Wednesday, July 22, 2009

XXXIX. The Three Defects, The Twin Myths and The Three Delusions

Truth be declared, I am having a tough time adjusting to the cultural amnesia, inability to acquire and assimilate knowledge, and gullibility that characterizes a sizable fraction of the American population. For example, many people still think that we should have stayed and “won” in Vietnam despite its chief architect, Robert McNamara, having publicly apologized for that war as a tragedy resulting from a profoundly misguided application of US power in foreign policy. Mr. McNamara was a long time (decades) in coming to the firm conclusion that this nation had fundamentally departed from the stated principles on which the country is based in waging that war. Unfortunately many of my fellow Americans still have not caught on; and, what’s worse, the example of Vietnam was often given as justification by proponents of the equally ill-advised invasion of Iraq! As I have written on previous occasions, diversion of resources toward war has huge implications for public health, including cancer prevention and control. Indeed, that is why I like to sign my emails with quotes from Dwight D. Eisenhower that underline that smart military minds understand this and are great allies in our effort to make the world a better and healthier place.
As I have promised earlier, I will be comparing and contrasting Americans and Indians on a number of cultural typecasts. More on that later. In the meantime, I note that these three characteristics; defects in memory, faulty comprehension, and gullibility, do appear to have unique expression in the US (which is not to say that they do not exist in varying degrees across many cultures). After all, this is what enables people of devious motivation and sufficient means to manipulate the poor and relatively uneducated.
Now the insurance companies are spreading their lies; and, as usual, the health of ordinary people (i.e., people who have no power to exert a direct effect on health or military policy) is at risk. Tied up in the fear-mongering about “socialized” medicine are the twin myths of public sector waste and inefficiency and private sector efficiency and responsibility. Having worked in both sectors, I know that there are individuals and entities in both who are very efficient. I also know that waste and wanton greed run rampant is much more common in the private sector. Witness the excesses of the financial industry in the past few years and the fact that top insurance company executives make salaries in the 7 or 8 digits (that’s to the left of the decimal point)! By contrast, the maximum salary allowed by the National Institutes of Health (NIH), is about $200,000/year. This applies to Nobel Laureates and others who are extremely smart, hard-working, and well-intentioned. Of course, the heavily compensated private-sector “tycoons” don’t want limits set to control their greed and avarice. Combining their virtually unlimited access to our elected leaders, media outlets, and the courts with a gullible, ill-informed public has enabled their salaries to soar to obscenely high levels, their corporate profits to expand exponentially, and our health indicators to become among the worst in the world.
Early last week (Monday, 13 July 2009: page A9) I published an abbreviated version of my last blog in the State Newspaper (South Carolina’s oldest and largest circulation paper). These were mainly entries on the State website, but I also received emails and phone calls. Overall, the piece generated about 3:1 favorable responses but the negative ones were pretty nasty and generally very ill-informed. There were three themes that emerged from these that I found really interesting. I do not listen to mainstream media, but have to assume that when crazy ideas are repeated over and over they must have a common source. Here goes:
Watch out, if we have “socialized medicine” you will pay 80% of your salary in taxes. Not only is this essentially untrue; but the highest rates would not apply to the people who are so easily duped. Besides, not to worry, in the US, anyone taxed at the highest rates have ready access to lawyers and accountants who are adept at lowering their rates to far below average (often to zero!).
Stories of waiting for essential care. Oh my, I love good stories, too. Just reading my blog entries is a dead giveaway on that! However, I also am an epidemiologist, and, even more importantly, have common sense. I cannot and will not (and you should not) take any action or base any decision on selected stories. To have any real meaning the stories must add up to a coherent picture and description of reality. Really, we must use our heads. If these stories of dying waiting for essential health care procedures to be performed were a common problem those countries about which the stories are being told (e.g., Canada, England, Germany, Sweden) would have the shameful health statistics, not us! (All pictures shown here were taken in the summer of 2007 when we were visiting friends who live in Stockholm, Sweden, – a place, according to right-wing American ideologues and apologists for the insurance industry, in dire poverty from "over taxation").
“They” make up the statistics. Well, I don’t know who “they” are, but this sounds like a giant paranoid delusion; or the refuge of true scoundrels. I suspect it is some of both – on the part of the duped and the perpetrators, respectively. Really, even the US keeps decent health statistics! And we have rules for quality control.
I would be willing to give a short course for people from the general public who want to begin a process of serious education and not just repeat mindless platitudes that keep us from reaching our true potential in becoming a healthy country with a fair system of health care delivery.

Monday, June 22, 2009

XXXVIII. Health Care Reform and Cancer Prevention and Control

Two years ago the American Cancer Society (ACS) made the bold decision to address severe deficiencies in the United States’ health care delivery “system” as its major concern. This was both startling and perfectly understandable. Startling because those of us in the cancer research community were (and to a large extent still are) committed to primary prevention of cancer as our primary goal. Understandable, because the debacle that healthcare has become in this country impedes everything else that we do promote health.

While the Cancer Prevention and Control Program remains strongly committed to scientific discovery that will lead to improvements in primary prevention of cancer, we also recognize that many severe deficiencies in our health care delivery “system” lead to a variety of poor outcomes for people who receive a cancer diagnosis. In general, and more starkly evident here in South Carolina than just about anywhere else, poor outcomes are most disparate for the poorest and most socially deprived among us. Unfortunately, like metastatic cancer, these social and economic problems are spreading in our population. Along with other major problems facing us at this critical time in human history, such as global warming, the denial must stop before we can mobilize the will, energy, intelligence, and creativity of the scientific community and its allies and supporters before we can make effective change.

In the preceding paragraphs I was very deliberate in using quotes around the word “system” because it really is fanciful to call the haphazard and profoundly unfair way health care is delivered in the US a “system.” For a very long time now individuals and groups have called upon government to create a fair, efficient, and accountable system of health care. Such voices were first raised in the Roosevelt and Truman administrations. This dallying over true health care reform has gone on for far too long. Besides denying care for easily treatable conditions it has allowed Americans to become profoundly unhealthy by implicitly promising to provide treatment that has little or no chance of improving quantity or quality of life; a promise on which it often delivers at great expense to all of us who pay ever-increasing taxes and insurance premiums.

Congress has an opportunity to include a strong public health insurance option this year, thus providing that option to anyone who chooses to participate. Such a broad-based plan would have real bargaining clout – especially important in keeping both the insurance and pharmaceutical companies honest. In order to control costs, a strong public health insurance option must be available nationwide and be accountable to us, the taxpayers. It also needs to stress personal responsibility to improve and maintain good preventive health practices. Unlike the current corrupt and profoundly unfair system of health care financing, it should be sufficiently transparent so that it can be monitored by our representatives in Congress.

There is no precedent, anywhere in the world, for anything but government to do this. What’s much scarier than the silly rhetoric about “socialized medicine” that began nearly ¾ of a century ago is the reality that we are spending an obscene amount of money making insurance companies and their chief executives fabulously wealthy while:
1. We experience some of the worst health indicators, including those associated with many cancers, in the civilized world
2. Our doctors spend more and more time dealing with insurance industry-induced red tape and regulatory requirements rather than the important issue of patient care for which they were called to their profession in the first place and spent many years being trained
3. Those of us who are insured experience red tape in the form of improperly denied claims that take many hours of our precious time to battle (and for which the insurance companies gladly pay their employees as a devious, but reliable, way to maximize profits)
4. Those of us who are uninsured or underinsured (who, together, now constitute the majority of Americans) are forced to use grossly inefficient methods for receiving health care and, when we do get seriously ill, are often left paupers by a “system” gone badly awry

For those of us who have experienced government-supervised health care in other parts of the developed world we know that:
1. These systems are much more efficient and easily accessible than the monstrosity that exists here
2. Health outcomes are much better than they are here, virtually across the board
3. These systems are humane and have shorter waiting times for most routine procedures than those experienced here
4. Doctors and other health professionals have higher morale and better measures of job satisfaction than their counterparts here – largely because they are allowed to actually practice evidence-based medicine most of the time that they are at work
5. Health professionals make reasonable salaries that are comparable to, and often exceed their counterparts here – except for some subspecialties

Having just experienced how well the greed-based financial services industry regulated itself while looking out for our interests, we should seize our rightful power to make the system of delivering health care accountable to the people. While we are at it, we actually might start paying better attention to the issue of health.

Wednesday, June 17, 2009

XXXVII. Poverty, Gender and Health

Many people in the world are too entrapped in the throes poverty to realize that combining a sense of intellectual curiosity with social activism is even a possibility. When we Westerners (even the poorest amongst us) talk about “stress” it is at an altogether different level than that experienced by the poorest half of humanity – people forced to live on fewer than a couple of dollars a day, for whom a day of missing work may literally mean the difference between life or death, and where medical care for even serious ailments is pretty much impossible.

I got into this work for a variety of reasons that I have discussed over these entries. Early on in my career I realized that poverty is the strongest predictor of poor health and female literacy is wealth’s most important modifier. When women have financial resources they generally tend to buy clothes, food, and school supplies for their children. When men have financial resources they generally tend to buy weapons; alcohol, tobacco and other drugs; and things powered by internal combustion engines. The typically male way of using resources digs families (indeed whole societies) deeper into the depths of poverty. The female way of using resources provides a ladder out – a means of escape. There are lots of exceptions, but this is useful generalization. Really, what percentage of people who go on homicidal rampages with semi-automatic weapons are women?

Kerala, a state in South India dominated by a matrilineal system of passing resources on to the next generation, has an overall adult literacy rate of about 90% (which is considerably higher than that of South Carolina), has health indicators better than that of South Carolina, has had a freely elected communist government for all but about 5 years of the 62 years since independence (quite unlike South Carolina’s regressive political system), and average wealth (expressed as State Domestic Product) less than 10% than that of South Carolina! Now there’s common sense and efficiency for you.

In an article we published 15 years ago [Hertz E, Hebert JR, Landon J. The influence of economic factors on life expectancy, infant mortality and maternal mortality rates. Soc Sci Med 1994;39:105-114.] we showed that overall wealth predicted health outcomes, but the most interesting lesson could be learned from four “outliers” (i.e., countries whose statistics were not fully explained by the economic-epidemiologic models). Egypt and the U.S. were much worse off than expectation – and both had military budgets far higher than the world average (at that time they each spent 43% of total government expenditures on the military). Costa Rica and Sri Lanka were much better off than expectation – the former did not have (and still continues not to have) an army and Sri Lanka (at that time at least) expended very little on its military. Twenty-five years of civil war, I am sure, has taken its toll on Sri Lankan health indicators.

Also as I have mentioned before, the trends I have seen emerge over the time that I have been in this line of work are not encouraging. Oppressive regimes, especially with respect to women’s rights, have emerged in a wide belt from North Africa, through the Middle East, Western Asia, and Southeast Asia and into the Malay Peninsula and the Indonesian Archipelago. India stands as one of the few bright lights in this darkening landscape.

What does this have to do with health and cancer in particular? Plenty. Without an engaged, well-educated female population no country will be able to throw off the shackles of poverty and poor health. This applies not only to whole countries, but to any political unit – just look at the states within India: from the male-dominated, generally regressive, unhealthy North to the more egalitarian, progressive, not all that much wealthier, but much healthier South. Cancer prevention and control requires careful use of scarce resources; eating good food; avoiding tobacco; and sensible screening for many of the common cancers that are becoming a bigger problem all over the world. Societies that value women so that their voices can be heard will make decisions that can reduce overall cancer rates and lead to downstaging disease at the time of diagnosis.

Wednesday, June 10, 2009

XXXVI. Reflecting on the Grand Opening

It has been 4 days since we finished welcoming people to the new home of the South Carolina Statewide Cancer Prevention and Control Program. I wanted to share some of what I said in my introductory remarks. Here goes.

This is a great and auspicious day. Many thanks to friends within the University of South Carolina, community members, faculty from other institutions of higher education and clinical partners from around the state, representatives from the National Institutes of Health and sister organizations around the country for being here to celebrate with us today.

What began as a promise and a dream those many years ago has moved decisively from the abstract to the concrete (and steel, glass, granite, and bamboo). I feel blessed to be able to celebrate the opening of the Cancer Prevention and Control Program in this new and beautiful place on this day in early June of 2009. It is a wonderful thing to contemplate the future dreams that will come to pass in our new home; the discoveries that will be made, and the promises that will be kept.

Many of us call ourselves “educators” and even more of us are parents and mentors of one sort or another. We all know that to live meaningfully means to learn and to teach. Though reflection is a necessary part of living life well, much of what we do does not happen in isolation – and some of it can, should be, and is very public.

In academia we are judged primarily by the papers we publish and the grant funding we garner. But we are called to this work for even more important reasons: to change the world for the better; to touch lives in meaning ways. So, as the director of the CPCP I need to reconcile the need to be productive academically as well as socially and ethically. My own heroes are people who understand that life has little worth without social, economic, environmental and healthcare justice. It was the driving force for Mahatma Gandhi and his disciple, Martin Luther King Jr. Their legacy lives on in the form of the two smartest, most enlightened leaders in the world today, Manmohan Singh and Barack Obama. So, the promise that we have for a better, healthier tomorrow is shared by people who understand the fundamental meaning of life and support us in the work we do here in the South Carolina, elsewhere in the US, in India, and in other parts of the world.

In the way that the National Cancer Institute, and the NIH more generally, classifies people I am a basic scientist. Really, that is the way I think. Still, I am a realistic and a keen student of the history of public health. That impressive, and very public record, shows clearly that those changes in the environment that lead to more equitable sharing of resources have had much more to do with increases in longevity and improvements in the quality of life over the past 150 years than all of the remarkable achievements in biomedicine over that time. An important part of our job is to ensure that findings in the basic sciences are not exquisitely irrelevant with respect to the cancer-related and other disparities we are charged with reducing and ultimately eliminating.

We are often led to profoundly incorrect conclusions when we choose the expedient over the correct way to do our work. Many of you have heard me give examples of how we can get things wrong when we think narrowly and in isolation. As the plan for this building evolved, it was clear that the new home of the Cancer Prevention and Control Program had to be a very public place. It needed to be on a very busy corner in our beautiful city. It needed to convey openness and a sense of optimism and striving toward excellence that captures the essence of our program. An area called Innovista and a building named Discovery seemed perfect. Here we are.

On days like today, I am called to reflect on the many connections that have brought me, indeed all of us, to a place like this. There are accidents in life, but much of what happens can be predicted in advance and even more can be explained in retrospect. We are here because of the excellent things that we do: the many papers that we publish in high-impact journals; the many grants that are funded. Not only are we productive in an absolute sense, but we are extraordinarily efficient in the use of scarce and precious resources.

Although statisticians warn about extrapolating beyond the range of the data, university administrators know that they can only project based on past performance and that we are very likely to continue to be highly productive by any standard. So, we were a logical choice to be the first tenants in this new campus so filled with the promise of a better tomorrow. It is my hope, desire, and plan to expand the program. We have tens of millions of dollars in outstanding grants that could lead to exponential growth in the near future. Expansion is a good thing. However, we need to understand where we have come from and the promises that we have made along the way. We are driven by a commitment to social, economic, environmental and healthcare justice.

The philosophy of what we do and our commitment to the community are not sideshows. They are fundamental to our purpose. As president Obama reminded us recently, it takes a special kind of courage to criticize your friends. You are the people who will hold us accountable. Consider this an open invitation to do so.

I have spent most of the last six months living and working in India. Although I worked hard and much was accomplished, including fulfilling my commitments to people back home, this time away has given me a special opportunity to reflect on life. Of all the words that I could pick to describe my feelings over this time, I would have to choose gratitude.

I am blessed to have a wonderful family, amazing colleagues, and daily contact with people who are dedicated to the mission of the program, and understand that they are only as great as the commitments they make and the promises they keep.

Three people will be speaking to you over the next hour and a half. Not only will this be entertaining but it will give you great insight into the future of public health and how three amazing and very different people see, experience, and wish to help in delivering on the promise.

I first met Patricia Pastides about 20 years ago, when I was a faculty member at the University of Massachusetts Medical School in Worcester Massachusetts and her husband, Harris, was a faculty member at the School of Public Health in Amherst. Over the years we have become good friends. I wouldn't say that our relationship is limited to food, but eating and cooking together has been a source of comfort, joy, and learning over these decades. I would not be in South Carolina if it weren't for Harris and Patricia. More than any academic leaders I have met in my life, they understand what the CPCP is fundamentally all about.

Dr. Claudia Baquet is my counterpart as an NCI (CRCHD) Community Networks principal investigator. She directs the Maryland Regional Community Network (MRCN) Program to Eliminate Cancer Health Disparities, which is a model nationally, and very much specifically for South Carolina, for how to work to effectively educate legislators and others to change health policy in larger systems to reduce cancer-related and other disparities. Claudia, a pathologist by training and public health educator and activist by avocation, has been a great mentor to me and other members of the South Carolina Cancer disparities community network.

Dr. Leslie Cooper is the Program Officer from the National Cancer Institute, Center to Reduce Cancer Health Disparities and team member of the South Carolina Cancer Disparities Community Network. The SCCDCN is the main vehicle through which we conduct community-based participatory. Over the four years that our network has existed, Dr. Cooper has evinced a deep interest in what we do and support for our philosophy, perspective, and work style. At the same time, we have come to understand just how very good she is at doing her job. Not only does she make truly amazing observations on the scientific and programmatic side of things, she is a great connector. She is one of those rare individuals who can see connections between things that may appear superficially to have no relation to one another, but when connected amazing things happen.
(NB: Many more pictures from the Grand Opening are available on the CPCP website)

Wednesday, June 3, 2009

XXXV. Grand Opening

I loved being in India. In the time that I knew I would be there, much was accomplished. When the time came to leave, I left with an overwhelming feeling of gratitude and just about no regret. As I had suspected, I also got some new perspectives on how we work here. I am gratified that after a week of being back home, this place still feels “new.” The depressing things I heard about American’s reactions to the economy news while I was a way are not hanging like a dark cloud over life here. There is great promise in the air. As life was in India, and just about everywhere I suppose, perception is formed by the close-up and personal relationships we have with the people with whom we have contact on the playing fields of life. We have wonderful people here and I am lucky to have helped to create the playing fields on which all play.
The South Carolina Statewide Cancer Prevention and Control Program was founded in 2003 to address some of the largest cancer disparities in the country; and, in some instances, in the world. For example, African Americans in South Carolina have the highest rate of one of the most deadly forms of cancer of the esophagus (squamous cell) in the nation. It is about 7 times higher than what is seen in European Americans, despite the fact that the rate of cigarette smoking (this cancer’s major risk factor) in African Americans is much lower. The prostate cancer incidence rate among African Americans is the highest in the nation (and about 80% higher than that of European Americans), and mortality is the highest in the world. Similarly, the death rate among African-American women diagnosed breast cancer is the highest in the nation. Indeed, it would be hard to find an example that does not disfavor African Americans.
In its short history the Cancer Prevention and Control Program has made good progress in describing the “cancer problem” in terms of both the scale and diversity of the kinds of cancers we see and where they are located within our beautiful, if somewhat beleaguered, state. This has entailed working with many other partners, including those in state government, such as the best-in-the-country South Carolina Central Cancer Registry. The August 2006 special issue of the Journal of South Carolina Medical Association was unprecedented in providing a graphical description of cancer in a state within the U.S., for and allowing the voices of the community to be heard in a peer-reviewed medical journal. On the front cover of the current (1 June 2009) issue of Cancer, is featured our article (1) on mapping cancer mortality rates within our state (and the first of its kind for anyplace in the world). It can be accessed through a link from the CPCP website. These careful descriptions are things about which South Carolinians can be justifiably proud. Indeed, they have become models nationally. This map (printed with permission from the copyright owner, American Cancer Society and the publisher, John Wiley & Sons, Inc.) illustrates the dire situation with respect to breast cancer.

It is not enough, though, just to describe the problem. We are not “ivory-tower” academicians. So, these careful descriptions also should point the way to solutions. So, we also have begun to address some of the underlying causes related to the larger environment in which we all live, and the various lifestyle choices we all make. Our goal in this is to identify things that individuals, or many of us working collectively, can do to reduce the rates of many different types of cancer and the destruction and suffering of individuals, families, and communities they cause. Many of the things that we have found to reduce rates of cancer also will help individuals, families, and entire communities to help control other major killers and causes of disability, such as diabetes, heart disease, and stroke. The wonderful Cancer Prevention and Control Program members that constitute our program are a smart, fun-loving and inviting group of people. It will take them, working in concert with members of the community (see XXXII. Interdisciplinarity and Community-Based Participatory Research), to really change things for the better.
Much of our work focuses on diet and physical activity. Fundamental changes are needed if we are going to make a real, durable difference in terms of lowering the rates of cancer and other deadly diseases. We also believe that these changes expand how people see, taste, smell, and otherwise experience the world. Indeed, the universe to which people are introduced is bigger than what they had known before. All of us believe that we cannot do this with a heavy heart; so, we really try to make it fun. This does not mean that it is not hard work. When one is confronted with a life-threatening illness, or whole communities whose very existence is threatened, it is absolutely essential to take it seriously. Most major changes that have occurred in the world have been made by people who understand the gravity of the problem they are confronting, while at the same time greeting the challenges with both resolve and great senses of humor.
This next weekend, the 5th and 6th of June, the Cancer Prevention and Control Program will celebrate the grand opening of our new location at 915 Greene Street (across from the Colonial Center) in USC's new Innovista campus. As careful stewards of public funding (though none of these events are paid from public coffers), we feel a special obligation to open the doors to experiencing the world in a new way to the public we are here to serve. On Saturday, the 6th, events including cooking demonstrations and many different forms of entertainment (including music and a visit by Cocky!) will be open to the public (see for more information).
Hebert JR, Daguise VG, Hurley DM, Wilkerson RC, Mosley C, Adams SA, Puett R, Burch JB, Steck SE, Bolick-Aldrich S. Mapping cancer mortality-to-incidence ratios to illustrate racial and gender disparities in a high-risk population. Cancer 2009;115(11):2539-52.

Thursday, May 28, 2009

XXXIV. Monsoon, Famine, Gandhi and the Spinning Wheel

Most of the time that I was in Navi Mumbai clothes would take only a few hours to dry after I would wash them. The drying time became progressively shorter as the days became hotter. Then, about three to four weeks ago (in the beginning of May), the air became noticeably more humid. The clouds began forming in different patterns (see XXIII. Expectations and Experience), and it even rained last Wednesday, the 20th.

India has two monsoons. The Southwest, or Advancing, Monsoon is the larger of the two. It is the one that arrives in Mumbai in the first week of June. The pressure differentials created by the blazing heat of central and northern India and the cooler moisture-laden air over the Arabian Sea is the engine that drives the monsoon. It typically transfers copious amounts of water from the Arabian Sea to areas on India’s West Coast, through Central India, over the Gangetic Plain, and up to the Himalayas in India’s far north. The Retreating Monsoon is associated with lighter rainfall and tends to drop more precipitation in southern part of coast of the Bay of Bengal; mainly in Tamil Nadu, where I used to live (near where the rice paddies shown are located), and parts of Andhra Pradesh.

The Advancing Monsoon visits India every year. Just how much it will rain is unpredictable. Two years ago nearly one meter of rain, i.e., 37 inches, fell in Mumbai in one day. One night in 1978 in Mussoorie, a Hill Station in Northern India, it rained so hard that I thought the force of the water would tear the roof off the house. Sometimes the rain is too light to allow for a decent crop; and the effects are sometimes quite localized. Because of the extreme heat, the difference in how the land looks and what it can produce can be striking, as these pictures taken in South India illustrate. However, it always rains; and in sufficient quantities over large enough areas to obviate drought as a sufficient cause of widespread famine.

Farmers depend on this rain. Though often having legitimate complaints about its amount and timing, it is dependable. We know this from records kept for hundreds, indeed thousands, of years. I learned about this because I had become interested in why Indian famines escalated to the scale of events that killed millions of people in the 19th century, slowly receded in the last seven decades of the British Raj, and disappeared entirely in the second half of the 20th century.

As mentioned in XXIII, and described in a full-length research article that I will be happy to provide to anyone who requests it (1), neither the occasional light monsoon nor population expansion were responsible for catastrophes such as the Madras Famine of 1866. Rather, these tragedies were played out against the background of human greed and disrespect for indigenous systems of social, economic and food security that had been developed over very long periods of time. These included the use of temple tanks for irrigation and water rationing; famine protection depositories into which grain stores were placed in times of plenty; the capacity to blend production of various food and non-food crops to meet the needs of the people; and the exigencies of the weather.

Many sincere bonds of friendship and love between individual British and Indians were formed over three hundred years. Indeed, there are numerous accounts in the historical record of British civil servants speaking out on matters of abuse, cruelty and neglect in the matter of resource allocation and unfair taxation. Still, the British came to India for one primary purpose; to extract its enormous wealth. Extractive economic systems do not much care for the needs of the people who produce the wealth. Simple visual inspection of a railway map of India reveals a system designed for moving goods from the interior to India’s main ports. That was the primary vehicle for extracting wealth, and because of how it was configured it would be difficult, or at least very inefficient, to move food and other commodities within the country on short notice.

The famines of the mid-1860s were a direct consequence of two essential factors: 1) the disrespect for human needs and cultural achievement and 2) events transpiring on the Eastern shores of North America. Beginning early in the 19th century, the British had forced Indians to purchase manufactured textiles made from cotton produced by slave labor in the Southern US. With the blockade of shipping during the Civil War they immediately ordered Indians to make up the large shortfall. Their intransigence to adjust to this reality by allowing Indians to revert to time-tested methods of allocating land resources to a combination of textile crops (cotton, jute, and indigo) and food crops and to move food around to meet local needs (the Retreating Monsoon did fail in parts of Madras State in that fateful year), they sentenced millions of people to death. So, as I tell my students in South Carolina, which was a major producer of cotton and Charleston was one of the ports most affected by the blockade, this is a superb example of a real, direct relationship between oppression in one part of the world and its affect on similarly oppressed people in another, seemingly unrelated place.

Even with excessive, ill-considered manipulation by the British, during the height of the worst famines, India produced more than enough food to feed itself – if only the British would have allowed its distribution to places of extreme need. Gandhi recognized that the disruption of cultivator-land and other labour relationships was a necessary cause of famine. He also knew that this disruption and the feeling of supremacy, and economic domination of one people over another that it required, would ensure continuation of the master-slave relationship that was the bedrock of colonial domination. Understanding that control over traditional means of production and the fruit of their labour would release Indians from the shackles of foreign domination, the spinning wheel became the symbol and, to some extent, the vehicle of the Freedom Movement that led to Indian Independence in 1947.

1. Hebert JR. The social ecology of famine in British India: lessons for Africa in the 1980's? Ecol Food Nutr 1987;20:97-107.

Monday, May 25, 2009

XXXIII. Good Bye India

It is a little before midnight on Sunday the 24th of May 2009. I am about to board an airplane bound for Newark, New Jersey.

For the 18th time in 32 years, I am saying goodbye to India tonight. Like an old friend that accompanies me on many such farewells, I was expecting to feel sadness. But that emotion has not surfaced. It may come to visit me on this long flight to Newark; in these many hours, as we begin our flight in the tropical latitudes and fly over the Asian Steppes through darkness ensured by moving quickly in the same direction as that of the earth spinning on its axis (and only a bit more slowly at the lower latitudes we will traverse). This time, when I am neither where I was nor where I will be, is unpredictable for what it can, and often does, bring up.

I thought that maybe the sun of a long arctic summer day would elicit the response. As we approach the East coast of Greenland I feel no sadness, but great nostalgia for the other times that I have done this and the way things have transpired over these decades. I recall being glued to the window the first few times that I took this trip. The vastness of the earth and the difference in the topography from what most of either India or the US looks like is a marvel to behold. The sight from this vantage point (39,997 ft) has been available to humans for only a small fraction of the time we have existed as a species in the vastness of time and space.
This departure was well planned and timed to mesh with the goals of a life lived in two places. I was deliberate in wanting to savor goodbyes over food and thoughtful conversation, two themes that characterized my time here more than anything else. After returning from the Kutch, it lasted a week; including a long, relatively relaxed weekend.

I leave India with a sense of profound gratitude for the relationships that have been strengthened and deepened over these months and for the new and wonderful people I have met over these months. I also feel blessed to have supportive family, friends, and colleagues back home who helped to make this productive absence from the day-to-day routines of life possible, even if electronic communication kept me very much engaged for nearly the entire time. Pictured here are Drs. Rajiv Sarin, Pradnya Kowtal and their lab personnel.

Despite working hard and accomplishing much, my life in India has been characterized by simplicity and lots of time to think in quiet solitude. I recall my friend Bill Hrushesky (here with Harris Pastides) expressing envy at my having the opportunity to spend long periods of time alone to be with myself, think, and recreate. I have loved this part of the reality much more than I thought that I would and have savored times that I have spent with people all the more because of it.
As I said back in the beginning, I began writing this blog in part to pay back the debt that is incurred on such journeys through life. Given that I wrote this mainly to explain myself to people back home, it is interesting that about half of the comments I receive are from are Indians. Apparently, thoughtful perceptions on great cultures have appeal both to those who live in some familiar corner of that reality as well as to those who are altogether unfamiliar. Pictured here are Dr. Ashok Varma, his family, and members of his lab.

At my best, I see the world through a scientific lens, as a seeker and a skeptic. I have tried not to be too analytical, but I want to learn enough to relate back to what I already know, synthesize the thoughts and perceptions; and inform others about the relationship between science and culture. As a Senior Research Fellow focusing on the epidemiology of cancer, that is how I interpreted my obligation to the Fulbright Program. I have accepted the charge with joy, passion, sincerity, and inquisitiveness. I am sure that Healis colleagues, especially Mayuri Sawant (far left), and Drs. Mangesh Pednekar and Prakash Gupta can relate to this.
There are many ideas that have emerged over these months. The list of topics is much longer now than ever. The creative juices have flown with the stimuli, which have been plentiful and varied. I hope that the discipline that I have established over these months will serve me well as I merge back into my home culture.

My plan is to continue writing after I return home. I realize that there are many things about life in my little corner of the US that people will find interesting and I know that I will look at things differently – at least for a while. The Grand Opening of the Cancer Prevention and Control Program in the new building, arriving back home in late spring having missed the seasonal transitions that I enjoy so much, and having Christine home from college for the summer should all contribute to my mind remaining open and receptive.

Wednesday, May 20, 2009

XXXII. Interdisciplinarity and Community-Based Participatory Research

As Bose came to understand and social activists like Martin Luther King discover in their work, the human tendency to create systems to preserve privilege and power are not expressed exclusively in archaic systems of social and religious hierarchy. Many other structures, though not as elaborately worked out as the Indian system of caste, devolve almost naturally and inevitably from this human propensity for control to create “clubs of the initiated.” These eventually stunt growth; and have done so across a wide span of human endeavor, including the sciences. Just as the leaders of “religious right” confound ignorance with faith, the leaders of these “clubs” confuse membership (often entailing affiliation with “elite” institutions and placement in special structures that they have created) with merit. The absence in major general medical journals of results from the Mumbai Cohort Study; well designed, uniquely positioned to pose and answer important public health questions, and one of the largest cohorts in the world, may reflect this subtle prejudice. Results from the study are widely published in highly ranked specialty journals such as the American Journal of Epidemiology and the International Journal of Epidemiology. So, it is not for lack of technical excellence that manuscripts are summarily rejected, without review, by mainline general medical journals in the West.

Blind spots inevitably exist within specific domains of scientific expertise and breakthroughs often come from the fresh perspectives of non-experts, as pointed out in Dr. Harold Varmus’ Book, The Art and Politics of Science, and was evident in the early discovery that tobacco causes cancer by one of my mentors, Dr. Ernst Wynder, when he was a medical student at Washington University! Recognizing this, the Cancer Prevention and Control Program is strongly committed to interdisciplinary science. Our nine core faculty represent four different departments in two schools at USC. Our pending Center of Biomedical Research Excellence application to the National Center for Research Resources will add seven new faculty from six schools within USC. Affiliate members represent nearly 20 departments in five different universities across South Carolina. In order to work together effectively we need to create intellectual oases where we can meet to discuss and exchange ideas in nonjudgmental ways. It also means that we need to get to know enough about what each other are doing so that our understanding is not superficial, even if we may not be able to function as bona fide experts in the “new” area. While talking about this is simple enough, doing it is another matter. Egotistical attachments to very deeply ingrained senses of order and worth are hard to break. It is rare to find people who can give these up at all, let alone easily. So, we work hard to maintain a respectful, inquisitive attitude towards each other as well as colleagues we invite in as collaborators.

We also are committed to community-based participatory research (CBPR), a collaborative approach to research that equitably involves partners in the research process and recognizes the unique strengths that each brings. CBPR emerges from a tradition in environmental health and social justice that encourages social activism and recognizes unique strengths and perspectives through active participation in the research process. The National Cancer Institute (NCI)-funded South Carolina Cancer Disparities Community Network is the main, but not exclusive, vehicle through which we do CBPR. Dr. Leslie Cooper, our Program Office at the NCI and an important team member, is pictured with Dr. Cheryl Armstead, CPCP core faculty member from Psychology, in the Congaree Swamp National Park, located in a very rural area of Lower Richland County just 25 kms (15 miles) from the University of South Carolina in downtown Columbia. By defining team building around projects more broadly to encompass CBPR we honor the community by acknowledging that it has special expertise and specific ways of collecting information and transmitting knowledge. In that sense the community, too, represents disciplines of thought and conduct that embody intellectual domains worthy of equal partnership. In the photo to the right Ann Pringle Washington, President of the Eastover-Lower Richland Business Association, with whom we work on issues ranging from organic farming to healthcare, is second from the right, flanked by Leslie and Cheryl. In a recently published article we describe the important philosophical and practical similarities between CBPR and interdisciplinary research (Hebert JR, †‡Brandt HM, ‡Armstead CA, *‡Adams SA, ‡Steck SE. Interdisciplinary, translational, and community-based participatory research: finding a common language to improve cancer research. Cancer Epidemiol Biomark Prev 2009;18(4):1213-1217.).

I explain to our community-based colleagues that, as with all human interactions, everyone enters the field of play with preconceptions and prejudices. This is not restricted to university members in relation to non-university members. When I have described some of the preconceptions and prejudices that I have witnessed (or even harbored!) to community members they quickly see the universal nature of the problem. The example on squamous cell cancer of the esophagus that we provide in the article is a mea culpa call to attention regarding the blind spots that we encourage when we work in relative isolation to produce academic products at high speed for personal professional advancement. I want to be clear that I do not think that academic promotion is a bad thing; indeed, I appreciate that is necessary for survival. However, we must be committed to supporting people doing this in a principled way that will lead to reductions in cancer-related health disparities. An important part of the process entails working together to overcome our own feelings of superiority and inadequacy, and acting courageously in support of others who have chosen this noble path.