What’s up with West Nile?

West Nile virus, that is. A widespread outbreak in the U.S. has attracted renewed attention to the virus, which acquired its name from West Nile, Uganda, although there is no evidence that it originated there. Unfair, isn’t it? The virus was first isolated in Omogo, West Nile district, Uganda, in 1937, by researchers at the Yellow Fever Research Institute, then based in Entebbe. According to a 1940 article by Smithburn et al. in the American Journal of Tropical Medicine and Hygiene:

In attempting to isolate virus numerous persons were seen who were suffering either from an illness suggesting yellow fever, or from pyrexia of unknown cause. From many such persons blood was drawn, and as soon as possible thereafter the serum was in oculated intracerebrally2 into mice. Subinoculations were done from mice which became ill. In this manner several transmissible infective agents were isolated.

The purpose of this paper is to report the isolation of one such agent, which we call the West Nile virus, and to describe some of its properties. Although this virus was isolated from the blood of a human being, the circumstances of its isolation were such that nothing is known regarding the illness produced by the virus in the human subject.

That the virus was identified in West Nile should, if anything, be a testament to the medical contributions that have been made from the region, but it is more likely to have inspired notoriety. West Nile virus outbreaks have occurred all over the world, but the virus was not identified in North America until 1999.

West Nile virus is carried by mosquitoes, which acquire the virus from infected birds. In rare cases (only about 1 in 150 cases), severe viral infection is characterized by “high fever, headache, neck stiffness, stupor, disorientation, coma, tremors, convulsions, muscle weakness, vision loss, numbness and paralysis“, according to the CDC. Up to 80% of those infected, however, do not experience any symptoms.

Current map of West Nile activity in the U.S.:

CDC surveillance of West Nile virus in the U.S., activity as of August 21, 2012

Kony2012 and the evolving marketplace for ideas

Published online March 19, 2012

After over 70 million views (100 million plus by the time this is published online) and countless tweets, the Kony 2012 video has reminded us of one thing: it is not quality alone that popularizes ideas.

Today, the marketing of your ideas matters as much or more than the content of the ideas themselves. At first blush, this seems a sorry or even scary state of affairs. But consider the evolution of the marketplace for ideas. Ideas have never found the light of day based on their merit alone. Access to bullhorns has long depended on identity – on status and class, on race and gender, on education and religion. Today technology is shaking things up, and democratizing the marketplace for ideas. The identity of the idea-producer is increasingly distanced from the idea itself. The barriers that once favored the voices of the few over those of the many are slowly fading.

Over the past week I have had countless conversations with students, friends, and even strangers about Uganda, the Lord’s Resistance Army (LRA), Joseph Kony, and of course, the campaign and video that started these conversations in the first place, “Stop Kony 2012”. This sudden and remarkable outpouring of interest about a rebel group that has been around for decades is the result of the work of a single organization, Invisible Children. There have been spirited debates about the veracity of the film, ethical questions about its content, financial issues, concerns over the stated goals of the organization and film, and a larger debate about the role and motivation of outsiders in “African affairs”. Perhaps the most maddening aspect of the Kony 2012 film is that agency is so consistently placed on the part of the three filmmakers who “discovered” the conflict in 2003. (You have heard this story before. John Hanning Speke too “discovered” the source of the Nile – this is what has been “marketed” to pupils in most schools up to today).  The version of the story told by Invisible Children tends to position the three men and their organization front and center at the expense of all other actors. It does not deal in nuance, and it shies away from complexity.

Critics of the film have struggled to put forth alternative versions of the evolution of the conflict, and the current challenges that the region faces, of which the LRA is only one. But many fear the damage has been done. They fear that Invisible Children has hijacked the conversation, pushing aside or simply ignoring the work that journalists, academics, policymakers, development workers, and ordinary citizens have been conducting for years. IC has proposed their own solutions to ending the terror of the LRA, which include sharing their video, buying an “action kit” (posters and bracelets inclusive), and raising money for the organization. They have virtually blanketed the web, at least for a period of time, with their own propaganda, their own ideas.

The phenomenal success of their campaign, at least as judged by the number of viewers, hinges not on the quality of their ideas and not on the feasibility or sensibility of their proposed solutions, as many experts will attest, but rather on their access to the platforms that get out the word. They are well equipped to execute their campaign  – trained in film production, with a snazzy website and killer social media strategy, they have the all tools to dominate the marketplace for ideas.

Is this not unfair? Wrong? Even dangerous?

If the simplistic, emotive, and well-marketed ideas are the ones that make it to the global stage, should this not give us pause? Some argue that it is the very ideas that play to our underlying prejudices and the stereotypes that we find most moving (i.e. the west must “save” Africa), amplifying rather than dispelling our biases. They argue that the vast and diverse sources of news and information allow us to further distance ourselves from ideas we don’t like and fixate instead on those that support to our prior beliefs.

To the extent that government policy is driven by the masses, whether they take to the streets or to their Twitter accounts, should we be concerned about the quality of ideas that eventually make it to the mainstream? What happens when these ideas are the products of sleek marketing rather than of cool-headed and careful deliberation? These are all important questions.

The process that brings ideas to the center stage of public debate is not fair and does not give everyone equal say. Nor has it ever. But the good news is that the very technologies that have allowed IC to kick-start the conversation on the LRA have also allowed competing voices to fight back and provide an alternative view. In fact, in a departure from days past, social media may differ from the platforms of old in that it cannot easily be controlled to produce dangerous hysteria. You cannot stifle dissenting opinion for long in this day and age of hashtags and viral videos.

Perhaps IC has not hijacked the conversation after all.

Youtube, Twitter, Facebook, blogs, and other online media have allowed critics to respond to the IC campaign in real time. No sooner had the IC video come out than online posts pointing out its many flaws began to pepper the blogosphere. Within hours, IC had posted a response on their website, and the debate raged on. Journalists and ordinary citizens used online platforms to share their responses and concerns, and millions of people watched and listened. This is remarkable. The platforms that allow the dissemination of ideas are increasingly open for business. The marketplace for ideas, however flawed, is expanding.

Don’t get me wrong. There is a long way to go. The fact that most people living in northern Uganda, even capital cities like Kampala, Kigali, and Kinshasa, were not even aware of the video (not that they missed much) only highlights the disparity in global connectivity, and as such, inequality in access to arenas where their voices can be projected loudly and widely. Those who set the agenda and those who have the first say in the debate are often still the most powerful not because of the quality of their ideas but because they know how to market them. The increase in information of all kinds means that people can seek out that which will confirm their biases and prejudices. But access to the microphone stretches farther than it ever has before. And this is good news. The question is what will we do with it?

Science in the time of cholera (and nodding syndrome)

Published online January 11, 2012.

In August 1854 a terrible illness tore through a London neighborhood, killing hundreds in a matter of days. The terrifying disease emptied the body of fluid until vital organs shut down, after which point the petrified soul would succumb to the illness. Death often arrived less than twelve hours after the first signs of an upset stomach. Londoners of the day had a name for this illness, but did not understand its cause. They called it cholera.

Though cholera outbreaks had hit London before the mid-1800s, the Broad Street Pump outbreak of 1854 is now perhaps the best known. It was during this scourge that physician John Snow was able to demonstrate that cholera was not an airborne disease, as was the popular and professional opinion at the time, but rather a waterborne disease. This insight proved critical to improving public health in London and beyond. Londoners had been emptying their waste into the Thames, often just upstream of intake pipes for water companies. Their water and city stunk. But because disease was thought to be airborne, they doused smelly sidewalks in chloride of lime in attempt to purify the air. They made few attempts to purify the water so obviously contaminated with their own waste.

When cholera inevitably struck, they applied all manner of remedies, most of them useless at best. Castor oil, opium, and leeches were all espoused to treat cholera, not just by ordinary folks, but also by doctors. Worse still were treatments such as laxatives or bleeding. The extreme dehydration facilitated by cholera was often “treated” by attempts to further remove fluids from the body.

In hindsight, both the cause and the treatments for cholera are straightforward, if not obvious. Cholera is a waterborne illness that spreads when one person ingests the cholera-infected waste of another person. The treatment for the extreme dehydration that ensues is most fundamentally rehydration – consuming copious amounts of fluid to replace those that are lost. Yet at its emergence, a series of facts and observations did not at first fit together in a single theory about the cause of cholera. When cholera struck a household, sometimes it struck everyone, sometimes just a single person. In a neighborhood, some homes would be hard hit, while others escaped untouched. Whether you survived or not seemed random.

So it is with another illness in our midst – nodding disease. Nodding disease sounds like a folksy and tabloid-inspired syndrome. Its name describes the telltale symptoms of the disease, a rhythmic head nodding in children. The fact that unlike many diseases its name does not betray anything about its likely causes demonstrates just how little we know about its transmission. For example, HIV (human immunodeficiency virus) is named for the virus that causes AIDS. The name malaria comes from the Italian mala aria, meaning “bad air”, so named because the illness we now know is caused by a parasite was originally thought to be airborne.

But despite its odd name, nodding disease is far from folksy or fake. It is often fatal. First reported in Tanzania in 1962, nodding disease has since spread throughout what is now South Sudan, and has been rapidly spreading in northern Uganda as well.

The pattern of incidence of nodding disease and its symptoms are puzzling, as were those of cholera in the early nineteenth century. First, the onset of nodding disease appears to occur almost exclusively in children between the ages of 5 and 15.

Second, nodding is reportedly often triggered by the presence or eating of familiar foods, or when a child becomes cold. Unfamiliar foods, such as chocolate candy bars, do not induce nodding. Third, when untreated, those with nodding syndrome cease developing both physically and mentally. They are often stunted and experience mental retardation. Fourth, most children affected come from very poor families. There are now thousands of children in South Sudan and northern Uganda who experience symptoms of nodding disease, and the incidence of the syndrome appears to be increasing.

Several theories regarding the cause of the syndrome have been mooted, but none proven. For the past several years, teams of experts from the U.S. Centers for Disease Control (CDC) and World Health Organization (WHO) have travelled to South Sudan and northern Uganda in an attempt to better understand the causes of nodding disease, and possible treatments. Their work suggests that nodding disease is a new epilepsy syndrome, and that the characteristic head nodding is caused by seizures that lead to temporary lapses in neck muscle tone.

A vast majority of children experiencing symptoms of nodding disease are also infected with a parasite called Onchocerca volvulus, which causes river blindness. The high prevalence of this parasite in victims of nodding disease means that the most plausible (published) theory about the cause of nodding disease links the syndrome to O. volvulus, but how and why remain unclear. Moreover, there are a number of children both in and outside the region who are infected with the parasite and do not acquire nodding disease, so the link between the two is not straightforward.

So far, therefore, we have accumulated a series of facts about the mysterious syndrome, which have yet to be pieced together in a coherent theory. We have many more tools at our disposal than did the Londoners of the 1800s, but answers to pressing medical and public health questions do not usually come without time and resources. Nodding disease is a terrifying prospect for those living in South Sudan and northern Uganda not only because of the debilitating effect it has on children, but also because families and communities do not understand why their children are falling ill in the first place. A confusing array of facts, theories, and observations are unnerving both to those in the midst of the outbreak, but also those who see its spread as a very serious health issue for the region.

Misunderstanding the causes of nodding disease can have disastrous consequences, as was the case with cholera some 150 years ago. So far, anti-epilepsy treatments appear to be helping children experiencing nodding disease, but supplies of these treatments are often scarce, and determining the ultimate cause of epilepsy in these children should be a high priority for health officials. Cases of epilepsy are often documented at high rates in hospitals in the region, and there is thought to be a link between epilepsy and cerebral malaria as well. In Arua Regional Referral Hospital, in northwestern Uganda at the border with Sudan and DRC, 7 percent of all outpatient children over age 5 in April 2009 were diagnosed with epilepsy. In 2004/05, 74 percent (nearly 4500) of all cases in the Mental Ward were diagnosed as epilepsy.

Clearly, epilepsy, whether nodding disease or otherwise, is a condition that deserves the utmost attention from public health and medical professionals. The sooner we understand the causes of this new breed of epileptic seizures, the sooner we can take steps to both treat it and prevent its spread. In the absence of a compelling theory about its cause, however, fear and futile treatments are likely to ensue.

thoughts on the U.S. troop deployment in Uganda

I am gathering here some opinions regarding Obama’s announcement that 100 U.S. troops will be/have been sent to Uganda to help fight the Lord’s Resistance Army, a rebel group who have been operating for the past several years in the Democratic Republic of Congo, the Central African Republic, and South Sudan and in northern Uganda before that. There seems to be a dearth of good analysis on this topic (I realize the news just came out yesterday), but I will try to add more as they become available/are brought to my attention. Anyone have any additions?

US deploys special forces in Uganda, but why? Angelo Izama

Obama’s troops in Central Africa to fight LRA; will they deliver? Rosebell Kagumire

Did Obama make the right call on Kony? James Lindsay

And here is a very neat link to the US cables mentioning the LRA. It’s interesting that there were practically no cables on the LRA before 2006, despite the fact that the group was most active in Uganda from the 1990s to around 2005. (h/t Washington Post*)

*I should note, however, that in general I feel this post doesn’t really capture the politics or even essence of the LRA.

Updates:

A new one not to be missed: Rush Limbaugh “Obama invades Uganda, targets Christians“. Foreign Policy post on Limbaugh’s blindly ideological and shockingly uninformed statements here.

NYT article here. US has provided $33 million in the region to fight the LRA since 2008.

Touring Uganda: Chobe Safari Lodge

A few weeks ago I took a trip with my family to Murchison Falls National Park, in northern Uganda. We stayed at Paraa Safari Lodge for two days before heading to the newly renovated Chobe Safari Lodge, both managed by Marasa, of the Madhvani family.

Murchison Falls, by boat

The two lodges provided a very interesting contrast (while keeping ownership constant! errr…). Of course, there is far more to do around Paraa, including game drives and boat trips up to the foot of Murchison falls (do falls have feet?), and the lodge at Paraa is much more antiquated than the sparkling new Chobe. But the clientele is different as well. During the two days we spent at Paraa, the guests were almost exclusively European (many German, in fact). At Chobe, by contrast, a majority (by my eyeballed count) were Ugandan.

Pool at Chobe Lodge, overlooking the Nile

Why? There isn’t much in the way of a domestic tourism culture in Uganda, though park fees for East African citizens are a fraction of the cost for non-East Africans (though not explored here, developing domestic tourism is a topic that deserves a post of its own). So, my guess is that, since Paraa is quite far from any towns, it is not so cushy that one would go out of one’s way just for the ambiance of the lodge.  It is mainly a comfortable, rustic place to sleep and eat between game drives and boating.

By contrast, it seems that many guests of Chobe are visiting from Gulu or other nearby urban centers, and are visiting for conferences and meetings, not to see sight-see — although there are some lovely sights to see (just not many animals). You can never get tired, for example, of the breathtaking view of the Nile. The hotel grounds and dining areas are also quite beautiful, and the rooms are much more elegant than Paraa (bed firmness notwithstanding). In short, the newly renovated lodge is a very comfortable place for those with the cash (politicians and NGOs alike) to get away for a weekend retreat. Chobe today could be considered the “Serena of Gulu”, for those of you familiar with the patrons of the Kampala branch of that hotel (h/t Angelo).

Plush bar, Chobe Lodge

The ambiance and clientele of Chobe may change as time goes on, and as the lodge develops more activities (a golf course has been proposed, for example). But for now it is a peaceful, if pricey, place to recharge for a few days. And the staff are fantastic.

Chobe is a short distance from Karuma falls, and is about 4 hours from Kampala, on good roads almost all the way. I’m happy to provide more details or a more extensive review to anyone interested in visiting.

on the road again

I’m off to Arua, Uganda, for a couple of days. I will try to send updates along the way.

Arua District in a few figures (from the 2002 census):

Population: 833,928

Religion: 57.1% Catholic, 26.9% Anglican, 14.8% Muslim

Literacy: Male 80.2%, Female 51%, Total 64.7%

Livelihood: Subsistence farming 78.5%, earned income 12.7%, property income 0.6%, other 8.2%

Olara Otunnu on the way

Dr. Olara Otunnu, former UN Under-Secretary General and Special Representative forOLARA.jpg Children and Armed Conflict, will be on his way back to his native Uganda soon. This is causing quite a stir in political circles, especially with talk of Dr. Otunnu, a northerner with longstanding ties to UPC, making a bid for the presidency in the 2011 elections. Below is an interview with Dr. Otunnu by Angelo Izama from yesterday’s Sunday Monitor:

Are you planning to come back?
It is indeed my intention to come home sometime soon.

What has motivated you to return?
Uganda is my home. One does not need any special motivation to return to one’s home. I will come back as a citizen, a son of the soil returning home. I must stress that my homecoming will bear no political labels or affiliation. It will be a completely non-partisan event, simply a much-longed-for homecoming. Continue reading “Olara Otunnu on the way”

Friday rant on good intentions

I hate to harp on this, but the whole LRA/Northern Uganda/Invisible Children issue is still grating on my nerves (is that the phrase?). I just came across an article by Pete Wentz of Fall Out Boy in the Huffington Post on Invisible Children’s “Abduct Yourself” event tomorrow. I don’t especially want to get into another debate on IC and the work they do/have done, but I want to say that how you approach and write about an issue or situation matters. For example, someone who did not know anything about Northern Uganda would have every reason to believe that the LRA was still active in this country after reading Wentz’ article.

He writes:

I watched the film Invisible Children: Rough Cut a while back, about kids sleeping in the streets in Northern Uganda — hundreds of them — because they feared being abducted by rebel leader Joseph Kony and forced to fight in his rebel militia, the Lord’s Resistance Army (LRA). They’re kids. Except no one told them they were, so they carry AK-47s, kill their parents and murder, rape and terrorize their own people on command. In the past two decades, 30,000 of them have been abducted. This is a reality neither you nor I could ever begin to understand. It was one of those times in my life where I was given a choice — continue ignoring the issue because it wasn’t in front of me, or forget about myself and do something. I was losing sleep, I had to go to Africa. My band Fall Out Boy traveled to Northern Uganda to film our music video “Me and You” to see it for ourselves and my experiences have forever changed me.

Everyone I met, everywhere I walked, with every step, the hardwiring in my brain began to change. I was quiet. Every time I wanted to complain, I made sure to bite my tongue instead. One day, we were stopped by some local men holding machetes; they wouldn’t let us pass. The fear I felt was paralyzing, but I looked into the eyes of these men and all could see was desperation. A pervasive hopelessness. These men stood at the mercy of a twenty-three year war.

Of course, the LRA are still active and wreaking havoc in the region (namely in Congo). They are continuing to abduct and kill with impunity, there are still many children whom they have taken captive, and whom they have forced to do terrible things. This is unacceptable, outrageous and terrible. It must be stopped. But I am not at all sure that Wentz himself knows that there is no longer a war going on in Northern Uganda.

There are many issues in Northern Uganda that may be publicized, but war is not one of them, and it doesn’t really do anyone any service to suggest that the war is still ongoing there. If anything, it continues to make the country sound like a scary and dangerous place (the whole “heart of darkness” thing, a line I wish had never been written). We are working on recovery and redevelopment, people are returning home and trying to begin their lives afresh.

I am more than happy to pressure government to get on with the promised PRDP already, to demand more from a Prime Minister who had never even been to the north until last year. But I am so sick of hearing self reflections and misrepresentation of the many challenges there actually are in the region, especially from people who come for a week or two and leave thinking they understand the whole of the situation. You had to go to “Africa” because you were losing sleep? Give me a break.

Anyway, I’m glad if this publicity will help people find Uganda on a map. I’m glad lots of young Americans want to make their world a better place. I’m even glad if Mr. Wentz’ trip has made him appreciate his own life a little more, or to think a little less about himself. Nevertheless, what you write and how you present yourself and your “cause”, whatever it may be, matters. Good intentions do not always save the day.

End rant.