Pakistanis need our solidarity

From the Huffington Post on Sept 21, 2010. 

Snow-capped peaks, shimmering lakes, and endless meadows – these are the memories from my last visit to Pakistan's northern areas fifteen years ago. The stories now emanating from Pakistan bear little resemblance to these memories. They are the stories of villages submerged underwater and schools washed away, of livestock destroyed and farmlands wiped out. “The world has never seen such a disaster,” UN Secretary General Ban Ki Moon said of the floods that have ravaged one-fifth of Pakistan. “It’s much beyond anybody’s imagination.”

Pakistan needs our help. Twenty million people are affected, a number that surpasses the number affected by the Haiti earthquake, Asian tsunami, and Kashmir earthquake combined. Ten people are homeless. Three million children are threatened by cholera. Seven thousand schools need to be rebuilt, five thousand miles of roads repaved, and an entire agricultural sector revived.

The national security argument for a robust American response to this crisis is compelling. Pakistan's help is vital for success in Afghanistan and in curbing nuclear proliferation.

This is about more than national security though. It is about how our country treats its allies. It is about the message of solidarity that we as Americans ought to convey to the Pakistani people. This message is that we value our relationship, and we want it to transcend the fight against extremists or nuclear proliferation. We want it to be based on mutual respect and trust. Only such a relationship can sustain cooperation on the difficult issues that our countries will inevitability continue to face.

Our response has been far from robust, however. Americans have given $25 million in private donations to Pakistan compared to the $900 million that we gave for the Haiti earthquake. The Red Cross has received $10,000 for Pakistan compared to $32 million it received for Haiti. The media coverage for Pakistan has been one tenth of what Haiti received. While our government has done better with a $200 million commitment, it is only a fraction of the estimated $7 billion that Pakistan needs to rebuild.

This tepid response is sending the wrong message. It confirms the widely held notion among Pakistanis that our relationship with them is merely transactional – that our commitment is limited to paying for their cooperation in fighting extremists. This perception is supported by the patterns of US aid to Pakistan. Billions of dollars were given in the 1980s to help Pakistani-backed militants fight the Soviets in Afghanistan. Once the Soviets were ousted, however, virtually all of the aid dried up. Since 2001, the same pattern has been repeated with billions in military aid to fight Al-Qaeda. This aid has had little effect on the lives of ordinary Pakistanis.

What Pakistanis have felt, however, is the fallout from our war on terror. The same people who suffer from Taliban bombings in their marketplaces have had to flee their homes when the Pakistani military retaliates. The US-backed military operation in the Swat valley, for example, forced two million Pakistanis to flee their homes, the largest such migration in recent history.

These same people are now facing another tragedy, one that dwarfs others in recent memory. This is our opportunity to show that we actually care about them. To succeed, however, we must act decisively.

First, we should all donate now to any of the organizations working on the ground. A ten dollar contribution can also be made to the UN operation by texting “SWAT” to 50555 and the State Department relief fund by texting “FLOOD” to 27722 from our cellphones.

Second, we must urge those with influence to step up. Now is the time for the celebrities and media personalities that have been conspicuously silent to speak up. Now is the time for our corporations to match employee donations. Now is the time for our politicians to press for a larger relief operation.

Finally, we can build bridges at home by reaching out to Pakistanis in our own communities, whether a taxi driver, physician, or co-worker. We should ask how the floods have affected their families and if we can help.

Last month, Secretary of State Clinton said, “I want the people of Pakistan to know that the United States will stand with you during this crisis. We will be with you as rivers rise and fall. We will be with you as you replant your fields and repair your roads. We will be with you as you meet the long-term challenges to build a stronger nation and a better future.”

My hope is that the stories that Pakistanis tell one day will actually resemble the words of our Secretary of State. Only then will we have finally achieved the relationship with Pakistan that both of our countries need.

Only then will the towering peaks and shimmering lakes of my childhood memories regain their true place in our world – not as venues of strife but as monuments to human resilience and solidarity.

HIV in America: Why you should get tested

From the Huffington Post on June 28, 2010.

Yesterday was National HIV Testing Day, a reminder for all of us to get tested for HIV. Among the one million Americans living with HIV, twenty percent do not know they are infected. This is despite Centers for Disease Control guidelines that recommend testing for all Americans between the ages of thirteen and sixty-four.

The consequences of not knowing one's HIV status can be devastating. I saw this firsthand a few months ago as a doctor on call at my local hospital.

Michelle was an Asian woman in her forties who had been hospitalized overnight. It was thought that she had a mild pneumonia. I took over her care the next morning and set off to check in on her before meeting my team for morning rounds.

Upon entering her room, I noticed that she was was thin-appearing and sleeping comfortably. I approached her gurney. Suddenly, the alarms went off. Her oxygen level was dropping dangerously low. This was unusual for a mild pneumonia. Could she have asthma or a clot in her lung instead? A list of alternative diagnoses ran through my head as I dialed up her oxygen.

Her nurse rushed into the room. "Someone from the lab is on the phone," she said. "Michelle's HIV test just came back positive."

She had PCP pneumonia, a rare fungal infection of the lungs that is seen when HIV cripples the immune system. If not recognized and treated promptly, it can be fatal.

Michelle's case reminded me that our country has not yet overcome AIDS. In fact, the rates of HIV infection in some American populations actually rival those in sub-Saharan Africa, the center of the global epidemic.

In Washington D.C., for example, one in thirty individuals is infected, a higher rate than in Ethiopia or Rwanda. New York City has the most infections in the country, with alarmingly high rates among specific populations: one in forty African Americans, one in eight injection drug users, and one in ten men who have sex with men. Increasingly, heterosexual women, not traditionally considered 'high risk,' are being diagnosed with HIV.

Despite such startling numbers, HIV is not part of our national consciousness as it was even a decade ago. In a 2004 debate, former Vice President Dick Cheney was criticized for not knowing that HIV is the largest killer of young African American women. Five years later, a Kaiser Family Foundation poll confirmed that fewer Americans thought that HIV was a serious problem domestically. Not infrequently, patients admit to me that they engage in risky sexual behavior without fear of contracting the virus. Many have not been tested.

Physicians bear responsibility for this trend as well. Despite universal screening guidelines, only seventeen percent of respondents in the Kaiser poll said that their doctor offered them an HIV test.

Thus, it is not surprising that a full one-third of Americans with HIV are diagnosed late in their disease. These are people that miss out on life-saving treatments and are likely to infect their partners without even knowing it.

Michelle was one of these people. By the time she was diagnosed, her immune system was irreversibly damaged. She was battling a life-threatening PCP infection. Fortunately, with intravenous antibiotics and steroids to reduce the swelling in her lungs, she eventually overcame the pneumonia. However, she had to endure a fifty-day long hospitalization in which she was nearly put on a breathing machine. All this could have been prevented had she been tested even once during the previous five years.

It is time that we all acknowledged the reality of HIV in our country. It is time for a renewed commitment to bring our domestic epidemic under control. We need a commitment from elected officials to increase funding for HIV programs, especially ones that expand testing. We need a commitment from doctors to offer testing to their patients. Most of all, we need a commitment from every American to understand their own risk of infection and get tested.

All of us have a role in overcoming HIV in America.

Identifying information has been changed to protect patient confidentiality. This piece was written as part of the Partnership for Physician Advocacy Skills program at UCSF.