: Epidemiologically, population-specific strategies are successful when a high proportion of all new cases are being generated by defined behaviours in a certain sub-population. If six houses on your block are on fire and there are no fires anywhere else in town, do you want to bring all the firetrucks to your block, or do you want them to go around filling a bucket in every household in town, because, well, you know, every house could be at risk of burning down? In most countries, HIV is a fire that tends to burn in two or three blocks. In Eastern Europe and parts of Asia and southern Europe, HIV is spread mostly between people shooting up drugs together. In much of the Americas (including the US), much of Europe and Australasia, it’s spread mostly between men having anal sex with one another. In East and Southern Africa, it is spread largely in sex between (often younger, often unmarried) women, and older men. A far, far higher proportion of the population in any country in East and Southern Africa fit that risk profile than fit the risk profiles for gay men or drug inejctors in other regions, so it is in those countries that you have to spread your firetrucks more widely. Obviously you’re going to need more firetrucks, too.

Elizabeth Pisani does it all. A journalist-turned-epidemiologist who has worked to fight HIV/AIDS all over the world, Pisani is the author of one of my favorite global health books, The Wisdom of Whores: Bureaucrats, Brothels, and the Business of AIDS. Her book achieves that rare, wonderful thing when it comes to epidemiology: it’s actually interesting.

You’ll laugh (her descriptions of female condoms are laugh-out-loud funny). You’ll cry (she puts a poignant, human face on the HIV statistics). And above all, it’s based on sound science, which as she reveals in her book, isn’t always the case when it comes to the big-bucks international HIV/AIDS industry.

She was kind enough to answer a few questions for me about her book and global HIV/AIDS policy.

Mara Gordon: To start off… What are you up to now? Your book is a wild ride that takes us from the brothels of Jakarta to the stuffy UN offices in Geneva. Where are you working? What could possibly top what you’ve done thus far?

Elizabeth Pisani: I’m trying to settle for a while in London, which I find wildly exotic. I’ve never really got over my frustration with the mis-match between the effort we put into data collection and the attention we pay to the results. If you look just at developing countries, we spend hundreds of millions on disease surveillance… and then we ignore the result… So right now I’m working with some of the big funders of health research to encourage researchers and even governments share their data. We’ve learned from genomics on the one hand and the open source software movement on the other that the more brains you get working on the same problem and sharing their findings, the faster you reach a solution. We ought to be able to bring that same approach to research that affects people’s lives and well-being.

MG: One of the most important ideas I took away from your book was that we should stop looking at people affected by or at risk for HIV as victims. Instead, you seem to argue, if we equip people around the world with the tools, education, and resources to make healthy decisions, they often will. Why is the global health establishment so wedded to the first line of thinking? How can we change that?

EP: Do you want the polite answer, or the one I think is closer to the truth? If you want the latter, I have to preface it by saying that I love my work and most of my colleagues. But let’s face it, most people don’t go into public health policy work because they are by nature wild party animals who live lives of competing and highly unpredictable risk. And the pay is pretty crap, so you have to believe that most also don’t do it because they have a very sophisticated understanding of the incentives that motivate a large part of humanity. You have to want to make the world a better place to be in public health, and that means that the profession attracts a higher goody-two-shoes quotient than, say, banking or drug-dealing or major league sports. A lot of people in public health are extremely rational, and extremely concerned about health. They expect other people to be rational and health-conscious too. The fact is that most of us ARE rational, but not always about our long-term health. Have really good sex right now (a dead certainty) or possibly come down with an annoying but treatable disease ten years from now, if I’m still alive. What’s the rational choice?

As for how to change that, hmmm, don’t know. Though I will say that the HIV epidemic itself has changed it quite a bit already, because it did bring into the field of public health a lot of people who ARE naturally party animals, or once were — gay men and drug users and people who like sex principally but by no means exclusively. That’s one of the reasons that HIV is such a fun area to work in, even though it obviously has its deeply depressing side.

In Part II of the interview, I talk with Dr. Pisani about where she thinks global HIV/AIDS funding is headed — and why we’ve made so many mistakes so far.

Where do you get your global health news?

Like you probably do, I read quite a smorgasbord of health news offerings, ranging from the Washington Post to niche blogs written by people working on the front lines around the globe.

And increasingly, I rely on non-profit news sources. Unlike traditional newspapers, they take many forms: organizations funded by wealthy philanthropists, fellowships for journalists to write about neglected diseases, websites of organizations and academics whose global health research I respect. These sources give me perspectives I’d never get from simply following the mainstream media, but do they give me rigorous, fact-checked, accurate perspectives, too?

To get some answers, I turned to Maralee Schwartz, a former Washington Post editor and fellow at the Harvard Kennedy School of Government’s Shorenstein Center on the Press, Politics, and Public Policy. I got in touch with Schwartz because she recently published a report on non-profit foundations that provide health news (most notably, the Kaiser Family Foundation, which produces an excellent daily aggregation of global health headlines). Her report focuses on U.S. health news, but it asks all the right questions.

Schwartz professed that she isn’t an expert on global health news, but she is quite well-informed about an issue that I think will be increasingly relevant to all of us who work in and care about international health. If the information is free, can we really trust it?

“If journalistic standards are applied to the material, I don’t have a problem,” she wrote in an e-mail interview. “Information comes from lots of different sources — the key is that the consumer of the information is clear about the source, and trusts the source.”

So will global health activists of the 21st century be getting their news from do-gooder sources, not publications looking for a profit?

“During the course of my interviews, Harvard Professor Robert Blendon mentioned that he could see a time when, say, the Gates Foundation might become interested in funding global health news or news on global education issues,” Schwartz wrote. “I think if these various nonprofit models on health care are viewed as successful, expanding the coverage to global issues is certainly a possibility.”

Check out Schwartz’s report on foundation-funded health news here.

Liberals, like yours truly, always like to use the “science” argument when debating about public health.

A common version of the argument:

Conservatives: Telling kids about condoms makes them have premarital sex!

Liberals: They have premarital sex anyway. Condoms are scientifically proven to prevent pregnancy and STIs. We should definitely tell people about condoms.

Science is empowering. When people have the right to access accurate, rigorously tested information, they can make informed decisions about their own health. But what happens when the science – the real, statistically relevant science – isn’t likely to encourage any healthy choices?

If you’re a dedicated reader of this blog, you already saw Alanna’s post on recent research suggesting that withdrawal may actually be an effective form of birth control. (For more information, take a look at the Guttmacher Institute study here.)

The New York Times published an article about the study this week, its headline proclaiming, “Withdrawal method finds ally.” The Times’ treatment of the subject got me thinking: What exactly is a publication’s responsibility when it comes to controversial health news?

Science, that reliable argument for causes like comprehensive sex education, is also subtle, slow, and rarely as clear-cut as we would like – not exactly headline generating material. So when science does make the news, it tends to be oversimplified and sensationalized.

A quick browse through most major publications’ health sections yields stunningly contradictory health news. To lose weight, don’t eat carbs! To prevent cancer, drink green tea!  And almost as quickly as the news arrives, new studies take their place, telling confused readers the new miracle cure for that which ails them.

It’s easy to laugh when it comes to news on trendy weight-loss schemes. But what about an issue, like pregnancy and STI prevention, where the stakes are higher? How should journalists cover it, when the data are limited and likely to cause confusion – yet it’s data nonetheless?

A decisively unscientific survey of some of my friends who work in public health yielded a pretty standard response to this issue. “Famous last words,” one friend told me when I asked her about the New York Times article. Most people I talked to worried that the coverage of the study would give people an imaginary free reign to have unprotected sex. After all, the science seems to say, withdrawal is just as effective as condoms.

But the Guttmacher Institute study’s leader author makes a compelling counter-argument: debates about public health should be data-driven, and she’s got data. We should no more blindly trust the status quo in family planning than we should blindly hope teenagers won’t figure out how to have sex if nobody talks about it.

What do you think? How should the mainstream media – and the public health community – cover an issue like this?

Global health news isn’t exactly the mainstream media’s strong suit. American publications are slashing their budgets for international coverage, and news about healthcare inequalities – when there isn’t a celebrity face attached – is not nearly as common as it should be.

A recent New York Times series on maternal health in east Africa is, thankfully, an exception. Health and science reporter Denise Grady traveled to Tanzania and reported on topics like maternal and infant mortality, orphan care, and unsafe abortions for the “Death in Birth” series.

I highly recommend you take a look at the series if you haven’t already. Ms. Grady’s writing cuts to the heart of complicated issues, and Béatrice de Géa’s photographs are beautiful and moving.

Ms. Grady generously agreed to answer a few questions about the series.

Mara Gordon: Public health issues aren’t known for generating headlines in the mainstream media. The problems are chronic and, especially when it comes to an issue like maternal and child health, complicated and intertwined. How did you choose to write about maternal health in Tanzania for the “Death in Birth” series? What choices have you made to make this very important issue “newsworthy” for the New York Times audience?

Denise Grady: I’ve been interested for a long time in maternal health in poor countries, particularly in the fact that so many of the injuries, deaths and illnesses can be prevented by things that are essentially basic first aid for women who are pregnant or in labor. I chose Tanzania because it is among the poorest countries in the world and its  statistics are bad, but neither the best nor the worst in Africa. It has a stable government and so its problems cannot be blamed on war or a despotic regime. So it’s a fairly decent representatitive of many other countries. I didn’t have to do anything special to make this subject newsworthy.  It is inherently newsworthy.   My editors agreed. And I’ve had lots of response from readers.  People do care.

MG: Tell me a bit about how you prepared for the trip to Tanzania. How did you decide who to interview and which hospitals to visit? What kind of background research goes into a major global health story?

DG: I prepared for this the way I think most reporters would – I read everything I could find and began to call people. Jeffrey Wilkinson, an obstetrician from Duke University who is working in Tanzania, was extraordinarily knowledgeable and helpful, and also offered to provide introductions and share the many contacts he had made in Tanzania.   It can be difficult to make connections and gain access to people and places and institutions overseas, so when somebody offers to help, I seize the opportunity. Dr. Wilkinson helped open doors for me and Beatrice DeGea, the very talented photographer who also worked on these articles.

MG: What was most challenging about the reporting?

DG: The most challenging thing was selecting the stories to tell.  For every one we published, there are several others untold. There just isn’t room in the paper for all of it.

MG: As your series shows us, there’s no easy solution to a problem like maternal mortality. But where do you think we can start? Which strategies in place in Tanzania – like training more auxiliary health workers, incentive programs to attract health professionals to rural areas – do you think are the most effective?

DG: I think that educating girls would be an important first step.  I don’t mean just teaching them about birth control. I mean providing a general education so that they could look forward to work of some kind and develop hopes and ambitions for themselves. Then they need access and information about birth control and childbirth. I spoke with young women in Tanzania who said they did not realize sex would make them pregnant, or who thought condoms or other types of contraception were dangerous. I think there is also a widespread misperception that sickness and death are inextricably tied to childbirth and are therefore women’s lot in life, so people accept it with resignation instead of reacting with outrage.  Education could change that.

In terms of specific, practical solutions – you need more trained people at every level, and you need ambulances, and courses in emergency obstetrics, and maternity waiting homes for women who live way out in the bush. I got the sense that when nurses and medical officers were taught things like how to prevent a woman from bleeding to death, they came to believe it could be done, and that they could do it.  You need to instill a sense of urgency, and that depends on people believing there is hope, something to be gained by taking charge and dealing with an emergency.  If you had to focus on one single thing, I think it would be in preventing and treating postpartum hemorrhage, because that is the leading cause of maternal deaths.

Take a guess at the answer to this question: What kills 1.3 million people worldwide each year, 90% of them in developing countries?

The hot-button issues probably crossed your mind: AIDS, perhaps malaria. If you’re a global health junkie, maybe you’d guess tuberculosis. When we think about large numbers of mortalities, we tend to think of the “big name” diseases.

The answer, however, isn’t even a disease, let alone one with a Global Fund and celebrity spokespeople to address it. It’s traffic accidents. That’s what kills hundreds of thousands of people in the developing world every year.

Earlier this week, the World Health Organization released its first Global Status Report on Road Safety. The statistics are chilling, especially considering how little international attention this issue receives. Very few countries have comprehensive road safety laws, and those that do rarely enforce them. Perhaps the scariest statistic of all: the WHO predicts that traffic fatalities will be the fifth leading cause of death by 2030.

Why doesn’t road safety garner the same kind of developed-world sympathy – and aid dollars – that infectious diseases do? I’ve done a lot of thinking about this, particularly because road accidents have directly affected me and several of my friends in Africa.

The WHO statistics indicate, by any account, a bona fide public health threat. Yet it’s rare to encounter any international NGOs working on the issue, let alone idealistic aid workers trucking off to new parts of the globe to fight for better seatbelt laws instead of HIV medication.

A few thoughts:

• Road accidents happen at home, too. A car crash doesn’t seem exotic to an American in the same way that many tropical diseases do. I’m not trying to undermine the importance of prevention and treatment for infectious diseases, but sometimes the ordinary problems don’t seem as noble to fix.
• We can’t deliver a commodity to treat it. As a donor, it feels good to imagine your money putting a tangible object in somebody’s hands: an anti-malarial bednet, a nutritional supplement for a child. We can’t prevent car accidents with a deliverable product.
• Addressing the problem means uncovering many, many more. Road safety in poor countries is a result of many complex, interconnected factors – safety standards for vehicles, unenforced traffic laws, shortages of trauma centers. A drug can’t cure it.

Take a look at the WHO report and let me know what you think. Where do we start?

Internet access in East Africa is slow. Really slow.

The instant connection I’m used to in the States is nowhere to be found, and getting online is a tedious and expensive process. Forget video chatting or downloading movies. Even sending e-mail attachments is a challenge. At the public health NGO where I worked in Tanzania, we’d often send documents on a flash drive in a taxi across town rather than try to transfer them via the Internet.

East Africa currently depends on satellite Internet access. Instead of the high-speed, underground fiber optic cables that North America, Europe and most of Asia use, East African service providers use an expensive and low-capacity network of satellites to get people and businesses online.

But in the next few months, all that is set to change.

“The Internet is coming!” is the phrase on the tip of everyone’s tongues in Tanzania. Two competing companies are building submarine fiber optic networks to connect Kenya, Tanzania and their neighbors to the rest of the world. There have been some delays, unsurprisingly, but it looks like at least one company is slated to be up and running in the next month.

Fast and reliable Internet access is about a lot more than Americans like me trying to load my Gmail while abroad. It will drive down prices, speed up productivity, and allow more people access to more information.

And, I believe, it will have profound effects for health.

The connection between the Internet and health may not be obvious. But think creatively, and the possibilities are endless. Internet access can help educate patients, keep physicians up to date with continuing medical education, even be an incentive for health professionals to work in rural areas.

Take the kind of health data projects I was a part of in Tanzania. I worked with many motivated government health professionals, all of whom know that improving the quality and organization of patient data is crucial improving Tanzanian health systems. Accurate and well-organized information means a better sense of where the problems are and a better ability to fix them.

But think about what my colleagues are up against. Many health facilities are in places where people can’t even get a cellphone signal, let alone fast Internet access. As an American, I think of data as inherently digital – but in many parts of Tanzania, reporting health data means somebody putting a paper form in an envelope, getting on a bus, and dropping it off at a district or regional hospital. You can imagine how hard it is to track and analyze public health trends that way.

Now think about it with speedy Internet access. A data clerk in a health center simply types numbers into an online database, clicks a button, and the information is accessible to health professionals all over the country. We can track where diseases are endemic, where resources need to be allocated, where health professionals need to be placed.

Of course, this is oversimplified. I know that fiber optic Internet access won’t mean a magic snap of the fingers that fixes East Africa’s health information challenges – just look at the endless debates on electronic medical records in the United States, where fast Internet access is available practically everywhere.

But I’m thrilled to see what will come as more and more East Africans get online. At the very least, I’ll finally be able to video chat with my friends there.

How do you sum up a year?

You can’t, so I’m not going to try. The precipitous drop-off in postings is due to the fact that I’m back in Washington, DC — and things basically aren’t as interesting here as they are in Tanzania.

Instead of offering some pretentious and probably false musings on “look at how much I learned in Africa!” or “I truly understand the nature of poverty!” or “wow, I forgot how amazing bagels and lox are!” (although they are quite amazing), I’m instead going to post a few pictures from my trip to Ethiopia and say: GO THERE. It’s one of the most beautiful places I’ve ever visited, and the historical sites are fascinating and well-preserved. The Ethiopian Orthodox ecclesiastical art is beautiful, and macchiatos run about 25 cents a cup.

In the Piazza, in Addis Ababa:

Castles in Gonder:

Fasiladas’ Bath, Gonder:

I definitely won’t be posting here as frequently anymore. I will, however, be posting at Change.org’s Global Health Blog — check it out!

And who knows? Maybe I have a few more tales from Tanzania up my sleeve. I’ll probably end up back there sooner than I imagine.

About a decade ago, the Institute of Medicine released a report called America’s Vital Interest in Global Health. The report, issued by an influential committee of policymakers and academics, called for a coordinated, sustained commitment from the United States on issues of global health – both for altruistic, humanitarian reasons and for America’s own “enlightened self-interest.”

Wednesday, the IOM released its 2009 update.

You can check out all 263 pages of the U.S. Commitment to Global Health here, and I highly recommend you do. As Ruth Levine, a senior fellow at the Center for Global Development and report committee member, put it on the CGD blog, here’s the “Twitter” version:

“Thanks for a good decade; don’t slack off now ($15b by 2012). Healthier world = happier, healthier us. It’s more than AIDS. Play nice with others. Get your act together.”

Get your act together, indeed. What’s most striking about yesterday’s report is not necessarily its (very sound and feasible) recommendations, but how much has changed since 1997 – and how much hasn’t.

Levine and two of her fellow committee members discussed the IOM report in a webcast on Thursday sponsored by the Kaiser Family Foundation, and what I found most interesting was hearing their perspectives on what the global health landscape is like in 2009, with big changes like the Global Fund, Obama administration, and Gates Foundation.

“We now have a momentum, I believe, in global health, that we simply didn’t have ten years ago. You see a remarkable change in attitude … We’re a globalized community,” said Maria Freire, president of the Albert and Mary Lasker Foundation. “That translates directly into excitement on our campuses … An enormous change in the philanthropic landscape … Frankly, new ways of doing business.”

But what hasn’t changed?

The report calls for a $15 billion commitment to global health from the U.S. government by 2012.

Sounds like a lot, but according to Levine, it’s comparable to what other developed nations give in aid for health.

And it’s money that the U.S. has already committed to.

The U.S. government has a bad track record in both these areas. We give a substantially lower percentage of our GNP in foreign aid than most other developed countries. And we consistently fall short on the aid promises we do make.

We have the tools and the energy, in 2009, to make some serious strides in international health. Let’s find the political will.

I’m in Ethiopia for a final week of travel before I head back to the States for class. I had planned to head up to the northern part of the country to see some of Ethiopia’s amazing historical sites, but a giant dust storm stopped out plane from landing and re-routed us back to Addis Ababa. In the hours I spent in line trying to negotiate a ticket refund, I got to talking with a fellow stranded passenger.

Turned out that passenger was in town presenting his research on the human resource crisis in global health. The World Health Organization and World Bank — among some other partners — are hosting an international symposium on the topic here in town, and my co-passenger invited me to drop by since I had some extra time in Addis on my hands.

It was exciting to hear the presentations, both from government officials from several African countries and from international development agencies. But with this topic, as with many in global health, I left feeling almost as overwhelmed as I was motivated and excited.

Where do we begin, on a topic as vast and problematic as the shortage of trained health workers in Africa?

In my own work in Tanzania, I experienced the “HRH crisis,” as NGOs like to call it, every day. The government health staff I met were usually overworked, underpaid, and shuffled around a circuit of government health facilities as they are frequently assigned to new posts. It’s no wonder so many African doctors and nurses leave their home countries to work in Europe, North America, or take more lucrative positions with NGOs.

There simply aren’t enough trained health professionals on this continent. According to a World Bank presentation I heard yesterday, Africa bears 24% of the global burden of disease. Yet it has only 3% of the world’s trained healthcare workers.

I admit the human resource problem wasn’t high on my radar before I worked in Africa. Like most Americans, I thought of global health inequality as a question of commodities — mosquito nets, HIV tests, penicillin. They’re tangible, easy to visualize.

But as a representative from the Tanzanian Ministry of Health and Social Welfare said yesterday, “I want the human resources for health agenda as a top global agenda.”

As it should be. How can somebody take his HIV medication if it isn’t prescribed to him? How can a mother treat her infant’s dehydration if someone doesn’t recognize the symptoms?

The conference yesterday was filled with interesting ideas about how to answer those questions.

Joan Holloway, a representative of the U.S. Global AIDS Coordinator, assured the audience that PEPFAR — that’s the President’s Emergency Plan For AIDS Relief, a multimillion dollar aid package to fight HIV — was increasingly dedicating funds towards training healthcare workers.

World Bank official Alex Preker argued that a boost in private sector programs, like private universities and training programs, could encourage health professionals to work in rural areas.

There was talk of eLearning, training village-level workers to diagnose common diseases, incentives to draw African doctors and nurses away from Europe and back to their countries of origin.

It’s clear there isn’t one easy solution. As a representative from the Liberian Ministry of Health and Social Welfare put it yesterday, any realistic approach to the African healthcare worker shortage will address recruitment, retention, incentives, and management. That’s a tall order — four tall orders, actually.

What interesting strategies have readers come across? Is this problem gaining traction as an issue of importance to American donors and activists?

Hello from Addis Ababa!

I took a quick detour to Ethiopia en route home to Washington, DC! Addis is huge, sprawling, and filled with cheap macchiatos. Any city that loves its coffee as much as Addis does is good in my book.

I was supposed to be traveling to some of the major historical sites, but a giant dust storm — from Sudan, as all of the Ethiopian Airlines representatives tell me — has enveloped the northern part of the country. The visibility is so bad that my flight couldn’t land. So I’ve got a little more time in Addis than I anticipated, and a moment to drop by an internet cafe to say hi.

I’ll post some of my amazing pictures when I get back to the States in a week, but in the spirit of getting ready for school, a few public-health related observations:

1. At the airport, a giant sign greeted me with this: “Protect this nation from the NEW FLU! Report any fevers or coughing to the authorities.” (Punctuation and capitalization not added.)
2. All over the city, you can get weighed for a few birr. Guys set up shop on the side of the road with scales, and people stop along the way to check out if they’ve packed on any pounds.
3. Vegan food is everywhere! I could barely find a meal without meat in Tanzania — and if I did it was probably chips maiaye, a dish that combines eggs and french fries. But here, since so many people abstain from meat and animal products during the hundreds of days that observant Ethiopian Orthodox fast, I’ve been finding delicious veggie dishes right and left.

Getting ready to say goodbye to Tanzania is harder than I expected. (Photo is from the beach in Mtwara Town, southeastern Tanzania.)

One of my biggest battles this year has been learning to talk like an aid worker.

Every field has its lingo. When I interned on a presidential campaign, we had media blasts and advance teams. When I worked as a journalist, we talked about cultivating sources and exactly what defined “off the record.” As I gear up for medical school, I worry daily that I won’t be able to cram all the medical vocabulary into my brain!

But something about the development-speak hasn’t sat well with me from the beginning.

There’s sustainable development, community sensitization, income-generating activities. There’s technical assistance, stakeholders meetings, and trainings of all shapes and sizes. Don’t get me started on the acronyms. How’s a poor girl like me supposed to learn it all?

My insecurities aside, I think this development jargon — one blogger in East Africa calls it “charitese” — has very serious implications.

Look at this example, which comes from a conversation I had with a lawyer friend of mine. A few months ago, we sat in a Dar es Salaam coffeeshop together as he prepared for a job interview. He was reading an independent evaluation of one of the NGOs he was thinking of working for, on a project to help reform the country’s legal sector.

One of the program’s biggest struggles? Nobody knew what the lingo meant.

Take “capacity building,” a term commonly used in the program description and subsequent reports to donors.

To the foreign philanthropists paying for the project, “capacity building” meant imparting legal skills to Tanzanian lawyers and judges. To the local organizations doing the on-the-ground work, “capacity building” meant donations of computers, Land Rovers, other tangible objects. To the Organization for Economic Cooperation and Development, “capacity building” meant improving the ability of the local organizations to manage themselves.

If development partners can’t even agree on what they’re talking about, how can they ever hope to make meaningful change?

Working in public health, I encounter these vague terms on an almost-daily basis. Some I’ve gotten comfortable with: the word “implementation” has seeped into my daily vocabulary to such an extent that my roommates and I joke about who’s going to implement the kitchen clean up after we have a party.

Others still rub me the wrong way. For example, “fieldwork” can mean anything from studying gorillas in the jungle to prescribing drugs in a Dar es Salaam clinic — the only consistent definition seems to be that you are away from an air-conditioned office.

The euphemistic quality of the development talk is a symptom of much, much deeper problems. When my high school English teachers would rip apart my essays on Macbeth and Huck Finn, they’d say I was unnecessarily verbose because my argument wasn’t clear. And in development, the same criticism applies perfectly: we aren’t sure what we’re trying to do — and we aren’t sure what to do to get there.

I joke about feeling young and naive after not knowing a UN acronym, but my insecurity as an entry-level staffer isn’t the real problem. There’s a cache associated with this development discourse — it shapes how organizations structure their work, how donors decide where to give their money, how NGOs work with governments.

If you’re comfortable with the terminology, you’re allowed in on the conversation. But if you can’t speak the language, how can you have a say in what’s going on around you?

I worry that all the fancy jargon prevents ordinary Tanzanians from being heard. I’m not talking about my co-workers, accomplished professionals with way more degrees than I have. I’m not talking about government officials, educated businesspeople, people with the knowledge and savvy to adapt to Western-imposed terminology — no matter how silly all the acronyms sound.

I’m talking about the very people we’re trying to help. To a woman in rural Lindi, stakeholders meetings and sustainable development are terms likely devoid of any real meaning.

The words that truly mean something? Vaccinations for her children, rehydration treatment when they have diarrhea, artemisinin combination therapy when they have malaria. That’s the conversation we need to start having.

My old apartment in Dar es Salaam overlooked a compound of studios and galleries. There were always tourists wandering around, painters hanging out and offering me a hello as I walked home from the bus stop, the smell of marijuana wafting up to my balcony. It took me an embarrassingly long time to realize I lived right above what is perhaps the epicenter of East African painting.

I’m unfortunately leaving Tanzania in the next few weeks so I can start graduate school. Along with the goodbyes and the packing comes another hassle of moving away -— the frantic rush to buy gifts for everyone back home.

So this weekend, I returned to Oysterbay, my old neighborhood, as a Tingatinga customer.

Tingatinga is an East African painting style named for its Mozambican founder Eduardo Tingatinga. He came to Tanzania in the 1960s and developed the iconic paintings, brightly colored animals and fish done in bicycle paint. Original Tingatingas hang in galleries and museums around the world, but “imitations” -— like the ones I looked at this weekend -— go for whatever price your bargaining skills can get you.

This weekend I brought along some Tanzanian friends to help me avoid the tourist prices. We spent a couple hours wandering through the studios, checking out works in progress and huge, beautiful paintings that I could never afford. It was cool to see the guys I had said hi to every afternoon in their element -— Tingatingas are complex, layered paintings, and each stage in the process is a precise one.

I ended up buying a few gifts for my cousins, and a bright abstract painting for myself. My friends and I really wanted to buy this one, too:

I had to restrain myself, though, because I don’t think any future roommates would be so happy with it. Excuse the poor photo quality (taken with an iPhone), but the title means “Dar es Salaam at Night.” The Salama condom brand is prominently advertised, and if you look carefully, you can see used condoms litter the ground amongst the obscene display.

The best thing about Tingatinga art? Its sense of humor.

When I first started as a reporter for my college newspaper, my editor gave me a piece of advice that I always try to abide by: never start a story by mentioning the weather.

Weather ledes are the easy way out. Most journalists I talk to agree that they’re a crutch for writers too lazy or uncreative to introduce the story in a more compelling way.

But those journalists I talked to never lived in Dar es Salaam.

This time of year, the only thing to talk about is the weather. Each morning, the sky opens up in some kind of thundering, biblical cliche. Roads flood, houses flood, everything floods.

I wasn’t going to even bother writing about the masika — the long rains that start each March — but I found myself staying late at the office tonight, not because of work, but because the watery roads have made my 5 mile commute home a two hour affair.

This time of year, healthcare inequalities are even more apparent. The rainy season means more contaminated water, which means more diarrheal diseases. The rainy season means impassable roads, which means rural women deliver their babies at home and not in hospitals — which in turn means they and their babies are more likely to die. The rainy season means big puddles, which means breeding grounds for mosquitoes and the malaria they spread.

Looks like this boat I saw on Lake Victoria might have some applications on land, too.

Check out some of the name brands available in Mwanza, Tanzania:

Last month, people all over the planet turned off their lights at 8:30 on a Saturday night. I had read about Earth Hour on blogs and even in the New York Times — it was a kind of worldwide protest, ordinary citizens darkening the globe time zone by time zone to draw attention to global warming.

Earth Hour was a pretty cool idea, and it generated — no pun intended — lots of publicity. But in Kilwa, I couldn’t participate. We didn’t have any electricity that night anyway.

There are merits and drawbacks to a supposedly global protest that excludes the quarter of the world’s population that lives without electricity. And expanding power grids all over Africa and all over the planet is a complex question. People need and deserve electricity, but whether or not the world can bear the environmental costs of such rapid growth is another story.

People who know much more than I do have more interesting things to contribute about this issue. But as somebody living and working in a place with unreliable electricity, I have one thing to say: Boy, I love my Solata!

This is an unabashed love letter to D.light Design, a quickly growing social enterprise that sells affordable solar-powered lamps. I admit I became interested in the company because one of my good friends in Dar es Salaam works for them, but after I bought a lamp, I realized the product speaks for itself.

I charge the battery on my little green Solata with solar power or with a ubiquitous Nokia cellphone charger. It looks like something you’d buy at Ikea. And it cost me about 20 bucks. While millions around the developed world voluntarily turned off their lights for Earth Hour last month, I read a book not by candlelight or flashlight, but by D.light.

What I like about D.light is that the company saw an untapped market and went for it — not waiting around, like so many of us who want to see development, for governments or the World Bank to make a dramatic, top-down decision that magically brings power grids to rural areas.

It works with the existing system, not against it. Instead of foreign NGOs deciding that people need the lamps and buying and distributing them in bulk, ordinary Tanzanians who think the price is fair buy them at local dukas, or roadside shops. Instead of huge-scale, bureaucratic infrastructure contracts, D.light sells directly to local distributors.

Tanzania still needs reliable power grids. I’d much rather read by overhead lamps than by my Solata, no matter how adorable it is. And my preferences are beside the point. This is about kids doing their homework at night, parents cooking nutritious dinners for their families, hospitals refrigerating medications and lab samples.

But a company that gets us at least partway there deserves a second look.

On dalla-dallas all over Dar es Salaam, bumper stickers proclaim, “Sikiliza Wahapahapa!” (Listen to Wahapahapa!)

Wahapahapa is a Tanzanian band like the millions of others that advertise around Dar, but I’ve been specifically curious about them because they’re subsidized by the American government. The stickers have the ever-present USAID symbol on the bottom, labeling them “from the American people” — the USAID slogan.

Last night, I finally heard them perform! Since the band is part of an American development project, I was worried it would be some cheesy Schoolhouse Rock-esque “educational music.” You know, some guys paid by the clueless USAID office to rap about using mosquito nets or boiling your drinking water. In other words, a total joke to anyone who actually likes east African music.

Well, I actually enjoyed the music. Check it out here. (They were a lot better live than this video portrays, but I can’t find another one.)

But the band is part of a public health education project, and I’m curious to know more about whether or not it’s effective.

Wahapahapa is a weekly radio drama broadcast all over Tanzania that follows a band — a fictionalized version of the one I heard last night — and discusses the impact of HIV/AIDS on their lives. It’s modeled after similar radio shows in Botswana, Zimbabwe, and Uganda, and it’s a product of talented Tanzanian producers and sound public health research from Johns Hopkins University. Sounds good, right?

I think so, but as I listened to the band last night, I couldn’t help but wonder how most Tanzanians saw it, and how they see the millions of other HIV education initiatives developed by well-intentioned foreigners.

For example, one of the tracks on their CD is all about a guy keeping his pants buttoned while his partner is away. A good message, sure. But it’s a fine line between effective health advertising and out-of-touch, moralistic preaching. In the States, I love the edgy Truth anti-smoking campaign, but I have to laugh and roll my eyes when melodramatic teenagers tell me that smoking pot ruined their lives.

In Africa, I think the risk of the latter is especially high. Foreign NGOs, in my experience, have a tendency to oversimplify their health education messages, which makes them easy to dismiss. I liked Wahapahapa, and I certainly hope it’s effective — because the music was good, and because lives depend on it.

The biggest lake in Africa:

We had a long weekend for Good Friday and Easter Monday, so I headed to Mwanza for the four-day holiday. Mwanza is Tanzania’s second-biggest city, the major port on Lake Victoria, and Tanzania’s connection to Rwanda, Uganda, and parts of Western Kenya.

I spent the trip enjoying the cool weather and eating copious amounts of tilapia, which is native to Lake Victoria and a huge part of the economy there. (And man, it tastes a lot better when it hasn’t been frozen in a Dar es Salaam grocery store for months!)

The lake’s ecosystem has a shaky history, however. The introduction of several non-native species during the colonial 20th century has had dramatic, unintended environmental consequences. The two major examples I’ve heard about are water hyacinth, a beautiful floating plant, and Nile perch, a giant carnivorous fish that can grow up to six feet long!

European colonial representatives and businessmen brought South American water hyacinth to the region over a century ago as a decorative plant for their gardens and ponds. Since the species has no natural predators, it has been multiplying over the decades.

I only saw a few floating colonies in Mwanza — it looks like something you’d see in a Japanese tea garden — but apparently huge, tangled water hyacinth bushes clog the ports along the western bank of the lake. It also blocks sunlight for the native species below the water’s surface. The problem is so damaging to the ecosystem and therefore to the lake-based economy, the World Bank has dedicated millions of dollars to dealing specifically with the out-of-control weed.

Nile perch has also upset Lake Victoria’s natural balance. The enormous, bigger-than-a-human-being fish — check out this picture on Wikipedia — was introduced to the lake in the 1950s, and has changed both the ecosystem and the local economies with large-scale commercial fishing.