Health information leads to…cheating!

Well, this is disappointing. A recent study in Uganda supported by Google and the Grameen Foundation, and implemented by Innovations for Poverty Action, has found a way to…increase infidelity.

When provided with information about sexually transmitted diseases via text messaging, cheating among participants more than doubled. Why?

Although the study and its findings have yet to be published, Bloomberg reports:

With the program in Uganda, which began in 2009, infidelity may have risen as women became more aware of the risks of cheating and insisted on going for testing with their husbands, said study author Dean Karlan, an economics professor at Yale University in New Haven, Connecticut. Some men resisted, leading women to deny them sex, which the men then sought from other women, Karlan said.

Basically, it appears that women wanted safer sex, while many men did not.

At first, this struck me as a classic case of unintended consequences, of good intentions paving the proverbial road to hell. However, having finished tearing my hair out (actually, gunning it through Ntinda wondering, what is wrong with these men?!), I realized we have actually learned something important despite the perverse effects of this intervention. Two things, actually. 1) men and women have different preferences regarding safe sex, and 2) women are willing and able to stand up for and protect themselves, at least in Uganda.

Now we need to understand why, faced with the same information as women, men made choices that did not improve their health and did not reduce their risk of contracting a sexually transmitted disease. We also need to find ways to support women to protect themselves and their families.

Looking forward to reading the paper; will update accordingly.

UPDATE: Ungated version of the working paper available here.

Angelina Jolie’s choice, our challenge

Today the New York Times published a very personal and, for many people, unexpected op-ed by actress, director, and humanitarian Angelina Jolie. Ms. Jolie, a carrier of the gene BRAC1 with a mutation that significantly increases breast cancer risk, recounts her decision and experience undergoing a preventive double mastectomy — the surgical removal of both of her breasts. There should be no shame in undergoing such a procedure. Still, Ms. Jolie feels compelled to note: “On a personal note, I do not feel any less of a woman.” This is a real concern for many women.

The more we talk about women’s health and the unique health experiences women face, the better. The same goes for men. Our bodies are often imbued with such greater expectations than their basic purpose, to allow us to live our lives. We make judgments about each other based on shape and size, and spend countless, wasted hours making these judgments about ourselves.

I applaud Ms. Jolie for her contribution to this important conversation. It also raises important issues for women’s health beyond the New York Times readership. Ms. Jolie writes,

For any woman reading this, I hope it helps you to know you have options. I want to encourage every woman, especially if you have a family history of breast or ovarian cancer, to seek out the information and medical experts who can help you through this aspect of your life, and to make your own informed choices.

I wish this were more true than it is. For many women around the world, there are not many options. Ms. Jolie is well aware of this, and I believe she will be one among many fighting to change the status quo. In the meantime, there are sobering facts to face at home in Uganda.

  • Breast cancer is the third most common cause of cancer among women in Uganda, behind cervical cancer and Kaposi’s sarcoma (the latter of which are largely preventable).
  • There are two mammography units in Uganda.
  • The vast majority of Ugandan women present at late stages in the cancer’s progression, at which point there is little chance of survival.
  • The estimated budget of the Uganda Cancer Institute is approximately Ushs 5.5 billion, just over US$2 millon (Sector Budget Framework Paper). The State House budget is 36 times that, over Ushs 200 billion.
  • The cost of testing for BRAC1 and BRAC2, as Ms. Jolie notes, is US$3,000 in the United States, and completely inaccessible for almost all women in Uganda.

In comparative terms, Uganda has relatively low rates of breast cancer. But it’s hard to know how accurate these figures are due to poor surveillance and diagnosis in much of the developing world.

Citation: Bray, Freddie, Peter McCarron, and D. Maxwell Parkin. "The changing global patterns of female breast cancer incidence and mortality." childhood 4 (2004): 5.
Citation: Bray, Freddie, Peter McCarron, and D. Maxwell Parkin. “The changing global patterns of female breast cancer incidence and mortality.” childhood 4 (2004): 5.

Who supports foreign aid in Uganda?

A new paper by Harris, Milner, Findley, and Nielson finds that while the Ugandan public generally prefers foreign aid to government programs, Ugandan elites (LCs and MPs) prefer government programs:

We examine the differences in behavioral and attitudinal responses between mass and elite recipients. We generally find that citizens strongly prefer foreign aid over government programs, and elites in most contexts express a preference for government programs over foreign aid. The results for masses are stronger than for the elites, but we interpret this as evidence that citizens see aid as an escape from clientelism, whereas elites may perceive more avenues for the capture of aid resources.

 

Full paper here.

Beautiful Bunyoro

I just returned from a quick tour of Hoima and Buliisa, in the Bunyoro region of western Uganda (now also known as the oil producing region of Uganda…).

Beautiful Hoima district:

P1030325
Hoima Municipality

And Buliisa – located on Lake Albert, tucked in the breathtaking Rift Valley. Commercial development is still lacking, but one imagines this will change in the next few years.

Buliisa District Headquarters (completed in 2008)
Buliisa District Headquarters (completed in 2008)
Main road through Buliisa, Buliisa Town Council
Main road through Buliisa, Buliisa Town Council

Uganda: The Health of the Nation

Published online Nov. 4, 2012 in The Independent.

The Health of the Nation
By Melina Platas Izama

Since Uganda hit 50 recently, it seems as good a time as any to check its vitals. There is the heartbeat of the economy and the temperature of the masses, the pressure of the politics and the weight of history. The health of this nation in one word? Resilient.

The Jubilee celebration was not made up of unfettered jubilation, as one might expect at 50 years of independence, but instead doused with a heavy coat of introspection.

The pristine Kampala Road, captured in black and white photos, is hardly recognisable today – a bustling, grating and downright stressful stretch of earth.  Cynics wandered and wondered aloud, are we better off now than we were a half-century ago? Teachers are striking, projects stalling, health clinics leaking staff, money, and drugs. This version of events is familiar. We listen to it every morning and read it every day. Frankly, it’s exhausting.

The health of the nation is in part a function of the health of its people. And here we have some great stories to tell. The greatest story of all is the about the survival of children. In the last fifteen years, death in infants and young children has fallen by nearly 40%. The drop in child deaths was faster in the past five years than it has been in decades.  This is fantastic news.

When Uganda raised her flag for the first time, mothers across the newly birthed state could expect more than one in five of their children to perish before age five and 13% of newborns would not survive their first year. This year, as the flag was raised once more, the death of a child is not foreign, as it should be, but neither does it go hand in hand with motherhood.

The results of the most recent round of the Demographic and Health Surveys (DHS), which have been instrumental in documenting these trends, have just been released for Uganda. Conducted across the country in more than ten thousand households, the DHS has been conducted in 1988, 1995, 2000, 2006 and 2011. While there are a number of improvements to report, the story of child survival, particularly in the last decade, stands out. It is perhaps the greatest achievement of the new millennium in Uganda. Continue reading “Uganda: The Health of the Nation”

Ivory trade in the DRC

Jeffrey Gettleman of the NYT investigates a growing illicit trade in the DRC — not diamonds, gold, or minerals, but ivory. Evidence suggests that military forces in the area, including national armies from DRC, Uganda, and South Sudan, and rebel groups like the Lord’s Resistance Army, have been implicated in the illegal and deadly trade. As much as 70% of all ivory is headed to China. Excerpt below, full article here.

Some of Africa’s most notorious armed groups, including the Lord’s Resistance Army, the Shabab and Darfur’s janjaweed, are hunting down elephants and using the tusks to buy weapons and sustain their mayhem. Organized crime syndicates are linking up with them to move the ivory around the world, exploiting turbulent states, porous borders and corrupt officials from sub-Saharan Africa to China, law enforcement officials say.

But it is not just outlaws cashing in. Members of some of the African armies that the American government trains and supports with millions of taxpayer dollars — like the Ugandan military, the Congolese Army and newly independent South Sudan’s military — have been implicated in poaching elephants and dealing in ivory.

Video: The Ivory Wars

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

News on Uganda’s Ebola outbreak

An outbreak of Ebola that started in Kibaale district, western Uganda, has spread to Kampala, say government officials (including the president). So far 14 people have died from the Ebola virus, and at least a dozen more have been infected. As more information becomes available, I will post it here.

Many of the cases so far are reported to have come from the same family, in addition to a health worker in Kibaale, Clare Muhumuza, who was transferred to Mulago Hospital, where she died.

According to the Centers for Disease Control (and common sense), a critical factor in stopping the epidemic is to recognize an outbreak and respond quickly. It appears as though this is the third week since the outbreak in Kibaale. Let us hope not too many people were infected before news of the outbreak and government response became public.

Some of the recent stories are below:

Museveni warns of Ebola threat, BBC news

Ebola in Uganda alert, World Health Organization

6 more patients admitted with possible Ebola, AP

Ebola kills Kampala doctor, Chimp Reports

Ugandans told to avoid handshaking, Reuters

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?

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