Wednesday, May 26th, 2010, 7 p.m. — Mark Pendergrast will discuss Inside the Outbreaks followed by a signing at Phoenix Books and Cafe in the Essex Shoppes & Cinema Mall, 21 Essex Way, Essex, VT 05452. Phone: 802-872-7111.
Archive for April, 2010
April 14, 2010
I have been too busy writing a speech and dealing with other deadlines (plus putting in new raised bed gardens and planting my snow peas — perhaps the subject for a future blog in conjunction with food-borne outbreaks I will avoid this way) to write a new blog, so here is an excerpt from Chapter 22 of Inside the Outbreaks called “L’Experience Fait La Difference.” This quotes from a journal I kept in Africa, and I may in the future put in some of that journal here. But for now, welcome to Niger:
Jan. 25, 2006, Niger, West Africa. After sleeping in a tiny mud hut, covered by my bednet, I arose and used the toilet – a four-square inch hole in the floor. Then I watched the village stir and come to life. Children drove donkey carts. A goat excreted by the dirt roadside. Women laughed and greeted one another as they got cook fires started in front of their adobe homes. A barefoot man in a blue satin robe and a white pillbox hat sat on a bench next to another whose head was swathed in a bright yellow turban. I was in the town of Tera, the middle of nowhere, but which, in comparison to the remote villages, seemed like the Big City, with its gas station, cell phone tower, Coca-Cola poster, and single restaurant.
After two years of research and hundreds of interviews, I was finally out in the field, following second-year EIS officers Natasha Hochberg and Melto “Jamie” Eliades in Niger, the world’s poorest country by United Nations criteria. The prior month, public health personnel had attempted to distribute insecticide-treated bednets to every household in the country with a child under five, along with vitamin A and oral polio vaccine drops. Hochberg and Eliades were training and directing a team of locally hired “enumerators” who would visit randomly selected villages throughout the country to assess how successful the distribution had been. I would tag along for the first week of the project, then fly to Kenya to follow another EIS officer.
The hanging bednets, which can repel mosquitoes within a 30-meter radius, were intended to prevent malarial mosquitoes from biting children and their families. This program had a very personal meaning for me. During a brief visit to Niger in August 2003, my friend Liz Lasser, who worked for an international health organization, had been bitten by a mosquito carrying the Plasmodium falciparum parasite. She hadn’t bothered to take anti-malarial medication. A vibrant, idealistic woman of 49, she developed fever, chills, and body aches. Her lungs filled with fluid, and she died of pulmonary edema shortly after entering a hospital near her home in England.
Each year over 500 million people become infected with malaria, for which there is (as yet) no effective vaccine. Nearly three million die, most of them young children in sub-Saharan Africa. Almost everyone in Niger has contracted malaria repeatedly. Having developed partial resistance, those who survive to adulthood usually have milder — but still painful — symptoms. The Niger villages I visited were in the southern part of the country, compounds of mud huts with thatched or pueblo-style roofs set on an arid plain surrounded by millet stubble and scrub bush, reachable by red dirt tracks or brown sand.
Trim and nearly six feet tall, Natasha, 31, was a Harvard graduate who had gone on to medical school. She had worked in clinics in Peru and Honduras, then matched with the CDC Parasitic Diseases Branch in July 2004. Her father, Fred Hochberg, had served as an EIS officer in the early 1970s.
Natasha was the lead EIS officer in Niger, keeping track of nine teams, getting enough gas, and dealing with money problems, glitches with the palm pilots with built-in Global Positioning Systems (GPS), and more. An intense perfectionist and worrier, she drove herself hard.
Jamie Eliades worked in the CDC Malaria Branch. In Tera the night before, he and I had eaten at the Restaurant L’Amitie (Friendship Restaurant), a shack of sticks with woven mats for roof and walls. We enjoyed our chicken and couscous, though I didn’t drink the water. (Natasha opted out, having once contracted typhoid from African fare.)
At 6’ 6”, with a relaxed manner and easy smile, Jamie, 37, was a “gentle giant,” according to Natasha. After a residency in emergency medicine, he had earned a masters degree in public health and eventually applied for the CDC program. By the time I met him, Jaime had been to 55 countries. He had helped with the first national bednet distribution and assessment in Togo, later volunteering for Niger as well.
He was a calming influence. “It’s good to have opposite personalities on a team,” he explained, finishing his meal. As we left the restaurant, I took a photo of its misspelled sign announcing: Specialite Afro-Eropenne, L’Experience Fait La Difference. Yes. Experience Makes the Difference could be the motto of my trip, or for that matter, of the EIS.
That day, after hours of rough driving, we had visited the village of Zoribi. As the interviewing team was choosing random huts and conducting the survey in Djerma, the local tribal language, a young mother carrying her daughter had approached Natasha to ask for help, pointing at the child’s grotesquely swollen heel. Natasha gently examined it and answered her apologetically in French. She advised her to go to the nearest health clinic to get antibiotics, since we didn’t carry any.
Why can’t someone give this poor little girl some medicine? I later wrote in my journal. I know that the argument is that we are doing public health, doing a bednet and polio vaccine survey, not primary health care. And if we get involved with trying to take care of everyone, we will go nuts and be diverted. But…
Later I gave Natasha a small amount of money and asked her to get it to the local health clinic for treatment of the girl’s foot. She thanked me and said, “You know, I get so wrapped up in our program, and so stressed out, sometimes I need a reminder that we can stop and help just one person.” One out of every four children in Niger dies before the age of five. It is through public health programs such as immunization, clean water, proper nutrition and vitamins, and bednet distribution that most of those deaths might be averted.
Since I would have been a distraction if I had gone into the huts during surveys, I stayed outside in the villages, where the children crowded round me. Most of the girls wore headscarves, bracelets, and traditional clothes, while the boys wore drab castoff Western tee-shirts and shorts. Most children smiled and laughed, pushing closer; a few shy kids hung back. They were beautiful. Intelligence and curiosity shone from their eyes. Over a quarter of the children die here, I thought.
To engage them, I sang, “If You’re Happy and You Know It, Clap Your Hands.” They began to clap. Then I gestured to them encouragingly, asking for a chanson, and after some hesitation one little girl sang in Djerma. Two children began to dance, stomping their feet, leaning in and circling one another, as the others sang and clapped around them. Finally, a man shouted at them, and they left, apparently ordered back to work, fetching water or carrying firewood.
One woman invited me into her hut. Like most of the women, she wore a startlingly bright traditional dress of white, yellow, blue and red, a shiny purple head scarf, two necklaces of tiny shells, and big hoop earrings. She proudly showed me the filter she used to keep guinea worm copepods· out of the water that she stored in carefully stacked clay pots, though she had no visible bednet.
At every village, Natasha and Jamie first visited the village elder. Because both of them towered over everyone, they usually squatted respectfully, explaining their mission. I was impressed with their ability to organize and train the teams (in sessions back in Niamey), plan this difficult survey of a vast and sparsely populated country, and maintain a sense of humor.
“Jamie and I made a great team,” Natasha told me after the survey was completed. “I tend to be compulsive, that’s how to get work done. He’d tell me it was OK to give the teams a day off.” There had been multiple flat tires, gas crises, cell phone inaccessibility, disgusting lodging, and software problems, but the teams actually finished ahead of time.
The effort revealed that 87 percent of the surveyed children under five had received polio vaccinations during the December 2005 campaign, and that 64 percent of the households with young children had received a bednet. Yet only 15.4 percent of the children had slept under an insecticide-treated bednet the previous night, presumably because the January-February survey took place during the dry season, when mosquitoes are not a big problem.
In September 2006, EIS officer Julie Thwing led teams that repeated the random assessment during the rainy season, finding that 55.5 percent of children under five had slept under an insecticide-treated bednet the previous night. Though not the official 80 percent goal, this was a dramatic improvement. From 2006-2009, ten other African countries have conducted similar bednet distribution campaigns in conjunction with immunization drives.
The bednet surveillance project in Niger is typical of the unsung work of EIS officers. It would have received little notice if I had not tagged along.
- · Guinea worm disease (dracunculiasis) involves a life cycle in which worm larvae are ingested by fresh-water copepods. When a person drinks water with Guinea worm copepods, female worms grow up to three feet long, emerging with painful ruptures. The worm releases her larvae into water, and the cycle begins anew. In 1985 the CDC/EIS joined a worldwide effort to eradicate the disease.
Thursday, May 20, 2010, Noon. Mark Pendergrast will attend a Rotary Club luncheon at the Hampton Inn, Colchester, VT, at noon, followed by a talk about his book, Inside the Outbreaks. Address: Hamton Inn, 42 Lower Mountain View Drive, Colchester, Vermont 05446 Tel: 802-655-6177
April 6, 2010
Instead of a regular blog, I am going to post the beginnings of an article that I have never been able to sell. It is a profile of Les Roberts, one of the EIS officers I wrote about in Inside the Outbreaks, primarily about his nightmare experience in the cholera-ridden refugee camps of Goma following the Rwandan genocide in 1994. He went on to specialize in the epidemiology of war — specifically, in estimating the number of people killed. Hence I called this profile “Body Count Man.” If any readers want to help me place this important article, let me know!
The Body Count Man
by Mark Pendergrast
We all know that statistics can lie in any number of ways, but the controversy over the number of Iraqis who have been killed since United States forces overthrew Saddam Hussein in 2003 is astonishing. Some “experts” say that the figure is less than 100,000, while others aver that over a million Iraqis have died a violent death.
Media outlets have tended to err on the low side. The most widely cited figures have come from the website Iraq Body Count (www.iraqbodycount.org), which says that there have been around 85,000 deaths as of February 2008. The IBC website features a plane unloading bombs with a quote from General Tommy Franks: “We don’t do body counts.” The implication is clear – this is an anti-war site that aims to tell it like it is.
Yet the British IBC organizers base their figures primarily on media reports, supplemented by severely deflated official figures. They make no attempt to do any kind of scientific population-based estimate. They have never sullied their shoe soles with the dirt of Iraq. So what we have is a kind of circular tail-chasing logic in which the media parrot back figures derived from inaccurate media reports.
The British medical journal, The Lancet, published the findings of a US-Iraqi team of epidemiologists, whose random cluster surveys for the periods of September 2004 and May-July 2006 indicated much higher numbers of violent deaths – 100,000 and 600,000 respectively. The Lancet reports were derided by supporters of the war in Iraq.
The Iraqi government commissioned its own study specifically to counter the Lancet conclusions, examining the same time period (through the summer of 2006), and coming up with only 150,000 violent deaths. Published in late January 2008 in the New England Journal of Medicine with the imprimatur of the World Health Organization, this latest survey has been widely hailed as more accurate because of its larger interview base, but it is flawed for a number of reasons – most notably because it shows no increase in violent deaths from 2004 to 2006, while all other studies and reports indicated escalating death tolls over that time period.
The raging controversy, with attendant innuendo and smear campaigns, has been quite an eye-opening experience for Les Roberts, the Johns Hopkins epidemiologist in large part responsible for the Lancet studies. His story is a case study of a public health scientist who, in attempting to change the world for the better, has put himself in harm’s way both literally and politically.
* * * * * * * *
On September 18, 2004, Professor Les Roberts, 43, was listening to All Things Considered through the satellite radio built into the TV set in his Baghdad hotel room. He heard a familiar voice. Martha Foley, a commentator for North Country Public Radio, was describing an exquisite fall day in upstate New York and how she had picked blackberries with her granddaughter. Roberts smiled, picturing the far-off scene as he looked at bombed-out buildings through the sliding glass door to his balcony.
Many years ago, as an undergraduate at St. Lawrence University, Roberts had reluctantly agreed to accompany his workstudy boss to Martha Foley’s house for dinner, though she had not invited him. As they pulled into the driveway, he had seen her look out her kitchen window, spot him, go to the sideboard, and pull off an extra plate. By the time they got to the kitchen, another place had been set, and she never mentioned that he was an unexpected guest. Roberts subsequently referred to such instances of invisible grace as “Martha Foley moments.”
Roberts could use such a moment now. As the world’s premier expert on mortality in war-torn countries, he had come to Iraq to help conduct a random survey of 33 community clusters throughout the country, with the goal of estimating the number of civilian deaths before and after the March 2003 invasion. Since 1992, he had worked in Bosnia, Rwanda, and the Democratic Republic of the Congo at the height of their genocidal conflicts. He had witnessed people being killed, had seen starving children, had been tortured by nightmares. He was used to dangerous situations. But he had not been prepared for the level of anti-American sentiment here.
After accompanying his Iraqi interviewers a few times, it had become clear that his very presence was a threat to their lives, so he had sequestered himself in this hotel room, descending briefly to the lobby at 5 a.m. each day to use the internet to contact his wife and to email precious data to colleagues. In the evening, his driver brought each day’s interview results along with some humus, fruit, or roasted chicken. Going over the questionnaires, Roberts would call his six Iraqi interviewers on his cell phone to ask for clarifications.
Fearing that he might be kidnapped at any moment, he wedged the top of a chair against the door handle, then shoved a bureau and ottoman against the chair, hoping to gain enough time to leap from his third floor balcony. He occupied himself by entering new survey data in his laptop, working on a draft of the final paper, watching BBC World News and Al Jazeera, doing 200 sit-ups and push-ups, and thinking.
As Martha Foley talked about her granddaughter’s blackberry-smeared face, Roberts watched two American helicopters approach an unseen target less than a mile away. As they circled it, he could hear the pop-pop-pop of machine gun fire and could see the spent shell casings falling to the ground. As Foley described making blackberry pie, thick black smoke billowed from the unseen target, as the helicopters continued to circle, flying in and out of the smoke in a surreal scene.
“It was a schizophrenic moment,” Roberts recalls. “Into my ears and into my eyes were coming two facets of America that couldn’t have been further apart. One was about nature, tradition, love, and nurturing. The other was about anger, aggression, and violent technology. It occurred to me that both Martha and the gunner were like people I went to high school with.”
* * * * * * * * * *
Roberts was born and reared near Syracuse, New York. His father repaired furnaces, while his mother raised four children. Young Les was an alarmingly fearless child, the first to jump off a ledge into water without knowing how deep it was. He was raised Catholic, with heavy sermons on sin. “Most of my life is driven by guilt,” he observes. After graduating from Saint Lawrence University with a physics degree, he taught high school in Mattapoisett, Massachusetts. “I was the only teacher under 30. It was quite a poor school. I was a terrible disciplinarian but good at getting them excited – why the sky was blue, things like that.”
In June 1984, when the financially strapped school laid him off after a year, Roberts decided to join his brother in Kenya, where he was on an exchange program. A month later, his brother went home, but Roberts stayed, trying unsuccessfully to find a teaching position. “Everywhere I went, as a white guy from the North American suburbs, I didn’t fit in. Everyone wanted a bribe. I got malaria. I was an idiot and took no prophylaxis. I was staying in Mrs. Roche’s Guest House in Nairobi, where tourists could pitch tents for $5 a night. I had spikes of fever, couldn’t tell which way was up or down in my tent.”
After he recovered, Roberts saw a thief grab a woman’s necklace, chased him 20 blocks and caught him. The police threw them both in a car. “As we drove to the station,” Roberts recalls, “the guy in the front seat bashed the thief in the testicles with a club. No one had even asked me what happened. I realized the police were far worse than the guy I had caught. I didn’t know what I was doing. Everything I touched I messed up.”
Roberts decided he needed a specialized technical skill. Every day he saw women carrying huge buckets of polluted water on their heads for miles. “It seemed so crazy. Meanwhile we could put a man on the Moon and spend money on Pet Rocks.” He returned to New York to teach high school for a year near Syracuse, saving enough to enter the Tulane School of Public Health and Tropical Medicine, where he earned a masters in public health.
“At the end of my Tulane time, all I knew was that I didn’t know much.” He went on to earn a Ph.D. at Johns Hopkins in environmental engineering, specializing in sanitation engineering and diarrhea prevention. For his dissertation, he spent a year in Peru proving that chicken coops helped prevent the spread of disease. Just before he left in May 1991, a cholera epidemic struck Peru – the first reappearance of the dreaded diarrheal disease in South America.
He met two Epidemic Intelligence Service (EIS) officers dispatched to Peru from the Centers for Disease Control to study cholera. They told him about the two-year training EIS program which required that the disease detectives keep their bags packed, ready to go anywhere in the world to battle an outbreak.
Intrigued, Roberts applied and joined the Epidemic Intelligence Service in July 1992. The EIS is a two-year CDC program which requires that disease detectives keep their bags packed, ready to go anywhere in the world to battle an outbreak. With the EIS, he worked on cholera control in Malawi, assessed the health crisis in war-torn Bosnia, then documented the 1994 Rwandan genocide and worked in the mass cholera/dysentery outbreak in Goma, Zaire, among Rwandan refugees. With the International Rescue Committee (IRC), he conducted mortality surveys in the Democratic Republic of the Congo.
In late August 2004 he snuck into Iraq to help conduct the first nation-wide mortality survey. In Bosnia, Rwanda, and the Congo, Roberts had witnessed people being killed, had seen starving children, had been tortured by nightmares. He was used to dangerous situations. Still, he was not prepared for the level of anti-American sentiment he encountered in Iraq, nor did he realize that his very presence would imperil his team of Iraqi investigators. But his most painful learning experience would come later, when his hard-won mortality estimates, published in The Lancet, were dismissed by the Bush administration and most of the U. S. media, and then undermined by the WHO/Iraq government report.
In contrast, Roberts’ previous work in the Democratic Republic of the Congo had a major impact. In 2000, that survey estimated 1.7 million Congolese deaths. These numbers, cited by Kofi Annan, eventually led to doubled aid and peace talks. During his subsequent 2001 Congo survey, which estimated 2.5 million deaths, Roberts’ foot was shattered when it hit a hidden log as he rode a motorcycle along a narrow jungle path. He had to continue anyway. (His foot is still deformed. Every step hurts.)
When the IRC leadership decided to accept money from the U. S. government just prior to the Iraq invasion in March 2003, Roberts resigned in protest, since he felt that it compromised the mission’s objectivity and tacitly provided “humanitarian” cover for the war. With $40,000 from Johns Hopkins and other sources he decided to go to Iraq to study mortality on his own. Through email, he arranged to work with Farzad (a pseudonym to protect him), a professor at Baghdad’s most prestigious medical school.
On August 22, 2004, Roberts flew to Jordan, where he found an expatriate Iraqi taxi driver willing to take him to Baghdad. The driver advised him to give him his passport and lie on the floor in the back of the SUV when they got to the border. There, the driver happened to encounter an old military friend, who took one look at the American passport and said, “Are you crazy? Put that away! Good luck, I don’t know you, go.” So Roberts entered Iraq without having his passport stamped, a circumstance that would come back to haunt him.
When Roberts arrived in Baghdad unannounced and called Farzad’s cell phone, the Iraqi doctor was astonished that he had made it across the border from Jordan. “Only Allah could have done this for you,” he said. Unable to afford the secure luxury high-rises other Americans stayed in, Roberts rented a room in a small local hotel, where he tried to dye his light brown hair and beard black, then looked in the mirror. “My hair was black black black. My beard, tinged with grey, looked sort of blue, my thicker mustache remained brown and grey,” he recalls. “I looked ridiculous, like a chocolate rainbow.”
The following day, he donned a long white Arab robe and flip-flops to meet his survey team. As soon as Roberts got out of the car, Farzad burst out laughing. From then on, he wore nondescript Western clothing, as did most Iraqis, and carried a fake ID saying that he was Dr. Abdul Salam from the Bosnian National University, so that he could have blue eyes, look European, speak no Arabic, and still not be seen as an American.
Farzad had recruited six interviewers, two of whom were women. Five had medical degrees, one a near-Ph.D., and all spoke English. Farzad had arranged for them to do test interviews in one of Baghad’s safest neighborhoods. For the only time, Roberts stood with them during the interviews. “I wanted to see their body language,” he says.
Two interviewers refused to ride in a car with him. Roberts wanted them to ask to see death certificates in order to remove any doubt about mortality reports. “No way,” the interviewers said. “People will think we don’t believe them. They might pull out a gun and shoot us!” After two days of practice, during which the questionnaire was refined, they split into two teams, one led by Roberts, the other by Farzad. Then they began to interview the first household clusters.
* * * * * * * *
The art of mortality survey epidemiology is not rocket science, but it is nonetheless a science, involving a fair amount of math, probability theory, and gumshoe experience. In an ideal world, each death would be counted as it occurred. But in the chaos of a war-torn country, what is the quickest, most efficient way to estimate mortality? It turns out that 30 is a kind of magic number. For any given population – refugee camp, city, region, or nation – you need to sample at least 30 clusters of people to achieve statistically reliable results. These clusters should be chosen at random, but areas with greater population are allocated more clusters, which is why Roberts had chosen seven clusters in Baghdad itself.
Within each cluster, you need to sample at least 30 random households. So, in total, the surveyors needed to visit 900 or more houses around Iraq. Each team carried a Global Positioning System to find a predetermined random point. From there, the three members on each team would interview the 30 households closest to that GPS point. To make sure at least 30 locations were visited, Roberts had chosen 33 clusters throughout Iraq.
The Baghdad cluster interviews went well, as did the first few outside the city. Roberts accompanied his team to the eighth cluster in the city of Balad, 50 miles north of Baghdad. Entering town, he encountered two huge pictures of the anti-American Shi’a cleric Muqtada al-Sadr and his father. The first random spot chosen by the GPS turned out to be the governor’s home. Waiting in the car with his driver, Roberts watched his two interviewers go into the house. A few minutes later, a police car pulled up. Roberts watched as the police took his two interviewers away. They will be killed, he thought.
After an hour and a half, the two interviewers returned unharmed. The team completed its 30 households and drove back to Baghdad. But Roberts never accompanied them again, realizing that it would only put the surveyors in danger. He sequestered himself in his hotel room, descending briefly to the lobby at 5 a.m. each day to use the Internet to contact his wife and to email precious data to colleagues. In the evening, his driver brought each day’s interview results along with something to eat. Going over the questionnaires, Roberts would call the six Iraqi interviewers on his cell phone to ask for clarifications.
Fearing that he might be kidnapped at any moment, he wedged the top of a chair against the door handle, then shoved a bureau and ottoman against the chair, hoping to gain enough time to leap from his third floor balcony. He occupied himself by entering new survey data in his laptop, working on a draft of the final paper, watching BBC World News (and occasionally Al Jazeera), doing 200 sit-ups and push-ups, and thinking.
Les Roberts barely got out of Iraq because his passport was not stamped. This first survey estimated that 100,000 Iraqis had been killed since the war began. The results, published in The Lancet just before the U. S. elections in November, were ignored or dismissed as overestimates.
* * * * * * * * * *
In May-June 2006, Roberts helped from afar (without returning to Iraq, since his colleagues insisted it was too dangerous for him and for them) as the same Iraqi team conducted another mortality survey. This time, it revealed that an estimated 600,000 Iraqis had suffered violent deaths since the invasion. Again, the study was published in The Lancet. Again, it was ignored. “If these assertions are true,” the Iraq Body Count website argued in dismissing the results, they implied “incompetence and/or fraud on a truly massive scale by Iraqi officials” as well as “an abject failure of the media.” Roberts would certainly agree.
Now, despite the recent WHO/Iraq government report, Roberts remains quite sure that the mortality in Iraq since the invasion is well over a million deaths. He is skeptical of the claims that violence in Iraq is down by half. While violence may have been reduced in Baghdad, no one is tracking what is going on in the rest of the country. No one wants to know.
Les Roberts teaches public health at Columbia University and Johns Hopkins and continues to agitate for change in American policy and to roam the world to try to prevent unnecessary deaths.
TO BE CONTINUED….(IF I FIND A SYMPATHETIC MAGAZINE EDITOR).