Indirect Effects

Before I decided to do a PhD in Epidemiology, I struggled between a clinical or public health degree. Being an epidemiologist might not be the best way for most people to feel like they're making a meaningful contribution, but I knew I wasn't cut out for day to day patient care, mainly when I realized it was frowned upon to invite every patient home to personally oversee their improvement. I also tried lab science and healthcare policy and found them to be more removed than I wanted to be.

Why epidemiology? Yes, it's mainly a methods based discipline which can be as far removed from direct patient care as you want it to be. On the other hand, it seems to be a field where non-clinicians can learn about clinical care and help patients, or at least help clinicians to help patients. It also appeals to my desire to collect, organize and interpret information. And, (don't judge) I like coding.

As a non-clinician, non-native working in Malawi, it's tough to know what's important. What can I do that will a) be useful; b) help; and c) not offend anyone.

The pace. In addition to not knowing where to start, once you make a decision to proceed in one direction, it takes awhile. You have to talk to a lot of people, set up lots of meetings, go through the motions and try to (clearly) explain what you think you want to do. Not a terribly easy task.

No matter what you do, you end up wishing you could do more.

Afri-CAN Cafe

http://theafricancafe.org/

I’m sitting at a café, typing away, enjoying some coffee on a beautiful day under an awning in Malawi. AfriCan Café is a non-profit, cooperative coffee shop made. They’re new to Lilongwe. Right now, they are only in Lilongwe, Malawi and opening soon in Blantyre, Malawi. Soon they will be found in different cities throughout Africa. It’s a little surreal.

The hospital is surrounded by gates and guards, with many sick people floating around the gates and others being treated inside and at other buildings around the hospital area. I can’t imagine many people come for coffee and pull out a computer to sit and write. It feels wrong--out of place. I wouldn’t have done it, but I managed to get what I needed done much earlier than expected (which is incredibly unusual) and now I have time to kill before my next meeting…in an hour. So, I’ll work until my computer battery dies.

The new maternity ward seems out of place too. It’s very nice, but there are buildings in disrepair and out of use surrounding the new building. Given the amount of people who are poor and in desperate situations nearby, I was initially unsure how a western-sty cafe would go over among locals, but as far as I can tell, the idea of a cafe has caught on pretty quickly. Customers are mostly hospital workers not patients and not the average Malawian. I feel a little guilty, but it is a treat.

Bottom hospital

I arrived at Bwaila (bottom) hospital in a giant truck. It seemed out of place. As my colleague opened the door on her way to work, I heard singing. Many, strong, voices singing in unison in the call and response format that defines the African oral tradition. It's beautiful. I asked the driver who was singing and for what. The women sing every day, he says. They learn how to take care of their babies. They learn about labor, delivery, nutrition, family planning, etc. And then they sing about it. Every morning. Half seven.

And then they wait. Lots of waiting.

Malawi has one of the world's lowest physician-to-patient ratio. The numbers aren't clear, ranging from 1:50,000 to 1:10,000 depending on how "physician" is defined; Malawi uses trained nurses, clinical and medical officers to provide the majority of care. It lacks the capacity to offer medical residency training to prepare new physicians. Many positions are unfilled and other still are underfunded. So the women and all the other patients will continue waiting. Waiting in line, waiting for an answer, waiting for care.

Diagnosing my perspective

As I sit here in Malawi reading this article in the NYtimes, I feel lucky to have no other health, financial or family issues. I'm lucky enough to leisurely read about the urgency of an objective test to evaluate ADHD.

Most mainstream researchers consider A.D.H.D. to be an authentic neurological deficit that, left untreated, can ruin not only school report cards, but lives. Nonetheless the quest for objective evidence has gained new urgency in recent years.

Many critics say the disorder is being rampantly overdiagnosed by pill-pushing doctors in league with the drug industry, abetted by a culture of overanxious parents and compliant educators."

Having just wandered through the wards at KCH and Bwaila for the first time, which were teeming with broken, ill and tired people...waiting for hours, the language used in this article appeared to be unnecessarily sensational at first. How can they be concerned about over-diagnosing ADHD in the US when there are so many people in need HERE!

Then I thought about it a bit more. It's a big issue in the US. As far as troubles go for what we're used to dealing with in a developing world, it's something that needs to be examined and made right. Who am I to assign worth to a condition that affects many people in the US and is a complicating factor for education and health resources. It's a burden to our healthcare system and that makes it important.

In fact, the underlying problem--establishing an objective diagnostic method for a difficult to diagnose disease to avoid over treatment--is a major issue in resource-limited settings as well.

In the US, over-medicating kids for ADHD is an imprecise solution to a difficult to characterize problem. In Malawi and other resource-limited countries, TB is difficult to define and diagnose so presumptive treatment is often the solution. Even with an accepted threshold of CD4 counts precisely measuring values is difficult here, which in turn makes the decision to initiate HIV treatment fuzzy.

Since healthcare provision is lacking in different ways in both countries, it's easy to compare and get frustrated with the US prioritization of resources. The diseases are more severe in Malawi, the life expectancy much shorter and the remedies are known and proven in other places (provided resources are available). It's frustrating and really easy to question the ridiculous diagnostics ordered to resolve noncritical health problems in the US. But, I have to keep it in perspective.

While the target may be different, the problem is similar.

If old then happy?

After reading a review of the results from the National Academy of Sciences, also from NYT, I immediately had to look up the findings to identify the comparison group. The population, objective and results from the study weren't clear.

The title of the Times article is "Happiness May Come with Age, Study Says". Did this study compare results from the same people from several years ago with current results? Did they only ask the question once of people of all different ages and find a generational difference in happiness? Could the NYT have presented a misleading picture of the results?

The times reports that "...by almost any measure, people get happier as they get older...". The problem is HOW this study was presented. From this description, I'm led to believe I'll become happier when I age, but first it will get worse until I reach age 50:

On the global measure, people start out at age 18 feeling pretty good about themselves, and then, apparently, life begins to throw curve balls. They feel worse and worse until they hit 50. At that point, there is a sharp reversal, and people keep getting happier as they age. By the time they are 85, they are even more satisfied with themselves than they were at 18.

In measuring immediate well-being — yesterday’s emotional state — the researchers found that stress declines from age 22 onward, reaching its lowest point at 85. Worry stays fairly steady until 50, then sharply drops off. Anger decreases steadily from 18 on, and sadness rises to a peak at 50, declines to 73, then rises slightly again to 85. Enjoyment and happiness have similar curves: they both decrease gradually until we hit 50, rise steadily for the next 25 years, and then decline very slightly at the end, but they never again reach the low point of our early 50s.

Maybe I'm reading it wrong, but the way I read it, it sounds like they followed people over time and evaluated their happiness from age 18 to 85.

But...these aren't the same people. What if the difference in happiness is generational, rather than a generalizable age-based trend. The ones who are satisfied with themselves at 85 may have not have scored the same when they were 18; it would have been 1941. If this same Gallup pole were done in 1941, we may have seen a very different picture.

Also, 2008 was the height of our recent economic crisis. Maybe people at either end of the age spectrum, who answered the phone for the Gallup pole, were less affected by the economic crisis and less stressed about it than those in their 40's.

For selfish reasons, I can't get too mad. When the details of the study design are ignored and results presented in a way that implies an impossible study design, I'm prompted to read things that I generally wouldn't get around to reading. And, I end up reading papers more carefully as a consequence.

For unselfish reasons, I wish the media was able to properly represent study results and entertain their audience.

OK, so I'm sure you get my point by now. Yes, there are flaws to this study (as with any study), but I like the idea. So. Let's just say people get happier with age. I'm hoping there's something to look forward to. What I want to know is...how?

Based on a systematic evaluation of no information at all, I FEEL like they get happier by moving in one of two directions: a) they find a routine, settle down and putz about in the comfort and familiarity of their daily doings; or b) they get more relaxed and adventurous--letting down their guard and escaping the worry of keeping up with the day to day. Both directions result in happiness. Not a bad deal.

For me it's interesting to see what happiness or stress is to each person--how the same experience might be are stressful to some, but adventurous or fun to others.

Mis-information dissemination

Lilongwe has a new parliament building. Last week I asked someone what she thought of the new parliament building. And then someone else told me something else. And then, it became a thing to ask. I never expected what followed. The parliament building was built by chinese prisoners? It was a gift from the Chinese in exchange for uranium? Malawi had the building built to attract business and foreigners and is now indebted to the Chinese three times over. And the list goes on....

Everyone seems to have a different idea. Some say they used some Malawian workers, but some say they didn't. It's surprising to think that in a poor city in a poor country the Malawian government would introduce a new population strictly to build an elaborate new government building. Is there a lack of skilled workers in Malawi? Are the Chinese more in need of work? Are they more trusted to complete the job than local workers? It could be anything. I just don't understand.

A brief google search revealed the following: In support of the UN One China policy in 2007, Malawi changed its alliance from Taiwan to China (apparently there used to be a large Taiwanese population in Malawi that was suddenly replaced with a large Chinese population). Building the parliament building cost 40 million USD. The People's Republic of China funded the endeavor along with a road, future five star hotel, future national stadium and future science and technology institute. The parliament building was completed in 13 months--five months ahead of schedule. The cited motivation behind the parliament building seems a little dubious--it was explained as a gesture by China to support Malawi for their allegiance.

With such conflicting information circulating about one of the biggest, most imposing, well-known structures in Lilongwe, it becomes more clear why information dissemination is so difficult for more nuanced topics.

Fresh Start

Today was a good day. Went to my first Malawian market and made it out with my ass being grabbed only once! I'll write that off as a success. I love the markets here. It's easy to be overwhelmed by the activity and swarms of people, but there's so much color, smell and life!

I was able to get some of my work started, although much less efficiently than usual (which isn't saying much!). One of the others here is leaving in five days, so she cooked a grand feast for some of her friends and co-workers that she's met here. The food was fabulous! It was also nice for me since I was able to meet a few locals and get to know the other people who have been living here a bit more.