Three Years of War

March 19th marked the Iraq war's 3rd anniversary. I remember well March 19th 2003 when the war actually started. I was a first year medical student struggling through my neuroscience block, but keeping an eye on the news via the internet.

I remembered being appalled by Bush's insistence that we must invade Iraq. I remember him pleading to the UN for permission to once again invade the country. The UN sent their investigators to look for weapons and found none because their were none. They voted not to allow the US to invade. But we invaded anyway. I was shocked and saddened that our country would subvert the UN's doctrine. It made the statement that we are the exception, that the rest of the world must abide by the UN's rules and regulations, but we do not have to.

I thought for sure time would prove me wrong. I thought that we would find the chemical weapons plant making awful gases and missiles loaded with anthrax. I wanted the US to find them. But they didnt. We found Saddam, but never saw any of his missile silos or nuclear weapons. Its bad enough to ignore the UN and insist that we are right. That we turned out to be wrong in the end, is shameful.

And here we are. Three years and over 33,000 civilian deaths later. What have we accomplished? I wont say nothing, because some good has come from our invasion. We took a madman out of power. We freed a country from tyranny, sort of. They had elections. All those things are good, I am not discounting that. However, there is still widespread poverty, crime, and violence in Iraq, and progress has been very slow, to say the least.

But my real concern is with how the world and history will view our actions and our priorities. We have set the precedent that its ok to ignore the UN when you have a really strong hunch about a country's intentions. Unfortunately, we have also set the precedent that its ok when that hunch is dead wrong.

More importantly, it says to the world that the US will invade who we want, when we want, primarily because we can. It says we will ignore events like the genocide that occurred in Rwanda and that which is occurring in Sudan today. We will spend 250 billion dollars, will sacrifice over 2,000 of our young troops to defend our interests. We will only donate a fraction of our war expenditure to the worst plague the world has ever known.

$250 billion dollars would fund worldwide AIDS treatment for 24 years. I worry not only about the US, but about the entire human race when I realize how much we spend on killing compared to that which we spend on helping.

So you may not agree with my statistics or my logic, and that is fine. Either way, I hope Americans take a critical look at what is going on in our world and what the United States role has been in it. We have been at war for three years now. Its time for us to think about that, and decide if its something we support, or perhaps something we now see as a mistake. Let those thoughts and decisions influence your politics, your vote, or even your words and actions. I obviously only present my views here. On this anniversary, I hope you are able to take a close look at our world, and a deep look into yourself, and develop your own.

Shepherd's Keep

Since we've been back in South Africa in 2006, Kylie has been working as a nurse at an orphanage here in Durban. Its called Shepherd's Keep and is located on the other side of Durban in an area called the Bluff. Shepherd's Keep is a privately owned and funded orphanage for abandoned infants. Most are less than 6 months old. Many were found in parks, wrapped in plastic bags, in public bathrooms, all discarded like unwanted property. As a result, many of them have anoxic brain injury and/or cerebral palsy. Some will hopefully grow up to be healthy happy adults, others will have permanent dysfunction and fail to fully develop normally.

We visited Shepherd's Keep a few weeks ago and took some of the pictures below.
This is a picture of Kylie and Sibusiso. He is 7 months old and has been at the orphanage since birth. He is a very healthy baby and has hit all his developmental milestones on que. Currently he has no foster parents.
Zuma is 14 months old. He was brought to Shepherd's Keep when his mother was sent to prison. The orphanage had been doing the paperwork for Zuma's grandmother to adopt him. The mother will likely be able to stay with them once she is out of prison. Luckily, Shepherd's Keep was around for him during the interim period.

This is Princess (the baby) with Happiness (the caretaker). There are about 6 caretakers looking after 16 babies at any given time. None are actual nurses (Kylie was the first) but all are certified caretakers. They get paid about $5 a day to work at Shepherd's Keep. Keep in mind "a day" usually starts at 6 am and ends at 7 pm. Kylie thinks they could all use a raise.

If you'd like to make a donation to Shepherd's Keep, please click here. You can rest assured that your donation will be going to a good cause. Might even help the caretaker's earn a fair wage.

Match Day

Yesterday was match day for medical students throughout the country. On this fateful day, every 4th year medical student recieves notifcation of where they "matched" for residency. After having spent much of their 4th year applying and interviewing at various residencies, med students finally discover which residency has decided to accept them as a new doctor and a new employee. Its a very important and very nervous day for most everyone. These agreements are binding and once the student has matched, they must work at their assigned location. Many students feel that match day is the culmination of all they have worked for as a medical student.

At UTMB, all the students gather in an auditorium. All the envelopes indicating the student's residency are tossed randomly into a jar. One by one, each student is called out to collect their envelope. When they do, they put a $1 bill into another jar. The last student to be called gets the money. The second to last gets the pity of the class.

I lived through the match vicariously as had I opted to stay in America, I would have likely been a part of it all. I emailed all my friends to find out where they had ranked. I wanted to be as much a part of it all as I could, despite the vast distance between Galveston and Durban.

So this morning I found the match list on the UTMB website and read it carefully. For some reason, I was nervous. I knew so many fates had just been decided, and I wondered who was going to be disapointed, who would be elated.

All in all, the results looked promising. Most all of my friends got their 1st or 2nd choice. Many people matched in competitive fields like plastic surgery, orthopedics, and (ughh) dermatology. Others matched at competitive places like Duke, UC San Diego, and the Mayo Clinic. It was great to read about the sucess of my former classmates, and I am truly proud of all of them.

I googled "match day" and came across this article in the New York Times about match day at Cornell. I imagine their match day was quite different than UTMB's, what with the hotsy totsy champaigne and fruit and cheese brunch.

AIDS Article

Found this article on news24.com about South Africa's AIDS crisis. Here are some important points if you dont feel like reading it all. Many I already knew, some were new to me:

-With over 5 million infected, South Africa has more HIV positive citizens than any other country on the planet

-Currently, about 500,000 people in South Africa urgently need antiretroviral therapy. I assume this means that 500,000 have CD4 counts below 200.

-The government and/or private agencies are treating around 200,000 leaving a deficit of 300,000 that will go without therapy and likely die from AIDS related illness as a result.

-50,000 children need ARV's, but only 10,000 are receiving it. (Personally, I would be suprised if 10,000 children in South Africa are on ARV's as I have encountered only one in my entire time here)

-One of the interviewees also argues that AIDS therapy should start at a CD4 of 350, not 200. I tend to disagree with this. In my study, those with CD4 counts in the 100's do just fine on ARV's. They respond well, they have good viralsupression, and low mortality. On the other hand, those who wait until their CD4 count is below 50 have a significantly increased risk of death and treatment failure (this is essentially what my paper is about).

Anyway, I am glad that the independent news is constantly talking about AIDS, even if many are tired of hearing about it (even myself at times). I think the SA government has fallen short and its up to the media to continue to make people aware that AIDS in South Africa is a pandemic of historic proportion.

Negative

My PPD test is NEGATIVE. Zero millimeters of induration. I dont know how in the world I managed to avoid tuberculosis while I was here. I've been around dozens of patients with active, hacking, TB cough. Heck, I did most of my research at a TB clinic! Regardless, I am negative. That's my story for now and I am sticking to it!

AIDS disability grant

I came across an interesting patient yesteday at Vulindlela. She was a mother of 4 and had been on antiretrovirals for a little over a year. She had a less than expected CD4 count response to the ARV's, but good viral supression. Essentially this meant that the AIDS medicine she was taking was keeping the virus from replicating, but her immune system was not coming back to life the way it should be. She was there with her youngest daughter of 2 who was also HIV positive, though not on any antiretroviral medicine. The mother still had some disability in the form of excessive faituge, skin problems, anemia and weight loss. After we discussed all the medical details, I began asking her how she supported her family and children.

Her husband had died a few years ago and she was simply too ill to work. Her children were too young to have jobs, and instead needed to be in school and looked after constantly. How is a single mother of 4 who is sick with AIDS supposed to find a job in rural South Africa? Under most circumstances, such a situation would be devastating to a small family. However, the South African government has instituted an AIDS disability grant for HIV positive patients that are too ill to work. Thus, this patient had an income of about $180 per month. Raising a family of 4 on what amounts to about a $2,000 per year income is certainly not easy, but it is much better than nothing. I realized that this small struggling family would have been lost without this grant. I was actaully quite proud of South Africa for deciding to support their disabled HIV positive population.

There is a small problem I forsee with the issuing of an AIDS grant. Only those with clinically defined AIDS are eligible for the grant. Thus, the patient's CD4 count must be below 200. Once the patient starts on ARV's and the CD4 count becomes above 200, they are no longer eligible and are expected to go find work.

This obviously presents a conflict of interest between taking your antiretrovirals and recieving your monthly grant. Indeed, I have told patients about the "good news" that their CD4 count has risen to 250 or 300, only to see them break down into tears because they know they will no longer be eligible for their AIDS grant. I have also heard of patients refusing to take their ARV's regularly to prevent their CD4 count from getting too high. Such behavior can have devastating effects on the patient, and on the course of the epidemic as it may foster viral resistance to the medications.

I dont really know the solution to this probelm. The SA government obviously needs to prioritize who recieves finacnial support, but by designing such a strict cutoff, you may also cause some major problems for an individual, and may worsen the epidemic itself. Regardless, I was happy that this patient had some financial support. I think its the humane and right thing to do if your government has the means to do so. For this family, it may have meant the difference in subsistence and starvation.

Honesty and email

Kylie and I had been planning for weeks that one of her friends from college would come out to South Africa and visit us. I'll graciously refer to her as Ms. X from now on so as to protect her identity. Kylie and Ms. X had plans to drive from Durban and Cape Town and do some scuba diving along the way. I was going to come a long for some of the trip. Flights were bought, rooms reserved, and Kylie even spent two weekends taking a diving course just so she could dive with her friend. We were all excited to see Kylie's old friend and show her a good time in South Africa.

The plan was that Ms. X was to going to visit her boyfriend in Florida just before her trip to South Africa. She emailed us from Florida saying she was about to head back home to pack and leave for her long flight to Durban. However, the morning that Ms. X was to leave, we got a very flustered email from her saying that she had lost her passport and could not make the trip. She seemed very apologetic and upset by the whole thing. Naturally, Kylie was too. We had been planning for weeks on her arrival, and this changed everything considerably. We scrambled to salvage what we could of the reservations, but ended up losing some money as a result.

I have never met Ms. X, but knowing what I know about females, I suspected she was lying. No one loses their passport 6 hours before a flight. I figured she decided to stay in Florida and simply didnt want to confess that she had ditched us for her boyfriend. Luckily, knowing what I know about computers, I thought I could prove it.

What Ms. X didnt realize is that every email has kind of "envelope" on the outside called a header. The header tells you a lot about where the email is going, and where it has been. Instead of physical addresses, the internet uses IP addresses. These IP addresses can easily be looked up and the actual, physical location that the email was written can be discerened.

So, with Kylie's permission, I looked at the header of Ms. X's email. It was supposedly written from her home in Washington DC amidst the confusion of her lost passport. However, when I looked up the IP address, this is what came up:

IP Address	Country (Short)	Country (Full)	Flag	Region	City	ISP	Map
216.106.180.10	US	UNITED STATES		FLORIDA	FT. LAUDERDALE	STS TELECOM

We can thus assume that she never left and had made up the whole story about her losing her passport as a cover.

Because Kylie is the sweetest, kindest person on the planet, she wouldnt confront her friend about it. She really wasnt even all that mad, though I think her feelings were hurt. She just played along with the story and said that these things happen. I thought she should have confronted her, but Kylie resisted the temptation. That is why she is such a great friend and good person.

I think this story teaches us somthing that we have always known: be honest! Sure, it would have sucked to email Kylie and explain that you have decided not to come to South Africa and stay with your boyfriend in Florida. But it would have been much better than lying about it, and getting caught. So if anything good can come out of Ms. X's bad decisions and my internet snooping, maybe its the realization that in most cases, the truth is a hell of a lot better than a lie, especially when it comes to your friends.

Also know that your emails can be traced with a minimal amount of effort. In fact, here are two sites that will teach you how to do it: This site shows you how to find the IP address of the sender. This site allows you to look up the IP address and will give you a print out like the one above.

So be good and honest to one another and hopefully you will never need to even use these sites.

Cully's PPD Placement

I just had a PPD skin test done to check for a latent tuberculosis infection. For med students, you already know what this is. For the rest, please allow me to explain.

Almost 1/3 of the world's population (2 billion people) are currently "infected" with TB. Now, this doesnt mean that they are sick. The vast majority of these 2 billion have what is known as latent tuberculosis. This means that theoretically, someewhere in there body there are TB bacteria that may someday wake up and actually cause the disease. This should not be confused with actual pulmonary tuberculosis, which innvolves night sweats, weight loss, coughing, and is highly contagious. Latent TB is not contagious. However, there is a 10% lifetime chance that those with latent TB will someday develop pulmonary TB. The chance is 10% each year for those with HIV.

To check for latent TB, a small amount of inactive TB is placed under the skin in the form of purified protien derivative (PPD). If your body reacts to the antigen, it is presumed that you are latently infected. You then need a chest X-ray to rule out active disease that may be contagious. Now, here is the awful part. Those who have a positive PPD will have to take a drug called isoniazid (or INH) for 9 months. INH is a toxic drug and is hard on your liver. People often develop tingling and burning in their toes and fingers while on INH. But worst of all YOU CAN NOT DRINK ALCOHOL WHILE TAKING INH! I know, isnt it terrible! Thats like being pregnant!!

In order to be allowed to rotate at USC this fall, I have to have a recent PPD placed. Mine was just injected under my left arm, and I am now PRAYING that it will not react. Please send all your positive energy, prayers, health chakras, etc to my left arm. Not only do I not want to have any TB bugs hiding out in my body, I really dont want to take INH for 9 months.

I'll know in 48-72 hours if its positive or not. Stay tuned to find out the exciting sequel to "Cully's PPD placement." Hopefully, it will be as boring and uneventful as it sounds.

Next day

Went back out to surf this morning and the waves were still up from the cyclone spinning way off the coast. The swell was still coming in, though not quite as large as the previous days. Plus the wind had settled and it was glassy smooth. I realized in my last post, I might have come off sounding perhaps a little un-intrepid (if there is such a word). I also realized that despite all my talk of surfing, I have never posted any actual photos of me in the water. After all, I could be making the whole thing up. Luckily, Kylie snapped this photo from one of the piers. I had to zoom in quite a bit, but if you look closely, you can tell its my behind bent out awkwardly.

This actually isnt one of my best moments. I am surfing a right, which is backhand for me (my back is to the wave) and the angle of my board is not pointing far enough to the right. I kind of skid down this wave at an angle, but had I turned right harder, I could have stayed on the face longer and gained more speed. Still, its a decent shot and much thanks to Kylie for taking it.

And no, I didnt take the other surfer's head off who is paddling out of my way in the foreground.

Southern cyclones and fear

In case you cant tell, this is a map of the southern tip of South Africa and Madagascar. Pressure bars and wind patterns are superimposed. The big orange circular thing on the right is a massive cyclone spinning just SE of Madagascar. A cyclone is essentially the same thing as a hurricane, a huge mass of coulds spinning around a low pressure area. But here in the southern hemisphere, cyclones spin in the opposite direction (clockwise) just like the toilets do. Its called the Coriolis effect

This cyclone is in perfect position to be spraying Durban with lots of swell. The system has two important aspects to wave generation: its very powerful with a low central pressure and there is a long distance between the storm and the shore. Its just starting to be the end of summer and the beginning of winter here in Durban, and the wind and waves are beginning to pick up.

This particular storm is causing pretty big waves in Durban. Nothing like the waves we saw last November at the Goodwave competition, but still powerful and tall. I paddled out yesterday afternoon and was a little frightened. Most sets were medium sized waves, around 4-6 feet. But then a big 8 foot set would come through and, to be honest, it scared me a little bit. I still have a strong respect and pretty healthy fear of the ocean. I looked around me at the handful of other surfers around, and decided I was in over my head. I fought the current for a while, and finally caught a smallish wave all the way to the beach.

Its always hard to tell if you are playing it smart, or just being a big pansy. Its such a fine line in surfing and in life. The balance of caution and hazard is something we deal with everyday. In this case, my perhaps exagerated fear of the powerful sea was too overwhelming and I decided to play it safe. Whether it was the right decision or not, I'll never know. Such is life.

Two articles

Two fantastic articles from the New York times.

The first, I must give credit to one Anand Reddi. He sent me this article about the wild optimism and relentless hope that seemingly all Africans share despite the disease, poverty, and civil unrest that plagues so many of their countries. I found it particularly poignant considering the last entry about Michael's party. There also seemed to be a shared belief that the bright future they had always hoped for was just around the corner. For many at that party, that bright future might have already arrived. Their situation is really quite promising compared to the refugee fleeing Sudan with her 3 month old child in this article.

The second is another Times article about the growing number of HIV positive children recieving antiretroviral therapy in Sub-saharan Africa.

Both capture a struggling, yet hopeful Africa. Their fight for peace, for health, and for well being is far from over. But I believe their optimism and resourcefulness will one day bring them into a brightened future when we no longer consider Africa to be the Dark Continent.

Unveiling

While we obviously live in Durban, we are, after all, in the province (or state) of KwaZulu-Natal. KZN is home of the Zulus and has more Zulu speakers than anywhere else in South Africa. You wouldnt know it by driving around the nicer neighborhoods in Durban, but the province is steeped in Zulu culture and tradition dating back thousands of years.

We felt very lucky to have been a small part of this tradition last weekend. Michael, a close friend to the family from whom we rent our house, invited us all out to his family's "unveiling." I have been a part of these ceremonies before, but still dont have a full understanding of what they are about. From what I can gather, it innvolves the slaughter goats or cows on a Friday evening, along with some ceremonial proceedings. These are usually watched over closely by a Sangoma (a Zulu witch doctor or traditional healer). Over night the animal is skinned, cut to pieces, and hung up to be drained. The next day an enormous party ensues as friends and family from all over come to eat the meat, vegetables, and drink lots and lots of beer.

Typically, I think this ceremony is meant to honor a deceased ancestor, as well as to honor a living family member. In this case, Michael's family was commemorating the one year anniversary of his mother's death, but also celebrating the life of his brother. Below are a few of the many pictures we took of Michael and his friendly family.

Lots and lots of meat. I am still doubtful that they were able to consume 2 whole cows over the course of 2 days, but they certainly made progress while we were there.The whole family.
I have now been to 3 of these parties in my lifetime. There is ALWAYS a group of men, off on their own, sitting around a pile of meat on a cutting board.
There also seems to be a tradition among the men to get totally wasted. As the afternoon wore on, the men in this tent became more and more intoxicated. They seemed to forget that they didnt speak English, and we understood next to no Zulu. This didnt stop them from having lenghty conversations with us.
The aforementioned tradition was also shared by many of the Zulu women.

The younger kids really seemed to look up to us. Especially when we were standing on chairs and taking their picture.

As we were leaving, we discovered that this woman's sweater was likely forged in our home state. We pointed to it and tried to explain that the shape she was wearing was a place called Texas. We even found a translator to explain it to her. I'm not sure, but I think she thought we were claiming to have once lived in her breasts. Either that, or she just wasnt very impressed. More likely the latter actually.

All in all, we had a great time with Michael's family. Despite the immense cultural barriers, and even more immense language barriers, they really made us feel at ease and welcomed us into their home. They very graciously shared as much food, beer, and cow as we were willing to eat. In exchange, we gave them the dozens of photos we took over the weekend and have now made them world famous by posting them on the internet.

Zuma pleads not guilty

I wasnt suprised to read this article in the BBC that Zuma has pleaded not-guilty to charges that he raped a family friend. As you may recall, Jacob Zuma is the former deputy president of South Africa (equivalent to a vice-president). However, he was recently asked to resign from his positiong due to innvolvment in a corruption scandal and this rape trial.

Do I think he is guilty? Yes, I imagine he raped that girl and that he was innvolved in the corruption and cover up. Do I think he will be found guilty? Not likely. Do I think he will succeed Mbeki as the next president of South Africa? Tragically, I think that he will.

I worry about what kind of message this sends to a country that is already embarassingly lenient on the persecution of rape victims.

South Africa has so much promise as a leader on the continent. I hate to see that opportunity lost to corruption and scandal.

Zimbabwe

When I wrote my last post on the SA elections (see below), I made the comment about a potential "Zimbabwe-esque" situation. I even searched for an article that would sum up what Mugabe has done to his country, but couldnt find anything in the 16 seconds I allotted myself to search. But today I came across this article in the BBC, which I think sums up what a dire situation they have in Zimbabwe, and why it is directly related to the decision Mugabe made that made it legal for blacks to seize white farmer's property.

Election Day

Yesterday was election day in South Africa. Unlike in the United States, all of South Africa votes on the same day. This means that it is treated like a national holiday and no one has to go to work. Even us Americans who clearly are not able to vote.

Persosonally, I think the good old RS of A (Republic of South Africa) has one of the most fascinating political situations in the world. I’ll try to share a little with you now, along with a healthy dose of my under-educated opinion.

First of all, South Africa has only had nationwide elections since 1994. Prior to that, blacks were not included in the election process. Thus, most people really seem to value their vote here as people indeed died for that right. Thus, South Africa tends to have a very high voter turn out.

The first party to really gain power in 1994 was the African National Congress (click here for an unbiased description) and they have dominated the political scene ever since. The ANC fought against apartheid in South Africa for decades and was Nelson Mandela’s party when he was elected in ’94. Today, Thabo Mbeki is the current president, and also a long time ANC veteran.

I have mixed feelings about the ANC. I appreciate that delivery to the poor is a fundamental aspect of their platform. I do think they are making great efforts to expand housing, electricity, and water to as many rural South Africans as possible. However, there is certainly an anti-white tone to much of their propaganda. They seem to still have some underlying resentment left over from the apartheid era. This may be understandable, but it really has no role in creating a unified, successful South Africa. No matter what occurred in the apartheid era, scaring off the white population of South Africa will undoubtedly result in a Zimbabwe-esque situation.

Further, the ANC has been subject to multiple scandals as of late. Vice president Jacob Zuma has been charged with corruption and has been accused of using bribery to try to cover up the allegations. He is also currently on trial for the rape of a 31 year old girl AIDS activist. He has since resigned from his vice presidential position.

I also have a tremendous problem with the way the current president, Thabo Mbeki has handled the AIDS crisis in his country. Currently, South Africa has more HIV positive individuals (over 6 million) than any country in the world. Yet, Mbeki continues to insist that there is no crisis. He only recently admitted the “possibility” that AIDS is in fact caused by HIV, rather than stubbornly clinging to his previous beliefs that AIDS is simply a "disease of poverty." I have particular issues with this beyond the obvious, as I was working in prevention and education in South Africa in 2001 when Mbeki made such outlandish claims. I had many students ask me if their president was right in saying that AIDS cannot be transmitted via sexual contact. His failure to act decisively amidst the AIDS crisis and his obviously fallacious comments will likely be responsible for thousands, if not millions of new HIV cases and AIDS related deaths. His failure to act amidst the most devastating epidemic that humanity has known is shameful and tragic.

The major opposition party in South Africa is the Democratic Alliance (click here for an unbiased site). They are a primarily white party whose primary role seems to be to expose the shortcomings of the ANC. The are truly the underdog in SA politics as they are almost always 2^nd to the ANC in every election. In theory, I agree with their mentality to create a unified, stronger South Africa that will benefit all races. But they don’t provide too much information on how. In fact, the majority of their publication seems to focus only on the ANC's mistakes. Still I have realized that even if they never win an election, their mere presence makes South Africa more democratic. Their ability to expose any corruption, broken promise, poor governing, etc within the ANC forces the ruling party to stay in shape. Kind of a check on their power, forcing them to provide tangible improvements int he lives of South Africans. I would really worry about how the ANC would behave if the DA were not around to at least threaten them with an upset.

Currently, it looks like the ANC has pulled off another landslide victory, despite the recent controversy.

Anyway, that is enough about politics here. Likely not too interesting to the lay reader. Sorry for that. If its any consolation, I spent the day surfing and lounging at the beach. We started at 8am in our usual surf spot and then moved to another beach in the afternoon. It was a very full, exhausting, fun election day for me and my friends.