The Academy in the time of Influenza: American medicine and the Great Pandemic

American medicine up until the twentieth century was an unmitigated disaster. Or so argues (quite convincingly) John Barry in his fascinating book, The Great Influenza: The Story of the Deadliest Pandemic in History. The first two sections of the book cover a brief history of American medicine and medical research, and I’ve only just gotten to the outbreak of the pandemic that killed between 20 and 50 million people, according to the best estimates. For comparison’s sake, WWI claimed 16 million lives, and AIDS an estimated 33 million.

Barry highlights a strong link between war and disease, namely, the emergence of epidemics or even pandemics. I’ll return to a discussion of this thesis when I’ve finished the book, but for now, what has been most striking is the utter catastrophe that was American medicine up until relatively recently. While scientists and physicians in Europe, including Robert Koch, Pierre Louis, Louis Pasteur, and John Snow were pioneers in epidemiology, germ theory, and more, the study of medicine in America was stagnant, suggesting the importance of healthy academic and scientific competition on the European continent.

Evidence of the United States’ relative backwardness is abundant. Charles Eliot, who became president of Harvard in 1869, wrote in his first report as president that, “The ignorance and general incompetency of the average graduate of the American medical Schools, at a time when he receives his degree which turns him loose upon the community, is something horrible to contemplate.” When Eliot proposed reforms within Harvard, including examinations (of all things), Professor of Surgery Henry Bigelow, had this to say:

Charles Eliot, Harvard President 1869-1909

“[Eliot] actually proposes to have written examinations for the degree of doctor of medicine. I had to tell him that he knew nothing of the quality of Harvard medical students. More than half of them can hardly write. Of course they can’t pass written examinations…No medical school has thought it proper to risk large existing classes and large receipts by introducing more rigorous standards.”

At the end of the 19th century, Barry reports that American universities had “nearly two hundred endowed chairs of theology and fewer than five in medicine…” showing where both the money and the power lay.  It was ultimately the initiative of a few individuals, combined with big money from illustrious families such as the Hopkins and Rockefellers, that turned the ship around.

The Great Influenza is an excellent read, and fodder for thought not only for those interested in medicine, epidemiology, and virology (guilty as charged), but also for those interested in the academy as an institution – how it evolves or stagnates, and the factors that generate innovation and massive leaps forward in our understanding of the world.

Uganda’s Anti-Homosexuality Law

Below is a copy of the text from a piece published in the Washington Post’s Monkey Cage blog:

The rise of morality politics in Africa: Talk is cheap and dangerous, but wins votes

Melina Platas Izama

Ugandan President Yoweri Museveni today signed into law his country’s Anti-Homosexuality Bill. The passage of this bill is part of an emerging trend of morality politics in Africa and beyond, including but not limited to the criminalization of homosexuality. Legislating morality, unlike improving social services like health and education, is nearly costless for politicians. It is also extremely popular. Legislators in Africa struggle to hold onto political power, and the majority of their constituents view them as corrupt, according to Afrobarometer surveys. Electoral pressures, combined with politicians’ poor record of service delivery, make legislating morality an increasingly attractive option. In addition to winning votes, however, laws such as the criminalization of homosexuality can also be used opportunistically against both the public and political opposition.

Uganda’s anti-homosexuality bill, which has been under discussion since 2009, criminalizes homosexuality and provides a punishment of life imprisonment for “aggravated homosexuality.” The law delineates particular same-sex acts as “aggravated homosexuality,” including  sex with a minor or with a person with a disability, or if the offender is an HIV-positive person or a “serial offender,” defined as “a person who has previous convictions of the offence of homosexuality or related offences” (the Anti-Homosexuality Act, 2014: Sections 1 and 3). In the original bill proposed in 2009, “aggravated homosexuality” was punishable by death, and failure to disclose an offense committed by another person was punishable by imprisonment for up to three years. Both of these provisions were removed in the final version of the bill. However, in a news conference held immediately prior to signing the bill today, Museveni seemed unsure of the bill’s contents, asking his aides in the audience whether citizens were required to report on one another.

The anti-homosexuality bill reflects popular sentiment in Uganda, where 90 percent of respondents said that homosexuality was “never justified,” according to the World Values Survey, and 96 percent of respondents said that society should not be accepting of homosexuality, according to the Pew Global Attitudes Project. Uganda is no outlier on the continent. Kim Yi Dionne and Boniface Dulani, using all publicly available data on attitudes toward homosexuality in Africa, found that although higher levels of education, living in urban areas, and lower levels of religiosity were associated with greater support for same-sex rights, the vast majority of Africans oppose homosexuality. Dionne and Dulani point out, however, that the limited data collected on attitudes toward homosexuality in Africa fails to capture the salience of same-sex issues among ordinary Africans.

Uganda’s anti-homosexuality bill reflects trends across the continent in criminalizing (or re-criminalizing, since more than half of remaining “sodomy” laws worldwide are colonial relics) homosexuality. The reasons for the recent spike in anti-gay legislation (not limited to Africa, by the way) are still being debated. Guy Grossman suggests therise in evangelical Christianity and heightened political competition explain the political saliency of LGBT-issues. These bills are undoubtedly politically popular, and thus useful tools for garnering electoral support.

David Bahati, sponsor of Uganda’s anti-homosexuality bill, was one of a handful of parliamentarians to run unopposed in Uganda’s most recent elections in 2011, in a country where competition over parliamentary seats is rising with every election. An average of more than five candidates contested for constituency parliamentary seats in the most recent election, up from less than four in 2006. Around half of the incumbents who ran for reelection were voted out of parliament in 2011. Bahati was subsequently elected vice chairman of the caucus of the ruling party, the National Resistance Movement (NRM).

At the presidential level, backlash and condemnation from Western countries, including the United States, where President Obama issued a statement warning Museveni that signing the bill would “complicate” the United States’ relationship with Uganda, have produced a rally-around-the-flag effect, where even Museveni’s most staunch opponents and a usually critical media have applauded his decision. Some have argued that he is calling Obama’s bluff, leveraging Uganda’s military role in the region. In any case, his signature, appended just weeks after members of his partypassed a resolution in support of his bid for a fifth term in 2016, must be seen in the context of a presidential campaign season that has, for all intents and purposes, already begun.

Recent “moral” legislation extends beyond homosexuality, however, and focusing on the salience of LGBT issues may obscure other arenas in which moral dictates are being employed for political purposes. The signing of the anti-homosexuality bill in Uganda comes just weeks after the signing of the Anti-Pornography Bill, widely reported by local and international media as the “mini-skirt ban,” despite no mention of skirts in the bill itself. Legislating morality may seem odd in a country where more than three quarters of survey respondents believe “some of” or “most of” parliamentarians are corrupt, according to Afrobarometer data, but perhaps it is precisely because of their credibility deficit that politicians are employing moral dictates as a nearly costless alternative to delivering the goods and services that are so badly needed.

In addition to serving as quick and cheap political wins, these laws can also be easily converted into tools for political witch hunts. Ashley Currier demonstrates how leaders of the ruling party in post-colonial Namibia have used political homophobia to stifle dissent. Uganda’s political opposition seems all too quick to forget that opposition leader and former presidential candidate Kizza Besigye was jailed andtaken to court on rape charges (in addition to treason and terrorism) in advance of the 2006 presidential election. The charges against Besigye were eventually dropped, but with Uganda’s new laws come a new arsenal of offenses; offenses that can mark if not jail a political candidate for life.

Apart from the intended consequences of these laws, unintended, if not unforeseeable, consequences are already becoming apparent. In countries where mob justice is a common replacement for weak or non-existent law enforcement, these laws give way to everyday opportunism. Immediately after the passing of the Anti-Pornography Bill, women wearing short skirts in Uganda’s capital city, Kampala, were reportedly attacked, disrobed and robbed. The Uganda Police Force had to issue an immediate warning against perpetrators of these attacks. Although it is too soon to tell whether citizens will also take the new anti-homosexuality law into their own hands, recent events in Nigeria suggest that mob justice against suspected or accused homosexuals may be swift, and potentially deadly.

Africa: The Devout Continent?

Published online May 1, 2012.

Between the Berlin Conference in 1884 and the beginning of the 21st century, something extraordinary happened. In the course of just over a hundred years, nearly the whole of sub-Saharan Africa adopted Christianity or Islam. The mapmakers who gave birth to today’s African states were mortal, but the legacy of religion they left behind would fundamentally alter people’s core beliefs about life and the afterlife.

In the year 1900 around 9% of the African population was Christian, and 14% Muslim. Today, nine out of every ten people identify either as Christian (57%) or Muslim (29%). Soon there will be more Christians living in Africa than in Europe. By 2030, there will be more Muslims living in Nigeria than in Egypt, and more Nigerian Muslims than Iraqi and Afghani Muslims combined. Much of the religious conversion occurred during the colonial period, but nearly half of the growth of Islam and Christianity took place after independence.

It is difficult to make many generalizations about the effect of new religious beliefs on politics and society over the past century because there is great diversity in the religious make-up of countries. Countries like Somalia and Mauritania are 99% Muslim while others, like Cape Verde and the Democratic Republic of Congo, are almost entirely Christian. Some countries are predominantly Muslim but have sizable Christian minorities, like Chad (56% Muslim, 35% Christian), while others are predominantly Christian with large Muslim minorities, like Ghana (64% Christian, 20% Muslim).

Even two countries with the same percentage of Christians are unlikely to look very similar. Countries like Rwanda are predominantly Catholic, while others, like Liberia, are largely Protestant. In Nigeria there is a strong Pentecostal following, in South Africa African Independent Churches are very common, and Uganda has a large percentage of Anglicans.

Despite these differences, there are broad trends to note. On the whole both Christians and Muslims in sub-Saharan Africa are very devout. In a survey of 19 African countries, a study by the Pew Forum on Religion & Public Life, “Tolerance and Tension: Islam and Christianity in Sub-Saharan Africa”, found that 80% or more of the survey respondents of all faiths said that religion was “very important” in their lives. This is a much higher percentage than most populations living in Europe or even Latin America. Perhaps ironically, the importance of religion among Africa’s former colonizers (and from where most missionaries came) is quite low – only 24% of Italian respondents, 23% of Spanish respondents, 19% of British respondents and 13% of French respondents said that religion was a very important part of their lives.

Both Christians and Muslims also attend religious services very regularly. In most countries, 70% or more of Christian respondents and 80% or more of Muslim respondents said they attended services at least once a week. The vast majority of respondents across countries say they pray at least once a day. Most Christian respondents reported fasting during Lent, and almost all Muslim respondents (85-100%) reported fasting during Ramadan.

Perhaps most surprisingly, there is huge support among both Christians and Muslims for biblical or sharia law to be the “official law of the land”. More than half of all Christian respondents in countries as diverse as Ethiopia, Botswana, Liberia, and Guinea Bissau favored making the Bible the official law, while more than 50% of Muslim respondents from Mali to Mozambique favored making sharia law official. Most Christians and Muslims in countries surveyed also said the Bible and Koran, respectively, were the literal word of God.

Thus, while there are many differences in the make-up of religious organizations and practices across countries, there are also many similarities. Most notably, the importance of religion and the conception of religious texts as absolute and literal truth, truth that should guide the organization of politics and society, are widespread. While the spread of Christianity and Islam in Africa has occurred in a relatively short period of time, these faiths and their teachings have dramatically changed people’s everyday lives and beliefs.

To what extent have religious beliefs translated into government policy? In countries evenly split between Christians and Muslims, like Nigeria or Eritrea, or in countries with large Christian or Muslim minorities, can we expect to see religious conflict in the coming years?

There are not clear answers to these questions, but there is a paradox emerging in many countries – people favor politicians and policies of particular faiths while at the same time ascribing to freedom of religion. They believe that religious texts should inform if not dictate laws governing a country, but promote religious tolerance. The separation of the church and state is not usually written into formal laws, but faith nonetheless finds its way into political behavior and policymaking.

It is impossible to predict whether religious conflict will emerge, and often ethnicity is thought to be more divisive than religion, but there are some findings to warrant concern. Perhaps most disturbingly, a substantial percentage of respondents across countries agreed that violence could be justified in defense of one’s religion. For example, 55% of Christian respondents in Guinea Bissau and 37% in Botswana agreed with a statement saying, “using arms and violence against civilians in defense of their religion is justified”. 58% of Muslims in DRC and 37% of Muslims in Kenya also agreed with this statement.

People of all faiths also expressed concern over both Christian and Muslim extremist groups in their country. Many also cited religious conflict as a “very big” national problem.

Christianity and Islam are still growing and spreading in Africa, and the long-term effects of religious conversion and organization on politics and society are only beginning to become apparent. Resolving the devout-secular paradox will likely have implications for governance and conflict in the coming years.

Faith in Politics

I’ve been traveling and have fallen a bit behind in posting my columns. Below is my article published a couple of weeks ago, and published online March 27, 2012. I’m starting to think a lot about the intersection of religion and politics, so there should be more on this topic soon.

Faith in Politics
The strategic and influential role of religion within our political systems

There is a certain structure religion gives to our lives. At the birth of a child or death of a loved one, we turn to some sort of faith more often than not. When oaths are sworn in courts of law, it is a holy book on which we swear to remain truthful. And when politicians promise to abide by the earthly laws we create, they raise a hand and address a god somewhere.

Faith shapes our lives, but not our governments – at least not directly, and not on paper. Laws uphold and protect only the legal separation of church and state in most countries. This formality can trick us into thinking that religion keeps its distance from politics. But the truth is that the two have never really been separated.

Simply take a look.

There are prayer breakfasts, the invocation of god’s name in such places as national anthems and currencies, and prayers at the start of government meetings and functions. Heaven forbid a U.S. president should end a national address without the words, “God bless America”. Although these are benign examples of the blending of church and state, the clashes can be much more fierce when religion comes head to head with public policy.

In the United States, there are vicious, and even deadly, battles over abortion laws and the teaching of evolution, as opposed to the more biblical creationism, in schools. In France, veils that cover the face (such as the hijab or burka) are banned in public places. In a number of African countries, including Uganda, marriage laws have been unsuccessful at prohibiting polygamy because such a ban is seen to violate religious practices.

These are perhaps some of the most blatant and controversial clashes between faith and the state, but the religious beliefs of political leaders can also sneak into their public policy in less obvious ways. The support of evangelical Christian groups for HIV/AIDS advocacy played a significant role, for example, in shaping and promoting U.S. President George W. Bush’s global HIV/AIDS initiative, The President’s Emergency Plan for AIDS Relief (PEPFAR). Even groups like Invisible Children, responsible for the viral Kony2012 video, are not outwardly evangelical, but are nonetheless headed by individuals whose religion plays a prominent role in the way they view their purpose in the world.

While it is tempting, especially for dispassionate analysts and policymakers, to take the separation of church and state at face value, it is necessary to more closely interrogate the ways in which faith shapes not only individual actions, but political systems. How does religion affect our political, social, and even philanthropic lives?

In an environment where voters have precious little information about their elected officials, apparent adherence to religious beliefs and practices can give some indication of the quality of a candidate. In an era of rampant corruption, a candidate who is perceived as religious may be more trustworthy than his or her atheist or less devout counterpart. U.S. presidential candidates, for example, must repeatedly discuss and proclaim their faith. Stories of redemption and renewal, often brought about by religious transformation, also win votes. A story of salvation from alcoholism and other exploits painted an inspiring image of former President Bush that many Americans admired, and one where faith featured front and center.

Indeed, many voters use faith as a prerequisite for their support of a political candidate. 35% of Americans and 45% of Rwandans surveyed by the World Values Survey believe that “politicians who don’t believe in God are unfit for office.”  Moreover, 62% of Rwandans and 42% of Americans agreed that it would be better if more people with strong religious beliefs held public office. As a politician in either of these countries, it only makes sense to announce your faith publicly.

At the same time, going into too much detail about your faith can be almost as career-killing as not mentioning it at all. It is one thing to be Christian, but quite another to be Mormon, much less Muslim. Most Americans and Rwandans are Christian, either Protestant or Catholic. About half of all Americans are Protestant, while a quarter are Roman Catholics, and less than 1% are Muslim. In Rwanda, the numbers are flipped – nearly 60% of Rwandans are Roman Catholic and 26% are Protestant. Another 11% are Adventist, and 5% are Muslim.

Politicians who do not come from the predominant Christian denominations are hard-pressed to demonstrate that their beliefs are not far removed from “mainstream”. U.S. Republican candidate Mitt Romney, for example, has been at pains to assure voters that as a Mormon, his beliefs to not differ greatly from those of more mainstream Christianity. But if Romney thinks he has a hard time, his experience would surely pale in comparison to a Muslim candidate. I would wager the U.S. is about as far from electing a Muslim president as any country on earth.

Perhaps it is not surprising that faith plays an important role in shaping people’s political preferences, even in a secular state. Nevertheless, the process by which faith seeps and soaks into politics and policy is not straightforward. Anecdotal evidence suggests that churches and religious leaders are a powerful force driving the political behavior of their followers. After all, from their pulpits, religious leaders have a great and even unique opportunity to shape public opinion. At the same time, however, most people do not react favorably to the explicit interference of the church in political behavior. About 60% of both Americans and Rwandans believe that religious leaders should not influence how people vote, and nearly 70% of Rwandans do not think religious leaders should influence government.

Thus, there is an ideological tug-of-war underway. On the one hand, citizens living in secular countries subscribe to values of religious tolerance and even the religious agnosticism of the state. On the other hand, they often favor politicians who declare their faith, and punish those whose faith is not in the mainstream. To understand how faith intersects with politics, these two conflicting preferences must be reconciled. The question remains, to what extent do we have faith in politics?

Condoms –> More AIDS

This is essentially what Pope Benedict XVI has suggested while on his current visit to Africa, where he will visit Cameroon and Angola. Regarding the HIV/AIDS epidemic, which has killed and affected millions, the vast majority living in sub-Saharan Africa, the Pope told reporters that it is “a tragedy that cannot be overcome by money alone, that cannot be overcome through the distribution of condoms, which even aggravates the problems.”

Criticism of condom use is an altogether unsurprising position from the Catholic church, which largely rejects the use of birth control. Nonetheless, the argument appears to have reached a new level, with the Pope actually suggesting that condoms are making the “problem” of HIV/AIDS worse. I disagree with the church’s position on condoms in general, though I recognize the valid point that condoms will not alone bring an end to the HIV/AIDS epidemic. Nonetheless, I find it incredibly irresponsible for such a powerful and influential leader to make a causal argument of this nature with little to no evidence to back it up. Millions of the devoted will be listening, and millions may thus come to the conclusion that condom use in and of itself may increase their chances of contracting HIV. This could obviously not be farther from the truth (if you are going to have sex anyway, wearing a condom will certainly not increase your chances of contracting HIV).

We can agree to disagree on ideology, but not on matters of scientific fact, especially when millions of lives are at stake. This kind of misinformation benefits no one.

For more thoughts on the subject, see the opinion by the Guardian‘s Ela Soyemi. Or yesterday’s NYT editorial. Or on Bill Easterly’s latest post.