Learned helplessness

If you seperate a predatory fish from some prey fish with some clear perspex the fish will initially keep knocking into the perspex to try to get to the food, after a while it will give up trying and just swim around and ignore them. The interesting part is that if you remove the perspex the predatory fish will continue to ignore the prey and will not make further attempts to catch them, this effect is so extreme that the predatory fish will actually die of starvation before it tries again to catch the prey again- hence the fish has learned helplessness.

Life in the Transkei can sometimes feel like the life of the predatory fish. For example I've developed learned helplessness towards accessing various tests for my patients. I have tried hard to access CT scans through the government hospital but have had virtually no success and had essentially given up.

What I've learned is that just as in the fish story it is a dangerous mindset to slip into because you just never know when the perspex has been lifted. It often takes the fresh approach of a new member of staff to spur you into action and in my experience you can get some great results when this happens. For example, I've recently learned by chance of a new approach to the CT scan problem that may well work and it has spurred me on to revisit some other obstacles that I had previously abandoned.

Bumblebees

I remember learning that while most animals behave to get as much done for a given amount of energy expenditure (maximise benefit/energy cost) this isn't true of bumblebees. They behave in such a way as to get the most done per unit time (maximise benefit/time cost). This is because after a determined length of time they essentially 'wear-out' and die. I've noticed something similar in human resource poor medicine which I wanted to share.

In high human resource settings doctors are generally encouraged to make decisions based on health cost vs benefits. Prescribe a certain drug to enough patients and the adverse side-effects will be out-weighed by the improved quality and quantity of life (health benefits > health costs). When human resources become limited the doctor is often faced with a different question. Is it worth me spending a certain amount of time on an intervention for a given benefit to the patients (maximise health benefit / unit of doctor time). There are a whole bunch of initiatives I would like to start including aspects of preventative medicine and intensive care of the critically ill. The question is not whether there is a cost vs benefit advantage to the patients but given that time is very limited, which of these interventions should I choose to do at the expense of the others. Basically you need to have a much greater understanding of how much something works and not just that it works at all. Financial resources must be considered in both settings but where I'm working financial cost comes into it less than you might think.

I have something else in common with the bumblebee because the only other thing I remember learning about bumblebees is that according to the laws of aerodynamics it is impossible for them to fly!

The similarities

It is easy to get caught up in all the differences and oddities you are likely to encounter when you move to a new culture. What I hadn't given a thought to were all the similarities that I would find. Steven Pinker talks about the fact that in all cultures people tell stories, recite peotry, sing, dance, decorate surfaces and perform rituals but isn't it the differences in the stories and the rituals that people generally find interesting in other cultures?

What I'm talking about are the things that appear to be all but identical. I'm not surprised that young men love football and drink as much beer as they can afford but it's easy to forget, when people appear engrossed in a daily struggle to survive and bring up children, that there is always time for gossip for example. The old women standing beside the road may have no shoes and smoke long wooden pipes but if you eavesdropped I'm absolutely sure you would hear the same conversation that could be heard the world over about who doesn't keep their house clean and who's husband has run off with a younger model.

The way women look after their children also seems so similar to me. The absolute amount of money floating around might be different but children still nag for a few cents for sweets and mothers still seem to resist for a while but eventually give way for 'a bit of peace and quiet'. Flirting is another thing. A bit of harmless flirting with slightly older nurses seems to get you just as far on the wards here as it does in the UK.

It's the little differences

When you move to a place like the Transkei it is pretty obvious that you are going to encounter areas where your own culture is at odds with the local culture. After all it’s one of the reasons for visiting a different culture in the first place. What is interesting then is not that you find differences at all but exactly which things are different and also which things are surprisingly similar.

The latest difference I have encountered is in the attitude to exercise. My naïve view of Africa, based on the seemingly endless supply of talented distance runners from East Africa, was of children running 10km to and from school every day and perhaps a few talented adults out on the roads training. I couldn’t have been more wrong.

I go running after work often wired up to an iPod and sometimes with a head torch, thankfully no-one can see that I also have a chest strap under my shirt measuring my heart rate. To begin with I quite enjoyed the small trail of children joining me on the roads. However, the only things I notice now are the old women who, when they spot me coming, start jogging in a caricature of accentuated strides, swinging arms and a mocking giggle. Worse are the groups of young women who simply burst into fits of laughter as I go by.

When you think about it for a minute of course it’s a completely crazy pastime. They all know that I have a car and a housekeeper and could quite easily sit on my veranda sipping cool beer after work. Instead I choose change my clothes and then to run off in a seemingly random direction only to turn around at an arbitrary point and run all the way back, sometimes I do all this in the rain and the pitch dark. I don’t actually go anywhere useful, meet anyone or collect anything. I just get tired, hot and sweaty for no obvious reason at all.

Worse than running is cycling, sometimes I take a bike to a peripheral clinic and rather than drive home in a nice comfortable 4x4 I put on a yellow helmet and some strange shoes and huff and puff my way home on a bicycle instead. To someone who would walk 10km because they don't have a few Rand for public transport this clearly seems like a crazy decision.

If they knew that one of the reasons I did all this was actually to lose weight it would be the last straw. In this area you can reliably predict the income of an individual by measuring around their waist and most people spend more than half or their income on food the idea of deliberately losing weight remains completely foreign. I can't wait to tell them about those crazy foreigners who eat as much as they can only to then pay a doctor to suck all the fat out of their belly so they can start eating again.

Frustrations

Up until now I've tried to resist writing anything too negative so I'll try to get it all out in one go. I think the worst frustration is that although there is often money available it often gets spent in ridiculous ways. There are so many expensive pieces of equipment lying around that either no-one knows how to use or are not working and no-one knows how to fix them but when you want something simple and cheap it is not available. For example, someone recently installed a very expensive state of the art piece of anaesthetic equipment in our operating theatre, it must have cost £10,000, yet we have no trained anaesthetist and no specialist surgeon with little hope of either arriving soon. Just recently the head of maternity services spent her budget on an enormous desk and comfy chair that are sitting in her office (I think the chair gets more use than the desk); this is in a department that often has inadequate resuscitation equipment for sick newborn babies. It feels like living in dictatorship when the despot spends the last of the foreign currency on fighter jets rather than grain.

I thought that because South Africa is a middle income country it might be spared some of the corruption found in other African states. However, even in the medical profession there are many stories of doctors who claim full salaries from the government but spend less than half of their time working in the public hosptials and the rest of it working in private practice.

I must balance these frustrations with some of the freedoms that working in this environment gives you compared to working in a First World setting. Paperwork for doctors is generally kept to the minimum required to deliver effective care rather than the excessive amounts required to stand up in court, and similarly it is not necessary to over investigate healthy people for reasons of avoiding litigation rather than because it is what they really need. The bottom line is that wherever you work there will be frustrations, when you move from the Developed to the Developing World you really just swap one set of frustrations for another.

About altruism

Some people have suggested to me that it is altruistic to leave the UK and come to work in a remote rural setting but in my view this could not be further from the truth. Altruism is when you behave towards someone in a way that is harmful to yourself while being beneficial to the other person. Being run over by a car in the act of saving a complete strangers life would be an extreme example. Such acts are pretty rare and when it comes to choosing a job or a way of life they are completely unsustainable. If the people who came to work here were true altrusits they wouldn't last more than a few months, the only way to stay for a long time is to enjoy it.

It has occured to me that if I wanted to be altrustic I would move back to the UK, live in a tent, work 120 hours a week probably in some private hospital somewhere and send all the money out her to be spent for the benefit of the community by someone I trust. Maybe I am overerestimating what that money could do or underestimating what I am actually doing here but it is possible that this choice would be of more benefit to the community.

Just because I'm not an altruists doesn't mean that I think this is any old job. Nobody's perfect and I don't mind admitting that I can feel a little pleased with myself when people ask me what I'm up to. I wish it wasn't so but I can't help it. Nor does it mean that I haven't made sacrifices, a clean hot shower would be real luxury at the moment for example, but hasn't everyone had to make sacrifices along the way.

It also doesn't mean that I think this is the most important thing in the world either. I honestly beleive that a group of motivated teachers, businessmen or water engineers could have a huge impact on this community that would probably far outstrip the benefits that can be acheived by improving healthcare. All I'm saying is that when it comes to leaving the world in a better place than you found it it certainly beats marketing cigarettes to children or writing computer viruses for a living.

The meme pool

Something that has struck me about the HIV/AIDS epidemic in the Transkei is the effect it must be having on the meme pool. A meme is a unit of cultural information such as an idea of practice that is transmitted from one generation to the next either verbally of by repeated action. An example might be a child noticing that her father always unplugs the television before he goes to bed, she copies this behaviour when she gets older, not because her father's genes have influenced her or because she has learnt that unplugging the television is important but because she is copying her father. This is a form of non-genetic inheritance which has some important differences to genetic inheritance. Firstly memes can be passed between individuals or group that are not genetically related such as between groups of friends and unlike genes, memes do not necessarily have to be beneficially to the individual to be propagated, like computer viruses they just need to be good at replicating.

In the Transkei approximately 20% of adults are infected with HIV and without treatment the majority will have died in 10 years. Assuming they are infected around age 20 and become sick some time before they die that means that many of the years that they could potentially spend propagating their memes will be lost. Remember that you don't have to be in your reproductive years to propagate a meme, you just have to be someone that people copy.

With our current level of knowledge about HIV there is only one way to avoid this once you are infected. You must possess the memes 'willing to accept HIV status', 'willing to join an HIV support group' and 'diligent pill taker for the rest of my life'. Although I wouldn't exclude genetic influences on these behaviours they might well be described as memes.

At the moment it seems clear that these memes are more likely to be present in the female popultion who often thrive on the support group environment and seem much more organised about taking medicines than men. Although this is of course a generlisation it seems likely to me that unless there are radical changes to the way we treat and prevent HIV, the popultion meme pool will shift towards acceptance of HIV status and disciplined pill taking as anyone not possessing these meme will die and have less opportunity to pass on their own memes to people around them.

Similar arguements could be made about the way people are infected with HIV in the first place. The meme 'only have unprotected sex with someone who you know (or are very confident) is HIV negative' would spread very successfully if it was readily copied by the group. The meme 'always use condoms when having sex' would also pass to the next generation, interestingly this would be at the expense of the genes as anyone who always used a condom would not be passing their own genes to the next generation.

There are of course many generalisations and simplifications to my arguement, including the interaction of memes with genes, although I would expect the gene pool to be altered in a similar way to the meme pool. Also as I said earlier these memes won't propagate simply because they are beneficial to the individual but given that not possessing them results in your early, death deleterious memes would have little time to propagate. Presumably there are experts in memetics out there studying these effects but if not I think it would make a fascinating study of non-genetic natural selection at work.