By Dylan Matthews, Idriss Fofana, Ian Kumekawa, Daniel Villafana and Lucy Caplan

Next week, President-elect Obama and the new Congress will take ownership of a struggling economy, devastated planet, and two overseas wars, among other challenges. Out of these myriad problems, Perspective has selected the nine issues most deserving of attention and constant scrutiny by the government and an active progressive citizenry. They are, in no particular order:

1. The Economic Crisis

A pressing order of business for the new administration is passing a stimulus package. The goal, according to Obama, is not kickstarting growth so much as creating jobs – 3 to 4 million of them, roughly. His proposal will cost $800 billion over the course of two years, and includes $300 billion in tax cuts, about 40% of the total proposal. The rest of the proposal includes incentives to create green jobs, infrastructure investments, grants to fund state-level social welfare programs, and extensions of unemployment insurance and health benefits.

While originally intending to have the bill passed in time for Obama to sign it immediately after taking office on January 20, Congressional leaders are now predicting slower passage. House Majority Leader Steny Hoyer is now forecasting House passage by the end of January, with Obama signing the bill by the Presidents’ Day Recess. House Speaker Nancy Pelosi has said that she will hold emergency sessions during that recess if a bill is not passed by that time. Whether it is finally passed in January, February, or even later, there is no doubting that the stimulus tops the Obama administration and the Congressional leaderships’ domestic agenda.

However, there are several stumbling blocks that may prevent timely passage. Predictably, the right is attacking the bill for being too reliant on government programs. Specifically, Senate Minority Leader Mitch McConnell objects to grants to fund state Medicaid programs, as well extending unemployment benefits and health coverage. He has said he fears the latter extensions would become permanent; after all, the last thing the Republican leadership wants is permanent health care for those who need it. The bill also faces opposition from liberal Senators, who rightly object to its over reliance on tax cuts. Sen. Tom Harkin has condemned the plan as “trickle-down stimulus”. That said, the perceived urgency of the economic crisis leaves little doubt that the stimulus will pass soon, albeit perhaps not in its original form.

2. Universal health care

Though Obama’s rhetoric in the primary was cautious relative to that of his rival, all signs point to a major push for universal health care during 2009. Obama’s health policy staffing decisions signal that he’s taking the issue seriously. He has selected Tom Daschle, the former Senate Majority Leader, to be Secretary of Health and Human Services. Choosing such a high-profile secretary – and one with the chops to push a reform bill through Congress – suggests that Obama wants health care legislation passed in the near-term. In addition, Daschle will be chairing a new White House Office of Health Reform, with well-regarded health wonk Jeanne Lambrew as his deputy. Placing health reform staffers in the West Wing means they’ll have a regular audience with the president, which will be critical if health reform is to get the attention it needs. Finally, the selection of Sanja Gupta as Surgeon General, with health reform as part of his portfolio, signals that health care will get the comprehensive press strategy it needs to pass. While bad PR helped doom the Clinton health care effort, Obama considers the job selling the plan to the media so important that he’s tasked it to the nation’s best-known medical personality.

For its part, Congress suggests it is going to cooperate in the reform effort. Senate Health, Education, Labor, and Pensions committee chairman Ted Kennedy has created special working groups to help craft legislation, and has been holding weekly meetings with stakeholders for several months now. Senate Finance committee chairman Max Baucus – a conservative Democrat who has voted for the Bush tax cuts and Medicare Part D – has introduced a plan of his own which is, if anything, more ambitious than Obama’s. Between the incoming presidential health policy staff and this news out of the Senate, health reform looks to be near the top of the agenda for 2009.

3. Afghanistan

The “good war” in Afghanistan could not be deteriorating more quickly. The Taliban is resurgent, US casualties are up, and al-Qaeda has retrenched itself on the Pakistani borders. The response of the military is yet another “surge”. 20,000 to 30,000 new troops will arrive in the country by summer of 2009, Admiral Mike Mullen, the chairman of the Joint Chiefs of Staff, has announced. Given as there are 31,000 American troops in the country already, this could result in a doubling of US forces.

There is broad political support for this move; both Obama and John McCain campaigned on deploying more troops to Afghanistan. However, it is doubtful that even a doubling of forces would make rebuilding Afghanistan possible. Afghanistan has a population 19 percent larger than that of Iraq, and a land area 49 percent larger, with much tougher terrain to boot. Under the troop ratios called for by current counterinsurgency doctrine, a force of 400,000 troops would be necessary to win in Afghanistan, meaning even a force of 61,000 would be inadequate. A better strategy would reject a troop surge in favor of more focused usage of current troops, diverting them away from nation-building in favor of their original purpose: driving al-Qaeda out of the region.

More promising is the incoming administration’s approach to negotiations. Obama, Defense Secretary Robert Gates, Afghanistan force commander General David McKiernan, and CENTCOM chief General David Petraeus have all indicated a willingness to broker negotiations between the Afghan government and more pragmatic divisions of the Taliban. Given the openness of Afghan president Hamid Karzai to the idea, this approach could result in a brokered peace settlement before the troop buildup boosts violence to dangerous levels. With Vice President-elect Joe Biden visiting the country for talks before even taking office, it appears likely that such peace negotiations will be a major priority for the administration.

4. Israel/Palestine

While certainly deleterious toward the prospects for a near-term peace deal, the Israeli butchering of Gaza has performed its thinly-veiled purposed of helping its executors politically. The centrist Kadima/Labor coalition that is conducting the campaign has shot up in the polls since the bombing began, overtaking the conservative Likud party that had been leading. While neither bloc is sufficiently committed to peace, Kadima and Labor have shown considerably more interest in the peace process than Likud. The coalition’s Prime Minister-designate, Tzipi Livni, was the driving force behind the 2007 Annapolis summit, and has shown a greater willingness to negotiate with the Palestinians than many within her party. Further, the victory of far-right, rabidly anti-Arab candidates in the Likud primaries mean that peace would be a virtual impossibility under a Likud government, making any alternative preferable by default.

For his part, Obama appears poised to appoint Dennis Ross as his envoy to the Middle East, including Israel and Palestine. This is an unfortunate decision. Ross was the head negotiator at Camp David, in which he represented a right flank that was transparently biased toward Israel and unreceptive to Palestinian concerns. One of his colleagues, Aaron David Miller, has dubbed him “Israel’s lawyer” for his conduct in those talks. Further, Ross has advanced a pernicious narrative since the talks, saying that their failure was the result of Palestinian rejectionism, and of perfidy on the part of Yassir Arafat in particular. Nearly every other participant has rejected this account, including Miller, Rob Malley, Daniel Kurtzer, and former Israeli Foreign Minister Shlomo Ben-Ami. Indeed, these participants all agree that the deal on offer at Camp David was wholly unfair to the Palestinians, and Ben-Ami has said he never would have taken it had he been on the Palestinian side. While appointing a high profile on envoy like Ross signals that the peace process is a priority for the administration, a more progressive choice, such as Miller, Malley, or Kurtzer would be better able to make headway in negotiations.

5. Education

Change has been the message of Barack Obama’s campaign since its inception. Therefore, we should expect the Obama administration to mark a departure from current education policy.

Obama has promised to downplay the importance of standardized testing which has contributed to an environment where “creativity has been drained from classrooms, as too many teachers are forced to teach to fill-in-the-bubble tests.” Obama has said that he will seek funding for alternative sources of assessment, but with the economy is dire straights, it is unlikely that large-scale changes in education policy requiring a greater financial outlay will be prioritized.

The importance of standardized testing is a key issue for Obama in his criticism of “No Child Left Behind.” President Obama has essentially indicted the implementation of the program and the lack of funding rather than its guiding goals. The president is proposing initiating new teacher residency programs as well as providing more money to schools which, again, may pose a problem for a country facing severe economic hardships. Also, Obama should still seek to address the weight that the program places on standardized testing, which has indeed left entire school districts behind.

Obama’s choice of Arne Duncan as proposed Secretary of Education represents a compromise. Duncan straddles the line between the camp that stresses the importance of holding teachers and schools accountable to underperforming students and the camp that pushes for increases in non-school-based government initiatives to help improve the educational lot of less advantaged students. Some have criticized Duncan for being too draconian in his punitive policies as CEO of Chicago Public Schools. But certainly, with the choice of Duncan, Obama has left the door open to a great number of much needed reforms.

6. LGBT Rights

Barack Obama’s change.gov website identifies LGBT rights as a key part of its “Civil Rights Agenda.” It prominently features a quotation from Obama stating that “the issue of LGBT rights…is about who we are as Americans. It’s about whether this nation is going to live up to its founding promise of equality by treating all its citizens with dignity and respect.” But Obama’s selection of Rick Warren to speak at his inauguration has already drawn his commitment to LGBT rights into question.

LGBT rights are sure to be a key issue during Obama’s presidency. Obama’s primary goal should be to repeal two federal acts, the Defense of Marriage Act, which says that a state does not have to recognize other states’ definitions of marriage, and the military’s Don’t Ask Don’t Tell policy. During his campaign, Obama indicated that he planned to repeal both of these acts, and he will hopefully live up to this promise. Marriage rights will certainly be another central aspect of the LGBT rights debate during Obama’s presidency. With the recent passage of Proposition 8 in California, twenty-nine states now ban same-sex marriage via constitutional amendments, and eighteen others have laws that prohibit it. The opposition of a constitutional amendment banning gay marriage will be Obama’s most important priority in this debate. While Obama is not a supporter of gay marriage, he does support civil unions that give same-sex couples the same legal rights as heterosexual married couples. Finally, Obama should work hard to establish a federal policy that prohibits employment discrimination against LGBT people. Only by committing to a progressive LGBT rights agenda can President Obama live up to the “founding promise of equality” that he has promised.

7. The Iraq War

2008 has been a very encouraging year in Iraq, at least by the appalling standards we’ve come to judge “progress” in this war. Only 314 US troops dies last year, almost a third the number of deaths in 2007. President Bush’s surge strategy appears to have contributed to the decline and violence. Nonetheless, important initiative will have to be taken over the coming years to ensure a safe transition in Iraq as well as the return of US troops.

The first objective of the Obama administration should be to continue the transition of US troops from combat missions to a police and security centered approach. Indeed, an equally important death toll is 8,000 to 9000 Iraqi civilian deaths this year. As the US shifts from the combat approach which revealed its limitations during the disastrous Rumsfeld years in Iraq, US forces must accelerate the training and transfer of authority to Iraqi forces. Iraqi forces will have to extend their efforts beyond Baghdad where violence has not declined as much.

Second, the Obama administration must devise a pull-out plan that makes continued withdrawal of troops contingent on reaching security benchmarks. A troop withdrawal is essential for a return to a fully functional Iraq. It should be evident to everyone that Iraqis are eager to return to a state of complete independence and the United States should not stand in their way. Nonetheless, pulling out of Iraq will be a very delicate situation and the Obama administration will have to take care to ensure that Iraqi forces are prepared to assume the void they leave.

Finally, Obama should not neglect the political work necessary to return Iraq to peace, something the Bush administration ignored too easily. The president and the secretary of state should regularly discuss the salient political issue in the country with Iraqi leaders instead of working through military leader. Such a shift in policy will be essential to moving Iraq away from a sort of American tutelage.

8. Nuclear Non-Proliferation

While the Bush Administration has made some progress in nuclear non-proliferation, however the President failed to establish a coherent non-proliferation policy. One of the successes of the Bush years was the signature of the Moscow Treaty with Russia. The agreement stipulates that the United States and Russia will reduce the number of their strategic nuclear warheads to between 1700 and 2200 warheads by 2013. However, the Bush administration non-proliferation initiatives were undermined promotion of research on “bunker buster” missiles designed to reach underground facilities while limiting the peripheral damage. The proposition was part a post-September 11th defense policy in which President Bush argued that the US needed an offensive policy in which it the US reserved the right to attack countries it believed were developing weapons. This policy was used to justify the war in Iraq.

An Obama nuclear policy should strengthen President Bush’s efforts to cooperate with Russia to reduce nuclear arsenals, while strengthening diplomatic efforts to prevent Iran and North Korea from developing nuclear weapons. President-Elect Obama’s record on non-proliferation is encouraging. Along with Senator Lugar, President-elect Obama introduced a bill that strengthened efforts to secure nuclear facilities in the former Soviet Union. More importantly, however, a President Obama would have to deal with what Mohamed El-Baradei, Director General of the International Atomic Energy Agency called the conflict of the “haves” and the “have-nots.” Over the coming years, nuclear powers will have to address increasing demands from developing nations to develop their own nuclear capabilities for energy use. As a result, the Obama administration must be mindful to undermine its message by expanding America’s nuclear capabilities. Also, America will have to engage in frank diplomacy with Iran and North Korea in order to prevent these countries from developing nuclear weapons.

9. Global Warming

The Blue Man Group’s claim that our planet does not have any emergency exits may be proven false as we transition to a new administration. Barack Obama’s New Energy for America Plan shows a lot of promise. The plan will improve the lives of millions of Americans while simultaneously reducing green house gas emissions substantially.

The pressure on oil companies will increase. Oil companies will have to give $500 dollar rebates to individuals and $1000 to married couples. These rebates are the first step to long term plan of providing middle class families with $1000 in annual tax relief. A “Use it or Lose it” plan, will force oil companies to drill on the 108 acres of land they have in the U.S. Although this will not lower emissions, it will decrease the country’s dependency on foreign oil.

Aside from the annual tax relief, families will benefit much more from the plan. New Energy for America is said to create 5 million new jobs. Of these jobs the “Green Vet Initiative” will provide counseling and job training for veteran soldiers in the Iraq and Afghanistan wars. LIHEAP will receive additional funding so that 1 million low-income homes will be weatherized annually.

Roads will also change. The plan will require that 60 billion gallons of biofuel be available by 2030. This may pose a problem if ethanol from corn is used however. As for our grid, 10% of the nation’s electricity must come from renewable sources by 2012, and 25% by 2020.

America’s new goals will not be kept within its borders. Obama will work with UNFCC and MEM to make emission reduction efforts a priority to other high emitting nations. Obama also plans to reduce America’s oil consumption by the amount currently imported from the Middle East and Venezuela within the next 10 years.

Obama’s biggest commitment to fight global warming is an economy wide cap-and-trade system that will reduce green house gasses 80% below 1990 levels by 2050.

By Mihir Gupta

In the summer of 2008, I traveled to northeastern India to study the impact of HIV/AIDS in rural and urban areas. With a team of social workers from the Indian government and several collaborating NGOs, I journeyed from inner-city alleyways to lush rural villages, on a variety of HIV/AIDS public health interventions. This series chronicles my encounters with several groups of people. Their narratives coalesce in a mosaic of experiences, each a function of time and place, but not far outside the definite contours of socio-cultural influence. The result is a snapshot of the impact of a devastating disease on a society and its core institutions; of chaos and uncertainty, but also of profound unity and hope.

Raju hobbles towards us on an improvised crutch made out of a sturdy tree limb. When I ask why he is injured, he points to his right foot and recounts what happened. Three days ago, he experienced a throbbing pain and swelling in his foot; there was no visible cut or sign of infection. The pain subsided over the next few days, but the swelling continued. Today his foot is swollen to nearly twice its normal size, feels as hard as the knob of his ankle and is slowly turning a deep reddish brown.

“You need to show this to a doctor,” I tell Raju. We add him to the list of individuals who have converged to visit our mobile health team, camped in this small village for the day. The list has reached almost one hundred names and shows no signs of stopping. Villagers continue to trickle into the clearing where we have erected a makeshift clinic. Our clinic has separate departments (each doctor is stationed beneath a different tree), an examination room (four bedsheets hung from bamboo poles) and a pharmacy (two hospital staff dispense pills stocked in a briefcase). We left the last trace of modernity, our Tata jeep, one mile away behind a defunct bridge and brought only what we could carry.

Raju’s foot trouble turns out to be a case of folliculitis that will turn gangrenous if he does not seek immediate treatment; if left untreated for too long, the infection could spread through his bloodstream and take his life. Raju’s case is the only one of its kind that we see, but the circumstances are hardly unique: a minor health problem (folliculitis can be caused by an infection in the follicle of a pulled hair) spirals out of control due to what are known as “ecological” factors: lack of education, delaying treatment, unsanitary water, malnutrition, etc.

Indeed, this young man who almost needed his foot amputated is hardly different from the dozens of children whose mothers tell us that they cannot see at night. The latter problem is caused by a Vitamin A deficiency whose symptoms include night blindness, and would be easily remedied by eating carrots or papayas – crops that could grow here easily but no one thought to plant. The list of easily prevented or remedied health problems goes on: severe anemia among menstruating women, sexual health problems caused by poor hygiene, and child mortality that, in some villages we surveyed, exceeded one in five children dying below age three. These individuals are victims of well-defined, treatable diseases, but more importantly of the ‘ecological’ parameters that define life in underdeveloped rural areas.

Diseases such as these that plague India’s rural community are often different from those affecting city dwellers. For example, cancer and obesity-related illnesses, which are prevalent in urban areas, are rarely seen in rural clinics. This, again, is attributable to ecological factors: many individuals die of infectious diseases like tuberculosis before they are old enough to contract cancer, or suffer from starvation and malnutrition before ever becoming obese. The asymmetry between rural and urban healthcare problems and outcomes underscores the drastic need for systemic change to uplift India’s rural residents, who comprise almost two-thirds of its vast population.

Uplifting India’s villages is also vital for combating diseases like AIDS that are much more prevalent in urban areas but are now breaching the increasingly porous border between cities and rural villages. AIDS and other infectious killers will flourish in villages where basic healthcare infrastructure is either nonexistent or ineffective, and healthy young men like Raju nearly die of a pulled hair. In one village our team visited, several individuals have already died of AIDS, but our surveys revealed no change in awareness about the disease or any significant medical response.

Unfortunately, many strategies for fighting AIDS that are routinely practiced in urban communities do not translate easily to rural areas. For example, awareness campaigns are extremely difficult due to illiteracy and unwillingness to talk about sexual health. But despite the differences, there is one redeeming aspect of the rural situation: the changes necessary to respond to AIDS are largely the same ones necessary to remedy the existing healthcare problems, which are rooted in the drastic underdevelopment of rural societies and economies.

In urban areas, the fight against AIDS encompasses awareness campaigns, empowering marginalized groups and updating the existing healthcare infrastructure. In rural areas, however, the more appropriate remedy is a holistic social and economic uplifting. This means addressing the asymmetries between rural and urban areas, and also between groups within rural areas themselves. For example, the way to stop the spread of sexually transmitted infections by migrant workers is to improve rural economies and give individuals an alternative to seeking work in already-bustling metropolises. Also, the gender imbalance in power and education must be remedied because, as several previous studies have shown, educating and empowering women in rural areas uplifts communities and improves healthcare outcomes.

The difficult question that arises is how to remedy these problems in ways that are both sustainable and respectful of rural communities. As one doctor on our team lamented, life (and death) in the villages has hardly changed over the course of his thirty-year career, despite technological advancements and enormous investments in rural welfare. The prevailing attitude among city-dwellers is to cast blame on the residents of the villages for their so-called “backwardness.” Villagers, the argument goes, are not making progress because they keep women uneducated and disempowered, malnourish their children (especially girls), avoid discussing topics related to sexual health, delay seeking care for routine ailments, and so on.

It is tempting to prescribe aggressive urban-style education campaigns as the remedies to rural ‘backwardness’ – but this is problematic for several reasons. First, the ‘experts’ are, in many ways, as short on information as the rural populations they study; as such, they are in no position to criticize villagers for being uninformed. For example, healthcare-related surveys of rural populations have been largely unhelpful in guiding disease prevention efforts. And even the most sophisticated data collection has failed to predict the trajectory of diseases like AIDS through rural areas.

Second, many years worth of educational efforts have failed to create meaningful advancements in all but the most exceptional cases. This should not be surprising because even Western countries, where awareness is in no short supply, have many preventable health problems caused by obesity, smoking and the like. Education, it seems, only goes so far towards changing individual behavior, even when it is a matter of life and death.

Finally, if India’s village communities truly are ‘backwards’ relative to their urban counterparts, this only increases the need for creative, grassroots solutions uniquely tailored to rural society. Educational formulations made by and for urbanites will likely be ineffective, and indeed they have proven so. One stark example of this failure is the common practice of counseling individuals who come to urban hospitals for AIDS tests and drugs. These counseling sessions are uncomfortable even to watch: counselors, despite their best intentions, struggle to communicate the concepts underlying viral infections, antiretroviral therapy and sexual disease transmission to individuals who lack even a middle school education and women who hardly discuss sexual health even with their spouses.

These difficulties inspire a great deal of exasperation and head scratching among India’s public health community, which has tried for decades to implement grassroots solutions to rural socioeconomic problems. One of our team’s social workers wondered aloud, “How do we help villagers help themselves? It would put me out of work, but we would save many lives.” The answer, luckily, lies in the programs, institutions and relationships that India’s public and private sectors have already cultivated in rural areas over the past several decades. However, these programs have failed in many ways to adapt to the changing reality in rural areas.

One such innovation is the Self Help Group. These are groups of ten to twenty women from the same village who contribute a small monthly fee towards a common pool of money that is stored in the Grameen Bank (founded by Nobel Prize Winner Muhammad Yunus). Group members then draw loans from the pool for expenses such as educating children, buying livestock or starting their own income-generating projects. One group that our team met used their savings to buy each member two goats and a cow, whose milk they now sell to generate more income for their families; several of the members have been able to fund their children’s education in this way. The group’s next project will be to stock their village pond with fish, which can also be sold on the market (this practice is now commonplace among villages who can afford the initial investment).

While this particular Self Help Group has created successful income-generating projects, the group we met in a neighboring village revealed that they have no plans for using their funds, and have had trouble keeping their group together. They had no knowledge of the other village’s highly successful project. The reason for this disparity between Self Help Groups in adjacent villages is that one received better guidance; social workers who organized the failing group several years ago never returned to the village to direct it, whereas the group in the other village maintained regular contact with social workers.

Beyond being poorly guided, Self Help Groups are also underutilized. The issue at stake here directly concerns women’s health. Interviews with several women in one village, including members of the Self Help Group, revealed widespread occurrence of genital pain (likely due to poor hygiene). The women do not discuss the matter with their husbands, but they do discuss it with other women, especially at group meetings. The Self Help Group is thus an important forum for women to raise, discuss and resolve their concerns.

Unfortunately, no social workers we knew of had ever tried to use Self Help Groups as conduits for health-related interventions. Doing so would be wise, and should in fact be a top priority for public health workers serving rural areas. Self Help Groups have shown their ability to change rural society by empowering women economically; this economic empowerment ought to be accompanied by social change as well. For example, Self Help Groups can be mobilized to provide young girls in villages with equal opportunities, and to educate young mothers on proper childcare and nutrition to lower child mortality. Men’s Self Help Groups can also be created to empower the indigent, revitalize rural economies and encourage men to become more involved with childcare and become more open to discussing sexual health with their spouses.

Working through village-based institutions like Self Help Groups will likely be much more effective and sustainable than trying to impose or deliver new ideas through external actors. Village leaders can serve as liaisons to outside public and private groups, but villagers themselves ought to discuss important issues and come up with creative, grassroots solutions to them in which they are fully invested. This kind of community-based, deliberative process is vital to strengthening and adapting the fabric of socially conservative societies like India’s to ever-changing threats, including diseases such as AIDS. India’s rural community can ill afford to stay uninformed about AIDS and other public health concerns, or fight them with social stigma instead of progressive action. Unifying rural communities, and especially women, through locally based institutions is the best way to ensure the latter wins out.

Even the success of village institutions, however, does not mean that they are a solution to all rural problems. Outside institutions, especially hospitals, remain vital service providers to villages across India, but they also suffer from many shortcomings. The most apparent problem is a lack of resources to combat new public health problems such as AIDS in the farthest-flung villages. One Community Health Center that our team visited is a perfect example of this. The Center is a government-run hospital that serves almost one-quarter million rural individuals. It is staffed by several physicians and specialists, and is equipped to perform some surgical operations in addition to routine vaccinations and infectious disease treatment. However, the hospital has no HIV testing supplies, AIDS counseling or antiretroviral therapy. Patients who need them must travel to the city, which is half a day’s bus ride away, a journey few can afford to make.

The lack of HIV/AIDS-related resources at this hospital is not due to low demand; in fact, the doctors claimed to have found several HIV-positive patients in the past year alone, and have requested HIV testing supplies for the hospital. However, the state-level authorities have been unresponsive, and continue to concentrate resources in urban areas. It is unclear what – perhaps a shortage of testing supplies – is preventing rural hospitals from obtaining these resources, but it is abundantly clear that they will be necessary before long.

Government healthcare facilities such as this Community Health Center also have less visible problems than resource shortage; these other problems directly concern the relationship of the healthcare infrastructure to the rural community it serves. One major unaddressed issue is the fact that rural individuals are increasingly choosing private sector healthcare over government services. Many believe that the reason for this trend is that government hospitals are impersonal, ineffective, and lacking in important services. This is true to an extent, but there is another factor driving patients away from government services, namely, unethical behavior by doctors. Several individuals whom our team interviewed reported that doctors in government hospitals correctly diagnosed their illnesses, but would not write prescriptions so they could get the drugs they needed. Instead, the patients were referred to private clinics staffed by the same doctors who had diagnosed them in the government hospital. The doctors created these private clinics in order to make patients pay for the drugs and services they would receive for free in the government hospital. In the private setting, unlike in public hospitals, serving more patients translates into more income for the doctors.

This practice, if discovered, is grounds for losing one’s job, if not professional licensure. Each time it occurs, an opportunity for the medical community to truly engage with the society they serve is exchanged for a quick profit made off a patient who is unlikely to ever trust the public healthcare system again. Practices like this “double-dipping” stand in the way of efforts to fight diseases like AIDS that quickly infiltrate the rift between healthcare providers and the individuals they serve. Indeed, these acts of individual irresponsibility may be as harmful to rural progress as the drastic underdevelopment and social conservativeness that have reigned for decades.

There are, of course, several legitimate reasons that patients choose private healthcare services over public ones. One main reason is that a village-based medical practitioner, who, although lacking formal training, makes accurate diagnoses, administers a variety of prescription drugs, and is a vital part of the community he serves, often delivers private services.

Our team met several of these village-based practitioners – elderly men who ride through the village on a bicycle making house calls, delivering babies and checking on infants; whose house all the villagers know how to find; who recount with startling clarity the malaria and tuberculosis infection trends in the village over the past decade. Most of these practitioners perform their duties as a public service, charging their patients only what they can afford to pay.

The doctors who staff the government hospitals are aware of these practitioners’ existence, and even cast a blind eye on their somewhat questionable practices (such as obtaining and administering prescription drugs without an MD) because of the benefits they provide to rural villages. However, there is virtually no coordination between government doctors and village-based practitioners. Providing the latter with some degree of uniform, semi-formal training to confront the most pernicious rural health problems would likely benefit both parties and the rural community. Such coordination would also enable a unified, large-scale response to diseases like AIDS that require leadership from the medical community.

The list of necessary remedies to rural healthcare problems goes on, and the specific steps to be taken are a source of constant debate that will only grow more intense if infectious diseases like AIDS continue their destructive course. There are, however, common underlying themes, the most important of which is to create village-based socioeconomic advancements as a platform for improving healthcare outcomes. Many of the required solutions are simply matters of taking simple steps like planting the nutritious crops that could stave off night blindness – that is, planting the right seeds in an environment that will readily support them. India’s rural community is not inherently ‘backward’ or hostile to progress. Rather, there is an inherent asymmetry between the remedies that work in urban areas as opposed to rural ones; these differences must be recognized and respected.

The good news is that many programs and institutions are already in place that can revitalize rural society and prevent AIDS or another future disease from achieving its full destructive potential. The important task now is to cultivate and adapt these institutions in responsive, forward-thinking ways. This includes, but is certainly not limited to, mobilizing Self Help Groups and strengthening the relationship between government hospitals and rural communities.

The twenty-first century ought not see the health of rural individuals in any country, especially one as rapidly evolving as India, suffering as a result of their circumstances. Every young man who dies of untreated folliculitis, every child with night blindness, every woman who faints regularly due to menstrual blood loss, scars the legacy of India’s otherwise-progressive national healthcare policy and medical community. This policy and this community will be tested in the days ahead if AIDS adds further strain to the already-overwhelmed rural social fabric. But if rural society, economies and healthcare infrastructure are properly bolstered, the lives of millions may be saved.

Please note that all names and personal references have been modified out of respect for subjects’ privacy. The previous installments of this series were published in the September, October and November issues of PERSPECTIVE.

By Joe Hodgkin and Ron Serko

Until everything fell apart, my heart lay with John Edwards

The soft hair, the soothing accent, the proletarian pandering…all too perfect! But Edwards soon abandoned me.  I fell sobbing into the warm embrace of the junior senator from Illinois, whose soar-ing rhetoric felt like a coded message to a solidly leftist base.

Such honey-sweet words! “We need fundamental change!” “If we have actionable intelligence about high-value terrorist targets and President Musharraf won’t act, we will.”

Anyways, millions of college students couldn’t be wrong.  We weren’t wrong in the 60’s!

And by the election, I had invested my hopes in the romanticized Fox News version of our man.

“I think when you spread the wealth around it’s good for everybody.” Obama would finally address the large-scale socio-economic root causes of racial disparity…right?

“Make them go to bed at a reasonable time, keep them off the streets, give them some breakfast, come on!”
Obama’s victory, of course, felt like a deeply moving personal victory for all of us

But in the months that followed, the magic wore off and I noticed that the president-elect possessed one trait that I hadn’t noticed before… centrism. Obama’s appointments were dis-appointments: Tom Vilsack…Hillary Clinton…fine.  But Rick Warren?!

But by now it was too late.  My feelings for Barack Obama ran deep…deeper than could be rationalized.

I wish I knew how to quit you.