KOLAHUN

Geography Quiz - Friday Edition #2

Name in order the countries with the longest coasts (all countries included):

Rank	Country	Land area[3] (km²)	Coastline[4] (km)	Coast/Area Ratio (m/km²)
1	Canada [5]	9,984,670	202,080	22.222
2	Indonesia	1,826,440	54,716	29.958
3	Greenland[6]	2,166,086	44,087	20.353
4	Russia [7]	16,995,800	37,653	2.215
5	Philippines	298,170	36,289	121.706
6	Japan	374,744	29,751	79.390
7	Australia	7,617,930	25,760	3.381
8	Norway	307,442	25,148[8]	81.798
9	United States	9,161,923	19,924	2.175
10	New Zealand	268,021	15,134	56.466

from wikipedia.  

The Chilling Fear of the Unknown

From a 2006 Frontline interview with Dr. Anthony Fauci:  

 

What was your first experience with HIV/AIDS?

Well, my first experience with HIV/AIDS I remember very clearly. I was sitting in my office at the NIH [National Institutes of Health] Clinical Center going through some literature that comes on my desk daily, and I saw the first Morbidity and Mortality Weekly Report [MMWR]from the CDC [Centers for Disease Control and Prevention] about these unusual cases that had occurred in L.A. and New York -- Pneumocystis pneumonia and Kaposi's sarcoma.

I remember being somewhat puzzled as to what exactly this meant. Was it some strange drug that a group of gay men had consumed that acutely and severely immunosuppressed them for them to get Pneumocystis and Kaposi's sarcoma, which we had known for years and years had been associated with an immunosuppressed state? I remember getting a feeling of anxiety about that, of this unknown, but it was only a few cases, and I had a lot of other things going on, so I pushed it to the back of my mind. But it kind of stood there for a while.

Then when the second MMWR came out later in the summer, then I remember getting a very chilly feeling that we were dealing with a brand-new communicable disease. I had no idea what it was, but the way it was acting was strongly suggestive of it being a communicable disease. It was an interesting, unique feeling, because it isn't very often in one's career that you run into truly a new disease. So I felt first something a little vague, a little confusing, and then a feeling of some significant anxiety about what the heck was going on here.

Here in 2011, the world is reaching a nexus of circumstance that could once again chill those at the forefront of disease.  The world's resources cannot meets our needs.  Climate change is making rearranging patterns of livelihood.  Technology is scaring the powers-that-be.  Economies are crumbling.  And as the same time as new diseases are emerging, successful treatments for old diseases are failing.  

Hopefully we can find the patterns before too much misery is inflicted. 

(Read more of the Anthony Fauci interview)   

 

Microfinance Misery in India

Microfinance is a way to expand financial credit to poor people, especially those who don't have collateral.  The system was designed to mitigate risk by pooling it in a group of borrowers rather individuals.  This incentivized each member of the group (say 5 women) to ensure that each paid back their loans.  The loans are supposed to encourage investment - a woman could get seed capital to open up a store, buy inventory, etc.  The loans are not meant to alleviate crushing poverty where consumption on necessities like food and clothing dominates personal income (people at this level of extreme poverty need to worry about today, not about investing form tomorrow).  

For a while it worked and some companies even found it profitable.  

And now we have reports from the BBC, from Bloomberg, the Washington Post that large swathes of the system are imploding - especially at the epicenter in Andhra Pradesh, India.  During the pre-Great Recession finance boom, microfinance companies grew at an astronomical rate.  They borrowed huge sums from other banks and made lavish loans on the poorest citizens.  They charged incredibly high rates (over 15%), didn't worry about investment versus consumption and didn't ask how many other loans a borrower simultaneously had.  (If this sounds ominously similar to the sub-prime loans...it is.)  

And in the inevitable default crash made when improper loans are made to overextended borrowers, many proud poor people have resorted to an extreme manifestation of tragedy - suicide.  The Indian  government, in turn, has started to restrict the conditions under which lenders can practice: limiting the number of loans a person can have, aggressive collection practices, etc.  The microfinance indurstry's wholly predictable response is that government limits will curtail their benevolence and hurt the poor.  

To which I respond - hopefully.  It would be nice if the microfinance indurstry wouldn't use predatory techniques, wouldn't target those in extreme poverty who don't benefit from loans and wouldn't offer the same individual six, seven or eight loans simultaneously.  It would be much nicer if this industry fulfilled it's limited mission of being earning small profits by targeting appropriate investments instead of just another big finance profit-maximization-get-rich-quick-scheme which leaves large piles of human tragedy in its wake.  

 

 

 

 

Kobe Bryant Passionately Argues for More Public Transportation in Los Angeles

Here's Kobe on why he declined to get medical care for a possibly broken foot:

He said he opted not to have tests on the ankle because it didn't feel broken.

"And even if it was it wouldn't have mattered," Bryant said. "I would have played anyway. So it was a waste of time. I would've had to go all the way up there and do that and then sit in 405 [Freeway] traffic for two hours."

These kind of decisions get made all the time by non-famous athletes.  Why wait a couple of hours in traffic when your chest pain probably isn't cardiac?  Why get on the two hour round-trip bus-ride to the public health clinic for your child's vaccinations when the probability of getting measles is almost none (except in Europe, of course).  

The basic argument for public transportation building is that it makes life easier for everyone.  For those without cars, having buses/subways/light-rail decreases the 'cost' in these 'cost-benefit' analyses.  And for those who do have cars, if more other drivers use public transportation and the roads become less congested, the daily commute becomes much more tolerable.

Here in 2011 - we have a unique set of circumstances.  We have poor public transportation infrastructure.  We also have massive unemployment and an idle construction sector.  Meanwhile, it's very inexpensive for the government to borrow money as interest rates are close to zero.  And finally, there's a reluctance on the part of consumers or business to spend money.  

Run this equation in the economic calculator of common sense and the result is: more stimulus for infrastructure investing.  

Right now the US should not worry about the debt - we are not Portugal or Greece since we have our own currency.  There's no sign of core inflation.  There's also no sign of government 'crowding-out' the private sector.  If this was the case the cost of borrowing money (i.e. interest rate) would go up.  But it's not.

It's time to worry more about employment than debt.  

Why Drivers Who Hate Bicycling Should Still Be In Favor of Bicycle Infrastructure

Let's face it.  Some people are car lovers and the thought of bicycling to work would lead them to gnaw at their ankles.  Maybe bicycling is tooeuropean or too bohemian.  Maybe their expensive clothes would set ablaze at first contact with sweat.  Whatever - to each his/her own.  But even these people should be happy to see more bicycle infrastructure in cities.   

Why?  More empty roads for them!

For example, take New Orleans -  a city with optimized conditions for more bicycle lanes, bike sharing, etc.  It's a flat city.   It's a city with a small footprint.  And it's a city with plenty of 'neutral ground' space to make protected bike lanes.  It's also a city with a high concentration of service-industry workers in the downtown hotels and restaurants who are generally poor (read: don't own cars and take the bus).

(and new orleans is a 'fat city' - so marginal improvements in exercise would have significant positive externality with improvedpublic health outcomes.)

 

Combine the practicality with building bicycle infrastructures could be built (bike rentals, bike parking, bike lanes, etc.) with the high density of low-wage workers downtown and quickly, the dedicated car lanes become de-congested.  Less waiting behind columns of buses at random stops.  No more worry of hitting a bicyclist after opening a parked car door.  No more struggling with passing a slow bicyclist.  

And best of all - more space on the road and shorter commutes for drivers.  

 

Geography Quiz - Friday Edition

Name the top ten countries in the world, by size (answer below map):

 

Gay Men ≠ Straight Women (at least in HIV Pre-Exposure Prophylaxis)

The NEJM published a major study in 2010 that showed that pre-exposure prophylaxis (using a two pill combination called Truvada) could decrease the risk that men who have sex with other men would end up contracting HIV.  While beset with loads of controversial application questions (should all gay men start?  who pays?  what about resistance?), there was pretty good evidence from this single study that this could be used.  And within reasonable circumstances, such as discordant gay couples or victims of sexual violence who cannot escape, this pre-exposure could be life-saving.

Disappointingly, the other shoe did not drop.

Yesterday, a multi-center study in 3 African countries was prematurely terminated when it failed to decrease HIV transmission in women who have sex with men, when the same drug was used in women to prevent HIV transmission.  The hypothesizing will now start:  were condom usages the same in both studies, what were the baseline HIV rates, did serum levels of Truvada show differential adherence rates, and so forth.  These are crucial to determine if we should re-try similar oral Truvada trials in women or if we should redirect resources to the path of anti-viral gels, which have proven effective in early trials.   

While we digest all this new information - we should remember three fundamental rules of implementing HIV research:

• Rule #1 - Always listen to Dr. Anthony Fauci.  He was an early proponent of the NEJM study, but wisely warned: “No single HIV prevention strategy is going to be effective for everyone and it is important to note that the new findings pertain only to the effectiveness of PrEP among men who have sex with men and cannot at this point be extrapolated to other populations. 
• Rule #2 - In the age of shortened research result cycles and multi-media amplification, it's foolish to chase or extrapolate good news.  This is true in the world of HIV research, but also in cholesterol treatment, diabetes treatment and so forth.  Miracles rarely are.  Unfortunately, it's going to take time and failure and re-trials to get more correct answers to some of our more pressing medical questions.
• Rule #3 - When in doubt, refer to rule #1. 

Humanitarian Work - Personal Reflections

There's a lot of controversy in the humanitarian field over the supposed misrepresentations in 'Three Cups of Tea.'  The book follows Greg Mortenson, a US mountain-climber, who in 1993 tried to climb K2 in Pakistan.  After some complications, local villagers tended to him.  He paid them back by building them a school and then formed an aid organization to build lots more schools in this area, especially for girls. 

The current controversy concerns whether he made up stuff about what happened in 1993 and also about his organization - how it spends its money and whether it's actually built all the schools it claims.  The best recap of the details and reprecussions of the story can be found at this website, called 'Good Intentions Are Not Enough'.  Reading that post illuminates much of the dirty underbelly of international humanitarian work.

As for my personal reflections - here are some lessons i've learned:

• local staff are thoroughly undervalued - none of us expatriates are 'saviours' and in most projects, more than 90% of the staff are local staff (doctors, nurses, drivers, guards, cooks, etc) and most of the work is done by them

 

• logistics is paramount - if a project doesn't have the ability to get materials in and out, to use generators, to build buildings, etc. then it doesn't have the ability to do that project.

 

• transparency with money is obligatory - donors (individual or institutional) stop giving money if it cannot be accounted for.

 

• projects need endpoints - in every sector (health, water-sanitaion, reconstruction), if there isn't an objective to be reached, it means the project is likely to be come an omnivore of funds rather than a productive tool.  If an organization can't imagine that it's goal has been achieved and it can cease to exist, it will just keep looking for money and disguise itself as whatever the donors want it to be.  

 

Snake Bites in India (and the Utility of Sample Mortality Studies)

On the opposite spectrum of Donald Trumps re-vitalization of the Birther cause is the death certificate.  In Western and developed countries, causes of death are readily available because most people die in hospital settings or under medical/hospice care.  The CDC publishes these yearly and so private and public health dollars can be guided appropriately.  

Meanwhile, in developing countries, most people lack access to health care and many die at home.  Even when they do die in hospitals, with limited diagnostic criteria, the proximate cause of death may be quite difficult to pin-point.  A way to estimate/circumscribe this is to just go around to villages and households and ask how people died.  

The (ominously named) Million Death Study hopes to do this through an ambitious mortality survey covering over 16 years (98-2014) and 15 million people.  They get community health workers to go around to these families to ask how and if anyone died.  The survey results are then sent to professional medical auditors who give the most likely cause of death.  

Their most recent publication in the Public Library of Science (PLoS) estimates that 45,000 (CI 40-60k) snakebites occur yearly, with the most deaths occuring in Uttar Pradesh and Andhra Pradesh.  Given that snakebites kill quite rapidly and anti-venom needs to be snake-specific, it's unclear if the medical health community can offer much - outside rapidly expanding to provide a clinic in every village.  The preventive health measures likely have lots more to offer - cutting grass low in rainy seasons, wearing boots ($$), etc.  

In the end though - really...45,000 people die in India each year from snake bites?  

DE

TEMPS

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SEULEMENT

The Ministry of Information

“more power to the misinformed”