Turning Left

Some of the best advice I ever got came to me was when I was 22 and early in my recovery from, despite the young age, a pretty serious history of alcoholism and alcohol abuse. I was sitting in a meeting, sick and terrified, and heard the speaker say, “when you keep running into a wall, it’s time to turn left”. Turn left. Sheer genius.

So, after a long spring and summer when, despite what I feel are some rather significant skills and talents and a strong desire to continue to try to ease the suffering of marginalized people in disadvantaged countries, I have been utterly unsuccessful in securing employment in the Global or Public Health arena. Every failed application, every absence of the phone ringing, has fallen on me like a pounding rejection. And, to boot, I have even had to deal with outright rejection on a personal level. So, the other morning I woke up and decided to turn left.

Several weeks ago I purchased what I consider a beautiful piece of property (~19 acres) in the high desert of southeastern Arizona. Now the desert is not to everyone’s taste, but once it gets under your skin, once you sense the mystical and the extraordinary in the mountains and the skies there, it will draw you back time and time again until you surrender to it. I had hoped to get a job and have a small house built while I was overseas; however, fate was uncooperative. Consequently, I have decided to move into the small, temporary trailer up on my property in the beautiful desert canyon under the starriest skies you can imagine in the developed world, and participate in the design and construction of my small (800 sq. ft.), completely off-grid, humble yet oh-so-magical home.

As I have said before, I don’t generally keep up my blog when there is only me to write about. I am not that interesting and the point was to provide a window into other places and events that most people will never have an opportunity to see. However, there seems to be tremendous appeal these days in the prospect of living off-grid. Consequently, I thought I would post about our progress in the hopes that someone “out there” might find the information interesting and even, perhaps, useful.

I should arrive at my home site during the second week in August. Until then, I will continue to draw up the floor plans with the assistance of my good friend, Grady. The trick will be to keep the costs down while still creating some “magic” in the design. Once the floor plans are finished, I will make a little model. I will post all of this for anyone who might be interested. I downloaded Google Sketchup7, which is a 3D user-friendly drafting and architectural design program and started there. This is all new to me so, if I can do this (with a little help from my friends) I suspect any of you can.

Floor plans to come…….

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a long drought

I have developed a taste for mutton and horsemeat.

My contention has long been that my life has been made more interesting by the people in it. I have written of small heroes in the battle against AIDS in Africa, the goliathian NGOs that consumed all the resources, about the magic of the girls in the orphanage where I lived in Swaziland, and the many lives that slipped away, almost unnoticed. I have shared marvelous adventures traveling through Dogon country where the tiny Tellum used to live in cliffs so high they must have flown to get to their dwellings, and about the taxi driver in Morocco who drove me out into the Sahara, me believing my life was in peril. I have described the souks in Marrakesh where the tradesmen poured tea for us in dark alleys, the Erg Chebbi dune in southern Morocco where I left my son's ashes, the temples and pyramids of Egypt, and the cave monsteries in India, a long life puja with the Dalai Lama, and the women in Kerala bathing in the ocean in their colorful saris. Nothing has been more interesting than the people whose paths crossed mine, nothing has been more powerful than those who lingered for a while.

I have written little in the past year. My life has consisted of Word documents and Excel spreadsheets, of meetings and strategic planning. In and of myself, I am not all that interesting. I am starved for meaningful human contact, I am starved for meaning.

Lately, I get the sense that life is about to get more interesting.

Stay tuned. Read more

Joel's Day

And so it is upon me again. It doesn’t creep up on me, nor does it crash into me, but I wake up and it is the day that everything changed. I never know what to do to commemorate, so generally I do nothing. Nothing I could do would match its enormity. The loss required something big. And so I changed my life- I went to Africa to face AIDS, I came to Mongolia to confront the bitter cold, it would seem. Every day on this journey now is a testament that one day, one moment, one heartbeat, one life, one death changes everything. I would gladly trade my own life. Perhaps I did. My sacrifices are still too small, my inconveniences minor by comparison. But I am not done. . Read more

This is Why

“This is why”. A small comment at the end of a long post, my last post. A tiny, inconsequential thing. It started as a whispered shiver just above my toes and traveled like growing icicles up my legs, circling my spine, weighing down my arms, and traveling over my brain like microscopic, cascading, frozen dominoes, neurons shutting down with each miniature collapse. Almost 2 months of not posting, of not finding anything interesting enough to post about, and “this is why” gets me. “This is why”. It resonates, but in a cold, indifferent way. “This is why”. Anyone who knows me will be sure that, now, finally, I have gone off the deep end. What am I talking about? And yet, and yet, there’s something inside of “this is why” that is so expansive and heavy, something just out of my reach... “This is why”. It calls me, it’s right there and not there. Does anybody get this? Obviously, if you do, you don’t have the words either, it’s a knowing, and yet not knowing anything. It slipped in on a knife’s edge and I want it to stay and replicate, a seed so foreign and so familiar, leaving the sliver of a hope that I will know something someday. Metaphysical crap? Maybe. Sure. But it got inside me. Read more

dream sequence

Every once in a while I have a recurring dream about Joel. It’s not really a recurring dream as much as a recurring theme: I can’t find him or I am not able to get in touch with him. It’s not a dream that evokes fear or anxiety. Not like the time, sometime in the 3rd grade or so, that he decided to forego the school bus and walk several miles, all the way across Gainesville, to get home from school. I recall waiting out on the sidewalk as the sun was setting when he finally showed up, his then tiny frame strolling onto the campus family housing property as though nothing was wrong, with all of us outside, frantic. And even then, although I did have to call the police to tell them he had been located, there was an underlying sense that if anyone could survive and prevail, it would be Joel (ah, but you didn’t, did you?). There were more than a few of those times, as there are with people who follow a different path than the rest of us. It just doesn’t occur to them that we would or should worry. They are following whatever destiny is laid out for them and can’t understand why we would expect them to do otherwise.

These dreams, though, these dreams are an exercise in frustration. It is as though I have the sense that Joel is “out there” somewhere. In some dreams, I physically try to find him. I look everywhere, feeling that I will stumble on him at some point or will match his own unconventional thinking and deduce his location. And there are dreams like last night in which I try to contact him, by phone, through friends, by any means possible, and I am unable to get a message or line through to him. Waking up is difficult; being pulled from the search when there is at least one option you haven’t yet tried. I want to go back into the dream because the urgency to find him or contact him is unbearably strong.

Last night’s dream came after a frustrating evening and was preceded by 2 equally strong dreams- one of Joel’s dad, Jim, my first love and now also gone, and the second was a dream of the man who was probably the “love of my life”, still living but a relationship that ended as soon as it began and never was allowed to play itself out to its inevitable conclusion. And then the dream of Joel… I don’t know if previous “searching for Joel” dreams followed a difficult time, perhaps they did, but this was pretty clear. However, I think the significance of the “Joel dream” goes beyond a troubling evening and my own conflicted issues with relationships. When I left California, after Joel died, to pursue meaning and redemption in the middle of an HIV pandemic in Africa, I said I was going out “in search of Joel.” I obviously wasn’t looking for Joel in a literal sense, but for something deeper. Anyone who knew Joel would have told you there was something quite different, quite unique about him. Alex referred to him as “the most random person [he’d] ever met.” There was something about Joel… and then he was gone. So I needed to understand that- I needed to understand how something so unique (and in my eyes magnificent) could arise suddenly (and from such unremarkable seed), only to be gone again so quickly. I live my life as an agnostic, allowing for the possibility of God or something beyond myself, but requiring some evidence, something clear cut, a burning bush. I recall saying that I was waiting for the Dalai Lama to come to me and say, “and, yeah, by the way, we got Joel” (in the spiritual sense). Then I could believe. So this search of mine isn’t for Joel, necessarily, but for some understanding of the underlying essence of this all.

And then real life happens. I find a position, or a “friendship”, or a new place that consumes my imagination for a while and it is not until those things lose their luster, that the newness or sheen starts to wear, that I remember that whatever it is that has momentarily captured my interest is just not the point. I am on a mission that transcends daily drudge or the momentary elation. It seems the further I get from Joel’s death, the more difficult it is to live like that for any extended period. Then things that are not the least bit important take on a great deal of significance and I get sidetracked. So the dreams remind me that death liberated me, that there is so much of this that I just really don’t have to do anymore, that life is unimaginably short for all of us, and that there is something inside me that believes that meaning exists.

. And here is the rest of it. Read more

summertime blues

I went out with some friends on Saturday to see the horse racing events for Naadam festival, the most celebrated festival in the country. Naadam takes place every year in July and people flock in by the thousands to view the horse races, wrestling events, and archery events. You can read more about Naadam at Wikipedia. UB litterally empties for a couple days as people from all over migrate out of the city to camp and picnic. As I walked around the streets of UB on Friday, I felt a slight lifting of the weight that has plagued me these past couple months. With the streets empty, I wondered if it hasn't been the explosive increase of population in the city that is bearing down on me,, as tourists deluge the country and residents come out of hibernation.

Although I initially enjoyed city life and a toilet that flushes regularly, especially after 3 years in rural and semi-rural Africa, I am unaccustomed to the constant barrage of people, noise and traffic. Perhaps it weighs on me at a level out of my awareness. More likely, however, I am simply suffering from a need to be useful. I left the States 4 years ago, after Joel died, because I needed to connect with something meaningful. 3 years in Africa combating HIV gave me a sense of purpose. Granted, we saw too many people die, but there were mothers who did not have to bury their children because we were there.

At the end of my time in Africa, I struggled with what to do next. When I got the invitation to come to Mongolia to help set up an HIV and STI prevention program for sex workers, it seemed like the perfect solution. HIV prevention is important, and we might actually be able to do it here. That said, there are plenty of highly skilled and well educated Mongolians who could easily do this job, and spending the money to bring and keep me and the other international volunteers here is probably not the best use of anyone's resources. Certainly I am finding ways to make a contribution, but the need here is not as significant as the need elsewhere and while, yes, I can make a contribution here, it is quite different from being in a place where your contribution is palpable. There are places all over the world where pain and suffering are commonplace and where they don't have the human resources to set up public health and assistance programs. I want to go there.

Mongolia is green and beautiful after all the recent rain. Read more

Post election conflict in Ulaanbaatar

Many of you have heard about the riots Tuesday night following Mongolia’s democratic elections on Sunday. The Communist Party has won a majority of seats in consecutive elections, this time 46 seats to the 26 won by the Democratic Party, giving the Communist Party more than half of the seats in Parliament. What appears to be at stake here are the rights to substantial mining resources, the most significant of which will be the mine at Oyu Tolgoi, developed by Ivanhoe and Rio Tinto, that is likely to be perhaps the largest gold and copper mine in the world. The mining law is currently under revision and will very probably be changed to give Mongolia a controlling interest, up to 51%, of mineral deposits that were discovered using State funds. While my understanding of the mining situation is admittedly limited, it appears that the contentious issue between the two parties revolves around whether the government will own 51% stake in the mine, preferred by the Communist Party, or whether that stake will be allocated to private companies, preferred by the Democratic Party. The more pressing underlying issue is the widening gap between the newly wealthy here and those who continue to eke out a meager existence, some on less than the equivalent of $2 per day. Although it would take an infinite leap of imagination to believe that things will change substantially depending on whom, in Mongolia, owns that 51% stake, the rioting and looting are essentially a symptom of the growing chasm between those Mongolians who have and those who have not. No question the mining industry will bring unimagined riches to this sparsely populated country. How those riches are allocated is a different question.

So, the rioting, burning, and looting are essentially symptomatic of the growing displeasure and disenfranchisement of a large proportion of the people. The election itself was overseen by a number of international observers and was probably fair enough. Politics are politics and I suspect that behind-the-scenes attempts to sway an election were no less common here than they are elsewhere. Tuesday’s rioting took place several blocks from my apartment and I could see the smoke from the fires and hear the sirens. The next day was business as usual with everyone out on the streets doing their shopping, going to work, eating in restaurants. The only telltale signs of conflict were a sparse scattering of tanks and armored cars, as well as small clusters of police in riot gear. It could be my overactive imagination, but I did sense an undercurrent of tension and unrest. Last night, after the imposed 10 p.m. curfew, the streets were eerily quiet.

I feel utterly safe. I am no judge of governments, least of all my own, but the ruling party here is not awful. Mongolia is having a difficult time making the transition from soviet occupation and domination to a free, democratic society. There are bound to be problems and people are finding the change difficult, much like what happened throughout Eastern Europe. It would be nice to see this done well somewhere, but I don’t get a sense of tyranny or oppression here. I have met many Mongolians who say they preferred their lives under Soviet rule and I find it a little distressing that we in the “free world” don’t do more to facilitate these transitions. It seems we are more focused on imposing democracy on others than on ensuring that people are actually moving on to something better.

My friend and colleague, Joscha, took these photos the day after the riot just a few blocks from where I live.. And here is the rest of it. Read more

wild horses

Much of my work these days has been administrative in nature and, although important, is less interesting to write and read about. I am involved in a multisectoral initiative to help clarify Mongolia’s response to the HIV crisis and to devise a strategy that will hopefully implement a strong prevention effort against the virus for the next several years. Although I miss the interpersonal interactions that working with HIV on the front lines provides, the work we are doing, although less immediately tangible, has the potential to affect the quality of lives for all Mongolians. If we do it well.

So although the work may be of interest to a handful, I will write a little about the parts of Mongolia I have had the opportunity to see during my leisure time. Last weekend I traveled out of the city with a friend who works with the Food and Agriculture Organization of the United Nations. It is always good to travel with people who know something useful and informative about the country or area you’re in. So it is with my FAO friend who, unfortunately, will be leaving soon, but from whom I seem to have learned a little more about this very interesting land.

We rode out to Khustai National Park, one of the three national parks in which the wild Takhi horses freely roam the hills. The Takhi (translation “spirit”) are considered the only wild horses left in the world. Although feral horses exist elsewhere, such as the “wild” mustang in the American West, those horses are descendants of horses that were once domesticated. The Takhi have always been wild and were saved from total extinction, in the early and again in the mid 1900s, by their capture and placement in zoos. Takhi are allegedly as spirited and undomesticable as zebra. The takhi were reintroduced into Mongolia in the early 1990s though a joint program between Mongolia and the Netherlands. Interestingly, the takhi have 66 chromosomes whereas domestic horses have 64. Takhi are capable of cross-breeding with domestic horses, and you can see their characteristics in some of the domestic herds; however the offspring have 65 chromosomes which are further reduced to 64 upon subsequent breedings. I thought this was especially interesting because everyone I asked said they couldn’t interbreed, despite the striking takhi characteristics that were evident in some of the domestic herds, and I felt somewhat vindicated to learn that they can and do.

The park is beautiful, especially now, in the Spring, when large expanses of green grassland replace the dusty barren patches of winter. We saw the takhi as well as a fair number of domestic horses, and group of grazing elk.

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An act of desperation

On April 26 the Financial Times reported that the World Bank was supporting a $1.8 million dollar experimental approach to reduce the new cases of HIV in Africa, in this case, specifically Tanzania. The program, jointly funded by the World Bank, the William and Flora Hewlett Foundation, the Population Reference Bureau and the Spanish Impact Evaluation Fund, essentially seeks to decrease new cases of HIV acquisition by paying people not to contract the virus. Briefly, the study enlists 3000 men and women in the southern rural regions of Tanzania who will each receive $45 if they continue to test negative for HIV in periodic testing over the course of 3 years. I could not determine if the participants received $45 each time they tested over the course of the 3 year trial or if this was a one-time payment to be received at the end of 3 years.

One of the things that surprises me the most about this announcement is the lack of discourse about this issue, both in op/ed pieces in national newspapers and in the blog community. In fact, I am stunned at the seeming complete absence of notice this news item has received. Paying people NOT to engage in a given activity, particularly on this scale, has to be one of the most unusual and controversial approaches in modern behavior change theories and models. So, let’s look solely at the economics of this approach. Currently there are about 800 million people living on the African continent. I will use Africa here only because the high incidence of HIV in Africa underscores the economics of such an approach but still leaves the numbers sufficiently manageable to establish estimates. Roughly 23 million people on the African continent are currently infected with the HIV virus. If we estimate that approximately half of the 800 million people in Africa are at an age in which they are likely to engage in sexual activity, and this is probably a low estimate, we are considering 400 million people who are at risk for contracting HIV. If you subtract the 23 million people in Africa who are currently living with HIV, that leaves 377 million people that are at some risk for developing HIV. At $45/person, if we were paying them not to contract HIV, that totals approximately 16,965,000,000.00, or roughly 17 billion dollars. Ok, so the Iraq War is estimated to have cost the American tax payers about 500 billion dollars in 5 years, averaging to 100 billion a year. Hmmm, 17 billion, especially over 3 years, seems like a bargain.

An article in the Journal of Acquired Immune Deficiency Syndromes estimates that the economic cost of HIV/AIDS in Africa is about 36.4 billion dollars a year. If you divide that figure by the 23 million people in Africa currently infected by the HIV virus, you come out with a figure of just under $1600.00 per person per year. God, is that right? The total figure includes loss of productivity, economic impact, etc. I think it’s about 10 – 20 billion dollars per year that actually comes in as direct funds, from governments and private organizations. Certainly that money doesn’t all go toward individuals with HIV. Some of that money goes toward programs for prevention, programs for orphans, organizations established to mitigate the ravages of the HIV pandemic, etc. Actually, most of that money goes down the drain. But, nonetheless, we have a figure of about $1600/HIV infected individual/year in Africa. Well, quite frankly, $45 per person, whether it is over one year or 3 years, if the program actually worked, would be a screaming deal. I have to admit, although I initially found this program conceptually repugnant, fiscally it would make sense. If it works. Even if it works somewhat.

So, what’s wrong with the idea? Paying people to make decisions that are for their own good as well as the good of society seems inherently wrong. Do we start paying people to stop smoking or to eat less? I suspect if we look at the cost to society, both in medical costs and with respect to lost productivity, if such programs were successful we would pay much less in the long run. And, if behavior change can be bought, do we then start paying people not to sell drugs or not to commit crimes? I think it’s a bad idea born of absolute desperation as the World Bank continues to pour billions of dollars into the HIV pandemic only to see the problem worsen as each year goes by. And I don’t think it will work over the long haul. The approach may enjoy marginal success in Tanzania, across 3000 people, but behavior change doesn’t come easy and sustaining it is challenging. As a former smoker I can attest to that.

The bottom line is that this approach sets a bad precedent. I have seen people in Africa refusing to come to an HIV workshop or seminar unless they receive a hefty stipend/allowance, a buffet lunch, and a t-shirt. I have been told that NGOs in Lilongwe, Malawi, won’t come to a meeting in Lilongwe itself because the daily allowance they receive is too low unless the meeting is held out of town. We have made HIV a lucrative business, perhaps the fastest growing industry in Africa, with Eastern Europe and Asia following suit. Whatever the outcome, I had hoped to see more debate about this approach in the popular media. So start talking about it and please feel free to leave a comment (below) and engage in a dialogue.

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Mongolia update

There have been some challenges with respect to my work here which have delayed the start of our project. Consequently, much of my time has been spent on administrative and program issues that don’t involve actual “hands on” HIV/AIDS outreach at the moment. So, why engage in HIV outreach in Mongolia at all when there are more immediate HIV/AIDS concerns elsewhere? While it is true that Mongolia has few reported HIV cases, between 25-35, UNAIDS estimates that approximately 500 people are currently living with the virus in the country. 500 cases is still an infinitesimally small number relative to the estimated 33 million cases of HIV worldwide, however that number is estimated to exist almost exclusively among particularly vulnerable populations in which the spread of HIV can occur explosively and exponentially, particularly with commercial sex workers.

Between 1990 and 1994, when Mongolia was making the transition to democratic governance and a market economy, unemployment and homelessness escalated as social programs collapsed. People migrated into the capital city, Ulaanbaatar, without jobs or prospect of employment. This period saw the advent of what is now a serious problem of street children, which I will address in a later post, and a significant increase in women who were turning to commercial sex work (CSW) to support themselves and their families. Currently, the estimated number of sex workers in Ulaanbaatar exceeds 4000. Many of them engage in their profession in massage parlors or “saunas”, of which often 1 or 2 can be found in every street block. Sex work is also commonly carried out in many of the city’s hotels and, additionally, sex workers ply their trade on the city streets at night. Studies carried out by researchers from Vanderbilt University in the US have shown that, while the incidence of HIV in sex workers in Mongolia is low, the incidence of sexually transmitted infections (STIs) is exceptionally high. Specifically, 67% of the sex workers were positive for at least one STI and 17% were multiply infected. This tells us a couple things: First, at least as recently as the 2006 study, “100% condom use” programs targeting CSWs were not working effectively. Second, because we know that having an STI makes one significantly more vulnerable to HIV infection, we subsequently know that the CSWs in Mongolia are an extremely vulnerable population.

If the story ended there, we might be looking at a long period in which HIV rose almost imperceptibly in the general population; however, we can add a couple additional variables that lead to an inevitable and devastating future if we don’t act aggressively and immediately. Mongolia lies snugly between 2 locations that are experiencing some of the highest HIV growth rates in the world. Since 2001, so we are talking about just 7 years, incidence of HIV cases in Eastern Europe and Central Asia has increased 150%, from 630,000 to 1.6 million. Russia, which comprises our extensive northern border, is estimated to have over 400,000 cases of HIV with an expansion rate that reached as high as 3000 new cases in one month (December 2007, PEPFAR data). China, to the direct south of Mongolia, experienced an estimated 45% increase in HIV cases in 2006 and, although obtaining accurate figures from the Chinese government is difficult, officials admit to an approximate 700,000 people living with HIV. The China Daily news service reported 3000 new cases/month over the course of one year.

Traffic across Mongolia from China to the South and Russia to the north is common. Trading occurs across both borders and Mongolians are reliant on imported goods. Men from both countries come to Mongolia and solicit Mongolian prostitutes and Mongolian prostitutes actively “work” the trade routes across the two borders. Given all of the above data, it is only a matter of time before we see what will seem like an almost overnight increase in HIV rates in Mongolia. This may be one of the few places in the world where we may have the opportunity to actually engage in “HIV prevention” activities. If we do not act now, and if we do not enlist the support of the CSW population, this group of people who can act as our frontline defense against the disease, in less than 10 years time we will be spending billions of dollars doing crisis intervention and damage control.

Make no mistake, this is important work.

In the meantime, I have had the wonderful opportunity to go hiking in two of Mongolia’s national parks near Ulaanbaatar.

Terelj National Park lies about 80 km northeast of UB and is comprised of over 1 million acres of seemingly inhospitable land and high dirt mountains. If I am not mistaken, we hiked to one of the highest peaks in the park, a grueling hike led by a man much more experienced at hiking and far more physically fit than myself. We blazed our own trails, going essentially straight up in parts and traversing dangerous rockslide areas on the way down. It is only through sheer grit and determination that I am not still up there, curled up in a ball and unable to go on.

My second hike took me to Bogd Khan, the first green area I have seen since my arrival in Mongolia- complete with white pines, moss, and grass underfoot. My hiking companion, a UN Environmental specialist for many years now, informed me that Bogd Khan is the oldest National Park in the world, protected since the 1770s. You can drive to just below the monastery, Manzshir Khiid which, after 200 years of serving Buddhist monks, was destroyed by the Soviets in the 1930s and is recently being rebuilt. The mountain, Bodg Khan, was officially declared sacred by Chingis Khan, known to westerners as Genghis Khan, and is considered the most sacred mountain in the country. Because it is likely I will make this trek again (I understand it is only a 12 hour hike from Ulaanbaatar), I will simply post some pictures now and describe in more detail at a later date.

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