XV. Connecting in Uganda

Despite that I was not quite done with my doctoral program at the time, when Cole P. Dodge called to see if I would come to work for the UN in Uganda for a few months in 1983, I jumped at the chance. True to form, he assigned me the toughest place in the country in which to work on the cleanup after the coup that deposed Idi Amin. Karamoja was an exciting, incredibly beautiful, exotic, and lawless place that would teach me many good lessons. It was the part of the country through which Idi Amin’s army retreated before entering Sudan and leaving Uganda forever. Idi Amin died in Saudi Arabia, the "great" ally of the U.S. in the Middle East, in 2003.

The Karamajong, are a nomadic population of herdsman who were the “beneficiaries” of the looting of the Moroto Armory from which thousands of AK47 rifles and millions of rounds of ammunition were “liberated” by Amin’s army. About the size of New Hampshire and Vermont combined, in the early 1980s Karamoja (on the map it consists of Kotido and Moroto Districts in Northeastern Uganda) had a population of under 100,000, the highest infant mortality rate ever recorded on earth (>600/1000 live births); the highest proportion of children under 5 years old in its population, kids less than twice this age toting AK47s, and severe proneness to famine and malnutrition on a scale unknown in its history.

Welcome James! Cole said with a broad grin after assigning me a Baganda driver (also named James), a Land Rover, enough fuel to last a couple of months, and so much cash that it took what seemed like several hours to stuff it into every crevice of the vehicle. I got to be very good friends with James over this time and in the next year, too. However, I still feel a bit of guilt in my complicity (more like acquiescence, perhaps) in the adventure on which I agreed to go and Cole had so elegantly planned.

My job was to assess the situation; including weighing and measuring thousands of children and working with the World Food Programme to get food to feeding centers in the region over roads that were so bad that it might take 2 hours to go 10 kilometers and where, only half facetiously, we would say that you could tell a drunk driver because he would drive (or at least try to drive!) in a straight line. We maintained a small fleet of Bedford Lorries with which to move the food around and a huge inventory of spare parts as we were constantly breaking major suspension parts (especially springs), wheel bearings and parts of the drive trains (usually drive shafts and differentials). Looting was common and there was a constant sense of excitement in the air. I have many tales to tell of that time, but I do not want to get too far off course from my theme of famine and drawing connections from local experience to world events.

I had lots of time on those long African nights to reflect on the situation of famine, violence, and the oppression of poverty and its twin sister, ignorance. There were a few foreigners working in the region and they were generally very colorful figures – ranging from Catholic Priests and Nuns, a couple of Italian doctors, Medicin sans Frontieres volunteers, and the UN staffers who were usually Irish, Scandinavian, French, or Australian. I would go to Kidepo to spend the warm days and cool nights of these tropical highlands writing my reports and thinking about the things I had seen. Kidepo was just south of the Sudan frontier and it had been crown jewel of the East African Game Parks before it fell victim to civil war. I could hear large gun fire on some of the nights, but for the most part it was remote and a relatively peaceful place to collect my thoughts.

XIV. On Being a Foreigner – Connections

I don’t mind being a foreigner at all – in fact, I find it very disconcerting to be in the company of people with whom I may share a superficial resemblance but whose worldviews usually diverge drastically from mine. This kind of dissonance strikes to the core of my being. Whether it concerns fundamental scientific understanding about how things work or a realization that other cultural perspectives (including those of different scientific cultures) might help to solve a problem, I have an aversive response to arrogance born of ignorance. On my first trip to Asia I commonly met people who measured their time away from their native countries in integer years; some for periods as long as thirty years. So, I found it comforting to know that being exposed to other viewpoints and being away from the “comforts of home” for so long was possible.

In the two years that I lived here in South India, from 1978 to 1980, events were playing out that have changed the world and have reshaped my life in fundamental ways. In 1979, the Soviets invaded Afghanistan and the US began its misguided support of enemies of that regime that would lead to the rise of the Taliban and its oppression of free-thinking people of any gender and age (but especially young women) and support of despotic regimes in countries of the region whose only recommendation was that they were enemies of our enemy (or so they said). What began as our overthrow of democratically elected Mohammed Mossadegh in 1953 and our subsequent installation of the regime of Mohammed Reza Pahleva as Shah of Iran ended with a coup that replaced that form of oppression with a fundamentalist theocracy 25 years later. That, in turn, set the stage for the empowerment of Saddam Hussein who received billions of dollars in military aid from the US back in the early 1980s when it was expedient to manipulate Iraq against Iran. Over the years I have met many casualties from that conflict. Africa had become a battleground of proxy wars, primarily for European powers and their vassal states in the Middle East, and one of these, in Uganda, was playing out for my mentor, Cole Dodge, and me.

When I left India to return to the States in the middle of 1980 after being here for a couple of years, I had this strange, paradoxical feeling that I was too comfortable being an ex-patriot. I modified my GTR (government travel request) so that I could ease back home through East Africa, Egypt, and Europe. In retrospect, this was a wonderful idea. Still, I had never before, nor have ever since, experienced the deep culture shock of returning to live in the U.S. in 1980. What got me through it were the very remarkable people (mainly other doctoral students and postdocs) that I met in Boston and at Harvard during that time. Many have remained close friends and one, in particular, has shared her experiences through 27 years of marriage.

XIII. Fear, Discipline and Learning

I went to the beach this morning and did my hatha yoga asanas in the sand. Over the five weeks that I have been in India I have maintained a discipline in this that literally grounds me in the place. In turn, I find that this practice makes me more focused in attending to both the work and play that I am called to do. Indeed, I think that it either creates the call or gives me the peace to hear it.

As a condition of this sabbatical and the Fulbright Scholarship I have promised much to myself and others. So, I must produce a lot in these few months that I am here in India. I was brought up thinking that instilling fear was the way to get good results; therefore, the idea would be to use fear to scare myself and others into performing. Over the years I have learned from my many teachers that the opposite generally tends to be true, and now do a much better, though still imperfect, job of avoiding the use of fear and the emotion into which it often evolves, anger, as a means for motivating myself and others. Still, it is deep in my being. So the hatha yoga and other forms of disciplining my body and mind are a way for me to maintain focus so that I am not hooked by the fear and devolve into a being that I cannot admire and do not wish to be.

Among other things, my best teachers have caused me to see my own fear by changing my life circumstances in some way. If the truth be known, I am a bit of a thrill-seeker; so, I am a natural for learning to see fear, using it constructively, and transforming it into peace and joy. One cannot enjoy the thrill without living near the edge of fear.

My daughter, Christine, is a great gift in many ways – not the least of which is that she has this same tendency. I recall her flying through the air with great joy in the swing that I put in our tall maple tree in Massachusetts (higher and faster than any of her playmates would dare to go), doing [very] high dives and jumps into a wide assortment of bodies of water, and riding the roller coaster together at the South Carolina State Fair (when she was still young enough to ride with me). My memories of all this are about joy. It is interesting though, that many of her memories of India (at least as told to me by Jane) are about overcoming fear….. on the path to joy?

While looking at the sea this morning I was briefly reminded of the beach at Edisto Island in South Carolina –long, sandy and also facing East. I have nearly drowned in these waters on the Coromandel Coast of the Bay of Bengal, so I have some intimate understanding that it is much rougher here than back home. The current is considerably faster and stronger and the waves pound hard on the sandy shore. The British and French were drawn to this coast (Pondicherry is only a short trip down the coast), just as they were to my ancestral home in Eastern Canada, to the Southern US where I now live, and to Africa, where I also have worked and played. These places are connected by much more than the waters that bathe their coastlines or my limited experience of each. These next several postings will present my experience of places, people and events (my teachers) that link seemingly disparate events to a grand story that is still being played out in the lives of people all over the world. Of course, I am writing this from my own perspective – but this is conditioned to a very large extent by the experience of my teachers and students, who, in the truest sense, are also my teachers.

XII. Teachers

Late this morning, I arrived in Chennai (Madras), greeted by my old friend Mocharla Satya. Coming here is, in many ways, like coming home. Satya connects me to a past that stretches very far back in time and reaches into many parts of the world. All the pictures seen here were shot around Satya & Bjorn's house on the beach south of Chennai or at some ancient (some 2000 years old!) temples in the Southern part of the city.

There are special teachers in our lives. Some of these are individuals. Some of them are the intersection points of places and people; events and experiences that shape us in marvelous and unexpected ways. Between my first trip to India and the second, when the first minor truths of Indian famines were revealed during my two years working in Madras, I met one such teacher in my life.

Cole P. Dodge was a fellow master’s student at the University of Washington when we met in the fall of 1977. He was a bit older than me (by 4 years) and, by far, the more worldly of the two of us. He had escaped a confining life as a poor kid growing up in rural Eastern Washington state through a series of events that put him in the first (and one the very few) batch of Peace Corps volunteers in India in the early 1960s. I believe that he had not even graduated from high school before setting out for the other side of the world. Working in South India he met his remarkable wife, Marilyn, the youngest of seven children raised in a Mennonite missionary family here in South India. By the time we met, Cole and Marilyn had lived and worked through famine and war in Bangladesh, Biafra and Ethiopia and had adopted the third of their three children, Jorna.

Despite our differences, Cole and I had a few things in common. We were (and still are) impatient, especially on matters related to social justice. We were captivated by the call to national service and international cooperation embodied in the presidency of John Kennedy; and that call changed both of us – him more dramatically and more quickly than me. Also, we were both impatient to leave Seattle. By a serendipitous series of accidents we wound up living in Madras for two years, from 1978 to 1980. Marilyn’s brother, Paul Wiebe, introduced me to the fisher (Pattinavar) communities where I did my masters and doctoral field work. Cole and Marilyn introduced me to many seekers of spiritual and other truths, such as Satya. During those years we would see each other pretty frequently – twice a month or so.

Cole and I also both love games – he taught me how to play squash when we were in Seattle and he beat me many times on three continents over the years. Like most great mentors, Cole let me into his life. I recall playing chess and eating dinner, singing, and telling stories on warm tropical nights in Asia and Africa over the next decade or so – then disappearing into warm South Indian and East African nights with the bond of friendship strengthened and lessons learned that made life a little richer and easier to fathom. I have many pictures that evoke the wonder and beauty from those days, lovingly developed and printed by my Dad (who lived vicarious adventures through my life over those years and died nearly twenty years ago). Those photographs are now in South Carolina; so, I cannot post them here.

There was a deadly serious side to all this, especially as we moved on to Uganda in the early 1980s. As I have learned over the years, those people who actually do change the world in fundamentally important ways understand the gamesmanship and fellowship that underlies all human interaction and know that our time on this earth is short and will not be easy no matter what.

XI. Observations on Famine

American children growing up in the 1950’s, were often admonished for not finishing all of the food they were given with the stern, if misguided, warning that “there are children starving in India.” These were the first years after India gained independence, in 1947. There was then, and still is, a lot of ignorance about how other people ("they") live, why they do certain things, and what they feel. I don’t think that the adults at the time meant anything particularly cruel in saying what they said. Neither did they think much about the current reality on the other side of the world nor the historical underpinnings to the half truth that they spoke.

The fact is that 19th century India was the site of the largest famines the world had even known. I had been taught the half truth (in reflection, perhaps the 1/10th truth) that famine is caused by drought, overpopulation, or the combination of the two. There was just enough truth in the explanation for me, as a child, to believe it. Years later, when I was living in India in the 1970s and working in the slums of Madras (now Chennai), I knew that large-scale famines were a thing of the past and was struck by the fact that there were many times as many people then living in both Madras and in India than there had been in the 19th century. So, I knew darned well that the overpopulation argument was, put simply, rubbish.

As I do in my cancer research (and my favorite example is the insufficiency of tobacco as an explanation for causing squamous cell cancers of the esophagus in African Americans) is search for another plausible explanation. Well, this was pretty obvious. If overpopulation did not explain 19th century Indian famines, then drought must. This is where the accumulation of human knowledge comes into play. I was based at the University of Madras at the time and universities are keepers of this knowledge. It took me less than an afternoon to find out that India in the 19th century was no drier than in the 20th. Sure, there were variations in rainfall that appeared to roughly follow the 11- to 12-year periodicity of sunspot cycling, but this had continued through the entire several hundred-year period over which the records to which I had access had been kept.

The mind of a scientist should constantly be searching for the answers to real, specific, and important questions. In so doing, we must draw inferences from what we learn in relation to what others have discovered about our problem. In this recursive process of going from the specific to the general and back again, our minds dance between inductive and inductive reasoning to both solve a problem and deepen our understanding of the deeper truths in life. That is what distinguishes real scientists from mere technicians.

X. History of Public Health

The converging histories of science and public health have emerged as a major interest of mine over the past 30 years. Particular events have provided the impetus for this. For example, the juxtaposition of 19th century India as the site of the largest famines the world had ever known and the realities both of observing its vitality and resilience in daily life and its remarkable record of achievement since independence struck me as kind of odd.

This apparent inconsistency, between the historical facts and current realities, became a major focus of mine when I returned to the US in 1980. At that time, I was just embarking on a doctorate at Harvard. As part of my daily routine in Boston I would walk on roads and by buildings named after the pioneers of the great sanitary and public health revolution of the late 19th and early 20th centuries; Shattuck, Bowditch, Walcott, Bigelow. At that time, I had no idea of how interwoven my deepening understanding of the roots of public health in my home country would become with the reality of India that was beginning to flourish in my consciousness and change my perception of the world.

Jane Teas, a postdoctoral fellow at Harvard whom I met the following year and married the year after that, introduced me to the history of public health in Massachusetts through a book entitled “Public Health and the State: Changing Views in Massachusetts, 1842-1936.” (Rosenkrantz B. Cambridge, MA: Harvard University; 1972.). I don't know the full story of how she came to possess this. However, I do know that I appreciated it so much that I purchased a copy which has occupied a treasured place in my library for 30 years. The ideas would transport me back and forward in time and space, to India, Massachusetts, Uganda, New York, Québec, and South Carolina. They would draw me deep into the stacks of the Widener and Countway libraries and leave me a pretty different person than I was before I opened myself up to these possibilities. Stories such as the one about Lind and the trial he conducted with sailors in the British Navy in the middle of the 18th century took on meanings at many different levels (or, more accurately, their meanings were revealed) .

When teaching epidemiology, I often remind the students that the biggest improvements in public health, which occurred during the age of health protection, had much more to do with social, economic, and environmental justice than with advancements in medical technology. This was very humbling to the students (especially medical students), and starkly evident. The largest decreases in overall mortality rates in human history occurred in the last decades of the 19th and early decades of the 20th centuries (about a 90% reduction in infant mortality in places like New York City). This was a direct result of providing some very basic sanitary services to people who were unable to provide these things for themselves. Before then, life, very literally, stunk. With a sense of purpose and social and environmental justice it changed – dramatically and very quickly. I think that these are lessons we must learn once again.

IX. The Present (time)

From my earliest memories of childhood I have been obsessed with time – both universal time and clock time. I recall driving along in the hoarfrost-covered hills of Eastern Tennessee with Jane, Christine, and Jane’s Grandma Perley when Grandma Perley turned her head toward me and calmly asked how old I was when I became fascinated with endlessness. Fascinated? Obsessed! By five!

I have a strongly “Type A” personality. I am sure that this is at the root of my successes. However, it is also at the root of what I see as my most serious flaws –related primarily to impatience. The dilemma for writing about both what has happened and what will happen is that it pulls me away from the point of thought, feeling, and action. The present, in a sense, vanishes into the past and is pulled into (or pushes us/me into) the future. So, there is no clean distinction between describing the past (and what I have done), and my plans for the future (where intention becomes action, or vanishes).

I think that it is a good idea to live in the present; to have a good time and to greet life’s challenges with enthusiasm and curiosity. I find that it is a bit easier when I am away from my home base. Here, I am constantly a little “off base” – struggling with the language, meeting new people at a rapid rate, and relying on simple routines that don’t require complicated upkeep and maintenance. That is what sabbaticals are for – to set aside time and space for reflection and to both see new things and experience old things in new ways. In this way, I then am “recreated” so that I will be more effective in my work.

As with many people whose intention is to be in the present, I often fail in my attempt to maintain a vibrant orientation to the here and now. The present is a vanishing point – something extraordinarily important to the life of the soul and the intellect, but which is very elusive. When I am not in the present, I am almost always in the future. I console myself in the belief that the ability to project ourselves into the future by more than a matter of few hours, days, weeks (or perhaps, for hibernating animals, for a full season of the year) is a uniquely human trait. My higher calling; to serve humanity and improve the public health (and I mean this in a very broad sense), requires anticipating problems and trends. So, I tend not to live in the past, even though I often actively remind myself that I must learn from the lessons that have been presented to me.

(All pictures were all shot in the past 24 hours)

VIII. Orthogonality

In mathematics, two lines or vectors are orthogonal if they meet at right angles (or are perpendicular to one another). I am very fond of this word, as it has a very clear and precise meaning in mathematics (and related subjects such as statistics and the wood working that I do on my table saw in my workshop back in South Carolina).

It also is widely applicable to human affairs, including those things that we can, should, and occasionally do, study in epidemiology. As I like to tell my students, the methods by which (i.e., how) you go about studying whether or not something (like diet) is related to something else (like cancer) is orthogonal to how it works. That is why Bradford Hill and the authors of the Classic 1964 Surgeon General’s Report on Smoking and Health (see chapter VI. Truth or the Water Heater) sought fit to relegate an explanation as to plausibility to dead last among the criteria for judging causality.

Now, don’t get me wrong: I love a good story as much as just about anyone I know. However, I am diligent about building a firewall between the story a priori and the scientific process of discovery. In science, without the truth vector, the story vector really isn’t worth very much. By contrast the truth vector often means a lot all on its own. Take the example of the very first clinical trial in nutrition (or as far as I know, anything else for that matter). Through much of human history, and especially in the northern latitudes, scurvy was a scourge. Conducted in 1754 in sailors in the Royal Navy, Lind’s classic study established that what we later discovered were vitamin C-rich foods could prevent and even reverse scurvy. From then on, as a very practical primary and secondary preventive, sailors were then given limes to keep them healthy (hence the name “Limeys”). Of course, it was another nearly two centuries later that Albert Szent-Györgyi received the Nobel prize (in 1937 just four years after the end of his experiments) for showing ascorbic acid’s critical role in collagen metabolism.

This Fulbright experience is a reminder that orthogonality of events literately punctuates my life (and the lives of many others) in numerous ways. These “chance” meetings in time, space, language and culture provide the clues (indeed the “stuff”) of deeper understanding. I will talk more about these later; much more – because they form the basis for why we are here. After all, these are intersecting universes of experience (though they may seem parallel for long periods of time).

VII. The Present

With 500,000 words in the English language (more than twice as many as in any other language) you would think that there wouldn't be very many words that have multiple meanings. Well, if you thought that, you're wrong. Take the word “set.” Some unabridged dictionaries ascribe more than 200 meanings to the word. Well, I have no intention of setting out to discuss the word “set.” However, I do wish to talk a bit about the present.

My friend Dr. Karen Peterson, whose birthday is today, used to say that every time that she would see me or my daughter Christine, it was like having a Christmas present. Until we moved from Boston (when Christine was still a little girl – 3 ½ years old), we would visit weekly (this was pretty much an every-Saturday ritual for years). This is a picture of Christine graduating from high school last May. She is on the left, with her friends Emily and Katie (who also ended up going to school in New York). This is another one of Christine and Karen, three years ago at my Mom’s 93rd Birthday Party, and one of Christine on the beach near where Mom used to live.

Of course, when it comes to feeling that I had gotten a present, I felt (and feel) similarly about Karen. I think that Christine did (and does), too. What Karen said used to reorient me to the here and now. One really is in the present when one is in the presence of a present. Friendships are like presents.

What’s especially nice about this “business” is that I am surrounded by people with similar values. Some of them, such as Karen and Dr. Prakash Gupta, become lifelong friends. That seems to be happening now with a number of people around here including Drs. Mangesh Pednekar (who is Associate Director of Healis) and Rajiv Sarin. Not only do these friendships produce such warmth and comfort, they are pretty productive in other ways, too. For example, on the academic side, Karen and I published seven papers together last year and Mangesh (on the far right), Prakash, and I published two. What's probably more important is that these people are changing the world in fundamentally important ways (such as setting tobacco use policies for the largest country on the planet and revolutionizing cancer care).

Yesterday afternoon, I got an e-mail from Dr. Sarin asking me if I'd like to go for a walk. I love going for walks here. So, I finished up my work at Healis and took Ruby back home to ACTREC. Just around sundown Dr. Sarin, Dr. Pradnya Kowtal (the director of the lab in which the single nucleotide polymorphisms for our breast cancer study will be tested) and I began a tour around the campus. It was a long and elegant walk on which we greeted patients and talked about the philosophy of patient care and careful use of scarce resources. Part way through the walk, Pradnya mentioned that it was Dr. Madhavi Chilkuri's (another one of these most interesting radiation oncologists – I’ll talk more about that later!) Birthday, too! So, we stopped by the Guest House, where both Madhavi and I are staying and where I took this picture, and proceeded to walk. Madhavi lagged behind because of her fear of snakes. We ended up having this very nice birthday toast with sweet lemon juice. Of course, we made sure that there were no snakes lurking before sitting down. Later, on our walk back to the Guest House, Dr. Sarin shared some stories about his appreciation for snakes and that the ACTREC grounds keepers present them to him after capturing them and before releasing them in the forest nearby.

VI. Truth or the Water Heater

Well, these ideas just keep popping into my head. Then they roll around for a while and come back out. Sometimes, they smooth out, like those bits of turquoise I would put in a tumble polisher when I lived in Colorado. I suppose they'll all get smooth over time. Some just take longer than others because of their size or hardness.

The water heater is a lot simpler than the truth; though you will see that that idea can go lots of interesting places and get quite complicated, too. Still, I figured that I would save that for another day.

People have been obsessed with truth (or TRUTH, as the case may be) for a very long time. Ancient philosophers from many traditions have contemplated this concept. There are many ancient symbols from different cultures that symbolize the truth. Where I went to graduate school the motto is “VERITAS” (NOTICE ALL CAPITAL LETTERS). This is a one-word statement. It doesn't state whether it is good or bad, desirable or undesirable, or what one might do with “it” if one had “it.” Is this Mysterious? Or maybe they just haven't gotten around to thinking it through quite yet.

When I teach epidemiology I make a point of going over the Criteria for Judging Causality as originally proposed by Bradford Hill in 1953 (Hill AB. Observation and Experiment. N Engl J Med 1953;248:3-9.) and popularized in the 1964 Surgeon General's on Smoking and Health (U.S. Department of Health Education and Welfare. Smoking and Health: Report of the Advisory Committee to the Surgeon General of the Public Health Services. 1964; P.H.S. Publ. No. 1103, Washington, DC.). This is all about discerning the “signal” of truth from all the “noise” of error, confusion, and the deliberate intention of some to mislead.

Of the six criteria listed in the 1964 Surgeon General's report, biological plausibility is listed last. It is interesting that this is the obsession of most “basic” scientists I know. In this sense, the obsession is much more consistent with Western philosophy in which truth is seen as transcendent. On the other hand, putting it last (after things like the strength of the association and consistency of the findings from different kinds of studies), is much more consistent with the view of Eastern philosophy in which truth is seen as imminent. This is pretty much the case throughout Asia, not just in India.

The reality is that the scientific method, in which we test whether or not something works (and the question of "how " usually transcends our experiment), is much more consistent with the Eastern view of reality in which truth is constantly being revealed. The Western view posits that there is some grand story that transcends the daily experiences of our senses.

Oh, those inscrutable Westerners.