The Waste Land

“You cannot say, or guess, for you know only
A heap of broken images, where the sun beats,
And the dead tree gives no shelter, the cricket no relief,
And the dry stone no sound of water.”


This will be my last post on this blog. It’s going to be filled with real talk, and will probably be less logical (and more personal) than I want it to be. It’s a rough draft of bigger ideas and burning memories. You’ve been warned.

Throughout this summer I’ve been able to go on some amazing weekend trips all over KwaZulu Natal. It’s been a luxury and I’ve had some adventures I’ll never forget. Last weekend, I was barricaded in Tugela Ferry. The community went on strike.

Water and power shortages have plagued the area for a few weeks, and many of the outlying villages have reached their wit’s end. Combine no water with a lot of very sick people, and you get a recipe for death—even above the usual “death is around every corner” or “life is crazy” threshold I’ve gotten used to. There’s a one lane bridge over the Tugela River. Strikers put boulders, bricks, tree branches, anything they can find on the only roads in and out of the town. They marched down the streets and closed down the local stores.

Monday morning came and nothing changed. There’s still no water; the roads were cleared. Life goes on. Life always goes on. I went to the store and bought a half gallon of milk and that night I had a hot shower behind the barbed wire fence that protects the hospital. As I showered I almost forgot that this water might be better used for a dying person. Should I feel guilty? I don’t know. I didn’t stop showering.

Things are rough here, but not that rough. South Africa is a middle-income country, and there are enough roads, hot water, cell phones, and Coca Cola signs even in Tugela Ferry for me to have lived quite comfortably. After getting internet and power back I read up on Gaza and Israel, plane crashes left and right, and Ebola doctors dying. Hey, at least here people are organized and civilized enough to go on a strike; it’s not a war zone. At least here, there’s a hospital, not the burnt up remnants of bombed medical facilities. Living here has made me appreciate New Haven, and hearing about Congolese refugee camps has made me appreciate Tugela Ferry. It’s all relative. I’m struggling to balance gratitude and discomfort; I have no idea how to contextualize my experiences.

I suppose that means it’s time for one last attempt to paint a picture with words.

At the bottom of South Africa there is a place called Cape Agulhas where the Indian and Atlantic Oceans meet. It’s a line in the water at which two worlds collide. This summer, I’ve walked that line every day.

Tugela Ferry is the Wild West, untamed and unruly and unpredictable. Driving down the road, and you hit a child? Talk to the police. Driving down the road and you kill a cow? Run (or drive) for your life; the vigilante “livestock police” will be out for vengeance if they ever get wind of your doing. Cows are money generators; children money drains.

Tugela Ferry is also modernizing, quick—and not always in the best way. Taverns are extremely popular, as is drinking. To excess. Any evening. Then driving drunk, getting in fights, and ending up on the street. French fries are served everywhere, and Coca Cola has planted its feet firmly into the rural landscape. The intricate Zulu beadwork is being replaced with mass produced plastic; authentic “Zulu cuisine,” as someone told me, is “eating whatever you can get.” That, and fermented milk (don’t try the fermented milk).

Everything clashes. The area is developing, yet poor, losing tradition, yet gaining very little of the positives of “modernization.”

It’s easy to point out the problems, easy to throw out buzzwords. Look at me go. Easy to say that the double burden of disease is so high due to the vicious cycle of poverty and food deserts. The infrastructure needs overhauling. Financial incentives to receive proper medical care aren’t overcoming the stigma of HIV. If only we had a few more startups, a few more NGOs, a lot more money, and perhaps dialysis for the god-forsaken patients that come in with kidney failure…

Is this too bleak? Maybe. I think I’ve realized bleakness inspires me. Because while things may not be efficient, while there may be too many problems to count, while everything seems like it’s on the brink of collapse, it is better than it was before. It takes time, so much time—the smallest of baby steps and the refusal to look back. Bringing about change is the process of water wearing down a rock or two oceans mixing. It’s about dedicating your life to a cause or a person or a reason and then realizing you may never reach that finish line, or tick the checkbox, or cross off the to-do list fully. No matter. Reflect, try harder, keep going. The contributions still count None of us individually does enough, but all of us combined make up the grinding gears of progress.

Almost done here. I’ll miss it and I won’t miss it at all. I’ll move forward and I won’t look back.

“What have we given?
My friend, blood shaking my heart
The awful daring of a moment’s surrender
Which an age of prudence can never retract
By this, and this only, we have existed
Which is not to be found in our obituaries.”

-T.S. Eliot, The Waste Land

Nothern Charm and Southern Efficiency – the tale of DC

Global Access to Fun
Global Access to Medicines team in our office.: Left to right: Me, Derek, Kelley – the interns – Burcu, Peter, Steve (top) – The staff, Alberto – the fellow. Oh and notice Burcu’s book – Out Sept. 25th in US.

Washington DC is a magical place to find yourself as a policy-nerd YSPHer. Every week there are events to attend both within and outside your field, happy hours galore, and people from all different types of fields to speak with. This year has been especially awesome with futbol (soccer) games to watch at at happy hours everywhere!

So far, I’ve had quite the summer experience. Working with Public Citizen has been a dream. I’ve been writing reports, working on advocacy materials, attending meetings, and following up on different campaigns with us and many other nonprofits I’ve worked with somewhat in the past.

Public Citizen Office
The Public Citizen banner on our DuPont Circle Office. I’ve really grown to love this sight every morning. Could not be happier!

A little background on what I’m doing here. Every year around 10 million people die because they cannot afford medicines that exist in the market and could treat or cure their ailments. Public Citizen works on this issue by helping change the rules that allow medicines to be priced so high. This means not only advocating for new law and incentive regimes for research (trying to remove the rhetoric of more profits = more research), but also by working with countries to know and use their rights to obtain cheaper medicines for their people.

I’m working on projects more based on the first point there. I’m using data from health and safety, clinical trials, pricing, and others to help form arguments we’ll use to try to remove barriers to competition and lower the price of life saving medicines.

This type of work I’d classify as “incredibly DC.” Access to medicines is a very niche field, without a ton of actors – maybe 20 NGOs or so that really work on these issues. And with that, being an intern means I’m actually making an impact. I’ve also had the opportunity to network with amazing people. I’ve met public health officials from Europe, State Department big wigs, and heads of nonprofits. I even met, through a related experience, the former president of the board of the Sierra Club. This has truly been an experiment in networking and professional life, and I have to say I love it.

All in all, even though the experience has and will continue to teach me so much, I am also very happy with DC. My other DC YSPHers can probably concur that this has to be one of the best cities in the world! With jazz in the garden on Fridays, brunch on Sunday, a zoo with Pandas (don’t even get me started… haha), too many museums to count, and happy hours to boot, there’s no place like it.

Simply put: if you’re ever thinking about working in Health Policy, you’d be crazy not to find yourself in DC over the summer.




A Geography Lesson

American Samoa is actually made up of five islands; the largest, Tutuila, contains the majority of the population as well as the capital, Pago Pago, and the hospitals and clinics where I work. Aunu’u is Tutuila’s next-door neighbor. A few weeks ago my co-worker, her family, and I decided to take the trip over to Aunu’u to see what the rest of American Samoa has to offer.


Turns out, not much. There is clearly a reason why most people live on Tutuila. We drove to the wharf on the other side of Tutuila and I saw that it wasn’t so much of a boat ride over as it was some sort of motorized raft ride. We all climbed onto the boat and zoomed across the fifteen-minute stretch of Pacific Ocean between Tutuila and Aunu’u.

Our boat and captain
Our boat and captain

When we got there the first thing we had to do was announce our arrival at the island government building, which I’m pretty sure was just somebody’s house. The man we talked to offered to show us around the island, so we jumped in the back of his pick up truck and took a ten-minute drive around Aunu’u. During this entire time everyone was talking solely in Samoan, so I didn’t realize we were taking a tour until well into our drive. I clearly have not picked up any Samoan during my time here.

If someone thought Tutuila was unpopulated and rural, they clearly have not seen Aunu’u. It didn’t take long to see the entire island- most of it is farmland and very few people live there; however, the landscape of Aunu’u is slightly different from Tutuila. Apparently there are species of sea life found only around the island, and often residents of Tutuila go to Aunu’u for its beaches. We also found a lot of quicksand, which I hadn’t seen anywhere on Tutuila.


Our entire trip took about four hours, a lot of which was spent driving to and from the Tutuila wharf. I’m told the other islands of American Samoa are similarly unpopulated; however, they are a bit too far for me to check this for myself. Manu’a, possibly the next most populated island after Tutuila, is about an eight hour boat ride away- farther away than the country of Independent Samoa.  While I may never go to Manu’a, the island is a source of pride for many American Samoans, since, as legend has it, this is where the first people of the world came from. Samoans who are from or who have family from Manu’a are quick to point out their direct ties with the island. Many Samoans also seem to have family in Independent Samoa, a former territory of New Zealand. Independent Samoa doesn’t seem to receive the same love as Manu’a; in fact, many people I’ve met are quite antagonistic to the country. In several weeks when I get the chance to visit Independent Samoa we’ll see if the feelings are mutual.

View of Aunu'u
View of Aunu’u

Battling HIV/AIDS Stigma, One Day At A Time

“Kimberly…Kimberly…Kimberly!”…. It felt like I heard my name a million times; the patients were all calling me over wondering when would it would be their turn. I cringed as I informed some patients that they would have to wait up to 2 hours to get survey and/or interviewed. To my surprise they all said they would be willing to wait.

In the HIV Clinic posing with a poster that reads "Before pointing out and discriminating, point your finger towards solidarity for those who live and coexist with HIV/AIDS"
In the HIV Clinic posing with a poster that reads:
“Before pointing out and discriminating, point your finger towards solidarity for those who live and coexist with HIV/AIDS”

Today was a very hectic day in the clinic. Natalia, Dan and Sarah were each personally administering the survey to a patient. Many patients need one-on-one help due to reading and/or computer illiteracy. I was left all alone to recruit additional participants in the waiting room. I had about 5 lined up survey participants and about 6 pending interviews. Since each survey and interview can last up to an hour, some of our patients had to wait up to 4 hours for their turn. This is actually an improvement because during our piloting stage, surveys lasted about  2 hours and were very burdensome on the patients.  We had to go back to the drawing board and delete about half our survey to ensure patient comfort and ease of completion.

Although the survey is shorter, our waiting times are sometimes pretty long. Today, we had one patient who decided to wait 4 hours for an interview because she had not eaten in over a day. All our patients are being compensated for their time with a supermarket gift card with 200 Cordobas (about 8 dollars). They can get up to two gift cards if they participate in both the survey and interview. This day was also difficult because one patient was also concerned about being seen by another patient who knew her. Luckily everything worked out for the best with our help and the assistance of the clinic’s psychologist. My experience with the qualitative interviews has so far been wonderful. It is amazing to listen to my patients’ stories of fear and pain because they always manage to find the hope and motivation to live their life to the fullest. My patients are the epitome of the strength and resilience that can emerge from even the most unfortunate circumstances. A prevalent theme I have noticed in the interviews is the presence of HIV stigma due to the general ignorance of methods of HIV transmission. I experienced this firsthand when I visited the local photocopy place. The middle-aged clerk asked what brought me to Nicaragua and I explained I was involved in a research project with HIV patients in the hospital. The clerk responded, “pero ellos no tienen a esa gente regadas con todas las otras personas?” (but they don’t have those people spilled among everyone else)? I simply responded, “why would they need to be contained, they are sick patients just like any other sick patient in the hospital”. He seemed very confused, so I proceeded to tell him that HIV could not be spread through a hug, kiss, a handshake, or through the air. I informed him that he could get HIV from unprotected sex or by sharing needles because HIV is found in blood, semen, and vaginal fluid. He seemed intrigued and thanked me for the information. Two weeks ago I had another teaching moment with the same clerk. Sarah and I were photocopying our materials for our “Drugs and Alcohol” workshop and he expressed confusion at our picture of a black lung. We informed him that lungs become black after smoking and he was so surprised. These experiences show that any moment can be a teaching moment in which we could possibly make a difference. In this situation we can only hope that this clerk takes this information and shares it with others. We can only battle stigma and misinformation one person at a time.

Next to the poster for the “Indicators for Highly Active Antiretroviral Medications”. Poster mentions antiretroviral adherence and virological suppression after a 12 months of treatment.

Toodeloo to Tuvalu

It’s the little things that make life worth it.

This cliché is used to describe everything from the taste of food to that feeling when you finally get to pee after holding it for two hours.

The phrase has never been more applicable than to Tuvalu though.

When I first arrived, high off the prospect of my upcoming six week adventure, Tuvalu was paradise. Snorkeling and exploring the novelty of everything in front of me only intensified my excitement.

But the truth quickly set in. Tuvalu has no reliable internet (and the poor internet that is available costs around $40-$60 per week), no immediately drinkable water, showers are frigid, the days are scorching, most items are vastly more expensive than elsewhere, almost all the food tastes bad, and there is very little access to fresh vegetables.

I’m not going to lie, there was one week, which just happened to be the week I had Dengue, that I was counting the seconds until I could leave this god-forsaken island. All I could see were the negative attributes of this country. Learning that there is no Tuvaluan translation for the word “flavor” didn’t help my feelings about the food. I was also angry about being all alone with basically nobody to talk to. I, for the first time in my life became homesick. I didn’t like that I always felt the need to be on the (very poor) internet, but it was truly my only form of social interaction. I admire the Tuvaluan’s lack of cellphone and internet dependence that has come to define the very nature of our generation in the states. But everyone here has family and friends with whom they can talk and play for hours. I have nobody. Even on the occasions that I engaged with locals, I still clearly remained the outsider.

But even more frustrating than the actual negative attributes of the country was the fact that these detriments disturbed me so. I’ve always considered myself to be a very independent and adaptable person, especially when it comes to travel. My inability to fit into this country was the most frustrating of all. I was actually afraid to put up blog posts for fear of only complaining about the conditions here.

But it was actually one Skype conversation with my girlfriend Nina that changed everything. She reminded me that I should still take the time to enjoy the place and to take lots of pictures. It then occurred to me that I had not used my camera in two weeks.

I had vastly underestimated how important photography is in my life. One beautiful sunset and portrait at a time, I once again found the positive side of Tuvalu: the little things.

I used my creative outlet to capture the beautiful faces of Tuvaluan children in the golden setting sunlight. My resentment dissolved as I marveled again at the daily painted skies of dusk, casting orange and pink glows through a deep blue backdrop. I smiled at the simple act of riding my motor bike the short distance between my home and the hospital, waving at locals and being inspired by the adjacent views of the glowing teal water of the lagoon. I began to wear my Tuvaluan name, Palagi (which means white person, pronounced ‘palangi’), with pride. I cherished the moments when rainstorms unleashed their fury for mere minutes only to be followed again by the glowing sun. I gazed nightly at the glory of our universe in the vast starlight above.

Steadily, the relative importance of the negatives in my experience began to dissipate. The little things overcame it all. The hot weather made me even more appreciative of shade and the rare air conditioning. I began to actually enjoy the cold showers for how much they refreshed me after a day of sweating. The lack of vegetables was still a burden but let’s be real, everyone needs a little bit more ice cream now and then. I have even now started feeling a sense of belonging in the community.

Yesterday was the most stressful day of my life but by some miracle, we finished 40 interviews in one day thus completing an anxious but fun two week interview blitz.

As my time in Tuvalu winds to a close, I am happy to say that my reflection on my experience is positive. Although Tuvalu may have several negative attributes, the beauty of the people, the nature, and the culture of this country more than make up for the flaws.

My mood towards my departure can best be described as a really spicy burrito. When you finish it, you’re ready to quench the fire in your mouth with a cool horchata and return to normal. But a little part of you still wishes you had more delicious burrito to eat. I am excited to be reunited with my community and enjoy some real food again (namely California Burritos). However, Tuvalu is filled with so many more little things that I will never have the opportunity to enjoy and to photograph. I wish I had one or two more weeks to spend here without any work so that I could continue exploring the enormous beauty of this place. But I really do want a burrito.

Since college, I’ve felt like I have no geographic identity. In the US, I constantly feel like I am too ‘West Coast’ for the East and too ‘East Coast’ for the West. But I also sometimes feel I would be better suited with my Jewish roots in Israel or my adopted ethnicity somewhere in South America. Some days, I reflect on this multi-faceted sense of self negatively: a man without a home. But most of the time, I cherish this global citizenship. I am perpetually eager to find the next place to call home.

Although I likely will never have the opportunity to return, I know that for the rest of my life, a little part of me is now Tuvaluan as well.


UGANDA be kidding me!

“Woah, slow your roll, bro. Aref…I thought you were in Botswana.”

This may be what you are currently thinking and you would be correct. Except, I spent the past week (I am a week behind) in Uganda.

“Woah, but you don’t have money. How did you get all the way to Uganda?”

Correct again! But, I am working for an awesome company that flew me there and put me up in a five star hotel. But I will get to that soon enough. While I was in Uganda I got to explore some of “Real Africa”. The country is completely different than Botswana. I would almost say that Botswana is closer to the United States than it is to Uganda. The people are louder and more vibrant, their homes are made of tin sheeting, and the number of people on the streets is shocking considering the quiet life I have had in Gabs. My opportunity to explore Kampala was all thanks to everybody’s favorite court case: Roh v. Wade. Michelle Roh that is!

Roh v. Wade
YSPH Photo Contest winner.

We met in the capital and began a makeshift tour, directed by Abullah the taxi driver. Oh, we saw the sights! Uganda is a largely Christian country and therefore has many religious sites that are quite interesting. Turns out that the first Christians to enter Uganda were, quite violently, burned to death. Nowadays they run the show, so that’s a change of heart. We also got to visit the only Baha’i temple in Africa. I have now seen two of the eight temples as I live next to the one in North America—how serendipitous!

The only Baha'i Temple in Africa
The only Baha’i Temple in Africa

We also visited the huts where the royal family of Uganda have lived for the past century or two. It turns out that the original huts were blessed with the blood of several men. They soaked the cords in blood which is why they are black in color. I asked if they were volunteers; the guide said they were likely not. Rough.

Ritualistic Sacrifices
Ritualistic Sacrifices

That night I went to bed soundly only to be woken up by the thrilling pains of death. Turns out I got food poisoning somewhere between Gabs and Kampala. I laid in bed for around 30 hours, but made a full recovery. Michelle was an absolute dear. Later that week I met up with THE power couple of YSPH. They somehow managed to both get their summer internships in Kampala. Bert and Sarah came over to celebrate the 4th of July, have a shot of Jack Daniels (The most American thing we could find), and watch Germany triumph over France. No fireworks, but still a great celebration!

Oh hey, just sharpening my machete.
Oh hey, just sharpening my machete.

So, what was I doing in Uganda? Well, my company has a grant to increase capacity in 5 African countries in the area of HIV health economics. The idea is to teach private companies, economists, the MOH, and international agencies (WHO, UNAIDS) in these countries about basic economic research principles, how to use economic tools, how to write a research proposal, and inform them of gaps in knowledge that could be addressed. I got to meet with the head of UNAIDS for Uganda, professors at Makerere University, members of the MOH, and other key players.

The program was highly instructive for me as well as the participants. I learned about economic analyses, costing, cost efficiency, and the Spectrum suite of models which was developed by my company and is used by the UNAIDS and MOHs all over the world. By the end of the program, the contingency of HIV economists had come up with two proposals that would be developed further for $50,000 total. I was there to listen, observe, learn, and in the end provide a final report of everything that occurred.

But, the hotel! Oh, my. I don’t think I will ever stay at a hotel as nice. It overlooked Lake Victoria, had an Olympic sized swimming pool, and had quite the fountain collection. I also stuffed my face every day. But alas, back to baloney and cheese sandwiches…

View from my room. It's OK I guess
View from my room. It’s OK I guess



I took a picture of this officer holding an AK-47, because it struck me as interesting. Guns are illegal in Botswana, but prolific in Uganda. He proceeded to tell me that I could be arrested for taking pictures without permission. I could handle Ugandan prison.

Today I didn't even have to use my AK. Got to say it was a good day.
Today I didn’t even have to use my AK. Got to say it was a good day.

Dancing in the Moonlight

Last night I decided to return back to my favorite photo spots to take advantage of the full moon for some long exposure shots in Tuvalu. The results surprised even me. Even though many of these photos are bright as day, all of them were taken between midnight and 2am using a 30 second exposure for each. Enjoy!


The Yale School of Public Health Class of 2015 Summer Internship Diaspora


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