CPCP Director's Corner

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

2009-07-22T07:31:00.005-04:00

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.

XXXVIII. Health Care Reform and Cancer Prevention and Control

2009-06-22T06:42:00.002-04:00

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.

XXXVII. Poverty, Gender and Health

2009-06-17T10:27:00.000-04:00

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.

XXXVI. Reflecting on the Grand Opening

2009-06-10T11:25:00.000-04:00

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)

XXXV. Grand Opening

2009-06-03T10:36:00.000-04:00

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 http://cpcp.sph.sc.edu/ for more information).

Reference:
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.

XXXIV. Monsoon, Famine, Gandhi and the Spinning Wheel

2009-05-28T21:16:00.000-04:00

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.

Reference:
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.

XXXIII. Good Bye India

2009-05-25T19:13:00.001-04:00

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.

XXXII. Interdisciplinarity and Community-Based Participatory Research

2009-05-20T11:23:00.000-04:00

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.

XXXI. Science and Caste

2009-05-18T04:24:00.000-04:00

In contrast to their modern Western counterparts that are just a few centuries old, Indian medicine, astronomy, philosophy and scientific reasoning represent unbroken traditions that had evolved over thousands of years. As an example of its sophistication, Vaisesika, one of the six systems of Indian philosophy, deduced the planetary-like motion of sub-atomic particles thousands of years ago and reduced time mathematically by describing its smallest unit (kala) as the period taken by an atom to traverse its own unit of space; thus anticipating the atomic clock by thousands of years.

The major caste designations refer to occupational categories: Brahmin (teachers, scholars and priests), Kshatriya (rulers and warriors), Vaishya (farmers and traders), and Shudra (service providers and artisans). However, over thousands of years, the system evolved into a method of social separation based on complex system of cultural-religious rules in which hierarchical status was conferred by birth. Indeed, the word for caste, Varna, derives from the Sanskrit word for color. The yoking of science and medicine to the caste system ultimately led to a rigidity of thought that eventually stunted the process of accumulating, storing, and transmitting scientific knowledge. This happened in two ways. First, the caste system prohibited the vast majority of people, with all their intelligence and creativity, from participating in the scientific process, or even from obtaining a general education (which might lead there by “accident,” as it often does). Second, caste prohibitions made it impossible for the Brahmins to undertake things such as dissection of human corpses or even to develop anything but superficial surgical procedures. This severely impeded the advancement of biomedical science.

By the time the Europeans arrived on the scene in the 17th century India was in decline on many fronts, including the sciences. By contrast, Western science was on the verge of entering a golden age of exponential growth both methodologically and substantively. The great Indian scientist, Sir Jagadish Chandra Bose, who was born in Bengal in the late 19th century, is credited with laying the Indian foundations of experimental science, hitherto considered the province of “Western intellectual tradition.” Bose understood that the Western method of submitting theory to scrupulous experimental verification could go hand-in-hand with the gift for careful observation and introspection that was his Eastern heritage; recall orthogonality. Like the dance of inductive and deductive reasoning (more on that later), the combining of Eastern and Western Traditions could lead (and, for Bose, did lead) to amazing breakthroughs across a spectacular array of the natural and physical sciences. Bose recognized that “science is neither of the East or of the West, but rather international in its universality.” And that “India [was] specially fitted to make great contributions. The burning Indian imagination, which can extort new order out from apparently contradictory facts, is held in check by the habit of concentration. This restraint confers the power to hold the mind to the pursuit of truth with an infinite patience.”

What Bose also understood, and evinced in this work, is that major scientific advances often come from individuals outside the disciplines originally called upon to either describe how things work or to find a solution to a specific problem. In some instances, this has involved the creation of entirely new disciplinary frameworks that draw from intellectual and philosophical domains theretofore not linked. Many such examples also exist in the history of science in the West, ranging from astronomy (e.g., the Copernican Revolution) to zoology (e.g., the Darwinian Revolution) to the fields that constitute public health.

Often progress in science is non-linear, resulting from breakthroughs against limits imposed on ideas that define them as "thinkable" at certain times and expansion of the intellectual options and strategies considered "available" at those times. That is, theory change in science depends more on changing intellectual circumstances and possibilities than on accumulation of knowledge within a discipline. Quotes from his meeting with Yogi Paramahansa Yogananda illustrate Bose’ keen understanding of how science progresses: “But high success is not to be obtained with a rigid exactitude. All creative scientists know that the true laboratory is the mind, where behind illusions they uncover the laws of truth.”

What Bose did not anticipate was a kind of caste system in modern science. Although an accomplished physicist, whose work on radio waves predated Marconi’s; he became interested in plant physiology. As that work progressed he “was advised to confine himself to investigations in physics rather than to encroach on their preserves…. [he] had unwittingly strayed into the domain of the unfamiliar and had offended its etiquette.” On the “religious” side he noted: “An unconscious theological bias was also present, which confounds ignorance with faith. It is often forgotten that He who has surrounded us with this ever evolving mystery of creation also implanted in us the desire to question and understand.” Both of these restrictive views are very familiar to those of us who have had to deal with the rigidity of thought within the domains of “techno-science” and “religious fundamentalism,” and the toxic combination of the two, especially over the past eight years.

XXX. Trust, Surrender, Expansion and Health

2009-05-16T12:28:00.001-04:00

Owing in part to the salubrious effects of the dry climate in the region and the serendipitous “discovery” that combining Ayurveda, Chinese Traditional Medicine (mainly acupressure, although that also exists in Ayurveda), and Naturopathy produces excellent responses in people with a variety of chronic conditions, the Kutch is now home to five “nature cure centres,” including Ananddhan.

Although the Cancer Prevention and Control Program does not function as a spa, we share the view that people have the capacity to prevent or to alter the course of most chronic health conditions, including potentially fatal diseases such as cancer. Healthful changes in diet and physical activity have central importance in our work and these also figure prominently in Eastern traditional medical systems (and Naturopathy). Of course, spending more time diversifying ones diet and becoming more physically active requires that one also learn to give up toxic, unhealthful things that may be comfortable in their familiarity. This requires that people want to change; which, in turn, entails that they trust that the changes they will make will improve their health. They need to surrender to a “master” whom they acknowledge has special knowledge and whom they believe has their best interests at heart.

Beyond the knowledge we hold, I think that it is important that such teachers impart the belief that by embracing the idea and committing to a path of fundamental change a new world of experience will expand on what had preceded it. I think that many people who will not make changes to improve their health (and I mean this expansively to include psychological and spiritual health) believe that what we might recommend represents deprivation or constriction – a net loss in their lives. As with any form of education, we teach people that in order to make healthful changes they become more mentally active in their pursuit of better health! With the increase in awareness it is inevitable that when they meet with success, their world expands.

Most of my time during this sabbatical has been spent in urban India. My work days have typically been 14 to 16 hours long; waking up very early to catch the tail end of the work day in North America, working through the entire Indian work day, and then working until past noon EDST (about 10:00PM Indian Standard Time) to participate in conference calls, etc., at the beginning of the day back in the U.S. I am good at my work and am a bit of a workaholic; so, this comes almost too easily to me. The facilities at both ACTREC and Healis are superb; so, that also enables me to work full-speed. Fortunately, I have learned that it is not altogether helpful (or healthful!) and I sometimes just need to stop. So, when my friend, Neena, who is a genetics counselor at TMH and lives upstairs from me in the ACTREC campus, suggested that I visit a nature cure centre in the Kutch, I took her suggestion very seriously. Having embarked on similar adventures in the past, I knew that it was important to commit before my natural tendency to resist change and stick with the familiar took hold.

Soon after arriving in India I had weaned myself from coffee but got a bit addicted to morning tea. Since coming here, I have had to give up caffeine in any form. After the first day at Ananddhan the headache disappeared. I have had to surrender to Dr. Joshi, who plans the program (but is very flexible with regard to my wish to experience everything on their “menu”); Tulsi and Giriraj, who do the warm packs; Tiwali, who is in charge of massage and acupressure (and is seen working on Dr. Joshi, who has surrendered!); and Manju, who runs the kitchen. My diet consists mainly of fruits, sprouts, and other vegetables. I am the only non-Indian here, and virtually the entire program is in Gujarati (though virtually everyone speaks Hindi and a little English). I do not always know what is going on, but people are patient and very good natured. I think that this is another important element of health. Whatever we do really should be done with a joyous, open and trusting heart. At my last meal at Dr. Prakash & Alka Gupta’s house before coming here I thanked them for dinner and mentioned that a special ingredient was love. Rather than being taken aback, Prakash simply agreed wholeheartedly.

Since coming here I tried just about every treatment available. It makes for about an 8-hour day, plus some really nice side trips. It is good for me to be on the receiving end of these things – as I think is true of anyone whose practice consists partly of preaching.

XXIX. Travel to the Kutch

2009-05-16T04:59:00.000-04:00

In antiquity there were two main trade routes from the Middle East and Africa to India and beyond. Caravans traveled the more northerly of these through Persia, Afghanistan, over the Khyber Pass, into the Indian subcontinent, and often then on to points further north, east and south. Essentially, this was the itinerary I followed on my first trip to India.

The more southerly route went over water, from Indian Ocean ports on Africa’s East Coast such as Dar es Salaam, Zanzibar, Mombasa, and Lamu, tracking a course southeast of the Arabian Peninsula and into the Arabian Sea. The ancient dhow trade from Africa and Arabia relied on persistent “trade winds” that move in a cyclonic pattern from south-southwest to northeast towards more northerly latitudes and from northeast to west-southwest toward more southerly ones; thus ensuring return passage from India and other places in the Orient. In the week that I have been here the wind has blown persistently, and at times strongly, from the west-southwest.

Located above the Arabian Sea and just south and east of the Sind (in what is now Pakistan), the Kutch is a place I have wanted to visit for a long time. Primarily through its port at Mandvi, the Kutch was a center of the dhow trade and therefore had more or less direct contact with Africa for millennia. One can see this in the facial features of some of the people in this region (these are pictures of Rashida and Raju, who work at the place that I am staying).

Because it is separated from areas further north by great salt deserts known as the Great Rann (of the Kutch), on its northwestern frontier, and the Small Rann, on its northeast, it remained in relative isolation from land passage from the north through most of its history. In more ancient geologic time the Ranns (indeed the entire region) was under a larger and more extensive sea than what currently exists.

Although the Kutch looks quiet geologically, it isn’t. The region was the site of a major earthquake in 2002 that leveled much of the built environment, including many villages and most of the medieval city of Bhuj. I am sad that I did not visit the place before that happened. Such is the price of procrastination and dalliance.

I had the privilege to visit the Great Rann on the second to last evening I was in the Kutch. As far as the eye could see there was a vast expanse of salt-crusted earth. When taking these photos with some new friends from the Ananddhan Nature Cure Center I was reminded of times spent around the Arctic Circle – in the summer when the sun has crested the horizon. In the far north, with the sun so low in the sky, there is the constant threat of impending cold (even with global warming it can get very cold). Here, though, that persistent west-southwesterly wind blows warm, almost hot, air across these timeless plains.

XXVIII. The Scientist-Saint in the Indian Tradition

2009-05-11T11:33:00.000-04:00

No matter what the pursuit, a limber mind is an important asset. Seekers of deeper truths may be, and indeed often are, technically excellent at one or a few things. Furthermore, as long as we live on this material plane there is a need to do things, make things happen, do what humans do: build! However, for these seekers the capacity to be technically expert is not the goal. Expressing technical excellence is the vehicle, or means, to a worthy end. These special people are able to evince and impart extraordinary grace in combining their sense of life’s deeper purpose with the imperative to serve both material and spiritual needs. My experience of such people is that they are mischievously clever, possess great senses of humor, and have the equanimity to live life with great joy and to convey this to others along the way.

A scientist is, at heart, a skeptic. Spirituality is, by definition, not of this material plane and therefore not “knowable” through the agency of our five senses. The process of scientific enquiry exercises the mind and that may (or may not) lead to pondering life’s deeper purpose or meaning. I tend to think that a scientist’s mind, like that of a yogi, is built to wander in the direction of deeper purpose. When it does, the inevitable question arises: Why? I like to think of this as a many-layered question. In raising a child (and teaching graduate students) I found this to be an especially valuable opportunity to look at such questions as a way to explain (as much to myself as the student) purpose, function, structure, meaning, and worth.

Hemali and members of her extended family, with whom I shared those days at the wedding in Delhi and in Nanital, explain that there is a scientific basis to Jainism. It is borne of careful observation over 2500 years. The Jain religion and philosophical orientation to life is contemporaneous with Buddhism and shares many concepts, including Ahimsa (a commitment not to harm living things). Christianity is newer, but many of its tenets are similar, if not identical (even if many organized Christian religions have drifted far from these fundamental beliefs).

All of these religious paths are consistent with general Eastern philosophical tradition that accords predominance to recognizing Truth as imminent and thereby ascribes central significance to careful observation (including ones own actions and their effects on other people and things). The vast majority of epidemiologic studies on which I have worked (including the Mumbai Cohort Study and other major cohorts and case-control studies) are observational in nature. So, I have chosen a field in which there is an imperative to watch, measure, and understand what “causes” sickness and health in the chaos and messiness of human lives. Patience does not come naturally to me; so, being forced to pay attention to things that can happen only in and through time has been a gift in more ways than just professionally.

India and the United States are different and similar in ways that are not revealed through casual observation. I will talk more about these dissimilarities and similarities later. One tradition that is unique to India is that of Sannyasa. After doing ones duty to career and family a person is free to pursue a spiritual path that may entail service at a level and in a manner not possible under the constraints of having to attend to the demands of professional advancement and acquiring wealth to provide for a family. While not everyone does this and those who do take myriad paths, there is a tradition stemming from a widely held view that doing so is a personal and societal “good.” Even if the Sannyasi suffers material hardship and may become obviously poor, he or she is held in very high regard in society – especially in the places where he or she performs service. This is a picture of Lochan Vishal Sharma, of Jodhpur, taken when I visited him for the first time in 1977 and whom Jane, Christine and I visited on my last sabbatical in 1997-8. He was a civil servant before retiring, can speak five languages fluently, is a mathematical wizard, and was taking care of two mentally ill men and providing water to the people on a daily basis.

Combining the widespread appreciation of spiritual and scientific development with social welfare, has produced some remarkable results. When I am in India I come face to face with people who embody such traits and tendencies. While these people are usually very accomplished professionally, that alone does not set them apart from their peers professionally. I have talked a bit about Dr. Prakash Gupta and his leadership in both epidemiology and in directing anti-tobacco efforts both here in India and globally. Dr. Rajiv Sarin and I are exploring how “big” (well-funded, highly cited) science is tackling the “big” problems of over-population, global warming, and as-yet unanticipated health effects of worldwide environmental change. In his role as the Director of ACTREC, the issue of humane and efficient treatment of cancer patients also figures prominently in planning how to use scarce and precious resources.

Dr. SS Badrinath and Shankara Nethralaya in Chennai are living examples of the scientist-saint and his creation. Shankara Nethralaya is a striking illustration of a first-class eye hospital providing a wide array of services in South India (and into Central India) to the full range of people, from the very wealthy to the utterly destitute. Its outreach includes some of the most amazing telemedicine on earth. It also conducts some exemplary basic science research spanning a broad continuum from the genetic control to environmental epidemiology of eye diseases. Along with Dr. Harris Pastides and other visitors from University of South Carolina a little over a year ago I was introduced to Dr. Badrinath and Shankara Nethralaya by Dr. Meera Nirasimhan, a similarly inclined colleague who grew up in South India, is now a faculty member at USC (in Psychiatry), and performs one month of service/year at a rural hospital in Andhra Pradesh. Since that first introduction I have returned to work with the Shankara Nethralaya team on the trip to Chennai that I talked about in XII. Teachers. Over this time I have learned that Shankara Nethralaya and Dr. Badrinath are nearly household names throughout India – testimony not only to their accomplishment, but to a society that deeply values such work.

I would like these examples to inspire our work in the Cancer Prevention and Control Program. The Scientist-Saint tradition of India is something to which people anywhere ought to aspire.

XXVII. Science, Spirituality and Religion

2009-05-05T05:48:00.001-04:00

I have written previously about the distinction between the essential character of a scientist versus that of a technician. In a purely technical sense, my aptitude was (and, perhaps, in some sense, still is) in those things that define and constitute an engineer. My college scholarship was in engineering and Boston University paid me well to go there as one of the first batch of students in their then-fledgling School of Engineering. I will always be grateful for the opportunity they gave me – and little did any of us know at the time just what kind of opportunity it would turn out to be.

It was the mid- to late-sixties, an illegal, unjust war was raging in Southeast Asia, and the tiny, backward, insular, provincial world of my youth was about to expand, indeed explode – quickly, dramatically, convulsively. Reflecting on that time, I must have known from early on that engineering would not be my path. I was a well-behaved child (not a single detention in high school), but troublesome in terms of the kinds of questions I asked. In the very conservative, Roman Catholic-Republican tradition in which my parents were trying to raise me, asking questions that could not be answered by the Catechism meant big trouble. For outsiders: up through the sixth decade of the 20th century the Irish and French in French Canada and much of New England practiced a very conservative form of Catholicism known as Jansenism. With its heavy focus on original sin, the depravity of the human condition, and predestination, this was great fun for children (and some priests who preyed on their innocence). Despite their religious similarities, the French are (or were in the last part of the 19th and first three-quarters of the 20th century) very different politically from the Irish or Italians or other immigrants from Europe, who tended to be Democrats.

For me and my siblings, who were similarly inclined, the reluctance to allow that members of the “flock” could think led to an early apostasy from the political party of my parents and the Church. Despite the outward appearance of resolve and commitment to the regressive politics and stifling religion they professed, my parents were considerably ambivalent. My father had a quiet inquisitiveness, appreciation for intellectual pursuits, and a timid distrust of authority. My mother was firmly, indeed avidly, committed to her children’s education as the way out of the kind of life that she was forced to lead. At a fundamental level she did not really believe that her boys should go to Vietnam to fight the “commies,” despite her avowed faith in the government’s anti-communist ruse. Unlike dictators who will stifle education because they know its power to threaten their authority, the love of a parent dedicated to the betterment of her children will overcome the reluctance that derives from the realization that education opens the mind in unpredictable ways – and creates troublesome, questioning children along the way. Each of us, in our own way, saw the cracks, drove in the wedge, and broke out.

Over the years I have come to understand that religion and spirituality are orthogonal concepts (see VIII. Orthogonality); and have sought deeper understanding of both the material and non-material bases of life. I have met many truly religious people who practice their belief through hard work for the betterment of others. This is in stark and wonderful juxtaposition to the shallow, showy, and blustery stuff that “fundamentalists” use to intimidate so as to exert control over individuals in order to gain and consolidate power.

I know enough about the life of Jesus to appreciate the importance he attached to social justice and good deeds as an expression of one’s commitment to things beyond our own material needs; and certainly beyond our hedonistic desires and pure greed. Despite the church’s malevolent, oppressive aspect in the Middle Ages, I see the great cathedrals of Europe as a dramatic expression of the belief in the power of the Church by the artisan class and their supporters and sponsors. I also see this power in India in many religious traditions, including the Assyrian Christians who are reputed to have entombed the remains of Saint Thomas, who died in India in the 7th decade of the 1st century AD, in San Thome Basilica in Chennai.

What I have sought, and still continue to seek, is to understand how some people in our modern world, with all of its inequities and chaos, have managed to live inquisitive, useful lives that satisfy both their own intellectual yearnings and the principles espoused by virtually all of the great spiritual leaders throughout history. I have seen this in Mennonite and Catholic Missionaries in different parts of the developing world (an image of Father Marco plowing a field in Karamoja comes to mind) and in the quiet practice of people who do not even profess a formal “religion.” Over the years, I have come to embrace the idea that true religion is “practice.” Neither a series of lectures nor posturing to advance ones position in the social and political order meets my definition of religion.

XXVI. Celebration

2009-05-04T07:59:00.000-04:00

Today is a big day in my family. It is Jane’s Birthday (Happy Birthday!) and my parents’ 74th wedding anniversary. It also is the 12th Anniversary of the laying of the cornerstone of the Advanced Centre for Research Treatment and Education in Cancer.

Things are going very well; so, I have many of life’s little miracles to celebrate. One thing that I was not anticipating being so grateful about is the clean smell of the night air. For several months, there was a very acrid smell of burning toxic waste that would permeate the ACTREC campus. I was advised by friends and colleagues to leave until it got sorted out. However, I felt that my presence was needed for a resolution. I asked myself what Gandhi, or Jesus, or Martin Luther King would do, and decided to stay. To abandon the cancer patients seemed like a cowardly exercise in privilege. So in a state fluctuating between scared, angry, and sad I set out to do what I could as a visiting scientist to make things better.

I wrote letters to the editor of several papers (the Times of India, Indian Express, and the Hindu). As many of you know, I have some practice with that sort of thing. I was interviewed by Mr Namdev More from Lokmat, a local Marathi paper, and there were stories in the local media that got some attention. I then wrote a letter to the regional authorities that apparently finished the job (you can blow this, or any image, up by clicking on it):

I was not willing to acknowledge this kind note from Dr. Sarin until I was pretty confident that it stopped: "If it was not for your persistent effort we would not have reached this stage." After several nights of clear air and word from Mr. Jayaraman, ACTREC Chief Security Officer, that the menace is over, I am ready to celebrate that we can breathe in peace! I think that Jane will be proud and happy that this came to a final resolution around the time of her birthday.

XXV. Family, Food and Fun

2009-05-04T05:19:00.000-04:00

Like the other bookend to this trip to North India I am waiting in Indira Gandhi Airport for my flight home to Mumbai. I miss the “family” already, but will take advantage of the inspiration our shared time and experience has provided.

When Hemali invited me to join her and her extended family for the wedding and on the trip to Nanital, I did not hesitate to accept. Hemali and I have worked together in India for nearly 20 years and she lived with Jane, Christine and me while on a UICC fellowship to UMass Medical School in 1998.

I love the idea of family but admit to having a certain amount of ambivalence regarding the level of commitment needed to actually live in close quarters with siblings, parents, children and in-laws for …. well …. Ever! I think of myself as a very committed person but I am quite an American in “wanting” my privacy. “Treasuring” might be a better word to use, because we expend such vast resources in living our very private, isolated lives.

I relish Indian food, find Indian weddings great fun, know Jains have very high culinary standards, and I like Hemali and Karun a lot. So, I figured this would be a good bet to go well. Still, I wanted to approach this as a true participant and not as an anthropologist.

Well, it takes very little in the way of dancing and good food to limber up. There was little doubt that this would go well from very early on. Even though my biorhythms are very different (I am such a “morning” person and they are such “night” people), other than the night of the wedding when we all got to bed about 1:45am, I was given extraordinary slack to go to bed early (around 11:30pm most nights). The only thing I regret is that I would not get through a single verse of a song during our sing-along! Still, folks were forgiving – and even that failure was fun and endearing in a crazy kind of way. In the morning, while they slept in, I would do yoga, walk and have breakfast on my own. So, we ended up spending about 15 hours per day together.

As Bobby (Suketu), Hemali’s brother and I agreed over lunch earlier today, children are our best teachers. In an Indian extended family there are always children – so, lots of opportunities to learn. Just about all of the time, these lessons seem to be great fun. I did not think about it at the time, but after nearly a week together, there was not a single word spoken in anger. Maybe this is Ahimsa (unwilling to cause harm to another) in action, but I think that it is made possible through unspoken rules that entail spelling one another when someone begins to become irritable or cranky. However it worked, though, it was very subtle and highly effective.

I will never forget this family. Meena, with her love of chilly peppers and an appreciation for mine. Bobby, social engineer par excellence – the competent only son. Their daughters; Aayushi – oh, what a smile and even, steady, soft, and secure presence – and Dhwani – oh, what a fireball (where does all that energy come from)! Karun, the South Indian that Hemali’s path in life was fortunate enough to cross (or was it Karma?) and their beautiful daughter, Eesha (the intellectual and surrogate older sister to Dhwani, who keeps the whole family on the run). Hemali is known as “Sweetie” and is the eldest sister and a huge favorite among the kids. I met Vinita, Hemali’s younger sister on this trip – what a laugh and what a voice: the “Singing Chemist” as I learned. Her husband, Nilesh, is the newest member of the family and his voice, athleticism, and willingness to engage are things I will remember. Both he and Karun, as the “outsider” and the “newcomer,” helped me to feel very comfortable, indeed. Their philosophical and cultural perspectives are something I learned a lot from. Then, there were the parents: Chandrakant, Hemali’s and Vinita’s father, the quiet intellectual and expert on Jain philosophy, and Vinita’s and Hemali’s mother, Sukanya, who took a real interest in making me feel at home. I think their smiling, happy faces speak more than my words can. Feast.

What does this have to do with cancer research, service and treatment? Plenty. I met Hemali through this work with Dr. Gupta and I know that what we “grow” in our lives comes from the “wells” we maintain and the “fertility of the soil” in which we plant our “seeds.” I also know that the “Jain Prescription” for life and living is probably good for improving immune response and controlling chronic inflammation – things that form the basis of the Mumbai Cohort Study (see V. Experience and Experimentation) and, more importantly, influence the process of carcinogenesis.

XXIV. Time – Passages

2009-05-03T00:34:00.000-04:00

It is a bit before 0700 on Monday the 27th of April 2009. I am in Chatrapati Shivaji Airport in Mumbai, on my way to join Hemali, Karun, and Eesha Shetty and their extended family for a wedding in Delhi, then on to Nanital. I see a young girl (maybe 5 or 6 years old) traveling with her parents; redolent of those days when we used to travel as a family. I started writing in my journal when I was about her age. I loved the images of life and wanted to capture them – fearing that when I got older I would not remember. I sometimes go back to the writings of my youth, and my writings about Christine’s youth. Precious memories. There is something true about the impermanence, but also about the ability for the writing to evoke the memories.

I love the tastes, smells, sights, and sounds of my life now. Talking with Jane and Christine on the computer! The wonderful Thali last night in the ACTREC canteen. The conversations with Ashok, Dilip, and Navin on science, patient care, and the meaning of life. The drive to the airport in the comfort of the ACTREC Director’s car. The gentle sort of self-discipline that I have learned over the years (and especially recently). The experiences that life has given me and what I have been able to take from them.

Still, I also love the memory of the tastes smells, sights, and sounds of those days when Christine was young – Diving in the Caribbean and eating conch on the beach. Playing in the snow. Cooking on the open fire in the Masai Mara. The 4-day Camel Safari in the Thar Desert; sleeping under the stars, milking the goats for tea. Christmases in Oaxaca, Central Massachusetts, Kathmandu, Nairobi, and Chico. Swinging high over the fire pit in Columbia, South Carolina.

People here ask me: Where is your family? Well, scattered in space I say. In South Carolina, New York, Massachusetts. If I go back in time (but I don’t in conversation) my mind wanders – to the French Cemetery in Fall River (Faux Riche, as Dad would say), to Ste. Moises, Quebec (where Pepé’s side of the family was buried until the last third of the 19th century). Nearly three hundred years before that – Normandy, Brittany….and those Micmacs who were living on the frozen shores and inland waterways of North America for thousands of years before that. Amazing people, these ancestors of mine.

I recall earlier times in India and Southwest Asia – evoking images of people who are vague memories. Are they real? Where does the dream begin? Where did this time go? Still, I have their pictures – stark, vivid, looking straight at me from decades gone, disappeared. But was there a time that I cannot remember? There is something pulling at me. Tens of thousands of years ago as they left Africa and traveled to the East, The Ancestors settled and then there was a second Diaspora, from South and Central Asia. Some went into Europe, but most traveled East, in the direction of the rising sun. Remember Australia? The Dream Time. The Ancestors walked these lands that I now fly over. Traveling East; in the direction of New beginnings. Youth. Love. East. To the New World.

Time – the playground on which the drama of life unfolds. Timeless India. Walking the streets of Varanasi (Benares) to the Burning Ghats. Ancient city when Christ was born. I am pulled from the past into the future – as I have said, my favorite adobe when I will not be in the present. India; Land of endless stories. Truth revealed – if I am only not too blind to see, not too deaf to hear, and not too closed to experience the touch, smells, and tastes that will come my way.

XXIII. Expectations and Experience

2009-04-24T05:32:00.000-04:00

When I come to India I expect certain things. Some of these are well known to people here. They would include: A plethora of wonderfully spicy Indian food from a country larger and more culturally and linguistically diverse than all of Europe, North Africa, and the Middle East combined. A riot of colors and cultural experiences. From late March until the monsoon begins in early June (and beyond), luscious mangoes in plentiful supply. Periodic, and in some instances daily, blackouts euphemistically known as “power shedding” (but not at ACTREC, which is a Central Government of India facility).

I also expect to speak Hindi on the street and in the market (which does surprise many people); but primarily English to colleagues with whom I work daily (which doesn’t); traveling by very punctual and highly efficient public transport whenever possible; and bucket baths using primarily cold water (which is getting harder to find right now).

Both in India and other places, I choose my colleagues because I see in them a combination of some traits that I do have and some that I lack. I suppose that they choose me for similar reasons. Generally, my colleagues become lifelong friends and acquaintances. I still publish papers with people who were in my doctoral program. It is not uncommon for one of my papers to have as co-authors people whom I have known for decades and others who are current graduate students. The are all very, very smart, insightful, punctual, kind, facilitative, and progressive in their thinking.

I have really good nighttime talks and walks with Dr. Rajiv Sarin, Director of ACTREC. These conversations, often involving a third person, almost always concern philosophy, global health and environmental problems, and how our work might change the world. Indeed, I sort of expect that any time we meet the conversation will go in this general direction. It does; but the exact path it takes is always somewhat surprising as well (just as these pre-monsoon clouds were to me). Of course, we also connect on the scientific basis of our relationship: to discover the genetic and environmental causes of cancer.

Similarly, when I am at Healis, the kernel of the talk is about science but it reaches into many other parts of life. Earlier today Drs. Mangesh Pednekar, Prakash Gupta, and I met to discuss a paper we are writing on tobacco use, including bidi smoking, and cancer incidence in the Mumbai Cohort Study. It seems that these little cancer sticks that are now being sold in the US and Europe as a “safe and more natural” alternative to cigarettes are more strongly related to incidence of several cancers. Discussing these issues with colleagues who are very statistically inclined and doctorally trained in epidemiology keeps the mind well focused on the science. Clearly, the implications for social justice are ominous; most of these bidis are made under brutal conditions by whole families, including children, who are locked in a cycle of poverty. The environmental effects of growing tobacco are equally unpleasant; I picked tobacco as a child and saw the effects on the land first hand, and going into rural areas in India (the 3rd largest tobacco producer after China and Brazil) brings one up close to the environmental devastation that it causes here (deforestation, habitat loss, topsoil degradation).

Sometimes, but not too very often, I make errors in judgment. So, what I might have expected does not occur, or is just plain wrong. Sometimes these errors in judgment create problems, but usually they are amusing or revealing, or both. Today, when I left home, I was thinking “I need a haircut.” I love getting a haircut here because for an extra Rs30 (US$0.60!) I can get a full head and upper body massage. Wonderful! Well, today was also the day that Healis is preparing to update its website. Given that our pictures will grace the new pages, it seemed clear to me that Mangesh (with whom I have lunch every day when I am at Healis) and I should both go to the barber, get cleaned up, and have massages. So we did. In my estimation It was one of the best such massages ever. So, when I asked Mangesh if he thought it was the best ever, he said he agreed – having never had one before! I was as surprised about that, as he was about my getting one every four weeks or so. When we got back to the office we had a good laugh about this, including with Dr. Gupta and Quayyim who also seems to like these little lapses into sensuality. As you can see, he knows a thing or two about haircuts!

Here we also are seen practicing our discussion of the acceptance, without revision, by the:
• New England Journal of Medicine of our recent paper on FEV and all-cause and cancer mortality in the Mumbai Cohort Study!
• Journal of the American Medical Association of our recent paper on body mass index and cancer mortality!
• Lancet of our recent paper on bidi smoking and cancer incidence!

XXII. Feeding Frenzy, Fear, and States of Grace

2009-04-11T11:00:00.000-04:00

It seems as though we Americans live in a world where most people feel desperate and overwhelmed too much of the time. Everyone in the whole world is grappling with “security,” but the US seems to be the most fear-gripped society on earth (at least compared to what I have seen and experienced in the 75 or so of the countries I have visited and the 4 in which I have lived for an extended period of time). It is amazing that Indians, though much poorer on average than Americans, are generally much less buffeted psychologically by these external realities. I do see glimpses of this deep insecurity other places as well, and as a species uniquely oriented toward the future we may just be hard-wired to be afraid. Also, it seems to be getting worse in India over time. So, this is not a uniquely American phenomenon – though it tends to be more extreme in the States than any other place that I have experienced.

The spring is always a difficult time for us in academic medicine and public health because many grant deadlines occur from mid-April until mid-June. This is an especially acute phenomenon right now with the “feeding frenzy” the American Recovery and Reinvestment Act (ARRA) has spawned in terms of enticing-looking grant opportunities. Of course, that is overlaid on, and in large part driven by, the greed-induced economic downturn. That seems to induce anxiety – all on its own.

As Parker Palmer, one of my favorite authors on the topic of education generally (The Courage to Teach: Exploring the Inner Landscape of a Teacher's Life) and life’s purpose (Let Your Life Speak: Listening for the Voice of Vocation), astutely points out, people don't think clearly in a state of fear or desperation. It may seem easy to talk philosophically about this from halfway around the world. My reality, though, is that I can feel the pressure from here. It is unmistakable. I am grateful to be here, partly because of the perspective and the relative simplicity of my life. Still I am driven to generate University of South Carolina-related products at twice the rate here as I do when I am there! It is like a blooming miracle; and not an entirely joyful one at that (though there is some joy in it, too)! Of course, the combination of all the work, including having to resubmit our Center of Biomedical Medical Research Excellence (COBRE), and the unbelievably bad timing of the CPCP move (nearly two years late) and a number of other things could have ruined my sabbatical; but I made two choices and prayed /meditated. The choices are:
1. To do this work, indeed all my work, in a state of appreciation and grace. In order to do this, I need to clear my mind and focus on things for which I am needed back home; yes, I hate the place in some ways (for the waste, consumerism, greed and arrogance), and love it, too (for the honesty and hard work of so many people, the willingness to self-correct, and the natural beauty of the place). It takes a lot of effort to stay in a state of appreciation and grace, but it is much better than any alternative I could (or can) imagine. It is wonderful to be loved and wanted; even needed!
2. To promise myself two wonderful holidays. One, along the way (i.e., after the ARRA and COBRE dates, but before the (CDC) Special Interest Project (SIP) final push (a wedding in Delhi and then 3 days in Nanital). The other at end of the SIP nuttiness (at an Ayurvedic Spa in the Kutch, Gujarat).

What I prayed for? Wisdom. Ganesh is always on my mind and usually staring me down. I think that his counterparts in my culture of origin are St. Jude and St. Christopher. Of course, some of this wisdom comes in the form of living in the present. I've talked about that before, too. Glorian and I had a wonderful day in Lonavala [See pictures at the top; the wooden beams in the hilltop temple (those are the steps up) are 23oo years old] before she left for the states (Glorian has a real eye and ear for the unusual – including these two hibiscus flowers kissing, at ACTREC). I had a great weekend with Hemali and her family last week, and then visited with Prakash and his family last night. Families are a big deal in India. Jane, Christine and I would almost always eat a homemade dinner together. Back in the US that is a rarity. Here in India it is the norm. I think that the social cohesion and the real support of the omnipresent family helps reduce the fear and anxiety.

XXI. Breaks

2009-03-22T12:02:00.000-04:00

When I am home, if I do not work in my garden, or at least explore around the place, a couple of times a day, my academic productivity suffers. That’s why I created an outdoor office (under the umbrella) by the pool. Forcing myself to sit and work does not produce good results. I am good for 45 minutes, at the most, before the most distressing things start to happen. I know this is true because I have done a few small experiments to test the hypothesis.

Self-discipline is another matter; it is something that all great masters recognize as essential to success. It is always some kind of yoga. Today, it was hatha yoga, walks, eating lots of fruits and nuts, and then a planned treat to go to Kharghar in the early evening and eat at a nice restaurant. The delay in gratification worked. It was a very satisfying day – including two postings here. At certain times, I need to build things in wood, or metal, brick or stone; though that option is mainly unavailable here. At others, I need to chase a ball moving at high speeds in a small space at close quarters with another human being (who is a friend). That option should be available soon!

I like being new places; and sometimes even visiting old ones. Typically, though, “being” someplace usually is a lot better than “getting” there. Like most things in life, though, it depends. After the 14th World Conference, I planned two outings – one with other conference attendees/friends (mainly Americans) to a beach house south of Mumbai and the other, with Glorian Sorensen, to Lonavala (a Hill Station West of here) on Monday before she went back to the states.

We left for the beach trip from the Gateway to India (that’s the boat we took for the great escape, a bit obscured by the early morning fog). This Gateway and the Taj in front of it got a lot of notoriety back in November. But I relate to these places mostly from having visited often with Christine when we lived here in 1997-8. On Sundays, we would often sit on the first floor (equivalent to the second floor in the US) restaurant of the Taj eating pesto and enjoying the scene below. Of course, it also was nice to be part of the scene, spending a little time hanging out on the esplanade in front of the arch.

Going into rural India is always such a treat. We passed by boats dressed up for Holi, a market with people selling flowers and food, another one of what must be millions of archeological ruins, and then on to this most amazing beach.

That’s Ratesh (who also applied to be a Fulbrighter next year) and his wife Petra (Glorian took the picture). I swam off this beach for a long time and it felt like a great big, whole body massage! Then, I actually got a whole body massage! Well, it doesn’t get a lot better than that. I don't get to see Americans, or any other foreigners, here very much. So it was a real treat to talk to people who shared elements of my culture. Our Indian hosts also made people feel very much at home, including providing a spectacular venue (that we agreed we would not photograph), exquisite food, and even massages!

XX. Meeting at The 14th World Conference

2009-03-21T23:12:00.000-04:00

The 14th World Conference on Tobacco OR Health connected people from many parts of the world. It also represented a real opportunity to see how these communities of scientists and activists are connected generationally. We can now assume that tobacco causes many chronic diseases. Accumulation of this knowledge is the bedrock on which the foundation of anti-tobacco advocacy is built. Science provides the means for testing hypotheses (Does it work or not?), estimating effect sizes (How much of the substance produces what effect?), maintaining the knowledge, and drawing inferences based on what we have learned. The assumptions that we can now make about the harmful effects of tobacco are built on the experience and findings gleaned over the previous half century of scientific work – much of it brilliantly thought out and meticulously executed, right here in India.

Dr. Prakash C. Gupta, President of the Conference, Director of Healis Sekhsaria Institute for Public Health, my main colleague here, and the official host for my Fulbright Fellowship, began working with a remarkable team of people led by the legendary Dr. Fali Mehta back in the mid 1960s. Many of these people, mainly dentists and oral pathologists (including Dr. Bhonsle, shown on the TIFR campus looking at the sunset 45 years after he was first hired), were Dr. Mehta’s students. In a very real sense they grew up with one another: attending each others’ weddings; rejoicing in the births of their children; thinking, planning, and analyzing data; and finally doing what needed to be done with the new-found knowledge. Over the years I have visited them in their homes and they have come to stay with Jane, Christine, and me in the US.

Though some have died and others have left India, their legacy is something that lives on in many ways. I love to tell the story of the Basic Dental Research Unit/ Epidemiology Research Unit, Tata Institute of Fundamental Research because it is a classic in combining excellent epidemiology, clinical practice, and laboratory-based basic science. It is through the work of this group, conducted over three decades in various parts rural of India, that we now understand the process of malignant transformation by which oral precancerous lesions become oral cancer. This formed the basis of our understanding of the basic process of tobacco carcinogenesis and led to intervention trials in many of these same parts of India over the next decade, and now are being conducted all over the world. This work also formed the basis for our investigations, in some of these same parts of India (Bhavnagar District in Gujarat, Ernakulum District in Kerala, and Srikakulum District in Andhra Pradesh) into the role of diet on which we collaborated and published in the 1990s and into the first couple of years of this century.

Seeing the Healis Sekhsaria Institute for Public Health booth at the Conference was a treat for experiencing the generations coming together to educate and make the world a better place, as an opportunity to actually feel the energy of this expansive group, and to see Dr. Bhonsle’s incredible traveling tobacco paraphernalia show.

This meeting, which spanned a half century of work and brought people together from around the world, provided a rare occasion to pause and reflect. Some newer members of the team (including Glorian Sorensen from Harvard, whom I introduced to Prakash nearly a decade ago) never met the original members, other than Prakash. Neha, pictured by Dr. Bhonsle’s traveling tobacco paraphernalia show, met some of them at the 14th World Conference. The team picture that you see here may very well be the only one that shows members of the original team with people who have joined as recently as this year. Some of these new members are younger than the children of the original cohort (some of whom also attended) and, has been the case from the beginning, remarkable people from all over the world are attracted by the magnetic pull of all that is good about these remarkable people and their calling.

XIX. Glimpses from the Mundane and the Material

2009-03-15T03:54:00.000-04:00

When I first traveled within India back in the 1970s, it almost always was by overnight train. On these trips, there were the inevitable 21, or so, questions. These included ones such as: Where is your family? Are you married? Friend or Wife? How much did that backpack cost? How old are you? What does your father do? What is your education? How much money do you earn? Do you like Indian food? I met this Canadian man, Peter, who printed out an answer sheet for the questions he was regularly asked. He mentioned that people received this very favorably, often asked a few other questions, usually by way of clarification, and then they would move on to other matters for discussion.

As much as I was amused by these questions, the latitude I was given to respond, and the true interest in my response; I was more struck by how very soon after we dispatched with the 21 questions and answers that the conversation would turn toward things spiritual. Religion was mixed up in this, but not in the kind of pedantic, often proselytizing way that I experienced religion to be used in the US. People really did want to probe the depths of human understanding to discover and ponder universal truths that would emerge from this kind of discourse. Over that time and in the subsequent years that I lived here I got very used to, and comfortable with, this kind of exploration. I was willing, indeed eager, to drink from this deep well of potential understanding because I learned a lot about myself and what I have found to be universal truths along the way. I think that everyone who seeks to understand life’s deeper meaning wants this. It is sad that so few receive it.

In retrospect, the absence of this probing introspection and deep connection with others was a major source of culture shock when I did return home. Big cars were the outward manifestation of the shock; and they have gotten ever bigger over the years! Of course, they are “needed” to cover vast distances at high speeds because we have been deceived into believing more mundane, crass, and
superficial things are the necessities of life. Having embarked on this cumbersome journey, the privacy entailed, indeed effectively required, shuts out any such possibility of spiritual striving – though I rarely even perceive dim glimmers of the urge.The Indian middle class is growing and with that growth has emerged a trend toward private automobiles (along with the hostile urban environments it creates) and airplane trips (with forward-facing seats and short travel times) that have dampened this experience in important ways.

Still, on the way back home to Kharghar by train from the 14th World Conference on Tobacco OR Health on Thursday night I was able to converse with a retired Army colonel on topics ranging from price supports for agricultural commodities to the inevitability of terrorist attacks in a world without understanding, respect and love for one another. It also comforts me to know that conversations with colleagues here almost always turn to the philosophical, if not explicitly spiritual, underpinnings of what we do. I cannot work this hard without belief in the inherent goodness and worth of it all. I am happy to report that I also have drawn colleagues back home into this kind of discourse; for example, we have written this wonderful paper, which I hope folks will have time to read when it comes out in April or May: 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;(in press):00-000.

XVIII. Hello, Kolkata and Mumbai

2009-03-10T23:59:00.000-04:00

I was torn between completing my thread from the more distant past to connect the ideas of social, environmental, healthcare, and economic justice back to famine or to focus on the intertwining of very recent events with memories of events and people who emerge from the more recent past. Knowing that many people who read this want to know something of the day-to-day life here, I have opted for the latter (that's Mangesh Pednekar, Associate Director of Healis and one of my main collaborators here with Hell's Preferred Citizen). I see a way to connect this newer thread to the other, older, one. So, I promise to do that in the near future.

After saying my goodbyes in Chennai, I said a whole bunch of hellos in Kolkata. The South Asian Regional Fulbright Conference brought together 78 Fulbrighters from countries throughout the region, but mainly India. About 2/3 were students of various types and the rest were lecturers and senior scholars (that's Janet Lilly, fellow Fulbrighter and Chair of the Dance Department at University of Wisconsin posing next to a poster of her then-upcoming performance at Tagore's ancestral home in Kolkata). I was among the older people present and recall with colorful and exuberant vividness those days when I was as young as the youngest people in the room. It was a wistful feeling of nostalgia that I savored – I loved both the energy and enthusiasm of the youth, which is expressed nowhere better than in relation to a foreign culture and the experience of us old India hands who have spent many decades sampling from the feast on which the young are now gorging themselves. The topics, ranging from classical Indian dance, to temple architecture, archeology of the oldest sites of human urban habitation (in the Indus Valley), law, textile art, public health street theatre, stem cell research, music, forestry, translation of ancient Parsee texts, and camel genetics was intoxicating. The energy of the students was equally amazing and there was absolutely no way anyone over 30 could have kept up (and, to the best of my knowledge no one tried). Kolkata prides itself on being the “cultural capital” of India; so, there is excellent scope for partying.

As I said earlier, above all else the Fulbright program is about international understanding. I would guess that this group of remarkable people, each in her or his own way, will doing more to advance world peace and the prestige of our country than the entire military budget of the US in a year. The bonds of friendship and understanding that are formed under such conditions of joy and deep respect for the lives, beliefs, and aesthetic values of others are deep. How beautiful; and what a bargain.

On Thursday morning I returned to Navi Mumbai and then shifted to Mumbai for the 14th World Conference on Tobacco or Health last Saturday. These days have combined meeting with old friends such as Prakash Gupta and Glorian Sorensen (flanking me in this shot) and taking in both the most amazing inaugural ceremony I have ever witnessed at a conference [the whole place erupted (in a nice way!) with everyone dancing – lead by troops of very talented Indian classical dancers and musicians and 110 slum kids trained and sponsored by Salaam Bombay Foundation] and a cultural night that was in many ways like celebrating Holi in the villages of Northern India (and it was Holi – marked by the last full moon before the vernal equinox).

XVII. Saying Goodbye

2009-03-02T20:55:00.001-05:00

There is a lot of asymmetry and apparent unfairness in life. But there are certain symmetries about which we can be certain. For each birth there will someday be a death. For each hello, however happy or sad, there will be a goodbye, however sad or happy. For every first step, first experience of the swim in the pool, first day in the office, first day of school (that's Christine with her parents on the day she left for college), there will be a last. If we are lucky and careful (but not too cautious!), these entrances and departures will be done with grace and aplomb. Whether it is a matter of simple luck, or perhaps something as complicated as karma, sometimes we are afforded the opportunity to say our goodbyes with the time needed to honor those relationships we cherish. So far, I have almost always had the opportunity that I felt I needed. The saddest final goodbyes are those reserved for those who have not lived long enough to have realized their full potential or those who depart with regret and remorse for not having lived a kinder or more meaningful life.

The last time I took this trip from Chennai to Kolkata it was by train (not airplane); my next birthday, which I would then celebrate in that great city with some very raucous acquaintances of mixed Indian and Russian descent, would be my 30th (not my 60th); and even the names, Madras and Calcutta, would roll off my tongue differently (and in a way about which I feel nostalgic) than these new names do.

As someone who likes to travel, I have always preferred being the one to leave to being the one left behind. Still, there is sadness in knowing that the things I have come to appreciate in my new “home” (and in some way, anything deserving of a real goodbye becomes home) will be greeted by the rising sun of a new day that I will not experience. When I left Karamoja after my last visit and before the coup that would remove Milton Obote from power, I assumed that I would never return. When I left Madras in 1980, I knew that I would return – and have done so in 1984, 1993, 1998, 2008 and 2009. Each time, however, it is a different place. Though they have the same names and some shared aspect of personal history, even the people are changed in some important way.

My stark assessment, and I say this with no bitterness at all – but more a sense of sad resignation, is that the world is worse off now for the many decades of our having lived here than it was before we started. The adults of today’s world have a lot of remedial work to do to make this planet a fit and sustainable place for the generations behind us. This must be done before we can say our last goodbyes with the kind of peace and satisfaction that comes from a life well lived. Most of the people I have come to know in my work and other aspects of my life know this, even we do not articulate that belief very often.

XVI. Uganda, Take Two

2009-03-01T20:19:00.000-05:00

When I returned to Uganda in 1984, it was to a different set of experiences. I had graduated from my doctoral program; so, there was a kind of earnestness that I had not had previously. Still, it very much had the feel of the “Year of Living Dangerously” and I can only marvel at my recklessness and naïve sense of adventure. Although I returned to Karamoja, and had the more frightening experiences on this second trip than the first; I spent significant (including in terms of my own development) time in the West Nile, the native region from which Idi Amin hailed and that had been totally off limits the year before.

Though situated at the same latitude as Karamoja, but in the northwest corner of the country, the West Nile was in many ways, but not all ways, its opposite – very lush, green, and humid – sort of the picture that I had of the tropics before 8 years of living off and on at these latitudes disabused me of that misconception. In many, but far from all, ways it was paradise on earth.

It was Cole’s idea that I would weigh and measure every child I could find in the region; ostensibly as a way to document the need for aid and to assess what could be done to reconstruct the region. Once again, James was my partner.

Roughly the size of Connecticut, the West Nile had a population of about a half million in the mid- to late 1970s. The nearly 10,000 children we measured on our excursion through the region were too young to remember having seen a European, as the last one had departed before the “War of Liberation” (wars are always given such nice names). So, I was quite a novelty. The only “crop” that we saw growing was cassava (yucca), as that requires little tending; so, it is ideal for people who need to leave on short notice with no guarantee of return. At that time, we estimated that the entire population of the region was no more that 1/10th that of the mid-1970s.

We were there in May, which is high mango season. I love the taste and smell of ripe mango; and it was eerie to drive for long stretches through mango forests (these were big trees, not the short cultivars of modern mango farms) without seeing people and the Land Rover’s wheel wells and undercarriage literally dripping and drooling with gloriously fragrant, deep yellow-orange mango juice. Many of the children had schistosomiasis, but were generally a bit better off nutritionally than their Karamajong counterparts.

On our last day on the West side of the Nile we engaged a ferry to cross the river. It was not terribly wide at that point – maybe a few hundred meters at the most. I recall our “guards” – there were 14 “soldiers” armed with AK47s and rocket-propelled grenades, had an average age of about 14 years, and eyes redder than any of my fellow travelers in Afghanistan 8 years earlier. When we started being shelled from several hundred meters upstream (perhaps even a kilometer, as we were in the very north of Moyo District in Ugandan territory and the fire probably was coming from Sudan) I really regretted that we had a petrol, rather than diesel, vehicle (as we were carrying an extra 200-liter barrel of the more explosive liquid in the back of the Land Rover). Swimming with the other creatures in the river while be shot was about as unappealing as finding ourselves in the center of a raging inferno. We made it out of there physically unscathed and decided to continue on to Kampala; even though we had lost radio contact (the UN radio was constantly on) along the way. Driving through the infamous “Luwero Triangle,” we entered the city in the evening a couple of days later. It was pitch black and, with the exception of small arms fire, very quiet.

The fog of 25 years is not heavy enough to remove the stark images of those days, but with the exception of trips through geographic space, the temporal ordering gets a bit confused. Perhaps just before that trip (but I think it was afterward) I got a call from Bjorn saying that Satya had suffered a stroke and might not live. Until then, the fear and excitement associated with trying to survive while helping others kept me numb. I now know that this is not an uncommon occurrence for soldiers and others living in war zones. The news of Satya stung deeply and very personally. I went home and cried myself to sleep.

XV. Connecting in Uganda

2009-02-24T00:10:00.000-05:00

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

2009-02-22T10:57:00.000-05:00

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

2009-02-21T11:01:00.000-05:00

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

2009-02-19T10:58:00.000-05:00

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

2009-02-14T21:27:00.001-05:00

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

2009-02-12T20:21:00.000-05:00

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)

2009-02-09T04:36:00.000-05:00

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

2009-02-08T01:15:00.000-05:00

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

2009-02-05T19:55:00.001-05:00

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

2009-02-04T05:03:00.000-05:00

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.

V. Experience and Experimentation

2009-02-03T04:07:00.000-05:00

There are many, interconnected reasons why I am here in India. The “official, proximal” reason is to study the role of diet in causing cancer. Good enough, let me start there. This business about diet and cancer is something that has interested me for a long time. All told, I have published several hundred peer-reviewed scientific papers on diet, dietary assessment, cancer, or some combination of these.

Any decent epidemiologist will tell you that the evidence supporting the role of diet in cancer is inconsistent. I have spent a good part of my career trying to explain why the results of studies conducted in the West should be expected to be inconsistent with results that we have obtained in our cross national comparisons. Those studies, published over about a 20-year period, have revealed associations between death rates for a number of different cancers (esophagus, oral cavity, lung, breast, prostate, bladder) and per capita consumption of meat and fat (positive correlations) and dietary fiber and other plant-based components (negative correlations). Laboratory animal studies that simulate the wide distributions of fat and other nutrients observed internationally also show significant associations between diet and many of these cancers. This, in turn, is consistent with a protective effect of primarily vegetarian diets and certain traditional foodways (e.g., East Asian, South Asian, Mediterranean, African cuisines) that are associated with lower rates of many cancers. So, much of the argument that I made to obtain this Fulbright Fellowship, and which also underpins the Mumbai Cohort Study, is based on these observations.

Many people in India are vegetarians, and even ones who aren’t tend to eat a diet that is primarily grain and plant-based. The traditional vegetarian Indian diet is loaded with flavorful and colorful things that are anti-inflammatory. It is now becoming more widely accepted that inflammation is important in causing a number of chronic conditions, including many cancers and heart disease, along with every “itis” under the sun (arthritis, diverticulitis, colitis, etc.). Acute inflammatory responses are necessary for wound healing; however, chronic inflammation is not good for you.

Plant foods are a rich source of bioactive phytochemicals; the biologic properties of which make them prime candidates to aid in cancer prevention. Phytochemicals provide protection and modify carcinogenesis by modulating several important biological pathways. They induce or inhibit Phase 1 (cytochrome P450 detoxification/activation) enzymes; modify carcinogen detoxification through Phase 2 (conjugation) pathways (to increase excretion of potentially harmful compounds); scavenge DNA reactive agents; suppress the abnormal proliferation of early, preneoplastic lesions; and inhibit certain properties of the cancer cell that are essential to their immortality and ability to spread beyond the host tissue or organ. So, there is increasing recognition of diet-induced modulation of inflammatory responses as being central to the processes of human carcinogenesis. The argument for this stems from the observations that pro-inflammatory and pro-oxidant states are closely linked to tumor promotion.

Now, I have always been a bit of a scientist. One of my earliest memories (at around 3-4 years of age) is of sitting on the bathroom floor with our heating fan disassembled. Ummm…. How does this work? When my mother discovered me and the fan she was distraught. When my father got home from work, I recall him being quite delighted (once he was certain that I had unplugged the thing). Apparently, I inherited a penchant for taking things apart. Also, I inherited a tendency towards arthritis. Well, I've been having these chronic joint pains for about the past year (especially my right ankle, for no apparent reason). On one of my long walks a couple days back I noticed (and mentioned this to Dr. Sarin) that after eating Indian vegetarian food for two weeks the joint pains are gone! Ummm …. How does this work?

IV. A Bus Named Ruby

2009-02-02T00:58:00.000-05:00

Today, I am working at Healis Sekhsaria Institute for Public Health. So, this morning I planned to take the ACTREC bus to Belapur. I woke up early (not the usual 4:30 AM or so that I arise in the states, but around 5:45 AM), made myself a cup of tea, caught up on some early-morning (or late-night, as the case may be) e-mails, did my morning yoga routine, and went to have breakfast in the ACTREC canteen. Often when I eat here, I think of Dr. Jim Burch. I think that Jim would love this incredibly spicy and complicated cuisine that people here get to eat all the time! I don’t know many people who relish food more than Jim. He works on the Mumbai Cohort Study, too; so, I think that he should come here some time. I am pretty sure that he would agree.

I boarded this bus, with which I have gotten somewhat familiar (and a bit attached), at 8:39 AM. She pulled out at exactly 8:45 AM for the 15-minute trip to Belapur. I think of the bus as "she," as her name is Ruby and the only other Ruby I know is a woman. Ruby Drayton is an important member of the CPCP. Here is a picture of Ruby (on the right), with another CPCP member (and former student), Jaclyn Guess, on the left.

This trip takes about as long as my commute by car takes in Columbia, South Carolina. Of course, I don't have to drive; so, I can take in the scenery, think about the future and the past (every so often, the present; more on that later), and not have to worry about driving into something or getting a speeding ticket. Ruby travels one way very full (55 seated passengers) and usually travels the other way fairly empty. Still, I think the overall fuel efficiency is about 30 to 50 times higher than what I experience in my "little" Mazda back home when I am driving alone (which is most of the time). If I miss the 8:45 AM bus, then I have to wait two hours for another. Consequently, I need to be much more disciplined in my comings and goings than I would be in the states where I've gotten used to simply jumping in the car and going whenever, or pretty much wherever, I please. I like the feeling of being disciplined, but also tend to become a bit lazy when I don't have to adhere to some other schedule for the greater good of the whole.

When I got to Belapur I walked through the railway station and on into the offices of Healis Sekhsaria Institute for Public Health. The first thing that greets someone after coming in the glass entry door on the sixth floor is a picture of Ganesh. Hindus look to Ganesh as the God of Wisdom; to whom people pray when they begin their day or start anything new. I like the concept of deliberately thinking about applying wisdom to our affairs – be they scientific, religious, spiritual, political, or how we treat the people with whom we interact on a daily basis. In this way, I think that we all can work more effectively (not to mention efficiently) in the greater service of humanity.

III. A Bridge To (& From) Somewhere

2009-02-01T07:39:00.000-05:00

Each day, on my frequent walks around the ACTREC campus, I see this bridge. I also walk across it. From along the bridge, there are some nice views of the campus and the hills beyond. I've spoken with Dr. Rajiv Sarin about the reality and the metaphor of this bridge. I have asked him to talk more about this later. I hope that he agrees to do this.

The serpentine bridge literally connects the clinical sciences building (Paymaster Shodhika, on the right, where the Epidemiology/ Clinical Sciences Unit and I sit) and the basic laboratory sciences building (Khanolkar Shodhika, which is on the left and shown below). It also represents the metaphor of connecting disciplines that in many places are kept separate, for ostensibly “good” reasons.

Dr. Sarin and, from what I can tell, most of the other people I've met here, are pretty strongly committed to connecting things that are often separated other places. Besides this kind of academic connection, I find it pretty cool that the patients and their families (who always accompany patients when they come for long-term stays; in the bone marrow transplant unit in Jussawalla Shodhika, for example) roam very freely around the campus, often sitting in the garden right by our building. On the walks I greet the patients and their families and try out my Hindi, which is somewhat effective but almost always very amusing. We also ride the shuttle bus together. What fun. Life here is very integrative of things that we often separate in the West. It is very humane and extremely efficient (more on that later)

There is much talk in the United States these days about translational research. Though some of this talk is sincere, as with most things in life, when all is said and done, more has been said than done. This is not to say that the game is over. Hopefully, that will be far from the case – especially with a large boost in NIH funding in the offing. We must assure that it is used wisely to improve people’s lives (not just our own!).

I've watched and listened pretty carefully to what the National Institutes of Health (NIH) says in its Roadmap and what has come out of the National Cancer Institute's Translational Research Working Group. The latter, especially, seems to embody what the Cancer Prevention and Control Program is all about. I don't think that we can ever make serious progress in the “War Against Cancer” without addressing prevention and control in the community. Just look at the major drivers of our recent reductions in cancer mortality to see what I mean: 1) tobacco cessation; 2) reduction in the use of hormone replacement therapy; and 3) colonoscopy screening.

If we are to take all the resources that have been invested in cancer research and make it work for the people who have given it to us, there will need to be lots of feedback between the basic sciences (including epidemiology and other things represented in the CPCP), clinical sciences (which, even in a tertiary care facility like ACTREC, should be a part of the community), and the larger populations and communities in which people live and, unfortunately, get cancer. By making these connections we will be much better placed to both prevent and treat cancer.

II. Something About the Present

2009-01-31T05:30:00.000-05:00

I am an academic. If had been told that this would be my life's path when I was young, I simply would not have believed it. This life that I now lead is as far from my early life experiences as were my travels through Afghanistan back in the mid-1970s. Even after three decades, I sometimes cannot believe that I am here right now, doing what I do. I know, though, that I am not here accidentally.

On the sunny afternoon of Friday, 16 January 2009 I left my home and the Cancer Prevention and Control Program at the University of South Carolina in Columbia, South Carolina, bound for Mumbai, India. I arrived here early on the morning of Sunday, 18 January 2009. I was greeted by Mr. Kumar, whose English was about as bad as my Hindi. My ride from the airport in the wee hours of the morning, narrated in broken Hindi, was a surreal blend of exotic smells and sights. No matter how many times I have taken that ride, each time it is pure magic for me.

I am here as a Fulbright Senior Research Fellow. The Fulbright Program, funded by the United States Department of State, Bureau of Educational and Cultural Affairs, and administered by the Council for International Exchange of Scholars (CIES), was proposed by Senator J. William Fulbright who, in 1946, was the junior senator from Arkansas. The program is as much about cultural exchange and providing a basis in understanding to foster peaceful coexistence than it is about joint intellectual and scientific development.

Two outstanding organizations, Healis Sekhsaria Institute for Public Health (Healis) and the Advanced Centre for Research Treatment and Education in Cancer (ACTREC) provide my home base here in India. Both Healis and ACTREC are located in Navi Mumbai, Maharashtra, India and I work directly with their directors, Drs. Prakash C. Gupta and Rajiv Sarin. I will have much more to say about Healis and ACTREC, and their remarkable leaders, over the coming months.

As those of you who have chosen this profession already know (and for those aspiring to do so, be warned!), this is not an easy life. For me, this has entailed getting hepatitis, malaria numerous times, dengue (Breakbone) fever, and a host of other “occupation-related” conditions. Despite the uncertainty of research funding, very long hours, relatively low pay and, for me at least, the accompanying health risks, the rewards in the form of positively influencing young people's careers and in changing people's lives for the better are priceless. So, I sit here now in this office on the beautiful ACTREC campus in appreciative awe of how things have worked out.

I. A Bit About the Past

2009-01-30T06:46:00.000-05:00

I first set foot in India about a third of a century ago. In those days one could, and I did, come overland through the Middle East and Western Asia – across Turkey, Iran, Afghanistan, and over the Khyber Pass into Peshawar, Pakistan and, finally, on into Amritsar, the Punjab. The relative quiet and harsh beauty of that journey, following the ancient caravan route, began after the autumnal equinox, continued through many days of lengthening shadows, and ended in India, shortly after the winter solstice. I was awestruck at seeing the great fortresses that Alexander the Great’s army built in places like Herat and the giant Buddhas at Bamian. This convergence of East and West, millennia of comings and goings, brought green eyes and red hair to Central Asia and exported Buddhism from its country of origin to these eerily beautiful valleys in the shadows of the Hindu Kush. For a kid who had never been on an airplane until setting out for France as the place of embarkation for this adventure, it was fantastic – something my overactive imagination could never have contrived. Each day brought new experiences; sights, smells, tastes, and sounds that were different in some elemental ways from than anything I had experienced previously. Sometimes there was just a deep sense of peace and satisfaction; at other times my traveling companions and I were in grave danger. Ah, to be young and foolish, and totally open to learning and experience! Those are stories for another day; ones that I hope to tell to my grandchildren some time far in the future.

I will remember that first day in India all the days of my life. Amritsar was beautiful, but so very intense; so very noisy and busy. What stark contrast to the silence of Afghanistan, whose beautiful people would maintain a more Western sense of distance and whose past only whispered through the many subtle reminders that had been left behind across those millennia. On that first day, I did not fall in love with this place that Mark Twain said is “the One land that all men desire to see, and having seen once, by even a glimpse, would not give that glimpse for all the shows of all the rest of the globe combined.” The show was overwhelming! Over the decades I have learned that India also is a land of subtlety; but its past also shouts, indeed screams, into the present and on into the future.

In my office at the University of South Carolina, there is a picture (actually, a 19th century lithograph) of the Taj Mahal that was presented to me by my wife, Jane. It is hung on the wall behind my desk among various diplomas, degrees, and awards. When my daughter, Christine, saw it there just after I moved in and before she went back to school in New York and I left for India, she intimated it did not belong there. Before I could say a word, Jane told Christine that were it not for India, I would not be who or where I am. So true; and I might add why.

So, this will be a continuing story of why I wound up here, how I fell in love with the place, how I see India connecting to my life in South Carolina and the people I am committed to serving back home, and how I am using this sabbatical experience to pay back the very many people who have enriched my life and have boosted me up so that I can see things that I otherwise could never have even imagined.