Mirror, Mirror In His Hand

“Our job is only to hold up the mirror — to tell and show the public what has happened.”
— Walter Cronkite

One thing that is noteworthy about all humans is that the longer we look at an object, a scene or even another human, the more our perception dulls. The object, scene or other person becomes familiar and we run the risk of not seeing changes.
Painters face this problem when doing a representation piece. If an artist steps away from a representational piece for a few days, he or she will often come back and notice glaring mistakes. To help alleviate this, the great painter and polymath Leonardo da Vinci had this suggestion written down in one of his many notebooks:

“When you wish to see whether the general effect of your picture corresponds with that of the object represented after nature, take a mirror and set it so that it reflects the actual thing, and then compare the reflection with your picture, and consider carefully whether the subject of the two images is in conformity with both, studying especially the mirror.”

Thus by holding a mirror up to a representational painting, an artist is able to see it for what it really is. The mirror becomes an instrument of reality.

Even though I could not find the exact origin, the term “holding up a mirror to something or someone” shows up throughout history. It shows up in Shakespeare’s Hamlet, Act 3, Scene 2: “…as ’twere, the mirror up to nature, to show virtue her own feature, scorn her own image, and the very age and body of the time his form and pressure.”
More interestingly, the phrase is captured as the symbol for the virtue Prudence. Prudence is depicted as a woman holding a mirror (into which she stares) with one hand and a snake with the other. The mirror symbolizes self-awareness whereas the snake represents wisdom and caution.
So we see that even in antiquity, it was wise to be reminded of reality constantly, then that is a mark of prudence and prudence is a great virtue to live by. By prudence, I do not mean the modern meaning of caution but the ancient meaning of wisdom, foresight, and knowledge.
It is not only important to hold up a mirror to ourselves to remind us of who we are like Prudence does. It is also important to hold up a mirror to society to remind all of who we are as a people.

One person who seems to do this quite well is the attorney turned investigative journalist, private investigator and sting operator par excellence, Anas Arameyaw Anas.
Like some, I have been critical of his methods. I even penned a piece titled “Who Will Watch Anas” in 2015. However, regardless of what you think of the man, his investigative style and his mode of publicizing his findings, he always succeeds in holding up a mirror to our society.
And anytime he holds up that mirror, the Ghanaian society recoils at what it sees.
Whether it is about his investigations into ritual killings of disabled children, the Chinese sex cartel in Accra, the Madhouse story, the crooked judges or now even the corrupt Ghana Football Association, his findings act as a shiny surface from which the ills of the Ghanaian society are starkly reflected.

Of all the ills that we see, there is one that seems to always be present — an unbelievable ease with which Ghanaians can be corrupted to do the wrong thing, even break the law, with money and/or even livestock. This ability to be easily corrupted seems to spin its way through all of Anas’ findings and many are those who think it may be the biggest ill afflicting this nation.

So why are we so corrupt as a nation and a people?
The answer may well lie in philosophy – philosophy, not as an art of reasoning but the art of living.
Every culture has a belief system that guides the lives of its people. This is often wisdom collected and passed on over centuries. It informs how the people think, behave and interact with each other. It shows up in the level of dignity, morality, and ethics in each culture.
With a culture of corruption as ingrained in our society as it is, one may safely say that the collective wisdom passed down through the ages has contained corrupt behavior as a hallmark.
Now, what would cause our philosophy for life to be marked by a habit as destructive as corruption? The answer is simple: because in our corner of the world, most people do not live; they survive! Thus, with a survival mentality, it is easy to see why corruption is so rampant.

Outside the big cities live millions who are struggling to make ends meet. Even in the big cities are many who are struggling to survive way below the poverty line. This breeds a survival mentality and philosophy. It is a survival of the fittest, dog-eat-dog mentality. Anything that gets one through the day is good. Morality, ethics and especially conscience become liabilities. In the face of such poverty, Ghanaians can be corrupted to do the wrong thing, even break the law, with money and/or even livestock.
The survival mentality also breeds a scarcity mentality. Thus even when people have no real need to steal, keep doing it because they are driven by a fear that their good fortune is not permanent. They become greedy.
Every and anything that fosters one survival is seen as good. Anything that threatens this survival is seen as bad. Even Deities one worships are seen as enablers. Thus, in Anas’ Number #12, one can hear some of the referees who are taking bribes thank God as they receive the monies. Even though the Christian God probably frowns on corruption as it is stealing, a man with a survival mentality sees this God differently. For him, God becomes a power to be harnessed in this fight to survive. This morality-free, unethical fight and any success that is notched, whether legal or illegal is seen as a boon from this God. Thus on Sundays when Ghanaians stream in their thousands into churches, the prayer that rises to the heavens is one for survival. Any wonder there are so many churches?

So as long as people survive instead of live, the last thing on their minds is raising a mirror to examine themselves or the society in which they are struggling to survive. That is a luxury reserved for those who live.
That is why what Anas does is so important. He has become our Prudence. With one hand on a serpent that winds around offering the corruptible the forbidden fruit to bite into, the other hand holds up a mirror to reflect the actions of these corruptible ones. When we see them biting into the forbidden fruit we gasp, not only because we are shocked at their actions, but also because we recognize ourselves.

Not until we become a nation that can provide the basics of life like food, clean water, electricity, and shelter for its people, we will only survive. Even those who are well-to-do will think they are just surviving and exhibit greed at destructive levels. Swamped by this scarcity mentality, our society will not know qualities like dignity, morality, ethics, prudence, justice, temperance, and fortitude. Such qualities that will make us want to lift a mirror to ourselves and our society. Qualities that keep the “Anases” of the world away.

Till then, we will wait expectantly for the next time he raises his mirror and asks, “Mirror, mirror in my hands, who is the most corrupt in all the land?”

The Hardest-Working People

On May 16 Bloomberg published a piece by the famed business columnist, Justin Fox, titled “Want Educated Immigrants? Let In More Africans”.
In it, he dissects the words of the WH Chief of Staff, Gen. Kelly from an interview with NPR that aired on May 11. At one point during the interview, the discussion veered onto the issue of undocumented immigrants. Gen. Kelly argued that since most undocumented immigrants were uneducated, unskilled and could not speak English, they were “not people that would easily assimilate into the United States, into our modern society.”
Based on the criteria Gen. Kelly seems to prefer, Mr. Fox in the column, presented data from the census bureau, to show which immigrants are the best fit. In one graph, he presents the list of countries with the hardest working immigrants in the US and Ghana is at the top of that list.
Let that sink in – Ghanaians are the hardest-working immigrants in the US!

As I read the piece and stared dumbfounded at the graph, I thought of a debate that has occupied psychologists for decades. The question of whether human behavior in any given situation is due to personality or the circumstances. I recalled 2 experiments, that in their own way, sought to shed light on this question.

The first one was performed in the 60s. In July 1961, in the shadow of the Nuremberg War Crimes Trials, Stanley Milgram, a psychologist at Yale started an experiment to research into how far people would go in obeying an instruction if it involved harming another person. The experiment was meant to focus on the conflict between obedience to authority and personal conscience. His motivation came from the justification given by those tried during the Nuremberg War Crimes Trials, that their participation in the Holocaust was purely out of obedience to authority.
He recruited 40 men who played the role of teachers who had to test learners played by actors. There were also “experimenters”, who acted as supervisors of the teachers. The learners were taught word-pairs and then tested on them. For each wrong answer, the teacher, goaded on by the experimenter, had to give the learner an electric shock. The shocks started from 15 volts and went up in 15 V increments all the way to 450 V. Even though the teachers thought they were giving real shocks, the shock generator was connected to a tape recorder which played back prerecorded screaming sounds. The learner was in another room so the teacher could not see him. The learner also added to the drama by banging on the walls of the room when the shock intensity got above 300 V. At 450 V, there was no response.
In the initial experiment and variations of it by Milgram and other psychologists, 65% of the subjects applied shocks up to 450 V. All of them applied shocks up to 300 V. 26 of 40 subjects were prepared to shock other humans with harmful voltages just because they were asked to!
Milgram would propagate the Agency Theory from this experiment — in the autonomous state, people direct their own actions take responsibility for the results of those actions but in the agentic state, they allow others to direct their actions and then pass off the responsibility for the consequences to the person giving the orders.

In the second experiment, the 1973 Stanford Prison Experiment, Philip Zimbardo sought to find out whether the brutality reported among guards in American prisons was due to the sadistic personalities of the guards (trait) or had more to do with the prison environment (circumstances). He turned the basement of the psychology building into a mock prison and recruited 23 students who were asked to role play guards and prisoners. 11 of them played guards and 10 of the prisoners. The experiment was supposed to go for 14 days but by the 6th day, the guards had become so abusive and the prisoners so submissive that the experiment was terminated. One of the prisoners had had a mental breakdown!
Zimbardo would conclude that people will readily conform to the social roles they are expected to play and that the circumstances made both the guards and prisoners who they were.

These two experiments, in spite of their shortcomings and biases, point to an important phenomenon — that our behaviors in certain situations can be a function of the circumstances and not our inherent personalities.

So how do these experiments and phenomenon apply to the Justin Fox piece? Well, the fact that Ghanaians are the hardest-working group immigrants in the US is remarkable.
Like my the friend, attorney, and social activist, Ace Kojo Anan Ankomah asked, “And in our own country are we the hardest working people?”
Do not get me wrong. There are plenty of very hard-working Ghanaians who will never leave the country but there is also a percentage of the workforce that exhibits a marked paucity of wanting to work hard.
A lot of business owners complain about the work ethic of some Ghanaians in Ghana but then these same Ghanaians migrate to the US and become the hardest-working group of immigrants! How is that possible?

If we assume that the personalities of these Ghanaians stayed unchanged, then the change in behavior has to be attributed to the only thing that changed – the circumstances. Thus somehow, a change in the environment brings out a better work ethic in Ghanaians.
If Ghanaians can, with a change in where they find themselves in the world, exhibit a better even great work ethic, then this trait was already present in us but had become dormant, even inert or was induced by the newer circumstances.
That will mean that there is something in Ghana that suppresses this trait and something in the US that allows it to blossom.
That “thing” is what makes Ghanaians put in their all in a strange land. The absence of that “thing” is what suppresses the work ethic when they are in Ghana.

Before we identify that “thing”, let me do a little exercise:
Say I am in downtown Lexington and witness a man collapse. Driven by my instincts as a doctor, I’ll run over and offer my help. I will start CPR, get someone to call an ambulance while I continue and I’ll keep pumping on the chest till help arrives. I know as long as I keep some blood flowing, once he gets to one of the big three hospitals in town, he’ll get the critical care he needs. Thus, I harbor some hope that my efforts are not in futility.
Now let’s transport me to Ghana. I am somewhere in Osu and notice a man collapse. I’ll rush over and start CPR. As I push on the man’s chest, I will wonder when an ambulance will show up. Even if it does, will the medics on the ambulance have a way to ventilate and monitor the patient till they get him to Korle-Bu or 37? At either hospital, will they even have a ventilator or even oxygen? How bad is traffic going to be? Can you feel my pushes waning?
Back in Lexington, I tell myself, “It is worth it!” In Ghana, there is a nagging feeling that it is not worth it. A certain hopelessness is making my efforts seem futile and with that my efforts seem to ebb. Circumstances are starting to affect my behavior.
After a year in Ghana, guess what I’ll do when I see a man keel over on the streets of Accra?

So that “thing” that induces an amazing work ethic in Ghanaians in the US but saps it when they are home might be HOPE and TRUST. Hope that in the US they will find a well-paying job and a trust that if they work hard, their efforts will be rewarded. Hope that they can make their lives and that of their families better by giving it their all. This hope is not just a pipe dream but an actuality that is borne out by the Rule of Law and institutions that work. They see this in the lives of other Ghanaians and trust that the system will work.
This work ethic is sapped away by conditions of hopelessness and mistrust. So even in this same US, African-Americans, have through years of racism and violence, neither hope not trust in the system. This hopelessness and mistrust have eaten and still eat away at the well-being of this group and may buttress reports of poor work ethic in some members.

Based on an unscientific poll I did on Facebook (above image), the majority of the 200-plus people who answered think personality is the deciding factor in how a person behaves in any given situation. The Milgram Experiment counters this. We realized that in certain circumstances, 65% of people exhibit behavior that is dependent on the situation. The Stanford Prison Experiment had even starker results!
However, the issue might not be that simple.

As far back as 1938, the Harvard psychologist, Henry Murray, posited that “situations ‘press’ individuals to exhibit traits”. Tett, Simonet, Walser, and Brown would crystallize that into the coherent Trait Activation theory in the Journal Of Applied Psychology in 2013. In short, it says that a trait will show up only in a situation where it is relevant.
Also, there is the thought that certain character traits make people seek certain situations. So a man who is promiscuous will always find himself in situations that lead to seduction. This notion was also brought up about the Stanford Prison Experiment – that sadistic people may seek out jobs as guards and be aided by that situation to realize themselves. In other words, people seek out situations that “press individuals to realize their dominant traits”. Hardworking people seek out environments that induce their work ethic.

So could it be that the Ghanaians with a strong work ethic are those who migrate, hoping to enter an environment where their strong traits are induced? Maybe!
Whatever the case is, we need to build our country so that it is a bastion of hope and trust. A place where the rule of law stands and institutions work. Even if, like me, you are one of those “working hard” in the US, you need to do the little you can to raise our motherland. Then and only then will very, very few find the need to leave so as to find themselves. Then and only then will we be “the hardest-working people in our own country.”

The Most Hallowed Right

Maybe it is because life is so serendipitous and unpredictable. Like the old adage that the Persians claim the Sufi poet Attar of Nishapur wrote or the Jews attribute to King Solomon, “This too shall pass”. The problems or the joys we face in life are fleeting and nothing is really as it seems.
Maybe it is because some see a Deity as the Creator of life. Life then is seen not as a gift but a loan from this Deity that we are supposed to treasure, protect and make the most of. Then one day, we will be called upon to account for that loan called life and will be punished if we misused it and rewarded if we treasured and made the most of it.
Maybe its because the State sees life – all life – as something sacrosanct that falls under its purview to protect.
Maybe it is because there is the feeling that we are all in this together and turning one’s back on the experience is a betrayal of a common cause.
Maybe it is the loved ones one leaves behind…loved ones whose love was just not enough?
Or is it that life is seen as being so precious that no matter how terrible and unbearable one’s circumstances are, its sanctity should be upheld?

Is that why the issue of taking one’s life is so controversial?

Most consider life a truly great gift. That this fleeting, ephemeral experience on this crazy planet is a wonderful thing. Or could be a wonderful thing.
If life is a gift, then each of us has the right to do with it what he or she chooses. That is a right that comes with life. No one else can decide for a mature adult of sane mind what he or she can do with his or her life.

Even if it is the decision to end it.
Which brings me to one of those questions without a right answer:
“Does any human have the right to end his or her life?”

The issue of suicide is a controversial issue. Is it wrong or right? Why does it carry such a stigma? Why do some societies criminalize it? If one has a right to live, should that same right not pertain to death?
You might feel strongly about it being right or wrong but your point of view is not inviolate and that is the aim of this exercise. To present a stand unlike the conventional which sees suicide as a very bad thing, even criminal.

Surely, there are diseases of the mind, like depression, that cause one to think of ending it all. Since one is not of sound mind, it can be argued that that is an exception.
On the other hand, the desire to live is such a strong phenomenon that very few people, who have all their mental faculties intact, think of ending it all.

The WHO estimates that about 1 million people die from suicide each year (the world’s population is 7.7 billion and is growing by about 83 million people a year).
The majority of these people are thought to have major depression but also substance abuse like alcoholism, financial woes, debilitating disease and societal pressure can lead to suicide. The highest number of suicides are seen in Europe and Asia (Lithuania and Japan come to end) with Africa having the least. This raises another question that I ponder about often: Do Africans value life or are we just afraid of death.
Anyway, I digress. Let us go back to the matter at hand.

This means that those who are not depressed or suffering from other mental illnesses who commit suicide do so because they cannot take their lives at that point in time anymore. They do not see any way out and see death as the only way out.

As ill-informed as that decision might be, is it not in their right to do so?

Should a patient with terminal cancer, with metastases all over, who suffers indescribable pain not have the right to end it? If that person continues to live in pain and suffering, what does that achieve?
A slave who jumped off a slave ship to his death in the churning waters of the Atlantic during the Middle Passage saved himself the horrors of bondage that befell Africans in the New World. Did that slave not have the right to do so?
A banker who loses it all when the market crashes and thus jumps out of a 30th-floor window to his demise chooses death over life. In much the same as the Japanese pilots of the Tokubetsu Kōgekitai who flew kamikaze missions against Allied targets in the Pacific during WW II did. They all at that point in time had a similar mantra in mind like the quote from 1775 that has been immortalized and is seen as one of the catalysts of the American War of Independence. Words uttered by Patrick Henry but probably written by William Wirt:
“Give me liberty, or give me death!”
Most people respect that and see valor and patriotism in those words. However, how is that different from the other scenarios I painted earlier?
The African slave leaping into the churning waters of the Atlantic made a decision to die rather than be in bondage. The terminal cancer patient wants death rather than pain.
The banker might well have screamed, “Give me wealth or give me death” and the kamikaze pilot, “A victorious Japan or death”.
What underlines all these scenarios is a freedom to make that choice between life and death. Society may hail one but condemn the others. Why?

The issue of suicide has bedeviled mankind forever. Camus put it best when he wrote, “There is but one truly serious philosophical problem and that is suicide”.
In ancient Greece, in Massilia and Ceos, a man who could convince the magistrate why he needed to die was handed a cup of Hemlock and bid farewell.
Pliny the Elder wrote:
“Life is not so desirable a thing as to be protracted at any cost. Whoever you are, you are sure to die, even though your life has been full of abomination and crime. The chief of all remedies for a troubled mind is the feeling that among the blessings which Nature gives to man, there is none greater than an opportune death; and the best of it is that everyone can avail himself of it.”

Sure there were also philosophers like Camus, Kant, Locke, and Satre as well as writers of Christian-leaning and the Church itself who opposed and continue to oppose suicide greatly. Hobbes’ position is probably the most revealing. He claims that natural law forbids everyman “to do, that which is destructive of his life, or take away the means of preserving the same.” Breaking this natural law is irrational and immoral.
Religions like Hinduism support suicide while Christians abhor it, citing the suffering of Jesus on the cross as an example of how tough life can be and how we are called to bear it.
However, even Jesus prayed for strength to carry that cross and ultimately made a conscious decision to bear it. So, if one cannot carry this burdensome cross, can one not just end it. To cull from Herodotus quote, “Does death not become for man a sought-after refuge, when life is burdensome?”

Maybe the person who looks at life, finds it unbearable and decides to end it does not commit “the greatest act of cowardice” but rather uses his or her most hallowed right – the right to live or not. The right to be a person or a memory.

The Small Matter of Implicit Bias

“No amount of money can reward the work and sacrifice of policemen, teachers and nurses. Their reward is in Heaven!”
– the late Michael Ghansah

I make the effort to see my patients before they are rolled back for surgery. I can easily say that 3 out of 4 times, when I walk up to the patients, the assembled family members assume I am an orderly who is taking the patient back to surgery. When I introduce myself as the anesthesiologist, the surprise or disappointment is always palpable.
Am I bothered by the reaction? Sure, who wouldn’t be in my situation. One just learns to live with it. The bigger question though is: what drives such an assumption?
Walk through most US hospitals. Most of the doctors are white, the janitors and orderlies are black. The doctors are male, the nurses are women. So implicitly, most people see a black guy and subconsciously think “Orderly”. I know several female colleagues who are addressed as “Nurse”!
It is not the fact that one feels demoted by being seen as an orderly or a nurse. No! It is the implicit bias inherent in the assumption that is bothersome.

Implicit bias!
“….implicit stereotypes and implicit attitudes that are shaped by both history and cultural influences. Implicit biases encompass the myriad fears, feelings, perceptions, and stereotypes that lie deep within the subconscious; they act on those memory records and exist without an individual’s permission or acknowledgement. In fact, implicit bias can be completely contradictory to an individual’s stated beliefs—a form of conscious-unconscious divergence.”

Compared to explicit bias, implicit bias is unconscious. So you may think all women who work in the hospital are nurses even though you do not realize it. An example of explicit bias is known and accepted prejudice or even hatred for a race or people – racism!.

With patients not really being in a position of power relative to me, their biases do not significantly impact my day. The situation is quite different when the roles are reversed. Where the one with the bias is in the position of power. Say the physician one sees in the ER or a sentencing judge or a cop with a gun.
In a 2012 study looking at how pediatricians treated their patients with pain, white patients were more likely to get pain medicine prescribed for pain than black ones.
Researchers found that when controlling for numerous factors like severity of the primary offense, number of prior offenses, use of force etc, individuals with the most prominent Afrocentric features received longer sentences than their less Afrocentrically featured counterparts. So if you had dark skin, a wide nose, and full lips, you were toast!
Racial bias in policing has been in the news lately. Events like the killing of Michael Brown in Ferguson, MO or Tamir Rice in Cleveland have thrust the issue into the news. The killing of Alton Sterling yesterday in Baton Rouge and Philando Castille in Minnesota today have escalated the tensions. Movements like Black Lives Matter, All Lives Matter and Blue Lives Matter have all arisen to defend different parts of the debate.

One thing is for sure though. Implicit bias plays a huge role in law enforcement and the broader judicial system in this country.
Cops intervene disproportionately with blacks and Hispanics. They are arrested or ticketed, searched, stopped or even surveilled more. Blacks are also apt to have force used against them more. One reason is that there could be more crime among minority groups. The other reason is police bias and prejudice. Implicit bias.

Armed

In 1999, a 23-year-old Guinean immigrant, Amado Diallo, was mistaken for a wanted serial rapist and shot by four New York City plainclothes cops. 41 shots were fired. 19 hit him. He died. The cops were indicted, tried and exonerated.
Shortly thereafter, researchers in Chicago and Denver started looking at the issue of implicit bias in the way white cops treated black suspects. They recruited subjects from the community as well as cops. They were shown scenarios where they had to decide to “Shoot” or “Don’t Shoot”. The scenarios contained armed and unarmed whites and blacks.
The subjects who were white ,were more apt to shoot an armed male more quickly if he was black than if he was white. However, they were quicker NOT to shoot an Unarmed White than a Black. Which means, they would shoot an Unarmed Black but not an armed White.
Researchers also found a more pronounced neurophysiological threat response when subjects were faced with a Black suspect and that this correlated with how fast they pressed “Shoot”.
A later study in Denver found that compared to people from the community, cops were less prone to have this bias – that of shooting an Unarmed Black over an Armed White. They attributed this to high quality use-of-force training that several police departments had instituted.
Interestingly, a recent study in Spokane showed that in some cases, cops may use less force against blacks – possibly putting the cop in danger – due to the media and legal backlash.

The good news is that in medicine as well as in Law Enforcement and the Judicial systems, the issue of implicit bias is now recognized and several psychologists are doing some great work in developing training programs to reduce this. The bad news is that progress is slow.
Can implicit bias be totally eradicated? I do not think so then after all we are human and having prejudices is as old as the human race itself. It surely does not excuse the killing of unarmed suspects but it helps to pinpoint where changes can be made.
Often the debate about Policing and Race is split along color lines with most minorities cognizant of a problem and most Whites thinking there is none. Well to my white friends who think there is no problem, I have news for you – THERE IS A PROBLEM!
One should appreciate the work cops do – laying their lives on the line daily to protect us. It is an unenviable job in a society awash in guns. However, the issue of disproportionate use of force against black suspects is an issue that won’t go away unless addressed. It creates mistrust, loss of life and makes cops afraid to do their job because of media and legal backlash.

I’ll end with another experience. We were flying back home and made a connection in Atlanta. As we were boarding, I couldn’t help but notice the passport of the gentleman in front of me. The inscription was in Arabic. My heart started pounding. On board the plane, I looked our for him and kept an eye on him all through the flight. When he headed for the bathroom, my fear went up a thousand notches. My relief when we landed was beyond description. When I decided to write this today, the memory of my reaction came back to me. It was the memory of my own implicit bias.

Role of Disease in Sub-Saharan Africa – Another Take

Sub-SaharanAfrica (SSA) seems to be the crucible of disease. Most of our modern day epidemics seem to emanate form this area – HIV, Ebola – to mention just two that have had significant mortality.
Disease in SSA is however nothing new. The region has always had numerous infectious and vector-borne diseases.
I seek to argue that the prevalence of disease in SSA might have changed the course of it’s history.

Lets go back several hundred years to about 1490. This is the period when Columbus landed in what is now Central America and initiated the massive migration of Europeans to the New World, as it was called. Through the activities of the migrant Europeans and disease they introduced, millions of native Americans were literally wiped out.
Now, SSA was “found” around this same time period. It ultimately became a the source of manual labor for the cotton and sugar cane plantations in the so-called New World. So why didn’t SSA see the same level of migration of Europeans like the Americas saw?

One argument is that black Africans were seen as an optimal manual labor force and so their bodies were priced over their lands. Some have also argued that SSA was more densely populated than the American continent. Yet another is that the Africans mounted a much stronger resistance against the Europeans than the Native Americans.
The argument, which I tend to favor, is the role of disease and specifically malaria. Malaria, a disease to which most indigenous Africans develop some form of immunity to over time, is devastating for anyone contracting it for the first time. It killed quite a number of European settlers.This dampened any desire for an exploration of the continent. A glimpse of what could have been is seen in South African a region with a climate and disease profile much kinder to the Europeans settlers.

Malaria as a disease was known since the time of Hippocrates. In the ancient times, it was attributed to bad air. The term Malaria was coined in Florence by the historian and chancellor of Florence Leonardo Bruni in his Historia Florentina around1400:
Avuto i Fiorentini questo fortissimo castello e fornitolo di buone guardie, consigliavano fra loro medesimi fosse da fare. Erano alcuni a’ quali pareva sommamente utile e necessario a ridurre lo esercito, e massimamente essendo affaticato per la infermità e per la mala aria e per lungo e difficile campeggiare nel tempo dell’autunno e in luoghi infermi….
After the Florentines had conquered this stronghold, after putting good guardians on it they were discussing among themselves how to proceed. For some of them it appeared most useful and necessary to reduce the army, more so as it was extremely stressed by disease and mala aria (bad air)…
It was introduced into England 1740 by Horace Walpole:
“There is a horrid thing called the malaria, that comes to Rome every summer, and kills one”, and into medical literature by John MacCulloch in 1827.

So Europeans knew of malaria and found out about other diseases that killed them in droves like dengue, yellow fever and the bugs that caused dysentery. Even David Livingstone, the Explorer and Missionary, died form malaria and dysentery. The cattle that the Europeans tried to raise were also killed off.
Unlike in the America, in Australia, the Polynesian islands and part of South Africa where European diseases killed off the natives, the opposite occurred in SSA.
A true exploration of the continent started in the mid-1800s and this was shortly after quinine was discovered to be a cure for malaria. And then you saw the true face of European colonization.

For Native Americans and Africans from the sub-saharan region, the “discovery” of their respective continents by the European explorers of the 15th century has spelled nothing but misery. For most, the misery still continues.
Unlike the Native Americans, most Africans still have control of their lands, even if they are still massively exploited by richer nations and their own corrupt leaders.
Even as disease continues to be a major factor in the lives of most people in SSA, let’s not forget that malaria might have been the one thing that saved us from extermination.

Role of Disease in Sub-Saharan Africa – Another Take

Sub-SaharanAfrica (SSA) seems to be the crucible of disease. Most of our modern day epidemics seem to emanate form this area – HIV, Ebola – to mention just two that have had significant mortality.
Disease in SSA is however nothing new. The region has always had numerous infectious and vector-borne diseases.
I seek to argue that the prevalence of disease in SSA might have changed the course of it’s history.

Lets go back several hundred years to about 1490. This is the period when Columbus landed in what is now Central America and initiated the massive migration of Europeans to the New World, as it was called. Through the activities of the migrant Europeans and disease they introduced, millions of native Americans were literally wiped out.
Now, SSA was “found” around this same time period. It ultimately became a the source of manual labor for the cotton and sugar cane plantations in the so-called New World. So why didn’t SSA see the same level of migration of Europeans like the Americas saw?

One argument is that black Africans were seen as an optimal manual labor force and so their bodies were priced over their lands. Some have also argued that SSA was more densely populated than the American continent. Yet another is that the Africans mounted a much stronger resistance against the Europeans than the Native Americans.
The argument, which I tend to favor, is the role of disease and specifically malaria. Malaria, a disease to which most indigenous Africans develop some form of immunity to over time, is devastating for anyone contracting it for the first time. It killed quite a number of European settlers.This dampened any desire for an exploration of the continent. A glimpse of what could have been is seen in South African a region with a climate and disease profile much kinder to the Europeans settlers.

Malaria as a disease was known since the time of Hippocrates. In the ancient times, it was attributed to bad air. The term Malaria was coined in Florence by the historian and chancellor of Florence Leonardo Bruni in his Historia Florentina around1400:
Avuto i Fiorentini questo fortissimo castello e fornitolo di buone guardie, consigliavano fra loro medesimi fosse da fare. Erano alcuni a’ quali pareva sommamente utile e necessario a ridurre lo esercito, e massimamente essendo affaticato per la infermità e per la mala aria e per lungo e difficile campeggiare nel tempo dell’autunno e in luoghi infermi….
After the Florentines had conquered this stronghold, after putting good guardians on it they were discussing among themselves how to proceed. For some of them it appeared most useful and necessary to reduce the army, more so as it was extremely stressed by disease and mala aria (bad air)…
It was introduced into England 1740 by Horace Walpole:
“There is a horrid thing called the malaria, that comes to Rome every summer, and kills one”, and into medical literature by John MacCulloch in 1827.

So Europeans knew of malaria and found out about other diseases that killed them in droves like dengue, yellow fever and the bugs that caused dysentery. Even David Livingstone, the Explorer and Missionary, died form malaria and dysentery. The cattle that the Europeans tried to raise were also killed off.
Unlike in the America, in Australia, the Polynesian islands and part of South Africa where European diseases killed off the natives, the opposite occurred in SSA.
A true exploration of the continent started in the mid-1800s and this was shortly after quinine was discovered to be a cure for malaria. And then you saw the true face of European colonization.

For Native Americans and Africans from the sub-saharan region, the “discovery” of their respective continents by the European explorers of the 15th century has spelled nothing but misery. For most, the misery still continues.
Unlike the Native Americans, most Africans still have control of their lands, even if they are still massively exploited by richer nations and their own corrupt leaders.
Even as disease continues to be a major factor in the lives of most people in SSA, let’s not forget that malaria might have been the one thing that saved us from extermination.

Let’s Remember

“What difference does it make to the dead, the orphans and the homeless, whether the mad destruction is wrought under the name of totalitarianism or in the holy name of liberty or democracy?”
― Mahatma Gandhi

Alexander the Great led his men to war, Genghis Khan did the same… the great Shaka Zulu, was front and center….Hitler sent men to die from the comfort on his bunker in Berlin…the Emperor of Japan from the comfort of his palace.
The great warriors who led their men knew the gravity of war and got good counsel before they did…Aexander the Great from Aristotle
In the world we live in now, the leaders do not have to lead their men to war. Even the advisors have never seen a battlefield. It’s easy to yell, “Attack” from the comfort of an air-conditioned office!

T-Stones015

Once upon a time these were not just headstones – they were sons, daughters, dreams, hopes, laughter, love, joy…they gave it all away on behalf of others so let’s remember!

Conversations

And then He took me to the top of the mountain and said, “Visualize a World with no strife!”…So I closed my eyes…and that is when I saw the chasm – a great chasm it was indeed…on one side was much prosperity and abundance and on the other much need, hunger and suffering…I opened my eyes and asked Him, “I see a great chasm. How can I visualize no strife with such a great chasm?”…He looked at me, smiled and said, “Fill the chasm!”…So I asked, With what?”….He said, “With Empathy”.

Then we entered the banquet hall – a huge cavernous place. It was the strangest place ever. At one end sat guests who were gouging themselves on large plates of food. Their full bellies glistened in the harsh light as crumbs and drops fell from their full mouths to the ground.
At another section were several guests sharing a plate of food. Their faces were glum for you could tell they did not have enough…..
And then was the last section where the guests looked like they were not even at the banquet. They were doubled over, faces contorted in apparent pangs of hunger. A few were even motionless on the floor.
I stopped, surprise etched on my face…. I asked Him, “Isn’t there enough food for all the guests?”….He looked me like you looked at a clueless son and replied, “You’d think, right?”

Protocolize It!

We live in the era of big data. With the introduction of electronic medical records, big data is also alive and well in medicine. Mining that data can help establish therapies that are most effective in the majority of patients. The mined data plus results from large scale prospective, randomized studies then result in recommendations and protocols that are supposed to improve patient outcomes.
A majority of physicians have historically looked at medicine as an art. Each physician had his or her way of treating ailments, often tailoring them to fit individual patients.
Medicine however is moving in a direction where the “Medicine as an Art” crowd is on the edge of extinction.
Who is right? Should the practice of medicine be based on protocols or should it be practiced as an art?

I’ll start off the discussion with two examples:
Close to a million Americans suffer from strokes each year and it’s the number 4 killer in the US.
For years, different hospitals and physicians have managed patients with strokes differently. Studies show that if patients having ischemic strokes are given intravenous tissue plasminogen activator (tPA) to bust the clot causing the stroke within 60 min of arriving at a hospital, their chances of survival go up significantly. However, a study in 2014 showed that less than 30% of ischemic stroke patients were being treated this way. On the other hand, hospitals that had established protocols to facilitate this recommendation lowered the incidence of death and disability from stroke.
Another area of concern is that of medical errors. The “To Err is Human” report sounded the alarm bell in 1999. That in part led to the institution of the Surgical Safety Checklist and the “Time Out” for all surgical procedures. A 2009 study in the NEJM showed a drop in death from errors from 1.5% to 0.8% since institution of the checklist and “Time Out”. Inpatient complications dropped form 11% to 7%.

These two examples illustrate the fact that protocols based on science and solid evidence can positively affect outcomes.
Should this then be extrapolated to all of medicine? Should every decision we make be decided by protocols culled from studies and hard data?

Which brings me to the other side of the coin.
Say a study S looks at therapy for say, Prostate Cancer, in a 1000 men. if this therapy is effective in 86% of the men and it gets adopted, what happens to the 14% who do not benefit from the therapy.? if one extrapolates that to a million subjects, that 140,000 men who do not benefit from this new therapy. A good protocol has to allow a physician to cater to this group.
Recent recommendations about two tests that affect men and women have raised the ire of patients. The first is mammography to screen for breast cancer in women and the Prostate Specific Antigen (PSA)to screen for prostate cancer in men. In both cases, based on data, the opinion was that they led to an increase in the false positive diagnosis of a cancer. In other words, patients were thought to have cancer who did not. This led to further unnecessary testing and procedures. With the PSA, it is thought that a lot of small prostate cancers could be diagnosed, which left alone would not grow to be a problem. Now imagine telling a patient:
“You have cancer but it is so small we are going to leave it alone. You will outlive it.”
Sure, in a calm and reassuring manner, a doctor can try to make a patient understand but how many will bear to live with that uncertainty. Then there is also the probability that that small cluster of cells could get bigger….So why not get them out now?
Even if these cancers are small, isn’t it the smart thing to do to diagnose them and follow them? Doesn’t that make these screening tests then necessary? Doesn’t that give the patient a choice?

The point I am trying to make is, in spite of all the data, there are these people called Patients who we are supposed to serve. They are ruled by emotion and are not always as rational as the data and evidence. Is it part of “doctoring” to do whatever is possible, besides causing harm, to reassure these patients?
So on one side are the those who preach a strict adherence to the evidence and on the other those who want to tailor things to the needs of the patient and the habits of the physician.

Into this fray drops Genomic Medicine. This is an emerging discipline that bases therapy on a patient’s genome. It is a well known fact that some drugs (e.g. Plavix) do not work in some patients because of lack of or too much of certain enzymes. Before a particular therapy is initiated, the genetic make-up of a patient is determined. It is now used extensively in psychiatry to get effective therapy.
This shows that in spite of the data or evidence, there are still individual variations.

All these arguments may not matter because of the Affordable Care Act.
The Affordable Care Act has decimated the private medical practice to the point where the majority of physicians are now employed by hospitals. The Act also rewards physicians whose practices are in line with the latest most effective therapy and management modalities. Hospital administrators are then going to compel their physicians to practice in accordance with protocol that fit the best recommendations. In that sense, the autonomy of the physician may already be a thing of the past and patients’ choice may be slowly narrowed to a few options.

All this makes me wonder what role the physician may play in medicine in the future. If every decision we make is based on a protocol, what will happen to the practice of medicine as we know it? Besides surgeons, are any other specialties even needed if all one needs is to follow a protocol? Protocols so simple that even a caveman can follow them? What are we then good for?