Thursday, April 30, 2009

Swine Flu: Stocking Up On Soup, Just In Case

There are still a lot of unanswered questions about the new human swine flu that everyone has been talking—and sometimes obsessing—about. US government officials keep telling us to “hope for the best and prepare for the worst.” Here’s how I am taking that advice. At this point in time, I think it’s reasonable to stock up on canned soup, soap, hand sanitizer and Kleenex—which I have done. I plan to take a train this weekend. If I had to travel further, I would not hesitate to take an airplane. That could change tomorrow or next week. But for me, that’s reasonable for today.

Just finished talking with Lisa Mullins of PRI/WGBH/BBC’s The World. The other guest was Peter Sandman, a risk communications consultant who has been talking about preparing for pandemic flu for several years now. You can hear our segment on the radio at 3 PM on WNYCAM, which is 820 AM in New York. Here's the link to the podcast of the program.

I keep hoping, perhaps vainly, that adults ought to be able to sort through contradictory pieces of information at the same time. Yes, there is reason to be concerned about the new human swine flu. Even if it fizzles out in the next few days to weeks, there is still reason to be concerned. It’s not a bad idea to check your pantry and stock up on a few things that might have gotten low—in case you need to shelter in place. As anyone who has ever been in a hurricane knows, the time to buy extra diapers is not when the National Oceanic and Atmospheric Administration says the storm is going to hit your area in 24 hours. No, it does not make sense to close down the border between Mexico and the US.

Having extra food around the house or gas in the car are easy precautions to take now. There is not enough space in my tiny apartment for a two-week supply of stuff but we have seven days worth to cover my partner and myself. I’m also collecting a few phone numbers from my neighbors and have posted New York City’s flu hotline number (1-800-808-1987) in my kitchen. I have also noticed that I am not shaking people’s hands as much.

It helps to keep a sense of humor. I bought a box of crackers—one of my favorite things to eat whether sick or not—and marked it “IN CASE OF FLU.” I have a tendency to go overboard on crackers and don’t need the extra calories—unless I really am sick.

And after that, it’s kind of a waiting game—to see what will develop.

People who know me well say that I sometimes try too hard to fix things. Curiously, with reports of the new human swine flu, I have adopted a more fatalistic approach. No, I’m not throwing my hands up and doing nothing. I AM taking some precautions (outlined above). I may change my actions in the future. But I do NOT believe that I can 100% guarantee that I or my loved ones won’t get sick if a severe pandemic emerges. Flu is much too contagious for that.

The die is already cast as to whether this particular flu strain goes pandemic and how much illness and death it might cause. We will know soon enough.

For more information on preparing for a possible pandemic, you can go through the checklists at

Related post: Swine Flu: Getting the Facts Right

Monday, April 27, 2009

Swine Flu: Getting the Facts Right

Is it me—or has there been more uninformed reporting than usual over the past few days about the developing outbreak of human swine flu? Could it be the wholesale exodus of experienced health reporters from many newspapers and magazines is having an effect on the quality of coverage? Flu is not a topic that general assignment reporters can easily get up to speed on overnight.

I have read news reports cautioning people not to get near pigs for fear of contracting swine flu.

Not true. The new human swine flu is transmitted from person to person. So you minimize your risk of getting it by keeping your distance from other people, washing hands, reminding folks to cover their nose and mouth when they sneeze.

A number of news articles ominously report that the new human swine flu is H1N1—the same subtype as was responsible for the 1918 pandemic. The implication—that a terrifying type of flu has come back after more than 90 years.

Yes, the 1918 flu was caused by an H1N1 strain. But the H1N1 subtype is now very common. Indeed, it has caused many seasonal flu outbreaks over the past 90 years. The current vaccine even includes a strain of H1N1, first identified in Brisbane in 2007.

So if the new flu is H1N1 and H1N1 subtypes have been around for years, why are health officials so worried? Because the arrangement of genetic components of the new flu have never been seen before—whether in pigs or people. And they are different enough from the recent strains that the body’s immune system may not be able to mount a quickly effective response.

Many news sites are also reporting as fact that the flu is killing more people under the age of 60 than the usual seasonal flu. We don’t actually know this for sure.

Yes, there have been lots of reports of middle-aged people dying from the flu in Mexico. That’s worrisome because it’s the same pattern of fatalities that was seen in the 1918 pandemic. But that is only part of the story. There are other possible explanations for the pattern of middle-aged deaths: maybe those were the folks who went to the hospital first. Maybe health officials haven’t paid as close attention to deaths among the elderly because they are so much more common. It could still be a true cluster of middle-aged deaths but we probably won’t know that for at least another couple of weeks.

Lots of headlines are also proclaiming that countries are racing to “prevent the pandemic.” Sorry, that horse is out of the barn. This flu has already been confirmed in Mexico, the U.S., Canada and cases are suspected in New Zealand, Israel and Western Europe. If there is going to be a pandemic, there will be a pandemic. That will depend on how virulent the virus is—something that we don’t know yet.

What people can do is mitigate the damage. Sort of like a hurricane. You can’t stop it from coming ashore but you can try to protect as many people as possible from drowning.

In addition to newsfeeds at the Centers for Disease Control and the World Health Organization, here are some of the folks I have come to trust for information on the current flu outbreak:

Anything written by Helen Branswell, Canadian medical reporter. Her coverage of flu and the potential for pandemic flu over the past several years has been stellar. She is also @diseasegeek on Twitter.

Tara Smith at Aetiology. Tara is an assistant professor of epidemiology, whose research focuses on pathogens that jump from animals to humans. Very readable and very smart.

The Reveres at Effect Measure. Anonymous, opinionated but well-informed, from public health professionals.

Crof at H5N1. Crof has been a smart aggregator about avian flu and potential pandemic news for years but is now including human swine flu.

The pandemic flu section of the Center for Infectious Disease Research and Policy (CIDRAP) at the University of Minnesota.

Good, if technical overview on swineflu, also at CIDRAP.

And here are some web resources to understand flu and potential flu pandemics better. I’m chasing down links to some other tools and will add them as I learn them.

One-stop access to US government information on pandemic flu

The Nieman Reports special issue on preparing to cover pandemic flu

Association of Health Care Journalists ($60 per year). Members have access on the website to excellent content created specifically for journalists covering flu. (Update: AHCJ has now made its flu resources freely available.)

The basic science section of the Flu Wiki

WHO's excellent guide to risk communications in a pandemic

General overview on pandemic flu, with history, by US government's Health and Human Services.

Related blog post: Swine Flu: Stocking Up On Soup, Just In Case
(Updated April 30, 2009)

Friday, April 24, 2009

Killing River Blindness and Malaria With the Same Drug

Researchers ponder whether a common drug that kills parasitic worms (helminths) might also prevent mosquitoes from transmitting malaria. The work is more preliminary than most in the field of malaria research, so don’t expect it to save any lives any time soon—if ever. But it is an interesting application of the old adage about trying “to kill two birds with one stone.”

In anticipation of World Malaria Day (which is tomorrow), the Bill and Melinda Gates Foundation held its first telephone briefing for bloggers who cover global health.

There were three researchers on the line—each of whom had won a $100,000 grant to explore an idea for fighting malaria that was a little unorthodox or “out of the box.” These are part of the Grand Challenges Exploration grants that the Gates Foundation has championed in recent years. Depending on the results, grantees are eligible for $1 million grants to further prove their concepts.

I focused most of my attention on Brian Foy, an assistant professor at Colorado State University.

Foy, who has previously done some work on malaria vaccines, started thinking about the life cycle of the malaria parasite inside the mosquito as an under-explored route of attack. It takes 10 to 14 days for the malaria parasite to mature in a mosquito’s body--from the time a mosquito bites an infected person (what entomologists call “taking a blood meal”) to the time that same mosquito can transmit the parasite to a different person. “If you could just make one of those blood meals toxic to the mosquito, you would basically kill it before it could transmit the parasite,” Foy says.

Enter ivermectin, a drug that targets parasitic worms, like heartworms in dogs or the worms that cause river blindness in people in West Africa. Ivermectin works by targeting certain neurotransmission channels in worms. It turns out those same channels exist in other invertebrates like mosquitoes.

So the idea is to give ivermectin to people, who then pass the drug along with their blood to the mosquito that bites them. To be most effective, the drug should kill only those mosquitoes infected with the parasite before it has a chance to fully mature. As an added bonus, you minimize the risk of resistance because you’re not killing all the mosquitoes, just the infected ones, so there is no selection pressure against the mosquitoes—at least in theory.

So far, the evidence from the field is encouraging. Foy reported data from Senegal that showed that mosquitoes died for up to a week after ivermectin was given in an anti-river blindness campaign. Now he is trying to determine if the effect is large enough so that if you expanded ivermectin treatment you could actually change the transmission of malaria.

You see, ivermectin is normally given only once or twice a year for the treatment of river blindness. To have any effect on mosquitoes, you would probably have to give ivermectin once a month.

But this is just a pilot test—a chance to see if the idea is worth pursuing further.

You’re talking about four very complicated organisms—humans, mosquitoes, malaria parasites and helminths. In 2007, there was a research paper that suggested that infection with helminths actually made malaria symptoms less severe and that treating the parasitic worms could actually make a co-infection with malaria worse. (TW Mwangi, et al. Annals of Tropical Medical Parasitology.)

So for now, the idea that ivermectin could make a dent in both river blindness and malaria at the same time is still just an intriguing idea that is being tested further.

The other two presenters on the Gates telebriefing were Szabolcs Marka, assistant professor at Columbia University and Pradipsinh Rathod, professor at University of Washington.

Marka is looking at the possibility of using laser light to interfere with a mosquito’s ability to find and bite people. Rathod is trying to see if genetic differences between Plasmodium falciparum parasites found in Asia and those in Africa might help develop more effective treatments.

You can hear a recording of the full teleconference until April 30th by calling (800) 475-6701 and entering access code # 997326.

Full disclosure: my 2008 Nieman Fellowship in Global Health Reporting was supported by a grant from the Gates Foundation. I believe I have no conflict of interest in this story because the Gates Foundation did not play an active role in my choice of study or of my field project on nurses in Malawi.

Tuesday, April 21, 2009

More Thoughts on Schools, Hospitals and Health

Yesterday's writeup of my notes about social determinants of health from the annual conference of the Association of Health Care Journalists focused a lot on the graphical sin of using circles (which tend to show equality) in an area where equality does not exist.

Just as important is the realization that when it comes to developing a recipe for promoting health, you cannot leave any of the important ingredients out--no matter if it is just a quarter of a teaspoon (a small amount) or a pound of something (a large amount).

So, while schools/general education may be more important than hospitals/health services in coming up with a recipe for promoting the overall health of a population, you cannot ignore the contribution of health services.

I was first introduced to this idea of how various factors relate to each other in David Bloom's class at the Harvard School of Public Health--although, being a health economist, he didn't talk about cooking and recipes. He talked about addition and multiplication.

More specifically, he told the class of future public health experts that they would eventually have to decide whether to think of health as a multiplicative process or an additive one. If additive, then the various factors that contribute to the health of a population (however you rank them) simply add up to whatever sum--and if one of those factors is zero, well, that's not fatal because the others will make up for it.

On the other hand, if achieving health is a multiplicative process, then any factor along the line whose value is zero ends up negating the whole effect.

As in 2 + 1 + 3 + 2 = 8

But 2 x 0 x 3 x 2 = 0

Changing a single one of the factors to zero negates the contribution of every other factor.

Monday, April 20, 2009

Schools Are Better than Hospitals for Improving Health

Education, social support and early childhood development play a more important role in determining the overall health of a country’s population than the condition of their hospitals and other health services, according to researchers who look at the social determinants of health.

Oh what a difference a choice of graphic makes!

If you think about it for just five minutes, you know that it’s not just doctors, nurses, hospitals and pills that determine how healthy we are. Those critical health services are part of an entire constellation that includes our genetic makeup, personal choices, the physical environment we live in (to overstate the obvious, it’s hard to stay healthy in a war zone), our social support, educational level and socioeconomic status.

Here is the way that Canadian public health officials visualize all these factors on an official government website—as spokes coming off a central hub.

The hub-and-spoke diagram makes it seem as if all these factors are playing equal roles in determining how healthy a given population is.

But what if you ranked those factors in order of importance?

That’s what Michael Hayes of Simon Fraser University in Vancouver, Canada and Stephen Bezruchka of the University of Washington did in a panel discussion at the annual meeting of the Association of Health Care Journalists in Seattle on Saturday, April 18, 2009. (Search twitter for #ahcj09 to get some of the raw tweets published during the conference.)

Hayes and Bezruchka placed health services (the doctors-nurses-hospitals-clinics-medications part of the equation) at the absolute bottom of the list in importance. At the top of the list are social determinants, like education (particularly of mothers) and socioeconomic standing.

The whole list goes something like this, in order of importance:

Most Important
Social determinants of health (education, socioeconomic status, social support, etc)
Early childhood
Personal behavior
Physical Environment
Health Care Services
Least Important

This ordering of the list, which is based on 25 years worth of data, Hayes and Bezruchka said, leads to some startling conclusions. First off, we in the press focus far too much attention on health services (the docs, nurses, new treatments and medications) as opposed to education, crime rates, poverty when talking about health. Second, dollar for dollar, you would probably actually get a better health benefit investing disproportionately more in schools than in hospitals. And perhaps, third, Canadian public health officials need a new graphics team.

To develop that last point a little further. Don’t use circles when describing the factors that lead to health disparities. It makes everything seem equal. Use ranked lists that tell you what the most important factors are—provided, as always, you have the data to back it up.

What is still unclear to me is just how widespread the consensus is that social determinants of health are more important than health services in determining the overall health of any country’s citizens. (Chime in on comments below if you can enlighten us.)

I asked Hayes about consensus in a quick follow-up at the panel table prior to the start of the next session. He says there is consensus that there are social gradients to health and even what the major influences are but not on how they play out. One camp favors the psychosocial view: people who are optimists tend to be healthier and live longer than pessimists. The other camp is more materialist: poverty is key.

The point, Hayes said, is to link biology to social being. Then he gave a quick example. We tend to focus on the fact that smoking cigarettes is clearly a matter of personal choice, he said. But we ignore the role that advertising plays.

In my mind, I was thinking well, we haven’t really ignored advertising—I mean smoking was banned from television ads. But I guess there are still plenty of billboards, sports sponsorships, etc.

Earlier in the session, either Hayes or Bezruchka threw out the statement that the relative risk of dying from smoking in Japan is much lower than in the USA. And then strongly implied that social determinants of health (a better social safety net in Japan, more family support, etc) explained the difference.

It was a memorable line but begs to be checked out further. What are the absolute risks in both cases? (Even though I knew about the importance of absolute risk before I knew journalism professor Gary Schwitzer, I can hardly think of one without the other anymore.) What ways do smokers compare/differ in the US and Japan? (Seems like you would have to compare Japanese-American smokers to Japanese national smokers to be truly thorough.)

Later, I was reminded of a conversation I had had with a woman, who was a physician, who had developed tuberculosis. She would not have survived, she said, had it not been for her own mother and sisters, who kept her on track. They made sure she took her medications over the course of many months, even after the pills made her violently sick.

She knew intellectually that she had to continue her treatment but that was not enough to keep her alive. She needed the pills but that was not enough to keep her alive. Her knowledge, the pills and her family’s willingness to make sure she took them every day—even when she begged them not to—is what allowed her to survive.

For further reading on social determinants of health:
"Toward a Healthy Future"
The 1999 Canadian report that studied and quantified social determinants of behavior.

Bezruchka's webpage of resources on social factors in health inequalities (hat tip: @HoltzReport

"Spreading the News: Social Determinants of Health Reportage in Canadian Daily Newspapers"
Hayes' own research into how much Canadian journalists are aware of the research on social determinants of health.

NB: This post is based on my writeup of my notes from AHCJ09.

Panel: "The healthy environment: it's not just medicine"
Panelist: Michael Hayes, Ph.D., associate dean, Faculty of Health Sciences, Simon Fraser University
Panelist: Stephen A. Bezruchka, M.D., senior lecturer, Department of Global Health, University of Washington
Moderator: Andrew Holtz, M.P.H., independent journalist, Portland, Ore.

These notes are as accurate as I can make them but if you use any of this for a published piece, you should be sure to do your own reporting to double check it--as I will if I write it up for formal publication.

I'll post other notes from the AHCJ conference as I write them up.

Update (4/21/09): Here are a few more thoughts on how to think about the non-medical factors related to health and how they relate to health services and each other.

Friday, April 10, 2009

MSF Challenges Nutriset on Plumpy'Nut

Reading between the lines of Medecins Sans Frontiere's letter to Nutriset, it seems to me that MSF is losing patience with Nutriset on both the patent issue and apparent continuing shortages of Plumpy'Nut. Special thanks to @bloodandmilk and @markarnoldy for bringing this to my attention.

Hardly a week goes by without someone emailing me privately about Plumpy'Nut these days. One of the most recent suggested that the American Peanut Council was looking into the issue (I have not confirmed this yet). So now, in addition to the moral/philosophical/legal issue about whether Plumpy'Nut should have been patented or whether the patent would withstand a challenge is the commercial pressure that major agro-businesses might want in on the action.

Will post more as I learn more.

In the meantime, here is MSF's letter to Nutriset:

Mr. Lescanne
Director General
BP 35 – Le Bois Ricard
76 770 Malaunay

Geneva, March 24, 2009

Dear Mr. Lescanne,

I am writing to you to reaffirm the position of MSF’s Campaign for Access to Essential Medicines with respect to Nutriset’s policy on intellectual property pertaining to nutritional pastes and issues concerning the production and export of such nutritional products.

Nutriset has played, and continues to play, a major role in the development and production of products used in the battle against malnutrition, which have made a large contribution to recent developments in the handling of this pathology. A growing number of international agencies and donor countries recognize the important role of ready-to-use foods. This results in an exponential increase in the consumption of these products, which can create serious stresses in the supply chain, as was the case in the second quarter of 2008. It is becoming urgent to increase and diversify the capacity to produce nutritional pastes.

In fact, the success of treatment of malnutrition with ready-to-use foods is arousing increasing interest among producers. This is good news and offers an opportunity to support the emergence of capacity to produce these nutritional products, especially in the countries of the South. Such a development would also create the conditions for better availability and a possible reduction in their prices, which would facilitate their supply in regions of the countries affected.

Currently, Nutriset allows NGOs, as well as several manufacturers under Nutriset franchise, to produce ready-to-use foods. However, agreements of this type include restrictions and limitations that can discourage other producers. At a meeting held in Rome in March 2007 that brought together a number of international agencies working in the field of nutrition, Nutriset made a proposal addressing this problem. Nutriset contemplated granting licences to producers in the South for the manufacture and export of ready-to-use foods in return for the payment of a fair royalty in the countries where patents are in force, in parallel to its franchise system. This proposal could indeed stimulate production on a larger scale and help to lower prices. We regret that this offer was not effectively followed up on a large scale and ask that you make it public and post it on your website so that any interested producer might benefit from it.

For reasons that are obvious, the intellectual property pertaining to nutritional products of a humanitarian nature must be handled differently from that pertaining to commercial products. As you know, we believe that, in the humanitarian field of nutrition, patents should be filed only on an exceptional basis, and when they exist, licencing agreements should be offered to third parties on flexible terms and conditions, so as to ensure the widest possible availability of nutritional products of a humanitarian nature.

This is also important with respect to supplements of ready-to-use products, such as Plumpy’doz®, which was developed with the participation of Médecins Sans Frontières. If such a product were recommended for young children by providers of food aid, the needs could be exponential. The supplies required for the delivery of such nutritional products adapted to young children would only be possible in the long term through the diversification of supply.

MSF, as well as other agencies working in the battle against malnutrition, can no longer continue to depend on a single source of supply for ready-to-use products. The current position of Nutriset in this regard is a source of concern to some of these agencies, as it is to MSF. We therefore encourage Nutriset to play a key and innovative role in the management of its intellectual property by offering humanitarian licencing agreements for the production and export of ready-to-use products.

I look forward to your reply.

Yours sincerely,

Tido v. Schön-Angerer

Executive Director

Médecins Sans Frontières International

Campaign for Access to Essential Medicines

Malawi Nurses' Project on WBAI Radio

Just finished a half-hour interview on WBAI radio about my three-month reporting trip to Malawi last year. The host was Diana Mason, a registered nurse and the editor-in-chief of the American Journal of Nursing. Will update the link to the archived audio file as soon as it is posted.

In addition to sharing what I learned in Malawi, I was also able to talk about the idea of creating a social network for independent global health news.

Wednesday, April 8, 2009

Brand Loyalty and Global Health

I have long been a fan of The Pump Handle, a self-described "water cooler for the public health crowd," with special expertise in mining and occupational safety. They also post on plenty of other public health topics, of course.

Many of the contributers have some tie to the George Washington University School of Public Health--although from the beginning that has seemed more incidental than anything else. They certainly do not act or blog like traditional institution boosters. And, in fact, lately, I have noticed that they are expanding their list of contributors well beyond Georgetown to academics at Boston and Tufts Universities, as well as a few well-chosen advocates and even one anonymous blogger.

I think that move to reach beyond institutional borders is particularly innovative--or should I say counter-cultural? Even if it seems like an obviously good idea, it does not happen that enough. Usually, the conventional wisdom is that in order to "get your message out," you need to focus on branding in general, and institutional branding in particular. Everyone is so worried about sharing credit that they don't realize how little credibility single-institution venues actually have.

Monday, April 6, 2009

Gorman Talk on Health and Human Rights

As promised, here is my talk on health and human rights, which I gave this past Friday at the GlobeMed Global Health Summit at Northwestern University in Evanston, Il. I met a lot of bright, enthusiastic students at the event and learned a thing or two myself. Thanks to Jon, Divya, Hannah, Victor and others for inviting me and organizing everything.

"Health and Human Rights: One Journalist’s Perspective"
By Christine Gorman

GlobeMed Global Health Summit
Keynote Address

Friday, April 3, 2009
Northwestern University
Evanston, Illinois

I would like to thank GlobeMed and the other sponsors at Northwestern University for inviting me to this Summit today. In keeping with the theme of the conference, I have taken as the title to my talk “Health and Human Rights: One Journalist’s Perspective.”

My talk today has three parts. I want to tell you a story, share some observations and finally issue a warning. The story comes from the 1980s, from the first few years of the AIDS epidemic in the United States. The observations are my own and the warning, yes, about the warning. Well, I’ll leave that to the end.

The story takes place in 1987. The two main characters are Archie Harrison, a 32-year-old gay man, and myself, a still fairly new, young health reporter for TIME Magazine.

First, I need to set the stage for you a bit.

In 1987, the AIDS epidemic was officially six years old. That summer, the government reported that 40,000 people in the U.S. had so far developed AIDS. And of those 40,000 people with AIDS, more than 23,000—or nearly 60%—had died.

We didn’t know it at the time but 1987 was the beginning of a turning point. The amount of stigma and panic that permeated the earliest days was beginning, just beginning, after extraordinary effort and struggle, to subside. President Reagan spoke publicly about AIDS for the first time, in a speech at a fund-raising dinner. The Food and Drug Administration approved a new drug—called AZT—that prolonged life for a while. But the price was incredibly high—about $8000 for a year’s supply of capsules.

Many people did not have insurance and could not otherwise afford the medication.

Here was hope—after so few years packed with far too many funerals. But it was hope that came at a price tag that put it well out of reach.

The rage was palpable. I attended the legendary meeting in Greenwich Village in which playwright Larry Kramer told the assembled room that two-thirds of them would be dead in five years if they didn’t “Act Up.” They quickly organized a die-in on Wall Street to protest the high prices. That was just the beginning. I sometimes wonder how much more they might have done with Twitter or SMS messages or even cell phones.

As part of TIME’s ongoing coverage of the news, I made contact with Archie Harrison, who was 32, and had just finished a clinical trial with AZT. Archie had responded well to the drug. Our first contact was on the telephone. I got the quote I needed for the article, but there was this extraordinary quality, this sense of connection that came through in our conversation.

I decided that I wanted to meet Archie in person and so I set up a follow-up interview.

We met in the home that Archie shared with his partner in the West 50s of Manhattan. There are some interviews, some conversations you have as a journalist that just stand out—and that you know you will take with you the rest of your life. My conversation that afternoon with Archie was one of them.

For a short while, the masks of politeness and self-protection and the pressure of everyday busyness that keep us separated from each other fell away, at least a little.

I had recently lost both my grandmothers, with whom I had been particularly close. People my own age were dying in unprecedented numbers around me in New York City. Having grown up in the Antibiotic Age, that wasn’t something that I had ever expected to happen.

Before I knew it, I was asking Archie an incredibly direct and admittedly naïve question. “What’s it like to know that you are going to die?” I asked.

He paused a second and must have decided that I was sincere. “I know I’m going to die,” he said. “Just as I know that you’re going to die.”

In truth, I don’t remember what he said right after that because I was so surprised.

“What? I’m going to die? But I don’t have AIDS. How can you say that I am going to die?” Honest to goodness, although it embarrasses me to admit it, those were the first thoughts racing through my head.

Did I mention that I was very young?

But you see what Archie did—don’t you? He drew a circle that included me. He didn’t let me forget that we share the same human condition—a condition that includes illness and death.

I had asked Archie a very specific question—about his own mortality—and he answered with a deeper truth, one that was universal.

I had asked a question that assumed—without my even being aware of it—that we lived in two different circles. And he gave me an answer that showed me where the boundaries really stood.

That is where I believe we must look for the connection between health and human rights. In that bedrock of our common humanity.

And yet, so often, the language and the arguments that I hear about health as a human right sound to my ear as if they are not about the common human condition at all. Too often the arguments smack of noblesse oblige. That the human right to basic health care is something that one group with an abundance of rights is willing to bestow on the poor and the lame. Not because they are equal but precisely because they are different.

This may seem like a subtle point but we ignore it at our own peril.

A hundred years ago, Christian missionaries spread across the globe to bring the “Good News” to the heathen masses. They knew that what they were doing was right—just as those who believe in health as a human right are convinced that their cause is just.

You have got to admit, something in us—at least some of us—needs to save the world.

But until we get it, until we get that it is we ourselves who are the ones who need those rights, I think we are likely to miss the boat and compromise the dream.

Have you ever noticed how often the talk of human rights sounds like preaching to the converted? Even the language, the phrase—“human rights”—depends on an international legal framework that may resonate in the groves of academia or NGO-land but that, quite frankly, doesn’t motivate most of the world.

I say this not to stop the conversation but to broaden it.

How do you translate the goals of universal access to health care in language that resonates with everyone from the ordinary Muslim laborer to the anti-abortion activist to the libertarian atheist?

Doesn’t this demand many phrases and many languages and many partners in conversation—particularly among those who are not yet convinced?

When I was looking over the list of participants at the GlobeMed Summit, I was glad to see a few representatives from the religious world—namely the Reverend Dan Dale of Wellington Avenue United Church of Christ and John Neafsey, a clinical psychologist and senior lecturer in the department of theology at Loyola. It is probably not that hard for most human rights activists to find common points of understanding with Dale’s and Neafsy’s social justice theology.

But I challenge you to find and make contact as well with those thinkers and believers of a more conservative brand of religion—such as those Christians whose focus on sin and opposition to condoms so often drive the rest of us to distraction.

Make sure you use language and engage in conversations that allow you to cast a wide net. Reach out to folks who are more genuinely motivated by an appeal to the Bible, the Koran or the Hindu examples of Rama and Sita than to the Universal Declaration of Human Rights.

Yes, there is a risk of unsatisfactory compromises and visions diluted by weak coalitions. Yes, you will find people who are not at all interested in engaging in conversation, only in shutting you down.

But if you don’t discover that circle in which you and the other both exist, then health as a human right becomes just another pretty ideal that you can feel really good about holding but that doesn’t make a difference in the lives of real people.

Finally, don’t be so GLOBAL in your focus on GLOBAL HEALTH that you lose sight of what is going on here in the U.S.

For decades, access to health care in the U.S. has been a group privilege—won by right of hard work and a prosperous employer. Follow the rules and you will reap the benefits. And, after all, don’t we deserve those rewards?

But the bargain is changing—isn’t it? Hard work and a college degree are no longer guarantees.

That has opened a few more eyes. It has taken the incredible cataclysmic forces of our current financial crisis to draw the circle wider, to see that we can no longer maintain our distance. Much to our surprise, we’re there, too, inside a desperate circle.

The upheaval has not yet been great enough for the majority of the middle class to throw in its lot with the poor, but, who knows, that may yet occur. People in a position to change the system don’t really think about doing so until the system stops working for them.

So much for the story and for my observations.

Now for the warning. For years, global health visionaries like Jim Kim and Paul Farmer have talked about AIDS as the wedge issue—the tool for mobilizing people from all walks of life around access to healthcare.

As a wedge issue, AIDS works better than some others—like malaria—because it crosses so many economic lines. You don’t have to work so hard at drawing the circle—at getting people to see themselves in the circle.

But I fear that window of opportunity is drawing to a close. As AIDS increasingly becomes a disease of the poor, its power to rally people from all walks of life around access to health care diminishes.

It’s human nature. Once I get my treatment, then I’m not in the same boat as you are. Once my husband, brother, lover, wife, sister, mother, father, son, daughter, best friend gets treatment, the lines of the circle begin to disappear.

If you don’t believe me, just think for a bit about tuberculosis. For centuries it afflicted rich and poor alike—okay maybe more poor people than rich ones. But still it afflicted enough folks in the corridors of power to finance the many sanitoria of Switzerland.

And then along comes streptomycin, which--along with better food and living conditions--does such a wonderful job that the sanitoria have to convert themselves into ski resorts or risk going out of business altogether.

In just a few decades tuberculosis becomes so completely identified with the poor that there is no market pressure to develop new medications beyond the first handful that scored the greatest success—albeit over a treatment course of many months.

No one now would ever think of using TB—or the fear of TB or sympathy about TB—as the wedge issue for folks from all walks of life to rally around access to effective health care.

How much longer until our perceptions of AIDS fall into the same pattern? It was recently reported that 3% of the residents of Washington, D.C. have HIV--a rate that is now higher than New York City's or San Francisco's. Yes, there was news coverage of the study but not to the extent there would have been 20 years ago.

So, that’s my warning: as wedge issues go, AIDS may have opened the door, but it cannot keep the door open forever.

The struggle to recognize health as a human right is about what is fair in a world that is demonstrably unfair, in which progress is never guaranteed and even the best of intentions can, and far too regularly actually do, prove harmful.

And yet . . . and yet . . . the words of the late Jonathan Mann, which you have quoted in the conference schedule, still ring true. Mann said, and I quote, “People say there is no use trying to change the world. But if we don’t try, will it change?”

Thank you very much.

Thursday, April 2, 2009

GlobeMed Summit in Chicago

On my way to the 2009 GlobeMed Global Health Summit in Chicago, where I will be giving one of two keynote speeches. (The other one is being given by Stephen Lewis, the former UN special envoy for HIV/AIDS in Africa.)

The title for my talk is "Health and Human Rights: One Journalist's Perspective" and I will post it on the blog after I give it on Friday evening.