Category Archives: Healthcare

Ebola, Cultural Responses, and the Funding Gap

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A few weeks ago I linked to a handful of academic works on Ebola outbreaks past and present. This week, as I round out my job as a high school teacher, I ran my sophomores through a couple of days on the virus and ongoing outbreak. In looking for accessible readings that deal with the cultural and political aspects of the West African Ebola outbreak, I’ve found Amy Maxmen’s reportage at National Geographic really interesting. In particular, I assigned excerpts from two of her articles that are worth highlighting here, if only to quote them in contrast to the Hewlett and Amola piece I linked to before about locally-rooted traditional responses in Uganda that contained the 2000 outbreak there effectively.

The first piece is from March and depicts the challenges of contact tracing in towns where people don’t want to be kept in isolation or taken to clinics from which they may not return. The second, from January, gives a thorough overview of how cultural traditions in the affected countries have enabled Ebola to spread, and outlines efforts to find culturally acceptable burial methods in order to help contain the outbreak:

In the three countries hit hardest by Ebola, preparations for burial typically are carried out by community members who handle the dead with bare hands, rather than by doctors, morticians, and funeral home directors. People were unwilling to have those practices casually tossed aside. That worked in Ebola’s favor. As death approaches, virus levels peak. Anyone who touches a droplet of sweat, blood, or saliva from someone about to die or just deceased is at high risk of contracting the disease.

To health authorities, the solution was simple. With so much at stake, science eclipses religion: Risky rituals must end.

“People were expected to go from one end of the spectrum to the other; from washing the bodies by hand, dressing them, and holding elaborate ceremonies, to having a corpse in a body bag and no goodbye,” says Fiona McLysaght, the Sierra Leone country director for a humanitarian organization called Concern Worldwide.

Of particular interest to me was the flexibility of such rituals, to which many who have done fieldwork can attest. As Paul Richards says in the article, “burial rituals were flexible… the spirits are totally practical!” The lede to the article is a story about a family that is trying to bury a pregnant woman who died – they want to remove the fetus according to tradition, but healthcare workers won’t have it. The solution? They found a ritualist who said that a reparation ritual would correct any problems caused by burying the woman without following customary rituals.

The idea of flexibility in ritual has been around for a while. Many rituals were only recent codified, and so many “requirements” and “customs” can be molded to fit what’s needed and what’s available. In my own line of work, Tim Allen’s argument that the traditionalist response to the ICC intervention in northern Uganda essentially invented universal Acholi reconciliation rituals where there hadn’t really been any before comes to mind.

Anyways, digression over. Back to Ebola.

After assigning these articles and discussing them with my students, yesterday I saw another article by Maxmen on the topic of Ebola, this time on the wide gap between money being donated to the cause and money being paid to frontline medical personnel. From Newsweek:

Hundreds, if not thousands, of nurses and other frontline staff fighting Ebola have been underpaid throughout the outbreak – and many remain so today. The lack of pay is not simply a matter of corrupt officials stealing donor money, because so-called “hazard pay” was issued through direct payments to frontline workers starting in November, then electronic payments to bank accounts and mobile phones beginning in December. The problems appear to be twofold: first, Sierra Leone’s national health system has been so underfunded for so long, that it was a monumental challenge to document all of the country’s care workers and set up payment distribution channels to them. Second, it turns out that relatively little money was set aside for local frontline staff within Sierra Leone’s health system in the first place. In fact, less than 2% of €2.9bn ($3.3bn) in donations to fight Ebola in West Africa were earmarked for them. Instead, the vast majority of money, donated from the taxpayers of the UK, the US and two-dozen other countries, went directly to Western agencies, more than 100 non-governmental organisations (NGOs), and to the UN.

[…]

When I visited Kenema Hospital in February, graffiti on one wall of the Ebola isolation area read: “Please pay us.” By then, nurse Kabba had cared for more than 420 Ebola patients, and had lost several friends. She had not received most of the €80 ($92) weekly allowance she’d been promised since September. Nurses around the country were in similar positions. “We hear about money pouring in, but it is not getting to us,” Kabba said. “People are eating the money, people who do not come here. We are pleading nationwide, we have sacrificed our lives.”

When I spoke with Kabba’s boss, District Medical Officer Mohamed Vandi, he acknowledged that his health force had been sorely neglected. “I am not hopeful for the future,” he said. As Ebola ebbed, world leaders had begun to make promises about improving fragile African health systems. Vandi looked on sceptically. “If we could not get support when the virus was here, I wonder how we could get it when the virus is gone?”

The whole article is well-worth reading, as it outlines how international agencies tried to implement payment programs isolated from corrupt government officials, but also bypassed numerous nurses. There’s also a strong critique of international NGOs’ tendency to do everything on their own rather than improve the state’s existing (and weak) healthcare infrastructure. For those studying aid, development, and public health, there’s worthwhile stuff here.

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Understanding Ebola

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The latest issue of African Studies Review includes a commentary from Adia Benton and Kim Yi Dionne titled “International Political Economy and the 2014 West African Ebola Outbreak.” It’s available for download here for the next month, and I think it’s well worth a read. In the piece, Benton and Dionne outline the domestic and international response to the Ebola outbreak that has caused so much damage in Guinea, Liberia, and Sierra Leone, but they also place the outbreak is a much wider context, looking at the setting in which this outbreak is taking place and looking at the outbreak in relation to past events. They even lay out the relevance of problems in the region as recent as the Mano River War and structural adjustment and as far back as the slave trade and colonialism. With this background in mind, they state:

[W]e should expect that ordinary people navigating an epidemic would be suspicious of the motives and directives not just of their governments, but also of local agents implementing health interventions on behalf of their governments. It should not be surprising that these suspicions could further antagonism toward governments.

In describing the response to the outbreak, Benton and Dionne provide a survey of attempts and failures from the weak response of a broken healthcare infrastructure to the inaction of the international community – led by a dismissive WHO. What’s really important, though, is their emphasis on how the international community responded to the crisis only when it began to threaten the West itself. We all saw this when Ebola became huge news as it arrived in hospitals in Dallas and in the streets of Manhattan, and faded out of the news cycle once those threats abated. Discussing the UN’s decision to create an emergency committee to focus on the outbreak, the authors write that “the resolution adopted at the end of the emergency meeting stated that ‘the unprecedented extent of the Ebola outbreak in Africa constitutes a threat to international peace and security.’ The security paradigm—and particularly one in which threats from West Africa were spreading to the West— therefore colored U.S. and European responses to the ‘crisis.” Kim Yi Dionne gave a talk at Yale earlier this year in which she talked about and around the issues discussed in this article. One thing she brought up that I found fascinating that isn’t discussed in the article is the role of “culture” in spreading disease. In particular, how many stories cite West African burial practices, belief in witchcraft, or mistrust of outsiders as cultural reasons that Ebola has spread. In relation to this, Dionne referred to the work of Barry Hewlett and Richard Amola, whose report on the Ebola outbreak in northern Uganda in 2000-2001 outlined a very different role for culture to play:

In early October, residents began to realize that this outbreak was more than a regular kind of illness and began to classify it as two gemo (two [illness] gemo [epidemic])…Gemo is a bad spirit (type of jok that comes suddenly and causes a mysterious illness and death in many people within a very short period of time). Gemo reportedly comes like the wind in that it comes rapidly from a particular direction and affects many people, but the wind itself does not necessarily bring it…Once an illness is identified as gemo, a protocol for its prevention and control is implemented that is quite different from the treatment and control of other illnesses.

When an illness has been identified and categorized as a killer epidemic (gemo), the family is advised to do the following: 1) Quarantine or isolate the patient in a house at least 100 m from all other houses, with no visitors allowed. 2) A survivor of the epidemic should feed and care for the patient. If no survivors are available, an elderly woman or man should be the caregiver. 3) Houses with ill patients should be identified with two long poles of elephant grass, one on each side of the door. 4) Villages and households with ill patients should place two long poles with a pole across them to notify those approaching. 5) Everyone should limit their movements, that is, stay within their household and not move between villages. 6) No food from outsiders should be eaten. 7) Pregnant women and children should be especially careful to avoid patients. 8) Harmony should be increased within the household, that is, there should be no harsh words or conflicts within the family. 9) Sexual relations are to be avoided. 10) Dancing is not allowed. 11) Rotten or smoked meat may not be eaten, only eat fresh cattle meat. 12) Once the patient no longer has symptoms, he or she should remain in isolation for one full lunar cycle before moving freely in the village. 13) If the person dies, a person who has survived gemo or has taken care of several sick persons and not become ill, should bury the persons; the burial should take place at the edge of the village.

As they reflect, “From a biomedical perspective, this protocol constitutes a broad-spectrum approach to epidemic control.” The Acholi response to Ebola varies widely from other groups’, but it is a response rooted in both history and culture. There are a lot of facets to epidemics and responses that only emerge with on-the-ground research and observation with local interlocutors. Benton and Dionne’s call for more research into the Ebola outbreak and the response to it is an important one to heed.

Their commentary is just one of a number of academic attempts to understand the Ebola outbreak and call for more investigations and responses. One that I found really informative and interesting was Cultural Anthropology‘s collection on Ebola. Another one is the blog of a development worker in Liberia, Codex Lector (HT Rachel Strohm for this link).

Why I Will Never Vote to Drug-Test Welfare Recipients

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Wednesday night I sat at home aghast at a lot of things. I was watching the Republican Presidential debate, for one thing, but I was simultaneously reading reports (both links are videos) about police violent cracking down on protesters at Berkeley and also hearing about Joe Paterno’s defenders at Penn State rioting and giddily flipping over a news van. But one thing that caught me off guard was one of the polls on Facebook’s questions app.

A number of my friends had voted “yes” on the question, “Do you support drug testing to get approval to be on Welfare?” Now, I’m a vehement no, but I know that A. a lot of my friends are pretty conservative, and B. there’s a strong (and incorrect) stereotype about the people who need welfare and how many are addicts who should just pick themselves up and work harder. But I didn’t vote, initially, because I’ve never answered a question before. Then my wife decided to take a gander, and reported back to me.

So, I voted, because that’s a lot. And at the time of this posting (Thursday night at 7:30), it was 2.2 million for, 108,000 against. I thought I would move on, but this morning I was still a little irked about it, so I threw this piece together. I naively hope that it changes some minds, but at the very least I’m putting my opinion out there, which is practically what the internet is for these days, right?

The Mythical Relation Between Drugs and the Poor

Apparently everybody thinks that the poor do drugs all of the time. I’ve heard, time and again, that the poor wouldn’t be so poor if they kicked the habit and got jobs. If they just picked themselves up, they’d be fine and dandy. Before we assume that this is true, we should acknowledge something else that is true: mental disorders, physical disability, trauma-related disorders, and depression are all things that can lead to substance abuse – and are also found in low-income communities. Now, do they use drugs at a higher rate than the rest of us? Michigan was the first state to implement drug testing for welfare recipients in the 90s, and it found that 10% of recipients were drug users. And a subsequent survey found that 9% of all Michigan residents, on welfare or not, were drug users. Regarding a similar law passed in Florida in the late 90s, some researchers have already said that such assumptions about the poor are “unwarranted.” In fact, another study showed that only 5% of those applying for assistance failed a drug test.

Some studies have definitely shown that those on welfare are more likely to use drugs or be dependent on them, but they are quick to qualify that if they stopped using drugs they would still be living in poverty because of illness, poor education, and unemployment.  And let’s take a second to note that addiction isn’t easy to break, and often one needs support in order to successfully kick a strangling habit like substance abuse. In 1996, over 200,000 people qualified for SSI because of disabilities related to drug addiction and alcoholism. That category has since been eliminated, and those people no longer have that support. Often, drugs are used as escapism, and being stranded without support will only lead to more abuse and less treatment and recovery. This is not the way to actually help people help themselves, nor is it the way to build a healthier society.

Oh, and it’s Unconstitutional

No authority can search you (or your property) without reasonable suspicion. That’s the law, and it includes taking urine samples. And applying for welfare is not reasonable cause, because – as we’ve discussed – there’s no reason to suspect that the poor are more likely to be on drugs. And that’s where the glorious Fourth Amendment comes into play. The wise authors of our Bill of Rights stated that “the right of the people to be secure in their persons, houses, papers, and effects, against unreasonable searches and seizures, shall not be violated.”  Which is why the Supreme Court decided in Chandler v. Miller that Georgia could not drug test elected officials, and why state efforts to drug test welfare recipients in the late 90s also faltered. This is also why Florida’s current drug-test-for-welfare program is on hold. Because it’s unconstitutional.

The Race Issue

In America, you can’t talk about “the poor” without talking about racial minorities. Most of our communities of color are disadvantaged, and many residents in these areas need assistance like welfare. Many are also targeted for drug use. Which is where policy regarding the poor is also policy on race. The National Poverty Center lists the 2010 poverty numbers with 27.4% of blacks and 26.6% of Hispanics living in poverty while less than 10% of whites (and 12% of Asians) did. So, we know the poor are predominantly minorities. Which is what makes it interesting that a study from The Sentencing Project (PDF) found that race had virtually no effect on the levels of drug abuse, stating that the disparate numbers were actually the result of law enforcement policy, saying that:

Police agencies have frequently targeted drug law violations in low-income communities of color for enforcement operations, while substance abuse in communities with substantial resources is more likely to be addressed as a family or public health problem.

And yet, The Drug Policy Alliance found that, in New York, young white people are more likely to use marijuana, but that black people were arrested at seven times the rate of whites and Latinos (PDF). The narrative continues to argue that the poor and the colored are the ones using drugs, when it’s really that poor minorities are just the ones being arrested for it. The stereotype affects the mentality of the law enforcement, who in turn reinforce the stereotype with disparate statistics every time they choose to arrest and jail minorities and only confiscate the white offender’s drugs, maybe with a warning.

An Unnecessary Hurdle

Last week I was talking with one of my clients in Glendale. He has lived in the U.S. over a year and is a permanent resident. Unable to get a job, he had run out of money a long time ago and relied on his roommate to pay rent. With his roommate moving, he applied for public housing. Lo and behold, to qualify for public housing in Glendale you have to work within city limits for five years. Because the type of people who can work for five years are the ones most likely to need public housing. And this is just a minor example of how we continue to place hurdles in the way of the poor, essentially keeping them that way forever.

Barbara Ehrenreich detailed how we have criminalized poverty ten years after writing her book on how the poor struggle to get by. She explains that food stamps have increased by huge numbers during the recession, but welfare has barely moved because it is so difficult to actually qualify. You can’t qualify for disability without medical documentation, which costs hundreds of dollars for those without health insurance.  Plus, the bullshit welfare system that we have now, ever since Clinton “reformed” welfare, provides supplemental income – which means you have to get a job first, then the government will help, which deals a huge blow to those who can’t find jobs. Ehrenreich explains how one couple down on their luck had to apply for 40 jobs per week while attending daily “job readiness” classes just to get assistance, which is a tall order for anyone having trouble paying for gas, a bus ticket, or a baby sitter. And that’s just to qualify for welfare.

If you find yourself worse off, you face constant harassment at the hands of useless laws like loitering, jaywalking, and the like. Ehrenreich also tells an anecdote of police raiding a homeless shelter to arrest the homeless (while in a shelter) for prior offenses like sleeping on the sidewalk. Las Vegas has even made it illegal to give food to the needy unless you’re a certified organization. When I was in high school I volunteered at a food bank where the poor had to bring proof of residence in order to receive meals – apparently the homeless weren’t allowed food (I didn’t volunteered there again). When you’re not poor, it’s easy to not realized just how many obstacles are on the path to assistance for those who really need it.

Spending Money on the Right Things

People continually argue that, it’s not a war on the poor and it’s not racism, it’s just about fiscal responsibility. We just want to make sure our tax dollars don’t go towards buying illegal things like drugs. So we put the poor through all of these steps in order to make sure that welfare money goes towards what it’s meant to. But, I say, why stop there? Other people receive public funds as well, and we don’t check them.

We should drug test all of the seniors on Social Security. I mean, they’re frail and dying, they’ve got to be on something. Have you seen Little Miss Sunshine? And while we’re at it, I know some friends in college who smoked weed and they were on state-funded scholarships. In a time when it’s harder to afford college, shouldn’t drug users have to fund their own addiction while we give scholarships to the ones who earned it? And we should definitely drug test anyone who wants a driver’s license. When I was teaching last semester, I got the impression that at least a few high school students do drugs, and yet they’re still allowed to drive. I don’t get it. It’s illegal to drive under the influence, but we don’t preemptively check. It’s like we’re just telling them it’s okay to do drugs.

But while we’re talking about watching our dollars, how much does it cost to administer drug tests, process results, and print out new forms and all of that? I mean, Florida’s currently-on-hold law stated that the state would reimburse applicants once they passed, which led to lots of additional costs when only 2% of applicants failed to pass the drug tests (no reliable data on how many chose not to get tested, for obvious reasons). Everyone knows that bureaucracy costs money, but they’re okay adding to it as long as it affects the poor. I mean, this isn’t to improve the welfare system at all, so much as it is about keeping them marginalized.

Drug War Turns 40

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So, last week was the fortieth anniversary of the infamous War on Drugs. The internet was abuzz with people talking about all sorts of aspects of how much of a failure it’s been. Instead of giving anything anecdotal or analytical, I figured I’d just share one of the most effective infographics I’ve seen on it, via Colorlines: