Wednesday, April 9, 2014

development through research??

15 years ago, when Chief Khunchai first took a job managing a malaria clinic on a remote stretch of the Thailand-Myanmar (still Burma at that time) border, there weren’t year round roads, there was no electricity, no telephones, and the endemic guerilla warfare between the Karen and the Burmese didn’t pay much attention to the international border.  A Karen military base was just over the mountain on the other side of the river.  Sometimes when fights broke out, mortars would fly across the river and land near the clinic.  It wasn’t personal; such things don’t always stop at international borders.

Moei River - the international border between Thailand and Myanmar

In the hot season temperatures regularly exceed 90° Fahrenheit, at midnight.  Without electricity, every degree above 80 is obvious.  There is a constant trickle of sweat behind your ears and down your lower back, and you eventually stop mistaking this feeling for mosquitoes and other insects that want your blood.

In the wet season, everything is permeated by the omnipresent moisture.  Pencils won’t write on paper, which has been collecting moisture from the rain and from your sweat, and pens make thick smudges on anything they touch.  Records are hard to keep.  The landscape is almost fluorescent green during this season.  The dichotomy between inside and outside is a false one.  Even the walls grow green with algae, plants and vines work their ways into the cracks and struggle for a nook or cranny to fill and exploit.

In this part of the world, the sun goes down at a consistent time pretty much year round – 6:30.  But this malaria clinic is surrounded by sharp mountain peaks and karst rock formations, and these geological entities hide the sun more quickly.  If work was to be done after 5pm or so, it was done by candle.  Malaria diagnoses would have to wait until tomorrow, when the light from the sun could be used in the small circular mirror that illuminates the slides and lenses in the microscope.

microscope for detecting malaria

Contacting the outside world could be done using military styled radios, through a tall antenna that stretched out of the top of the clinic.  This was handy in case people needed to be evacuated because of flooding, fires, or fighting to relay information about the epidemiological situation, or to request shipments of dwindling medical supplies.  A lighting rod was placed at the other end of the building to keep people from getting barbecued during storms.

a storm over the Moei

Over the years, Chief Khunchai has become a much respected member of society.  He knows almost everyone in the district in some way or another, and he holds a lot of political weight.  His office gets nicer over time.  Still the chief of a malaria clinic, he looks back on those days with little nostalgia.  He shudders a little when he tells me about working by candle light and having to worry about the fighting.  Yes, today things are quite different.  

He now manages a new malaria clinic about 35 miles south of the one he started at.  This malaria clinic has electricity.  At first this meant an electric microscope and lights, and that work could be done at night.  It also meant fans, which make work much more bearable during certain times of the year.  Even more recently, it meant that sealed doors could be installed in the main room and office so that wall AC units could also be installed.  AC isn’t frequently used, but it is very nice to turn the units on when there are special guests (usually political superiors) visiting.  

There are at least three different large malaria projects running in the district, and each of these projects has hired staff that are housed at the clinic.  A room was built on to the back so that they would all have desk and computer space.  A little data entry and a lot of facebook and youtube happen in that room.  

In the same period of time, malaria cases appear to have decreased, even while the population of the area has increased.  This is especially the case with regard to cases in Thai nationals.  Most cases here are in Myanmar nationals or Karen people with no nationality.  In fact, it is entirely possible that today there are more malaria-related personnel in Thailand than there are cases of malaria in Thai people each year.  That is, I think, a very strange thing.  

I begin with this story so that I can paint a picture of a kind of situation that I think has occurred in many parts of the world.  Malaria persists in places where “development”, for whatever reason, hasn’t extended.  One (I) could easily argue that such “development” is actually destructive in many ways, but it is hard to argue that life for many people hasn’t become easier.  And malaria cases have gone down at the same time.  

At least some of that development must be a direct result of the research cash that flows in from major malaria research projects and initiatives.  Those data entry people in the back facebooking can now purchase relatively nice motorcycles; some of the managers might even buy cars.  It’s not just the malaria clinic that has changed, there are also new restaurants, roads that are mostly good (or equally bad) year-round rather than only being traversable during the dry season, and more recently, a 7-11.  I joke that next year there may be another 7-11 across from that 7-11, but you may not understand unless you’ve recently visited Bangkok.  All of these things have associated workers who in turn buy stuff from places that also employ people.  In this part of the world, and I think in other parts too, malaria is mostly a “rural” disease.  It exists in places without 7-11s and year-round roads.  As you pave the ground for those roads and build concrete jungles, this particular disease tends to go away.  

And I find in this all a great irony.  

I’ve previously heard jokes that the best way to get rid of a disease is to try to study it.  I think this means I’m not the first to notice what is happening.  

The malaria industry is huge and there is a lot of money in it.  Frustratingly, much of that money winds up getting wasted through corruption and through things that ultimately aren’t necessary for what I think really matters: helping people who are sick with malaria, or even better, getting rid of malaria.  

For that matter, a question I’ve increasingly worried about over the last several years is: Should we really be setting up an industry, a vast network of jobs, that are all geared toward halting a disease?  Will these people really be motivated to stomp out the very thing (in this case, malaria) that keeps their own lives, at least economically, afloat?  Is that why people heatedly argue that we should be trying to control malaria rather than just get rid of it??!  Even more-so, while I can see the value in having electricity at a malaria clinic for diagnosis purposes, is AC, more space, new desks, etc. all relevant for combating the malaria problem?  

But perhaps there is another way to look at this too.  That is, perhaps all those research dollars that get pumped into malaria research do actually work.  I think they really do.  I just don’t think they work in the way that any of us really intend for them to.  They wind up spurring the local economy, they boost peoples’ economic well-being, and then in some cases and for some extremely complex reasons, people who move out of deep poverty are no longer faced with the immediate health consequences of that poverty.  For them, malaria isn’t any longer an immediate danger.  They can sit in a nice office, preferably behind a nice fan and in front of a nice computer screen, and check boxes on the computer that correspond to a malaria patient’s age and sex (or to a “like” button on someone’s post).  After half a life’s worth of work in less-than-ideal conditions, maybe it is more than OK that Chief Khunchai no longer has to dodge mortars or work by candlelight.  Hell, maybe he deserves the occasional AC – I certainly convince myself that I do.  

Sometimes I’ve gotten quite riled-up by the ways I see malaria research dollars getting spent but maybe I’ve completely missed the point.  Maybe all that really matters is that those dollars with the malaria name on them wind up having the effect that (I think) we all ultimately want.  Even if the functional mechanism behind this cause and effect has basically nothing to do with the one(s) that many of us think matters.      

*** I know several "Chief Khunchais" - but this name is of course made up


Manoj Samanta said...

"There is a constant trickle of sweat behind your ears and down your lower back, and you eventually stop mistaking this feeling for mosquitoes and other insects that want your blood. "

Oh, how much I miss those days !

Also, we did not often have electricity, when I grew up. Getting all power-plants shut down was the biggest achievement of our communist government. No lights or fan makes living in those lands even more exciting.

Manoj Samanta said...

I have seen similar industries being set up in India too - funded by UN and other organization. One project was about protecting wild animals, but the people managing it were all in Delhi, where humans are the only wild animals.