Worldwide Readership Up, New Report Shows

It has been a while since I welcomed new readers to the blog. There are now readers of Smarter Than the Average Bearnot in 44 countries around the world, up 12 from the last time I reported. A big Hello to new readers in the following countries:

India
Trinidad and Tobago
Israel
Turkey
Singapore
Namibia
Palestine
Thailand
Romania
Norway
Burkina Faso
Brunei

I hope you guys are liking what you're reading so far - and I would encourage you to post comments or e-mail me directly if there are any topics relating to HIV/AIDS or life in South Africa you'd like me to address.

I am swamped under loads of work this week, including starting to design a half-day training for the staff of the clinics I have been visiting on basic Monitoring and Evaluations principals and the benefits of keeping accurate statistics on HIV and HIV-related care. It is already a bit nerve wracking to realize that I'll be leading this training session for nurses, counselors, and data capturers in three and a half weeks, but I think I have a handle on the information I need to impart. And I also have some good Power Point presentations drawn up by the United Nations and the US government covering some of the relevant information to use as templates for portions of this training.

Alright, I've distracted myself long enough. Talk to you soon.

Setting the stage

I am currently in the throes of putting together a primer on the growing epidemic of Tuberculosis in immunosuppressed South African populations (as well as elsewhere in the developing world). As I am no expert on the subject myself, I have been spending a lot of time assembling the proper sources and trying to figure out the best way to organize the discussion to include my personal observations alongside the growing mountain of medical and public health literature on the subject.

I actually knew very little about the burden of TB in the developing world before I arrived here, except for the early (largely pre-HIV) work done by Paul Farmer and his wonderful organization, Partners In Health, in Haiti. There has been an infinite amount of material for me to absorb over these past few months – and as I am rapidly finding out, writing about these topics is a really good way for me to start to make sense of things.

So, while you wait for my more substantive piece, here are two abstracts regarding TB/HIV from recently published papers I have found to be extremely illuminating. I have the full text of both of these papers, so feel free to drop me a line if you’re interested in reading on.

Hope you guys all have lovely weekends, and I'll catch up with you again soon. Hamba kahle.

The Prevention and Control of HIV/AIDS, TB and Vector-borne Diseases in Informal Settlements: Challenges, Opportunities and Insights.

David AM, Mercado SP, Becker D, Edmundo K, Mugisha F.

J Urban Health. 2007 Apr 12; [Epub ahead of print]

Health Partners, L.L.C., Tamuning, GU, USA, amdavid@guamcell.net.

Today's urban settings are redefining the field of public health. The complex dynamics of cities, with their concentration of the poorest and most vulnerable (even within the developed world) pose an urgent challenge to the health community. While retaining fidelity to the core principles of disease prevention and control, major adjustments are needed in the systems and approaches to effectively reach those with the greatest health risks (and the least resilience) within today's urban environment. This is particularly relevant to infectious disease prevention and control. Controlling and preventing HIV/AIDS, tuberculosis and vector-borne diseases like malaria are among the key global health priorities, particularly in poor urban settings. The challenge in slums and informal settlements is not in identifying which interventions work, but rather in ensuring that informal settlers: (1) are captured in health statistics that define disease epidemiology and (2) are provided opportunities equal to the rest of the population to access proven interventions. Growing international attention to the plight of slum dwellers and informal settlers, embodied by Goal 7 Target 11 of the Millennium Development Goals, and the considerable resources being mobilized by the Global Fund to fight AIDS, TB and malaria, among others, provide an unprecedented potential opportunity for countries to seriously address the structural and intermediate determinants of poor health in these settings. Viewed within the framework of the "social determinants of disease" model, preventing and controlling HIV/AIDS, TB and vector-borne diseases requires broad and integrated interventions that address the underlying causes of inequity that result in poorer health and worse health outcomes for the urban poor. We examine insights into effective approaches to disease control and prevention within poor urban settings under a comprehensive social development agenda.

Tuberculosis, Drug Resistance, and HIV/AIDS: A Triple Threat.

Friedland G.

Curr Infect Dis Rep. 2007 May;9(3):252-261.

AIDS Program, Yale University School of Medicine, 135 College Street, Suite 323, New Haven, CT 06510-2483, USA. gerald.friedland@yale.edu.


The worldwide epidemics of tuberculosis (TB) and HIV/AIDS have been joined by an insidiously developing third epidemic of TB drug resistance. Fueled by the disruption of TB control programs and the explosive growth of HIV/AIDS, the presence of TB drug resistance, particularly multiple drug resistance, is worldwide and threatens the gains made in the past decades in the treatment of both TB and HIV. Although treatment success is possible, the diagnosis and treatment of drug-resistant TB is difficult. Advances in TB diagnosis and treatment have been minimal in the past 40 years, and there is an urgent need for wider distribution of available diagnostic technology and for the development and testing of newer rapid molecular diagnostic techniques and therapeutic agents. This review discusses current information about the distribution of multiple drug-resistant and newer extensively drug-resistant TB as well as available diagnostic and therapeutic strategies with an emphasis on the relationship between TB drug resistance and HIV/AIDS.

Cutz of the Week: v1.0

I feel like I should balance that last post out with something a little more accessible. Here I present to you the two tracks that have gotten the most play on my iPod this past week. My homie Kerry sent me the links to these songs weeks ago, but I hadn't gotten around to listening to them until recently.

The first is a track by the inimitable Isley Brothers - an incredible musical group who have been recording since the mid 50's moving from gospel, to (bluesy) rock, to Motown, and eventually to modern R&B. I'm actually not sure when this cut was recorded - but this fact seems trivial when faced with its unabashed awesomeness.

the Isley Brothers - I Turned You On: http://www.tradebit.com/usr/palmsout/pub/8/I-Turned-You-On.mp3

The second track is a remix of a Biggie Smalls song originally recorded in '93. The New York based electronic music duo Ratatat have given the song a brand new sound for a new era of music, replete with devastating guitar riffs and dramatic electronic effects. I highly recommend that you check both of these songs out.

Notorious BIG (remixed by Ratatat): http://ratatatmusic.com/mp3/02%20Party%20and%20Bullshit%20(Ratatat%20remix).mp3

(Note: I am thinking that this will become a regular part of the blog. You guys have probably figured out that I quite enjoy writing about music [past and present], and that I have made a lifetime commitment to improving the quality of music that friends and family listen to. In light of this, I will do my best to share some of the tracks in heavy rotation in my life.)

On the Frustrations of Working With the South African Department of Health

As you might have been able to guess, there are many challenges associated with rolling out antiretroviral medications and comprehensive HIV services to a clinic. Some of these difficulties are purely logistical (how to package and distribute ARVs from a centralized location, the mind-bending complexities surrounding transport of blood and sputum samples to the laboratory). Other difficulties are more deeply entrenched in the pre-existing health care systems (how to train the overworked and understaffed employees of a clinic about the importance of keeping quality data on HIV care provided to patients). However, all of these tribulations are rendered trivial when one realizes that all (please forgive the hyperbole) proposed solutions to the aforementioned complications must eventually be run by the South African Department of Health before implementation can take place.

Now while I may be young, I am not without experience working within bureaucratic systems. In my Program Manager position at New York Cares I spent significant amounts of time working with the New York City government and its ever-growing web of affiliated agencies. And while this was often a maddening process, I was able to take some solace in the fact that the lives of the physically and developmentally disabled individuals being served by these agencies were not imminently endangered by this inefficiency. I was working hard to help these organizations improve their programming, and I generally got the sense that the proposed expansion would eventually take place – even if it took unreasonably long.

However, my experiences with the SA Department of Health have been a different experience all together. Peoples’ lives are on the line here; any lag in implementing improved HIV services can be causally linked unnecessary morbidity and mortality of infected patients. This, one might imagine, would give this organization the moral imperative to act quickly and decisively to employ the most effective treatment regimens available. This, I have very quickly learned, is not at all the case.

After writing out my exhaustive laundry list of complaints about the DoH employees I have interacted with thus far, I decided that it would probably prudent to keep that inventory of in-/semi- competency to myself. You never know who is reading this thing, you know? And, more importantly, I don’t want anyone to think that my frustrations have arisen from feeling personally slighted by the Department. My objective criticisms stem mainly from the Department of Health’s inability to utilize what effectively amounts to free help. We (McCord Hospital, in affiliation with Zoe-Life) are offering to use a significant portion of the money granted to us by the US government to provide extra staff, increased trainings and mentorship, and strategic systems development at Department of Health clinics. And yet we are consistently met with unmotivated staff who seem relatively uninterested in helping us expedite comprehensive HIV prevention and care in KwaZulu Natal.

In discussing this issue with colleagues and friends here in Durban, there seem to be several prevailing sentiments about why the DoH comes across as such an ineffective organization. One line of reasoning centers around the difficulties of working for a governmental organization concerned with combating a pandemic that the highest levels of that very same government are committed to sweeping under the rug. Another thought we had involves the inevitable burnout that must come along with working tirelessly on a crisis fueled by many entwined social, economic, and medical features. And finally, some speculate that it is the burden of elevated unemployment that has caused the South African government to overstaff its Department of Health – resulting in the mess of red tape and infinite levels of sub specialization (with concomitant increases in managerial complexity – that is slowly grinding the DoH to a halt.

This discussion will, unfortunately, be limited to observation. At this relatively early stage in my experiences in South Africa it would be presumptuous of me to think that I could propose steps that might be taken by the South African government to mobilize change within the Department of Health. However, I thought you guys might appreciate an Insiders’ View of the pandemic – even if it is early on.

I think I could probably write a lot more about this subject, but the weekend us upon us! All of South Africa has another 3-day weekend ahead of it. It’s still unclear where I’ll be headed – but I’ll be sure to bring my camera along just in case. Later.

Be jealous; be very jealous.

I now present to you some gorgeous pictures of a Cape Town sunset. (A big thanks to Philippa - a friend of mine who has left McCord to return to her life as an Intern in the UK - who took these photos while sitting on her parents' deck in C-Town.) And I think I'll save the rest of what I have to say for another moment.

Sunday = Beachday

I'm off to enjoy a lovely day on the beautiful beaches of Durban. We have tended to mostly hang out at one particular stretch of beach maintained by a resort/casino (with an awesomely fake Art Deco facade) right on the water - but I'm thinking that we might try and mix things up today. Some beaches have reputations for being safer than others - but when you're with a group of people and there is always someone around to keep an eye on your stuff, I don't think it makes too much difference.

Oh yeah, and I'm growing a beard. For now. (My brother, Ed, will probably write me to tell me it looks uneven or something. But because I've preempted him, he's going to have to find some other way to make fun of my facial hair.) Here's a pic, since I'm sure you guys are all so interested.


I'm going to go throw on my board shorts and split. Maybe I can muster something more substantive after a few hours of rejuvenating body surfing and beach reading.

From my mixed up files (a la Mrs. Basil E. Frankweiler)

I think that this is going to be the penultimate paragraph in my personal statement. Yeah, yeah - I'm laying it on a bit thick. But I think I might actually mean it!?

"It has been astounding how much these experiences have done to solidify and reinforce my deep commitment to becoming a physician. Working on these projects at one of the epicenters of the worldwide HIV/AIDS pandemic has spoken to all of the aspects of being a physician that appeal to me, confirming that I am pursuing a profession that will engage and motivate me. I am enthusiastic about the possibility of a career as a physician where – in addition to my excitement about the clinical care of patients – I might be able to pursue my deep interests in medical science and health policy, while utilizing my skills in problem solving and writing."

I'm actually trying not to look at the statement for the rest of the weekend; I've gotten too close and need a little distance before I go back and fine-tune. Also, thinking about applying to medical school all the time is lame. A trip to the beach, a game of tennis or a run, and some dinner with friends sounds like a much more Civilised way of life to me.

I've also started thinking about some other trips I would like to take while I'm here. Mozambique sounds like a must (Beautiful beaches and Portuguese. In Africa. Like Brazil, but possibly even poorer) and I am also planning to go visit my friend Evan in Senegal. He's a Peace Corps volunteer doing AgroForestry (I don't know what it means, but it sounds awesome) outside of Dakar. Hopefully I can also make some time to get to Swaziland and Namibia. Not to mention that I haven't been to Cape Town yet.

Alright, it's time for me head out and enjoy the rest of this beautiful day. We just experienced three days of soaking African rain, and it's been nice to see the sun out once again. I'll catch up with you guys again soon.

Breaking the news (and sending other people the bill)

Again I've been caught napping at the blog wheel. This lapse in posting in no way corresponds with any lack of activity in my life:

The team I am working on the TB/HIV coinfection study with has been asked to present to the staff of the clinic early next week on our observations so far. Because we have not yet entered our retrospective data into the Access database, we will be limited to making qualitative assessments of tuberculosis care in the clinic. However, I'm sure that this will prove to be a very interesting process and I'm looking forward to hear what all of the other clinicians feel are the strengths and shortcomings of the current methodology.

I am currently coordinating another round of site visits to eThekwini municipality clinics in the coming weeks, as I continue my intensive systems evaluation and development projects at each of the sites scheduled to start rolling out more comprehensive HIV care starting at the beginning of next month. Sometimes this project feels totally overwhelming, but I have been working with some most excellent people at the Sinikithemba Clinic who have been wonderful in helping me to systematically and strategically think about all of the upcoming hurdles.

I've actually managed to write a first draft of this personal statement, which is now circulating amongst my small cadre of readers. I am actually pleasantly surprised with how it is progressing, but I still have a bunch of work to do before the May 1 deadline.

My housewarming party last weekend was a rousing success. People from the various circles I have been hanging out with all showed up over the course of the evening and we managed to do some solid grilling and chilling. And because it is something that I take very seriously, I was excited to hear that people were feeling the compilation of music that I put together for the evening.

I've been trying to respond to all of your e-mails as quickly as they've come in. I'm starting to realized that it's a dangerous business when I tell you guys to drop me a line; I invariably find myself digging out from underneath an inbox filled the the most wonderful e-mails from friends all over the world.

I've been spending a little bit of my free time watching the ICC Cricket World Cup on the SABC Sport network. Because South Africa is still in the mix there is lots of attention being paid to these matches by the local media. Ireland, England, Sri Lanka, Australia, Bangladesh, New Zealand, and the West Indies are also all still left in the Super 8 round of the tournament.

That's going to be all for tonight - talk to you guys soon.

Great music, less filling!

(Update: At the request of Route9, I'm taking the music down from the blog.)


So, the a cappella group I sang with in college has just put the finishing touches on their second CD. Lots of the material was recorded while I was with the group, so my voice (and even some beat boxing) is on many of the tracks. Listening to the album makes me realize how long it's been since we were in the recording studio, but the results are actually pretty good. I've posted a few of the tracks below for you to check out. I know that some of the songs are a bit cheesy. I have nothing to say in our defense, other than that we were a bunch of 18-22 year olds trapped in Amherst, Mass. But I hope you like them anyways. (Hint: I sing lead on one of the songs; I wonder if you can figure out which one it is. No cheating, for those of you who know.)

Explicit content; Hip-Hop and Motown Collide

That mystery album from my previous post is Re-Release Therapy, a most excellent mashup of the vocals from the most recent Ludacris album - Release Therapy - over beats sampled from a wide range of Jackson 5 songs. The results are quite spectacular - with Luda's lyrics flowing over those laid-back Motown/funk/soul beats from the 70's. Interestingly, this mashup manages to show us all of the redeeming qualities of what was one of the more disappointing releases of last year. If you click on that link up there you can download the whole album gratis.

I heard about this disc first at La Pura Vida, the blog of a friend of a friend (or maybe it's a friend of a friend of a friend?) back in NYC . Thanks, Monica.

The invitation for my housewarming party this weekend went out earlier today. Let's just hope the weather holds out. It would be quite a problem if we get rained on; my place isn't nearly large enough to accommodate the number of people I've invited. Oh well.

A Brief State of Our Union

There have been many interesting parts of writing this blog so far. It has obviously been – as any of us might have guessed even before I left - a nice way for me to keep in touch with you guys and for all of you to feel like you’re keeping in touch with me while I’m in Africa. However, this particular process has at times been seriously mitigated by my editorial sensibilities; I haven’t felt entirely comfortable sharing the aspects of this trip that have been particularly challenging for me. (I am of the mind that airing dirty laundry in public spaces is invariably a Bad Idea.) What has been of even greater surprise to me is how much I have enjoyed sharing my thoughts and experiences surrounding my work at the clinic. I have been intellectually engaged by the both the conceptual underpinnings and the practical execution; both the purely scientific and the wider policy-related aspects of the work have been eye opening and engaging.

Maybe I would like to try to spend some more time in my upcoming posts outlining some of what my projects have entailed – highlighting some of the features that have provided interesting insights into my own thinking about the health crisis in the developing world and my (possible? probable?) career in the health-sciences.

So, consider this a Heads Up. I will also do my best not to estrange that portion of my readership that only read my blog for all the juicy gossip and the gorgeous pictures of yours truly. I even have a music recommendation for those Hip Hop- and Motown- heads out there. That’s enough of a hint for the time being; I’ll try to post a proper write-up of the album in the next few days.

I’ve loved hearing from all of you guys – even when (especially when, I guess) things haven’t been going so well here. Please keep the posts and e-mails coming; they are greatly appreciated, and I’ll try to respond to you as quickly as possible.

Mi casa

...and now for something completely different: some pics of my new apartment.

It's a small, modern studio in a nice neighborhood with lots of light and a full wall of sliding glass doors that open onto a patio with a gas barbecue (a proper piece of braai-ing hardware). Upstairs is a sleeping deck with (not enough) closet space, a TV, an air conditioner (!), more windows, a small deck, and a surprisingly comfortable bed which is slightly, but only slightly, bigger than a twin.








As you can see from these pics I'm not completely unpacked just yet; I still have a day or two of vacation left, ok? And I am fairly sure that you haven't heard the last from me today. I have promised myself that I'll write a another ~500 words for this personal statement, which obviously means that I will need to take breaks with staggering frequency. I don't need to have this thing done until June 1 when the AMCAS (the Med School common application) goes live, but Amherst wants a draft for May 1. In any case, I'll probably be back later. Until then...

A triumverate of sorts

Three of my idols (well, more like two idols and one guy I simply find hilarious - I leave you to figure out who's who) were profiled in the New York Times this week.

First was an article on Atul Gawande, a surgeon at Brigham and Women's Hospital and assistant professor at the Harvard School of public health. He is also a gifted writer; having written extensively on medicine and public health for The New Yorker and is about to come out with his second book, Better: A Surgeon's Notes on Performance. (If you have never read a piece by him before, I suggest reading "Piecework: Medicine's Money Problem," a 4,000 word essay on the U.S. health system's fiscal underpinning that's classic Gawande.)

Second was an article on Timbaland, a famous American Hip Hop producer, who has just released an album entilted "Timbaland Presents Shock Value." Of additional interest to me, the profile was penned by Kelefa Sanneh - one of my favorite music writer on the Times staff.

And the final article I'd like to highlight was about the new season of the HBO show Entourage, which centers on the lives of a fictional movie star and his group of childhood friends (including his failing actor of a half-brother, his friend-cum-manager, Eric and Turtle - a third friend whose job description seems to involve equal parts "hanging out" and "spending his friends' money). And while the article was mostly a puff piece to hype the this upcoming season, there is are several paragraphs extolling the virtues of the character played by Jeremy Piven, who is always angry, mostly misogynistic, and unfailingly hilarious.

Life is South Africa is continuing to roll along, but it's been nice to spend a few moments thinking about parts of my life in the States that make me smile. If you're interested in the articles, the links are below. Have a Happy Easter weekend, and I'm sure you'll be hearing more from me quite soon. Now that I'm living in my own place and have access to internet at home, I have even fewer excuses to not post consistently.

Article on Atul Gawande

Article on Timbaland

Article on Entourage and Jeremy Piven

At long last, here are some pictures from my trip to Lesotho last weekend. It turns out that some of the best pictures were taken with other peoples' cameras - some of which I've been able to get my hands on, and some I'm still awaiting receipt of.

As I've mentioned in all of my previous posts about Lesotho: it is a country with the most striking scenery. Huge mountains, blue skies, and green fields all contribute to Lesotho's natural beauty.


The huts in small town of Semongkong are built of stones with expertly thatched roofs


and these little corrugated tin (or is it aluminum) shacks comprised the vast majority of the commercial district. Each one was it's own small business with a hitching post outside for patrons to tie up their horses while they shopped.

Just 10 kilometers into the mountains from Semonkong is a 200+ meter waterfall plunging into a mountain stream. The rains hadn't yet come to Lesotho while I was there, meaning that the falls weren't as torrential as they might otherwise have been - but it was quite beautiful nonetheless.

It seems that all the stores in the whole of the country carry the exact same items. It was quite surprising at first, given that I'm living in a city in South Africa where - much like in the US - we are never at a loss for choices of brands/products in supermarkets. However, once it was explained to me that each of the towns are on one long supply route, with most of the goods being imported up through the difficult-to-navigate mountain passes, it all started to make sense. This reasoning also seems to explain why goods became more expensive as we moved further outside of the capital city of Maseru. More difficult destinations on the supple route = greater transportation costs = greater costs of goods for consumers.


On the way back down from Lesotho we were able to spend some time with a few of the shepards who were walking their sheep across the road as we were driving past. Many of the shepards were quite young, but were dressed in the Basotho uniform of rubber galoshes and a blanket of synthetic material wrapped around their shoulders to keep out the cold.



And if you are interested in looking at some more of my pictures, you can find them on Flikr,
or you can always e-mail me directly. I'm starting to take pics of my new place for everyone to see. Hopefully I can post them in the coming days.

Talk soon.

Opening Day

My trip into Lesotho was pretty spectacular. The country is extraordinarily beautiful, extremely impoverished, and full of extremely challenging terrain for a group of five macho men (or - more accurately - four and one poseur) to hike, trek, bike, and climb. Pictures will be forthcoming, but the trip was a perfect blend of outdoor activities and ARV clinic/orphanage visits; I'm still digesting a lot of what I took in over the course of the past 4 days. And, best of all, I was able to renew my visa at the SA border on the way home - giving me another 90 days of being a legal resident here.

However, what I am most excited about today is that the Yankees are playing their season opener against the Tampa Bay Devil Rays at 1:05pm EST this afternoon. I haven't been able to stay on top of all of the off-season moves that we've (yes 'WE' - it's the only way to talk when you're a fan) made - and I'm particularly confused about why the inimitably mediocre Carl Pavano is our Opening Day starting pitcher - but I am quite stoked about the 2007 baseball season. I think it has something to do with being so far away from home, but the thought of listening to baseball broadcasts and reading daily box scores sounds quite comforting to me at the moment. Don't worry, I've already purchased my MLB.com radio subscription, and will be listening to as many games as I can while I'm here. I might even be back in the States in time for the post-season; hopefully the Yanks will still be in it at that point.

I'm off to go buy some things for the Seder I'm going to tonight. It's been a little bit tricky finding matzah and macaroons here in Durban, but I think I've finally tracked them down. Happy Passover, and I'll be back again soon with some pictures from my trip and some more thoughts about life, health, and the state(s) of affairs here in Southern Africa. Peace out.