The devil's hunter and his weapons

This is part 2 of a longer article on Sam Childers, the “Machine Gun Preacher.” Part 1 is here, or you can read the whole series as one long article. Crush the wicked where they stand

Some of Childers’ most outrageous claims are his most recent. An April 2010 Vanity Fair profile, “Get Kony” by Ian Urbina – worth reading in full – focused on Childers’ personal quest to kill Joseph Kony. Kony is, of course, a really bad guy. He’s the leader of the Lord’s Resistance Army (LRA), a guerilla group in northern Uganda known for its use of child soldiers. Childers claims to be hunting him. Urbina’s story doesn’t present Childers as particularly good at hunting or much closer to catching Kony than any of the others who are out for his head. But the beginning gives you a taste of Childers’ character:

It’s two a.m., and we’re barreling down a deeply pocked dirt road in Southern Sudan. In the cool of night, the temperature is nearly 100 degrees. Sam Childers, 46, is behind the wheel of a chrome-tinted Mitsubishi truck. Christian rock blares on the speakers. He has a Bible on the dash and a shotgun that he calls his “widow-maker” leaning against his left knee. His top sergeant, Santino Deng, 34, a Dinka tribesman with an anthracite complexion and radiant black eyes, sits in the passenger seat, an AK-47 across his lap.

In time, he liquidated his construction business, sold his pit bulls, auctioned his antique-gun collection, and mortgaged his home to help pay for regular trips to Sudan, where he began spending most of his time. He became obsessed with the fate of the thousands of children who have lost their parents to the fighting. In due course he would set up an orphanage in Sudan. But it was Joseph Kony who grabbed his attention. “I found God in 1992,” Childers says, in what is by now a ritual formulation. “I found Satan in 1998.” He has vowed to track Kony down and, in biblical fashion, to smite him.

From there the story gets more elaborate. According to Vanity Fair, Childers claims to be feeding and supplying the Sudan People’s Liberation Army (SPLA), a southern Sudanese armed group whose political wing has more recently become a major component of independent South Sudan’s government. Childers said that he “made his home in Uganda available to the rebels for a radio-relay station.” He also claims to have been present when the SPLA captured “an L.R.A. soldier believed to be part of Kony’s inner circle. Childers wanted to sedate the man and surgically implant a transmitter so he could be tracked when he returned to the base camp. An S.P.L.A. commander overruled Childers and dealt with the man the old-fashioned way—he executed him.”

No word on whether Childers reported this to anyone before the interview; executing prisoners is a war crime.

God’s RPG stockpile?

The profile continues, describing how a group of soldiers arrive to discuss the hunt for Kony. They ask to see inside his church:

The building, with a high sheet-metal roof and glassless windows, displays no religious markings. Inside, stacked floor to ceiling, sit hundreds of oblong olive-green crates. They contain rocket-propelled grenade launchers, AK-47s, and thousands of rounds of ammunition. The room is dusty, and birds flutter in the rafters. Childers says he supplies mostly the S.P.L.A., and also stores some of its arms. He adds that he has sold weapons to factions in Rwanda and Congo, but declines to specify which ones.

Childers said he gets his weapons from Russians, but only legally. He eventually got frustrated with Urbina’s questions about his arms dealing, but he already admitted a lot. Childers is stockpiling arms, including heavy weapons like RPGs that seem excessive for the needs of an orphanage’s self-protection. He’s storing these weapons in a church at his orphanage (which presumably might make it a target) and he sells weapons to the SPLA, which is not a squeaky clean group. While better than the LRA, the SPLA also has been known to use child soldiers during the period Childers sold them arms. Worse is Childers’ mention of selling weapons to “factions in Rwanda and Congo,” all of which are involved in a convoluted series of conflicts in which all parties have committed terrible crimes. If Childers is truly trying to bring an end to conflict in the region, he should start by recognizing that pumping more small arms into the area isn’t going to help.

In addition to selling arms, Childers claims that his “rescue missions” have also led to his personal engagement in combat. When asked how many LRA members he personally killed, “[Childers] reluctantly admits to ‘more than 10.’” In another long profile – from April 9, 2011 in The Times of London (which I unfortunately can’t find online) Childers appears to say he's only killed in self-defense, though it’s hard to deem armed expeditions to find the LRA “self-defense.” That profile also emphasizes the primacy of Childers’ hunt for Kony. It also describes him showing off the guns he keeps in his bedroom at the orphanage:

He hauls an Uzi machine pistol out of one [plastic crate] and clicks in a 32-round magazine. From another comes a longbarrelled Magnum revolver, and from under his narrow metal-framed bed comes a case containing a Mossberg bolt-action sniper rifle and a pump-action shotgun. Another box beneath the bed is full of hand grenades.

If you’re not convinced already that his tactics are shortsighted and part of the problem, rather than a solution, you might be wondering if – just maybe – Childers knows the local situation so well that he was able to pick the “right” side in the conflict. Other stories indicate that Childers is impatient and interacts poorly with the Sudanese people. Urbina's profile continues (emphasis added):

A little later we pull to the side of the road for firewood to bring back to the orphanage. A woman and her husband stand there with a listless baby who is gravely ill from parasites and malaria. Childers offers to take the woman and child to the hospital in Nimule. The father shyly declines, saying he plans to take her to a different clinic tomorrow. A look of rage flashes in Childers’s eyes. “I ought to beat you right here, you know that?” he yells. “What kind of father are you? You are not serious about your children.” Childers points to a nearby grave, where the family has already buried an infant. “What is wrong with you?” Childers by now is surrounded by several of his soldiers, guns on their shoulders. He steps toward the man. “I should really beat you,” he repeats. Terrified, the father gives in. We take mother and child to the hospital.

The child recovers; Childers almost certainly saved its life. But the bullying lingers in memory long afterward. I remember once asking Childers whether any vil­lagers had ever declined his offer to take their children, or whether he had ever taken any against their will. He erupted angrily: “You know what? I don’t have time to be distracted by this sort of interrogation.”

This is hardly reassuring. While Childers doesn’t answer Urbina’s questions about taking children against their will (or detailed questions about his arms dealing), it’s clear that his own ambitions feed off of media coverage. How else did Urbina come to profile him? Self-aggrandizing is a good word for it. Urbina describes Childers as “droning on about the feature film that he hopes will be made about his life, a proj­ect advanced by a Hollywood agent.” Who does that?

Continue reading part 3 here, or you can read the whole series as one long article.

Who is Sam Childers?

He goes by many names, Reverend Sam and the “Machine Gun Preacher” amongst them. If you haven’t heard much from Sam Childers, you will soon. To date he’s been featured in a few mainstream publications, but most of his exposure has come from forays into Christian media outlets and cross-country speaking tours of churches. In 2009 he published his memoir, Another Man’s War. But Childers is about to become much better known: his life story is being made into a movie titled Machine Gun Preacher. It hits the big screen this September, starring Gerard Butler (300) and directed by Oscar-winner Marc Forster (Monster’s Ball, Quantum of Solace).

Why should you care? If you’re concerned about Africa (especially the newly independent South Sudan), neutrality and humanitarianism, or how small charities sometimes make it big on dubious stories, Childers is a scary character. By his own admission Sam Childers is a Christian and a savior to hundreds of children, as well as a small-time arms-dealer and a killer. And, as far as I can tell, he’s a self-aggrandizing liar who chronically exaggerates his own stories and has been denounced by many, including the rebel group of which he claimed to be a commander.

It’s hard to get to the bottom of much of Childers’ story. I first heard of him months ago and have been scouring the web, but the trail is still pretty thin. On the on hand there’s a ton of copy written about him – but almost all of it originates with Childers’ own storytelling. I think there are a number of good reasons we should be skeptical.

The short version of his coming-to-the-big-screen story is this: Childers used to be a drug-dealing gang member who loved motorcycles almost as much as he craved women, drugs, and violence – especially violence. He fell in love with his wife after they met through a drug deal, and she convinced him to turn his life around. Sam found Jesus, got involved with the church, and went to Africa. There he encountered the Joseph Kony’s Lord’s Resistance Army and it use of child soldiers. He found his calling leading armed rescue missions to free enslaved children in northern Uganda and southern Sudan. Now that his life story is being made into a movie -- a goal Childers has long sought -- his ministry will only grow stronger and save more children.

His website, MachineGunPreacher.org, makes no apologies about his violent tactics. Here’s one of the banners that adorns the front page:

What you see now is a slickly-polished presentation, but it hasn’t always been that way. Childers’ story has grown over time, apparently aided by a PR firm, sympathetic media, and a quest to be ever more sensational. My gut reaction is that he’s making much of it up – and I’ll present evidence that shows at least some of his claims are likely falsehoods. We can choose to believe that Childers’ claims are true, in which case he is dangerous, or that they’re false and he’s untrustworthy. The reality is probably that he’s a bit of both.

This is part 1 of a longer article on Childers. Continue reading part 2 here, or you can read the whole series as one long article.

The Onion of Africa advocacy

"The Onion of Africa advocacy" is my new nickname for Falling Whistles, the Congo advocacy group that appears to be staffed more by graphic designers than people with policy chops or good taste. On first read it's hard to tell whether all of their material might actually be a big inside joke designed to mock tasteless, shallow advocacy messaging. Which would be awesome... except that they're serious. Their latest email, with the subject line "Announcing the Hamptons Edition Whistle" and a message body composed entirely of an image, is pasted below (click for larger version):

Judge for yourself?

New books

... that I wish I had time to read: 1) Laurie Garrett's first book since Betrayal of Trust (2000) is I Heard the Sirens Scream, which takes on 9/11, the anthrax attacks, and the US response to both. I'm most interested in the discussion of "the bizarre chemistry of The Plume that rose from the burning crushed World Trade center for four months." Alanna Shaikh interviews Garrett about the book in UN Dispatch.

2) The Other Barack, though it sounds depressing.

3) The Invention of Brownstone Brooklyn: Gentrification and the Search for Authenticity in Postwar New York. A review:

By 1982, Osman writes, the number of hardware stores in Park Slope was more than three times the per-capita average in the rest of the city, and surveys indicated that a majority of Park Slope residents were undertaking most improvements themselves. In the current age of multimillion-dollar brownstone sales, it’s easy to forget the more modest roots of these neighborhoods....New, politically savvy residents sometimes found common cause with local residents in lobbying for services and opposing large-scale development. In 1975, the Fort Greene Non-Profit Improvement Council was powerful enough to obtain a court injunction halting study of the construction of a new Giants Stadium on the Atlantic Terminal site. Such coalitions, however, don’t always hold together....

Sounds interesting throughout, especially now that I've been to Brooklyn. Yes, before this summer I had never really ventured outside of Manhattan on my few visits to New York. Also, the question of gentrification is one of those things I used to think was simple, when I first read of it. Surprisingly (or not?) it was talking through those issues in DC with several friends who are urban planners that made me realize that there generally aren't easy answers to any question involving old and new residents and changing economic fortunes in a neighborhood.

Not #4: After reading J's review, I think I'll pass on Inside the Everyday Lives of Development Workers.

Avoid immunization, go to jail. Eek.

Via Foreign Policy:

In Nigeria, avoiding a shot could mean going to jail

As Bill Gates unveiled his plan this week to rid the world of polio, health officials in the northern Nigerian state of Kano announced their own assault on the disease. "The government will henceforth arrest and prosecute any parent that refuses to allow health workers to vaccinate his child against child-killer diseases, particularly polio," said a health ministry official.

This news, which was announced at the outset of the government's four-day vaccination campaign targeting six million children, marks a shift in government policy toward immunization programs in the north of the country. Nigeria's polio vaccination program stalled for more than a year after Muslim leaders raised doubts over the inoculations' safety in the summer of 2003 -- resulting in bans issued by some northern state governments....

I'm not familiar with every vaccination law in the world, but this seems like a first to me. If not a first, at least an exception to the norm. I don't like this more coercive approach. If you have enough resistance to a policy that you feel you need to threaten jail time, then actually making that threat -- and following through on it -- seems likely to breed more resistance.

I think governments can and should both incentivize vaccination and make it difficult to avoid without a really good reason. Any government policy should make it easier to get vaccinated against childhood diseases than avoid vaccination, because having a fully-vaccinated population is a classic public good. I like the fact that most states in the US have opt-out provisions for religious objections to vaccination, but I also think that states should not design a policy such that getting that exemption is simpler -- in terms of time and money -- than getting a child vaccinated, as is the case in many states.

But threatening to throw parents in jail? Way too heavy-handed to me, and too likely to backfire.

Happy Hep Day

Today is the first ever WHO-sponsored World Hepatitis Day:

These successes and challenges are amplified because viral hepatitis is not a single disease. Hepatitis is caused by at least five viruses—including two spread by water or food contaminated with feces(hepatitis A and E) and three transmitted by blood and body fluids (hepatitis B, D, and C) during childbirth (from infected mother to child); through injecting drug use, needle sticks, or transfusions; or through sexual contact. Hepatitis B and C infections can cause cirrhosis of the liver and lead to liver cancer.

Today, more than 500 million persons worldwide are living with viral hepatitis and do not have adequate access to care—increasing their risk for premature death from liver cirrhosis and liver cancer. Each year, more than 1 million people die from viral hepatitis and millions of new infections add to this global burden of disease and death.

It is not, however, the first ever World Hepatitis Day – it’s just the first one recognized by WHO. Many of these international attention-raising events grow out of smaller things which pick up steam and eventually get official recognition from international organizations. It turns out that World Hepatitis Day has been going on for several years.

On a related note, did you know that Hep B is a cause of discrimination in China, and that there is a burgeoning carriers’ rights movement? I didn’t either until I started browsing the impressively worked out Wikipedia Hepatitis B page (some epidemiologist had a field day) and found that there’s an entire page for Hep B in China. An excerpt:

Discrimination

Hepatitis B sufferers in China frequently face discrimination in all aspects of life and work. For example, many Chinese employers and universities refuse to accept anyone who tests positive. Some kindergartens refuse admission to children who are carriers of the virus. The hepatitis problem is a reflection of the vast developmental gap between China's rural and urban areas. The largest problem facing Chinese people infected with HBV is that illegal blood testing is required by most employers in China.[17] Following an incident involving a Hepatitis B carrier's killing of an employer and other calls against discriminatory employment practices, China's ministries of health and personnel announced that Hepatitis B carriers must not be discriminated against when seeking employment and education.[18] While the laws exist to protect the privacy of employees and job seekers, many believe that they are not enforced.

"In the Hepatitis B Camp"

"In the Hepatitis B Camp" is a popular website for hepatitis B carriers' human rights in China. Its online forum is the world's biggest such forum with over 300,000 members. The website was first shut down by the Chinese government in November 2007. Lu Jun, the head of the rights group, managed to reopen the website by moving it to an overseas server, but the authorities in May 2008 began blocking access to the website within China, only 10 days after government officials participated in an event for World Hepatitis Day at the Great Wall of China. An official had told the head of the rights group, Lu Jun, at the time that the closure was due to the Beijing Olympic Games.[19]

(h/t to Tom)

Grad school advice from bloggers

If you want to take advice from bloggers, they're generally happy to give it. I've written a bit about my own motivation in selecting programs. I think the best advice comes from people who know you, your interests, and aspirations well. That means family and friends, especially if your friends work in similar fields. It's also invaluable to talk to both experienced mentor figures who have some perspective and recent graduates of the programs you're interested in (programs do change over time). Over the past year I've come across a number of resources written by bloggers that I think are worth highlighting: Dave Algoso, a recent graduate of the MPA program at NYU's Wagner School, wrote a grad student’s guide to the international development blogosphere which answers these questions:

1. Why should I read blogs? I do plenty of reading for class/work already… 2. Blogs can be overwhelming. How do I manage the information flow? 3. Okay, I’m sold. What should I be reading?

From Chris Blattman (everyone's favorite development blogger at Yale):

Dani Rodrik responds to Blattman on graduate programs in development.

From Greg Mankiw's blog:

Let me know if you think of something I'm missing. There does seem to be more advice out there about economics programs than those in public health. Personally I'd love to see a similar set of posts from Karen Grepin, Alanna Shaikh, and Elizabeth Pisani, amongst others.

Update: Dave Algoso suggested these posts by Amanda Taub of Wronging Rights, which I missed since I never seriously considered law school:

Monday Miscellany

Oxfam on the worsening situation in the Horn of Africa. Related: Edward Carr on "Drought Does Not Equal Famine" from 4 days ago,and a follow-up from yesterday on remedies for the famine. Texas in Africa has a round-up on what's going on in Malawi.

NPR: Vaccine Mistrust Spreads To The Developing World - this was a subject of some discussion in Orin Levine's Vaccine Policy Issues class at Hopkins this spring.

The Economist summarizes a likely rough patch ahead in South African politics.

On two lighter, linguistic notes: 15 wonderful words with no English equivalent and the Economist demolishes BBC's "anti-Americanisms."

Also, Campus Crusade for Christ has rebranded itself -- now it's just called "Cru" (from Hemant Mehta, not The Onion.)

Football epidemiology

In an attempt to prove Cowen's First Law -- "there is literature on everything" -- I enjoy highlighting unusual epidemiological studies (see tornado epidemiology, for one.) These studies may seem a bit odd until you start thinking like an epidemiologist: measurement is the first step to control. The latest issue of Pediatrics has a new study by Thomas et al. on the "Epidemiology of Sudden Death in Young, Competitive Athletes Due to Blunt Trauma." Some of the methods seem a bit sketchy, but that's kind of the authors' point as they note,

"without a systematic and mandatory reporting system for sudden cardiac deaths in young competitive athletes, the true absolute number of these events that occur in the United States cannot be known."

While this study is mostly concerned with the sudden deaths not caused by cardiac events, the same principle holds true: if anything, the problem is under-reported.

Thomas et al. use 30 years of data from the "US National Registry of Sudden Death in Young Athletes," looking at 1980–2009. Deaths in the database came from a variety of sources including LexisNexis searches, news media accounts assembled by other commercial search services, web searches, reports from the US Consumer Product Safety Commission and the National Center for Catastrophic Sports Injury Research, and direct reports from schools and parents.

Of the total deaths included in the study, about 261 were caused by trauma, or around 9 deaths per year. 57% of the 261 deaths were in a single sport, football. Notably, there were about four times as many deaths due to cardiac causes as to trauma.

In football they find defensive positions have more deaths than offensive positions, "presumably because such players commonly initiate and deliver high-velocity blows while moving toward the point of contact." While the majority of deaths were in defensive players, the single most represented position was running backs.

Why the focus on deaths in young athletes? The authors note by comparison that lightning causes about 50 deaths per year, and motor vehicle injuries case 12,000 deaths per year. (Aside: You can tell the authors don't work in injury prevention since they say "motor vehicle accident" rather than "injury" -- injury prevention researchers prefer the latter terminology because they believe "accidental" deaths sound unavoidable.) The authors explain their own focus by noting that these sudden deaths attract "considerable media attention, with great importance to the physician and lay communities, particularly given the youthful age and apparent good health of the victims."

In related news: "The Ivy League [announced that...] in an effort to minimize head injuries among its football players, it will sharply reduce the number of allowable full-contact practices teams can hold."

The battle for hearts and minds

A major difference between the public health approach and the beliefs and strategies underlying fields such as human rights or medicine is that public health concerns the prioritization of limited resources. There is a limited pie. Even if you believe that pie can be expanded (it can, at times), it cannot be expanded infinitely, and so at some point in the policy process someone has to make a decision about how to prioritize the resources at hand. This traditional public health approach overlaps with and gets blurred into human rights and medicine and politics such that the value judgments underlying different claims aren't always apparent. We have a certain number of interventions that are known to work -- they save lives and reduce suffering -- but we don't have enough resources to do all of those things in every place that needs them. If we choose option A, some people will be saved or helped, and some will die. If we choose option B, a different number of people will be saved or helped, and some other group of people will die. The discussion of who will be saved is often explicit, while the discussion of the opportunity cost, those who will not be saved is almost always lacking. Both groups are abstract, but the opportunity cost group is usually more abstract than the people you're trying to help. These are generalities of course, and in reality there is uncertainty built into the claims about just how many lives could be saved or improved with any one approach.

The problem is this: pretty much everything we do in global health is good. Sure, we can argue specifics and there are glaring examples to the contrary, but for the most part we all want to save lives, prevent suffering, and improve health. No one is seriously against successful interventions when they stand alone: no one thinks people with HIV shouldn't get antiretrovirals, or children with diarrhea shouldn't get oral rehydration therapy. Rather, they may oppose spending money on HIV instead of on childhood diarrhea (or in reality, vice versa). Who is comfortable with making an argument against preventing childhood burns? Being against treating horrific cancers? Any takers? So we all argue for something that is good, and avoid the messy discussions of trade-offs.

Thus, much of the conflict in the global health fields is about spending money on X intervention versus intervention or approach Y. Or, better yet, traditional and known intervention A versus new and sexy and unproven-at-scale approach B. I don't think I'd want to live in a world where all health decisions are made entirely by cost-benefit analysis, nor would I want to live in a world where all decisions on care and policy are made from a rights-based approach -- both approaches result in absurdities when taken to their extremes and to the neglect of each other. My impression is that most professionals in global health draw insight from both poles, so that individuals fall somewhere on a continuum and disagree more with others who are furthest away. The tension exists not just between differing camps but within all of us who feel torn by hard choices.

So the differences between the mostly utilitarian public health old-guard and the more recent crop of rights-driven global health advocates aren't always clear-cut, and they often talk right past each other ... or they just work at different organizations, teach at different schools and attend different conferences so they won't have to talk to each other. To some extent they're fundraising from different audiences, but they also end up advocating that the same resources -- often a slice of the US global health budget -- get spent on their priorities. These tensions usually simmer under the surface or get coated in academic-speak, but sometimes they come out. Which brings me to an anecdote to leaven my generalities:

A few months ago I was having a private conversation with a professor, one who leans a bit towards the cost-benefit side of the continuum with a dose of contrarianism thrown in for good measure. Paul Farmer came up -- I don't remember how. I paraphrase:

Resource allocation is the central dilemma in public health. Period. If people don't get that, they're not public health. Paul Farmer? Fuck Paul Farmer. He just doesn't get it.

You won't hear that in a lecture or in a public speech, but it's there. I've heard similar sentiments from the other side of the spectrum, those who see the number-crunching cost-benefiteers as soulless automatons who block the poor from getting the care they need.

These dilemmas are not going away any time soon. But I think being conscious of them and striving to be explicit about how our own values and biases shape our research and advocacy will help us to collectively reach a balance of heart and mind that makes more sense to everyone.

HIV/AIDS is one of the areas of global health where the raw passion of the heart most conflicts with the terrible dearth of resources we have to fight the demon. Decisions have ugly consequences either way you choose, and, rightly or wrongly, dispassionate research is often anything but. The recent news that pre-exposure prophylaxis (PrEP) can prevent HIV acquisition in sero-discordant heterosexual couples is huge in the news right now. Elizabeth Pisani (epidemiologist and author of The Wisdom of Whores) hits the nail on the head in this recent blog post. She notes that there are voices clamoring for widespread scale-up of PrEP -- treating the HIV negative partner -- but that PrEP prevents infection in 60% of cases while treating the HIV-positive partner cuts infection by 96%. Continuing:

That leaves us with the question: who should get PReP? Right now, there are not enough antiretrovirals to go around to treat all the sick people who need treatment. If we’re going to use them selectively for prevention, we should start with the most effective use, which appears to be early treatment of the infected partner in discordant couples. We could also give them to people who aren’t in a couple but who know that they’re likely to get around a bit and might want to stay safe without using condoms. That’s potentially a lot of people; it will stretch our purses. But more than that, it will stretch our political will.

So who is PReP for? We’ve got a better option for discordant couples. We’re not going to want to give it to randy adolescents. We know it works for gay men, but some of the countries where the trials took place would rather thump or jail gay men than protect their sexual health.[...] But I think we would be unwise to rush around talking about massive roll-out of PReP before we actually figure out who it works for in the real world.

Treating people with HIV is good. Preventing infection via treatment is good. Prevention infection via PrEP is good (assuming it doesn't breed more drug resistant strains and make it harder to treat everyone... but that's another story). But most voices in the debate have an agenda and are pushing for one thing above the rest. One of them -- or a balance of them -- is right, but you have to understand their values before that can be discerned. And I think many people in global health don't even think explicitly about their own values, such as the mix of cost-benefit and rights-based approaches they find most appealing. Rather, we all want to promote whatever we're working on that the moment. After all, it's all good.

Weekend meanderings: rockets, Apollo 13 and development

Outer space and rockets were what first sparked my interested in science. My 4th and 5th grade GT teacher, Wanda Holland, taught a summer model rocketry camp for 5th grade science students in my hometown in Arkansas. I went to the camp, fell in love with rockets, and built so many in the next year that Mrs. Holland invited me back as an "assistant" the next year. I kept assisting, then co-teaching the camp through 9th grade and along the way acquired an immense knowledge of mostly useless trivia about astronomy and rocket science. By the time I reached 9th grade I had a collection of hundreds of rockets -- including multiple stage rockets, gliders, scale models, and onboard cameras. I even remember asking a friend once why he would spend money on clothes when he could buy another rocket kit. Needless to say, I was cool. At some point in high school I discovered interests in travel, in playing guitar, in cars, and in girls. Rocketry slowly fell by the wayside. In 10th grade I was building a greater-than-full-scale model of the AIM-9 Sidewinder missile in the family garage (the real thing is 9 feet tall, mine would have been 14'). I had already done the composite reinforcement on the main airframe body tubes when I calculated out how much the construction supplies, avionics, and solid fuel motors would cost, and I realized it would take much more money than my part-time job as a grocery bagger would provide. Then good fortune struck: I won $500 in a regional grocery bagging competition (seriously) which would have let me complete the rocket and buy the fuel to fly it once. But by that point my priorities had shifted and I chose to use it towards a trip to Ghana. That decision is one of many small steps that led me from wanting to be a rocket scientist or astronaut to an interest in global health. The experiences I had in Ghana, and later in Zambia and South Africa, led me to my current interests, and rockets have been a sideshow ever since.

While rocketry hasn't been my primary interest in years, I still try and keep up with my rocket blog, especially when I get around to flying one of my own projects. The old urge to be an astronaut, still strikes now and then. I was a bit bummed that I didn't make it down to the last ever Space Shuttle launch since I always told myself I'd make it to one of them. So this weekend I indulged myself by re-watching Apollo 13, one of my all-time favorite movies.

Apollo 13 holds up surprisingly well 16 years after its release. The casting, the acting, the writing -- it's all excellent. The special effects hold up well too. The soundtrack fits the movie perfectly, especially the triumphant horn riffs during the launch sequence (which I used to watch over and over for hours when I was in junior high). The movie manages to sneak in a surprising amount of jargon, but it works because it's a compelling human interest story focusing on the astronauts and their families. And director Ron Howard managed to infuse the movie with considerable suspense despite everyone knowing how it ends.

Since this is a blog (mostly) about international health and development, I feel it's my duty to draw a few extremely tenuous connections between space flight, this movie, and my current interests:

  • Computers are older than I often think. I mean, they're relatively new in the grand scheme of things, but in my head I often date the importance of the computer to the wide availability of the personal computer. The first Apple home computer I had access to in the early 90s had an operating system contained entirely on a floppy disk, and a separate drive for another floppy disk on which you could load programs and files. Computers have come a long way since then, but even that little Apple was an incredible advance over the computers of the NASA era. Still, they were good enough to take us to the moon in the 1960s. Though you do get the distinct impression that Lovell sure could have used a USB thumb drive to transfer the 'main operating program' from the command module to the LEM at the height of the crisis.
  • Organization as technology. Part of my summer reading is Charles Kenny's optimistic take on global development, Getting Better. In an early section describing the history of theories of economic development, Kenny discusses how some economists have argued that institutions are as important for development as any given technology. Example institutions include specialization of labor, "double-entry bookkeeping, just-in-time management systems," etc. There's an early scene in Apollo 13 where Jim Lovell (Tom Hanks) is giving a tour of the massive Vehicle Assembly Building and describes astronauts as only the most visible part of a massive system. Having just read about institutions -- and economists' attempts to predict national growth rates -- I couldn't help but think of the massive specialization of labor that allowed us to go the Moon. One of the delights of being a hobby rocketeer is that you can do it all, at least the fun parts, yourself. But real NASA engineers are part of massive systems that work together to do much more than any individual could. That's one reason that disasters like Columbia and Challenger are almost always ultimately traceable to problems in how those systems of people work together, rather than a single failure in materials or a single mistake by an individual. The question "what caused the Challenger disaster?" can be answered on as many different levels as "what sparked the recession?"
  • Why did we win the space race? Relatedly, if economists or engineers had tried to predict who would win the race to the Moon in 1950 or 1960, there would have been any number of reasons to pick the Soviets over the Americans. Both sides had natural resources, large numbers of engineers, and rocket scientists poached from the Germans after World War II. While we got the better German, the Soviets had an early lead in rocket development. Then the 60s were particularly rough for the Soviet rocket program (see the Nedelin catastrophe). Arguments abound as to why the US eventually got to the Moon first, but my impression is that US institutions, and especially the engineering systems (not just the particular technological fixes) developed by the US played a significant role.
  • Rubella. Astronaut Ken Mattingly (Gary Sinise) was supposed to be on Apollo 13, but he was exposed to a virus and bumped to the flight lest he become sick on his back to the Moon -- his removal from the flight set the stage for Jack Swigert (Kevin Bacon) to take the third spot just 72 hrs before launch. In the movie they just say "measles," but in reality it was German measles -- a synonym for rubella. The other astronauts had natural immunity because they had had rubella as kids, but Mattingly hadn't, so he got bumped. The rubella vaccine (see graph at right) wasn't introduced until the 1960s, so Mattingly's kids would have gotten the vaccine, but he hadn't. Oops. Rubella is also one of the few vaccines not developed my Maurice Hilleman. OK, that's a slight exaggeration, but Hilleman did invent vaccines for eight diseases: measles, mumps, hepatitis A, hepatitis B, chickenpox, meningitis, pneumonia and Haemophilus influenzae bacteria. Incredible.

NYC mystery of the day: trash collection

I keep hearing complaints from both New York residents and visitors alike that the city smells. You get used to it pretty fast, but it's true -- especially during the summer. In the two other cities I've lived in (Washington, DC and Baltimore) I would put the trash out in a specially marked bin or garbage can for pick-up. My apartment in the East Village has a designated bin on the sidewalk, but we seem to be an exception rather than the rule. Most people just stack their trash bags on the sidewalks, like so:

This contributes to the smell, and probably to the rat problem as well. So why doesn't New York require trash to be placed in bins like at least some other American cities?

This brief history of trash collection in NYC is fascinating, but it doesn't really offer an answer. So I'm stumped for now, but my best guess is that sidewalk and building entryway space are at such a premium that space-consuming trash bins have never been popular. If you have another explanation I'd be happy to hear it.

CIA's despicable Pakistan vaccination ploy

Via Conflict Health, The Guardian reports that the "CIA organised fake vaccination drive to get Osama bin Laden's family DNA":

In March health workers administered the vaccine in a poor neighborhood on the edge of Abbottabad called Nawa Sher. The hepatitis B vaccine is usually given in three doses, the second a month after the first. But in April, instead of administering the second dose in Nawa Sher, the doctor returned to Abbottabad and moved the nurses on to Bilal Town, the suburb where Bin Laden lived.

Christopher Albon of Conflict Health writes:

If true, the CIA’s actions are irresponsible and utterly reprehensible. The quote above implies that the patients never received their second or third doses of the hepatitis B vaccine. And even if they did, there is absolutely no guarantee that the vaccines were real. The simple fact is that the health of the children of Abbottabad has been put at risk through a deceptive medical operations by the Central Intelligence Agency. Furthermore, the operation undermines future vaccination campaigns and Pakistani health workers by fueling conspiracy theories about their true purpose.

Albon notes that the Guardian's source is Pakistan's ISI... but this McClatchy story seems to confirm it via US sources:

The doctor's role was to help American officials know with certainty that bin Laden was in the compound, according to security officials and residents here, all of whom spoke only on the condition of anonymity because they feared government retribution. U.S. officials in Washington confirmed the general outlines of the effort. They asked not to be identified because of the sensitivity of the topic.

The sensitivity of the topic? No kidding. This is absolutely terrible, and not just because the kids originally involved might not have gotten the second round of vaccine (which is bad) or because it will make the work of legitimate public health officials in Pakistan even harder (which is very bad). Vaccines are amazing innovations that save millions of lives, and they are so widely respected that combatants have gone to extraordinary lengths to allow vaccination campaigns to proceed in the midst of war. For instance, UNICEF has brokered ceasefires in Afghanistan and Pakistan for polio vaccine campaigns which are essential since those are two of the four countries where polio transmission has never been interrupted.
I hope I'm not overreacting, but I'm afraid this news may be bad for the kids of Pakistan, Afghanistan, and the rest of the world. Assuming the early reports are confirmed, this plot should be condemned by everyone. If US officials who support global vaccination efforts are going to control the damage as much as possible -- though it's likely much of it has already been done -- then there need to be some very public repercussions for whoever authorized this or had any foreknowledge. What tragic stupidity: a few branches of the US government are spending millions and millions to promote vaccines, while another branch is doing this. The CIA is out of control. Sadly, I'm not optimistic that there will be any accountability, and I'm fuming that my own country breached this critical, neutral tool of peace and health. How incredibly short-sighted.


Update: In addition to the Guardian story, Conflict Health, and McClatchy stories linked above, this NYTimes article offers further confirmation and the CNN piece has some additional details. Tom Paulson at Humanosphere, Mark Leon Goldberg of UN Dispatch, Charles Kenny of CGD, and Seth Mnookin all offer commentary.


Randomized Medicaid. Also, working papers

Karen Grepin gives some background:

"Back in 2008, Oregon had a long waiting list of low-income adults wanting to enroll in its state Medicaid program. Given severely constrained resources it was not able to provide insurance to everyone who wanted it, so it decided to allocate eligibility to enroll into the program by lottery – it randomly assigned insurance eligibility – creating one of the most incredible opportunities to study the impact of health insurance. Period."

This study is the talk of the town amongst health / economics / research methodology wonks: here's some other commentary by Ezra Klein, David McKenzie of the World Bank, and William Savedoff of CGD.

One outstanding question to me is how on earth the Medicaid lottery happened in the first place. Yes, it was an environment of limited resources, which explains not making health insurance available to everyone who needed it in this particular timeframe. But why not choose to give the insurance to the poorest, oldest, sickest, etc? Did the officials who made that decision not have data to make such decisions? Did they think it would be less ethical? Did they think it would be more expensive to put the neediest (and most likely to use the service) on Medicaid? Did they anticipate the evidentiary value of their decision? I'm guessing it's some combination of the above, but I want to learn more.

A side note on working papers: all this talk is about a working paper (available here), which reminds me of Berk Özler's recent post on the World Bank's consistently excellent Development Impact blog criticizing the system of economics working papers. Özler cites as an example his own experience with a working paper on the role of conditionalities in cash transfer programs:

"Our findings in the March 2010 [working paper] suggested that CCTs that had regular school attendance as a requirement to receive cash transfers did NOT improve school enrollment over and above cash transfers with no strings attached. Our findings in the December 2010 version DID.... However, the earlier (and erroneous) finding that conditions did not improve schooling outcomes was news enough that it stuck. Many people, including good researchers, colleagues at the Bank, bloggers, policymakers, think that UCTs are as effective as CCTs in reducing dropout rates – at least in Malawi."

Ouch. This hits home in part because I remember reading that original working paper as part of a literature review for a grad school project on health impacts of conditional cash transfers (in which we designed a hypothetical community-based cluster-randomized trial in Bangladesh). I disseminated those results -- in part because they were counterintuitive -- to more than a few of my peers, but I didn't realize Özler had reversed his findings. If nothing else, we should take working papers that have not been through the full peer-review process with a large grain of salt.

Equality in NY

I had this post saved as a draft for the last week or so -- oops: ------

It's a great summer to be in New York City. I was watching the news on same sex marriage pretty closely, and as soon as the religious exemptions amendment passed -- signalling that passage of the bill itself was just a matter of time -- bloggers started noting that crowds were gathering in front of the Stonewall Inn in Greenwich Village. I live about a mile east of there in the East Village, so I headed out immediately to be there at the historic moment.

This may come as a surprise for gay rights advocates -- or for pretty much anyone who didn't go to an extremely conservative university -- but I hadn't heard of the Stonewall Riots until a year or two ago. The Stonewall has been on my long list of historical sights to see in New York but I hadn't been there yet, and what better time to visit than on this historic occasion?

Sure enough, there was a big crowd gathered and quite a few media outlets on hand. I snapped this shot of an endearing older couple being interviewed:

And here are two NYPD officers doing crowd control, chatting amiably with the celebrants:

While the pace of change can often seem glacial for those eagerly advocating (as they rightly should) for justice now, it struck me that on a grander scale this progress has come impressively fast. Just a little over 40 years ago -- half a lifetime -- the police were systematically oppressing and raiding the few gay establishments in New York. Their actions were hardly inconsistent with popular will either, as there really was no gay rights movement yet. And now, in 2011, there the officers were, guarding a peaceful and spontaneous celebration by New Yorkers -- male and female, gay and straight -- of marriage equality, something that was probably inconceivable to the Stonewall rioters. Yes, the law is not yet perfect and we still have far to go, but for that night it felt right to pause and reflect on just how far we've come.

A few updates

Hopkins: In May I finished final exams for my 4th quarter at Johns Hopkins. That means I'm done with the required four quarters (one year) of coursework towards the MSPH in International Health "Global Disease Epidemiology and Control" (GDEC) track. Looking back I realize that I've learned an incredible amount this year. At some point I hope to write a bit more about the Hopkins experience and major themes in our GDEC coursework, especially for the prospective students who I see end up here through Google searches. The quarter system has pros and cons: it moves fast, which can burn students out by the third or fourth term, but you're also able to shovel a huge dose of knowledge into your brain in a short period of time, leaving the second year of the Masters program more open-ended in comparison to other programs. One reason I chose the MSPH at Hopkins is that flexibility in the second year: you can return and take additional classes after your practicum, or you can spend the entire second year working abroad gaining additional field experience. That flexibility is nice, especially since I'm hoping to work abroad after completing my graduate education and most of my experience in the developing world has been for short periods of time.

In early June I took the comprehensive exams for the MSPH (and hopefully passed!). That means the only requirements I have remaining are a practicum -- 4+ months doing work in international health using the skills I've acquired -- and a Masters paper/thesis based on that practicum. My original plan was to move abroad for a year-long practicum in September, possibly in Nepal, and be done with the MSPH in May of 2012, but that's changed a bit.

New York: This summer I'm part of the New York City Department of Health's Epi Scholars program. Epi Scholars is a training program that pairs graduate students in epidemiology with researcher mentors in the Department of Health. It's been great so far and I plan to write more about the Department, the training experience, and my particular project -- an in-depth review and analysis of severe lead poisoning cases in New York City in the last 5-10 years. The Epi Scholars program is in its fifth year and has its largest class to date (11 participants this year) so it's been great getting to know the other students as well.

Princeton: This fall I'll be starting work on a Masters of Public Affairs (MPA) at Princeton's Woodrow Wilson School. I'll be doing the Field IV (Economics and Public Policy) concentration at WWS to get their most rigorous training in economics, but I imagine I'll take a number of courses from the Field III (Development Studies) concentration as well. While Hopkins and Princeton don't have an official joint degree program, I've been able to make arrangements to complete both Masters degrees in a total of three years. The right people at both schools have been incredibly supportive of this idea and have helped me work out the details. My timeline will be something like this:

  • August 2010 - May 2011 - coursework at Johns Hopkins in Baltimore, MD done!
  • June - August 2011 - summer internship (NYC Dept of Health Epi Scholars Program) in New York, NY (in progress)
  • August 2011 - May 2012 - coursework at the Woodrow Wilson School in Princeton, NJ
  • June - December 2012 - practicum work abroad (including writing my Masters thesis for Hopkins), location TBA
  • January - May 2013 - back at Princeton for a final semester

The Woodrow Wilson School also gives students the option of taking a "middle year out" if their summer internship is going well or leads naturally to a full-time job. If I went that route I might not finish the MPA until May 2014, but I'd have significantly more work experience when I finally get back on the job market.

I decided to pursue the dual degree as I realized more and more that my interests -- and the work I want to be prepared to do -- lie at the intersection of global health and economics. I'm interested in the traditional 'applied epidemiology' of studying public health interventions, as well as how those methods are increasingly being used to evaluate development interventions outside of health programs. (Aside: fascinatingly, a recurring critique this year of the development economists conducting RCTs from my public health professors has been that they are much, much too concerned with randomization.) I'm interested in cost-effectiveness evaluations of health and other interventions, and how politics and evidence from various disciplines -- from epidemiology to economics -- get used and misused to make health and development policy.

I'll wrap up the Epi Scholars program here in New York in August in order to move to Princeton by August 20 to start "Math Camp" -- a three week crash course in math and economics to get us all up to speed before real classes start. I've already started to meet some of my incoming WWS classmates as they pass through NYC and I think it will be an amazing experience.

The next step in tobacco control?

From The Guardian:

Iceland is considering banning the sale of cigarettes and making them a prescription-only product.

The parliament in Reykjavik is to debate a proposal that would outlaw the sale of cigarettes in normal shops. Only pharmacies would be allowed to dispense them – initially to those aged 20 and up, and eventually only to those with a valid medical certificate.

The radical initiative is part of a 10-year plan that also aims to ban smoking in all public places, including pavements and parks, and in cars where children are present. Iceland also wants to follow Australia's lead by forcing tobacco manufacturers to sell cigarettes in plain, brown packaging plastered with health warnings rather than branding.

Under the mooted law, doctors will be encouraged to help addicts kick the habit with treatments and education programmes. If these do not work, they may prescribe cigarettes.

I'll hazard a guess that this approach would not be popular in the United States.

From the front lines of public health

Rashida is a Peace Corps volunteer in Uganda teaching "teaching life skills/health/whatever at a local secondary school," as well as a blogger. She also happens to be in the same Hopkins global health Masters program as me (but a year or two ahead, so we've never met). Her latest post starts with this:


Since the kids are often shy around the muzungu (and in front of their classmates), I thought it would better to set up an anonymous questions box, where students can ask questions about health, etc. without having to ask them in front of everyone. Well, no one else seemed as excited about this idea as I was, so I thought the box would just be forgotten about, or maybe even stolen by a trouble-making student. Imagine my surprise when I came back to the school two days after setting up the box to find it overstuffed with questions. I was a bit overwhelmed by the volume of questions posed to me, so I told the students to let me take them home and prepare my answers for next week. Well, here are some of the questions that I got:
  • If you have sex during your menstruation, do you get pregnant?
  • Is it true that if you kiss someone who has HIV, you’ll also get HIV?
  • There are some boys who disturb me during my leisure time, but if I see them I feel like vomiting. What can I do, please help me?
  • Is it true that if young people play sex before menstruation begins you can still get pregnant?
  • How can I know when playing sex that sperm is coming through the penis?
  • Is it true that if you delay having sex you become an abnormal person?
  • Is it bad to practice homosexuality?
  • People usually tell us to have sex when we are still young in order to become perfect in sex. What is the meaning of perfect in sex?

There are quite a few more in the rest of the post,  and they just get more disturbing. Personally I wouldn't know where to start, and I greatly admire those who have the patience, courage, and tact to do this badly needed work. It must be especially difficult to do this sort of work as a foreigner.  Alas, I described this post -- and the sample questions -- to a friend who does sex ed in New York City and was told that the questions are remarkably similar to what you get asked here.

Advice not to trust

Yesterday morning I came across the gentleman pictured below in New York's Union Square. I've been meaning to take more pictures of "things you only see in NYC" -- a category which generally consists of extremes of pets and fashion -- but I think this deserves its own post:

He was either selling or trying to give away copies of a book titled Uropathy: The Most Powerful Holistic Therapy by one Martin Lara. Since the review of Uropathy on Amazon.com is from the Village Voice, I assume that the evangelist was either Lara or one of his disciples. The review:

Vitamin Pee! Urine is a natural remedy, so raise a glass! That's what alternative therapist Martin Lara wants everyone to do. In his Uropathy: The Most Powerful Holistic Therapy, pee's the ultimate cure-all. Gagging aside, it's not so unconventional: former Indian prime minister Morarji Desai guzzled ounces each morning, observing an ancient Hindu practice. Lara learned about it 11 years ago, when the self-taught therapist he's never studied traditional medicine became disenchanted with science's inability to cure his ailments. Since then he's lectured to thousands. Not any pee will do it must be your own, which Lara says is a nontoxic biofeedback stimulator that boosts immunity by activating the lymphatic system, thus restoring the body to an internally balanced state of health. Dosages range from a few drops of Lara's "Ultimate Universal Remedy" an elixir of water, urine, and white rum to several ounces for serious conditions like cancer, dysentery, or Alzheimer's. Of course, not everyone is ready for this leap of faith. On his Web site Lara argues against obsessing over taste and smell: "Urine is a sample of what is flowing through your veins and repulsive urine should be a motivation to improve the internal conditions, rather than an excuse for not using Uropathy." -- The Village Voice

He was quite earnest. I didn't engage him in conversation because two other passersby were already talking to him. A girl was explaining that urine is what your kidneys decide your body doesn't need. But she wasn't just explaining it, she was disgusted, and angry. His response was similar to a major defense of homeopathic medicine, that the "toxin makes the remedy" (or something like that). The girl got exasperated and left with her friend, and you could hear her ranting as she walked away. I chose not to continue the conversation because I was on my way to meet friends, but in hindsight I wish I had stayed because there are some questions I don't have the answers to:

  • How often does he talk publicly about this? What does he do for a living? Ie, is this it, or does he have a boring day job and this is his true passion?
  • Does he feel that drinking urine has cured whatever health problems that he originally sought help for? (I would guess so.)
  • Why does he think drinking urine has not been more widely adopted?
  • Does he think that his approach (especially the t-shirt and public 'evangelism') is the most effective way to spread his message? I would guess he enjoys the attention on some level, but also promotes his beliefs through other, more effective channels.
  • What are the typical reactions he gets? How many people stay and talk with him at length, and of those how many eventually adopt his therapy?
  • I'd like to talk a bit about Western medicine. Not necessarily the biomedical interventions we favor, but the scientific process by which we (ideally) establish that a practice is beneficial. Does he think urine therapy could be tested by a randomized controlled trial? If not, why not?
  • If the passerby had stuck around: why did she choose to argue with him? Did she really think that a guy wearing a bright yellow "Drink Urine" t-shirt in Union Square was likely to change his mind? And for the man himself: how common is her argumentative reaction?

I think a natural first reaction to something this out of the ordinary is laughter or mockery, or the assumption that he's clinically insane. On further thought, what he believes -- in factual support and argumentative method, if not in substance -- isn't that different from much of alternative medicine, and his methods have been widely adopted by many mainstream religions and social movements as well as less-respected 'fringe' beliefs. If those are both true, why isn't his belief more widely adopted? Is it just too taboo?

I think I could have learned valuable things about the mixture of reason and emotion and belief that guide human choices if I had stayed and asked some of these questions. I don't think I'll change his mind, but I plan to look for him if I'm ever strolling through Union Square on a weekend again.

(Note: evidently "urine therapy" is a thing. The Wikipedia page starts with "In alternative medicine..." -- never a good sign.)