Oh yeah, that school thing...part three

After a week's break between terms, the second five-week blocked started. This was split between a course in Medical Anthropology for Public Health and a course called Epidemiology and Control of Communicable Diseases.

I've always found anthropology to be a mixed bag, at least in the couple of classes I took in it during my undergraduate years. On one hand, the idea of trying to understand phenomenon of human behavior from within its cultural context seems like the few legitimate ways to try to make peace between factions throughout the world who are constantly at each other's throats - and it has a role as well in trying to make medicine less of a top-down do-as-I-say profession and more of a partnership between providers and patients who often seem to be a cross purposes. But I also find it frustrating that there's a tendency in anthropology to over-explain things, to ascribe grand meaning to details of other cultures so minute that we wouldn't ascribe meaning to the equivalent in our own cultures. Well, that and the fact that apparently no self-respecting anthropologist can write anything in less than fifty pages. I think the official term for that latter phenomenon is "thick description" - trying to capture every nuance and detail and variation rather than the trends and generalizations that epidemiology focuses on, for example - although half the time I feel like it's just bad editing. (And the final irony is that the exam for this class required four essays in one hour - which seems to be in ironic opposition of anthropology's tendency to require at least 10,000 words to describe the variation on how people drink their coffee in the morning.)

The class did cover some interesting territory though. Each student presented one journal article and a relevant example to their respective seminar group; I focused on an article by Paul Farmer, the Harvard-trained doctor who opened up one of the only TB (and later AIDS) clinics in rural Haiti. His thesis was, ironically, that anthropology as a discipline has a lot to answer for over some of the omissions and biases that it indulges in. For example, when it became clear that Haitian immigrants in the US were a major risk group for HIV infection in the early 1980s, anthropologists got on the case and conjectured how it must be bizarre blood rituals associated with voodoo beliefs that sparked the epidemic in that group - without an iota of evidence to say this was true. In retrospect, it was almost certainly the international sex trade in the dirt-poor capital city of Port-au-Prince that caused the initial cases, and from there it spread like wildfire via trucking routes and the near-constant military movements that marked the era of coups and counter-coups after the fall of the Duvalier regime in 1986. Farmer went on to accuse anthropologists (quite rightly, I believe) of entirely ignoring the factor of poverty in determining how people behave, instead searching for arcane cultural reasons why so many Haitian do not, for example, finish TB treatment regimens when even the TB patients themselves know that non-compliance to prescribed medications causes worse disease later on down the road. The thesis ended with perhaps the most important factor for understanding why TB control has failed so miserably in places like Haiti, Russia, and the entire African continent: "Those least likely to comply," Farmer says, "are inevitably those least able to comply." Very well said.

The other class - Epidemiology & Control of Communicable Diseases - is one of the foundation classes for my course in Control of Infectious Disease, and it was required for most of us in this track. This class largely covered the conceptual and mathematical approach to describing, predicting, and controlling infectious disease (in case that wasn't obvious from the title!). The course director was an American-born professor who had a very effective stage presence in lecture, which somehow devolved into an arrogant and assinine persona in the smaller seminar sections. He managed to make arcane subjects like "stochastic micro-simulation of disease transmission" not only palatable but even kind of interesting, using a physical model full of colored marbles to mimic the probability that one sick kid in a school will run into another kid and pass on a germ. At the same time, he managed to alienate just about every seminar group he taught, which ended up in a fiasco that I can only describe as The Day I Told Off The Course Director. About fifteen minutes into one session, I raised my hand and was called on to contribute during the discussion (the first time I'd said anything); I got about half a sentence into what I was going to say when he threw a dismissive little wave in my direction and told me he didn't want to hear what I had to say. I do believe that first my jaw dropped and then my eyes rolled (me? rolling my eyes? never!). I take full responsibility for what happened next, though I should also mention that I was a few weeks into a new medication for chronic headaches, and I was still pretty loopy while I was adjusting to it. Anyhow, we broke up into small groups; when he came by the group I was in, I told him I thought that was the rudest thing I'd ever seen a professor or any other supposed professional do in public. He sorta dropped his jaw, muttered something I didn't catch, and walked away. During the break, I was walking out of the computer lab to go back to class when I ran straight into him. He apologized with a fair amount of grace, but I was still pretty loopy (and totally not prepared to run into him) and all I managed to get out of my mouth was something like, "Uh...errrm...uh...ok...uh...thanks, man." It was not my finest moment, but it apparently made for a great piece of gossip, since I heard back about it from about half of my classmates in the next day or two. Apparently I wasn't the only one who was itching to tell him off, and if anyone thought I was wrong, I sure didn't hear about it. That was however a moment in which I was profoundly glad that a) all assessed work is turned in with an identification number and not a name so that graders don't know whose paper they are grading, and b) that this class is entirely graded by a multiple choice test at the end of the term so there is zero arbitrary input into final grades.

Aside from that run in, this class offered a rare view into the classic material that the school - indeed, tropical medicine as a whole - is all about. Toward the end of the term, with the basic concepts under our belts (as well as a hectic three-day stab at a simulated outbreak investigation), they brought in a series of lecturers on the major diseases that still plague the tropics and anywhere else that poverty is rife: malaria, TB, AIDS, and a handful of smaller ones like meningitis and polio. In the last couple of days came a series of guest speakers and debate presentations that tackled the issues that have defined tropical medicine ever since the field started to its shed history as an instrument of imperial dominion (largely focused on how to keep white settlers from dying in droves when they shipped out to colonize Africa and Asia) and began to turn toward the health of the populations who actually come from the tropics and have endured the additional blow of colonial rule over the last couple centuries: disease eradication in face of successes like smallpox and rank failures like malaria; health priorities in the face increasing inequalities across the planet; and emergent epidemics like bird flu that threaten an ever-more tightly globalized world. This profound redirection has shaped the field of tropical medicine today - and forced a hard shift away from imperialist intent and toward the days when celebrity causes-du-jour include debt relief and the wealthiest couple in world (all bow to Bill & Melinda Gates!) hand out funds by the millions for programs to improve the health of the people that imperial rulers once sought to exploit. It's a transformation that is far from complete and promises no smooth road in the decades to come. But there are signs that new priorities are emerging and that LSHTM and the network of similar institutions around the world do have something to contribute. Most profoundly, the halls of this little world of academia that used to be dedicated to supporting the exploitation of the tropics now house an increasing number of individuals from those regions - students, doctors, community advocacy workers - who are training to bring improvements back to those regions. While I find the topic fascinating and hope to keep global medicine at the forefront of my career, I am also under no illusion that my education will profoundly affect the health of people in poor nations. But the training provided to citizens of those tropical nations may yield profound impacts far greater than the majority of the student body that comes from the US, the UK, and the rest of western Europe. Their presence and their voices are what signify the profound possibilities of real improvements in global health, more than the Gates' and all the celebrities that Bono can recruit to the cause. It's a quiet shift, and often ignored, but it's those students who forge the hope that the field of tropical medicine can be more than just a way to provide first-world travelers with the right drugs to head off malaria when they vacation near the equator.

On the evening of the last class, the course director arranged for a gathering of all who wanted to come at a pub in the Soho section of London, not too far from the school. The pub is called the John Snow, after a long-dead gentleman who is credited with being the first to use on-the-ground epidemiological sleuthing to identify the source of a cholera outbreak that was plaguing London. In the days when the idea that microbes caused disease was still only brewing in the imaginations of a few future scientists, Snow mapped out the cases, tracked the water source for each household, and zeroed in on a particular water pump on Broad Street. He demanded that the local authorities simply remove the pump so that no further water could be obtain from the contaminated ground it drew from; with no other viable suggestions on the table, the authorities acquiesced. The pump handle was removed in September of 1854; the outbreak petered out, and modern infectious disease epidemiology was born. Soho is now a fashionable part of town, but if you look you can still find the site of the Broad Street pump, where a small plaque and a statue remember the outbreak. From the second-floor window of the John Snow, you can see the memorial and raise a pint to the grandfather of epidemiology.