Tuesday, July 15, 2008

Body Mass Index

I’ve been thinking a lot about body mass index (BMI) lately. Body mass index is the weight to height ratio that is an indicator of whether one’s weight falls within a healthy range. (Google “body mass index” and you will discover any number of conversion devices to calculate your BMI.)

My BMI falls within the “normal” range – but just barely. I’m getting perilously close to a BMI of 25 which would put me in the “overweight” category and increase my risk of co-morbidities. The Centers for Disease Control defines co-morbidities as “conditions that exist at the same time as the primary condition in the same patient” (e.g. hypertension could be a co-morbidity of diabetes). Although BMI is just one indicator of health, mine is high enough to give me pause before eating a cheeseburger and fries.

I was curious about my BMI because of all the discussions I had in Ethiopia about the body mass indexes of people living with HIV/AIDS there. While my BMI may affect how I eat, a person’s BMI in Ethiopia may determine if they eat.

You see, George Bush’s HIV/AIDS initiative, The United States President’s Emergency Plan for AIDS Relief (PEPFAR), outlines three priorities for food support for people with HIV/AIDS: 1) Orphans and vulnerable children; 2) HIV-positive pregnant and lactating women in programs to prevent the transmission of the disease to their children; and 3) Adult patients in anti-retroviral therapy (ART) who have evidence of severe malnutrition as defined by the World Health Organization (WHO) as having a BMI less than 16. PEPFAR actually provides food support for individuals with a slightly higher BMI of 18.5 or under.

While in Ethiopia I met with representatives from a PEPFAR-funded program that distributes food to people living with HIV/AIDS through the World Food Programme. Those who qualify for the food receive wheat, oil, beans, and micronutrient rich flour called, Famix. This got me wondering, if I were Ethiopian and had HIV/AIDS, how little would I have to weigh to qualify for these food supplements through PEPFAR?

The answer: To meet the qualifying BMI of 18.5, I would have to lose nearly 45 pounds and weigh no more than 129 pounds – about what I weighed when I graduated from high school in 1977 – to have a chance of receiving these staples. A BMI of 18.5 is considered mild malnutrition with a moderate risk of co-morbidities.

Now, to meet the WHO’s standard of a BMI of 16, I would need to drop over 60 pounds and weigh approximately 112 pounds. This would classify me as moderately malnourished with a high risk of co-morbidities.

So, let’s say I have HIV, I live in Debre Zeit, Ethiopia (a town on the “high risk corridor”), I’m receiving HIV meds, and I qualify for supplements from the World Food Programme because my weight is below 129 pounds. With medication and access to food, I start to gain weight. Once my weight reaches 130 pounds for two consecutive months, I “graduate” from the program because, according to PEPFAR “Supplementary feeding support should cease once the patient’s BMI stabilize above 18.5 (e.g., two consecutive months greater than 18.5).” (http://www.pepfar.gov/pepfar/guidance/98836.htm)

You read that right, once my BMI is slightly above the “mild malnutrition” classification, I no longer qualify for food supplements. Unless my weight drops when I’m no longer receiving food and my BMI again dips to 18.5 or less – as frequently happens after people with HIV/AIDS “graduate” from the program. Then I can go back on the program and receive food again.

Now in PEPFAR’s defense, qualifications and restrictions do have to be set somewhere, and a BMI of 18.5 is significantly higher than 16. And, in countries like Ethiopia where many people are hungry and malnourished – not just those with HIV/AIDS – diligence must be observed to not create programs that actually offer incentives for being HIV-positive. However, merely encouraging “...the program to leverage other resources and linkages with longer-term food-security activities” will not make it happen. Here’s what I suggest.

PEPFAR retains the current BMI classification of 18.5 for people with HIV/AIDS to receive food support. For those adults who fall in the “normal” BMI range of 18.5 – 24.99, PEPFAR allocates significant funding to pilot local, sustainable, food and nutrition programs including gardens and poultry raising projects. Presumably, if someone’s BMI has improved to the “normal” range, their health would allow them to maintain vegetable gardens and animal husbandry projects. The harvest would provide food for themselves and their families with the excess being sold at market as an income-generating component to the plan.

Should someone’s BMI actually go above 25 and move from a “normal” classification to an “overweight” classification, then “graduating” from the program seems appropriate, since now the increased weight could possibly be contributing to ill health. As someone with a BMI hovering very close to that classification, what a great incentive for staying as healthy as possible.

Friday, July 11, 2008


My morning routine changes considerably when I travel and wake up in a hotel in a city like Addis Ababa. The one thing that is constant is that my day always starts with a cup of coffee. Most hotels now have electric pots to boil water for instant coffee, like the one available in my room at the Hilton in Addis, but I have also been known to travel with my own coffee and a French press. A hot cup of coffee, first thing in the morning, is the only creature comfort I really need to get my day started (though a hot shower is always a plus!).

I had some work to do in preparation for today’s round of meetings and site visits in Addis. While waiting for water to boil, I brushed my teeth and – looking at my weekly reminder pill box – I snapped the “Friday” compartment open and took my daily aspirin and multi-vitamin. I then mixed hot water into the instant coffee the hotel provides, and sat down at my computer to begin strategizing my day.

About 20 minutes later, I started feeling a little queasy. The queasiness changed to nausea. A fleeting thought of a terrible case of food poisoning I contracted in Rwanda flashed through my memory, before I correctly self-diagnosed my malady. I was feeling the affects of taking a single aspirin and a vitamin on an empty stomach, exacerbated by drinking coffee. Although I knew the symptoms would pass, especially if I stopped drinking coffee, I dressed and went downstairs to the hotel restaurant where I grabbed two bread rolls from the breakfast buffet, and quickly devoured them. Almost immediately, the nausea disappeared and I ordered a cup of coffee from the server and resumed my activities.

Part of what I had been strategizing upstairs in my room was an upcoming appointment with Ato Shallo, the Director of the Regional Health Bureau of Oromia, the largest – both in geographic size and population – of the nine regions in Ethiopia. I first met Ato Shallo on an extremely cold January morning when he visited our operation in Minneapolis, Open Arms of Minnesota. Ato Shallo had come to Minnesota as part of a twinning program established between the Minnesota Department of Health and the Oromia Regional Health Bureau. The partnership was facilitated through the efforts of the National Alliance of State & Territorial AIDS Directors (NASTAD). I gave Ato Shallo, and representatives from the Health Department and NASTAD, a quick tour of our building and programming before sitting down to discuss the critical role of food and nutrition for people living with HIV/AIDS, and how services can be dramatically expanded and enhanced with the assistance of volunteers. Ato Shallo turned to his partners at the Health Department and NASTAD and said, “Why aren’t we working with Open Arms.” That initial conversation turned into an invitation from Ato Shallo to spend a week in Ethiopia conducting an assessment on possible models for nutrition intervention for people with HIV/AIDS and increased mobilization of volunteerism.

Six months later it was now my turn to visit Ato Shallo in his office in Addis Ababa. I finished collecting my thoughts, and also finished my large breakfast, before leaving the hotel for our appointment with Ato Shallo to discuss our findings.

Ato Shallo began the conversation by talking about the number of Ethiopians with HIV/AIDS who have access to potentially life-saving Anti-Retroviral Treatment (ART). In a country with massive food shortages and malnutrition, few of these people with HIV/AIDS have that same kind of access to food and nutrition that they have to medications. Given the potency of ART, Ato Shallo said, “If you take ARTs without food, it is like poison.”

Ato Shallo’s comment transported me back to my hotel room earlier in the day. I had merely taken an aspirin and a vitamin on an empty stomach, then compounded the severity of my body’s reaction to those pills by drinking a cup of coffee, to gain a slight insight into what it must be like for tens of thousands of Ethiopians who swallow AIDS medications on empty stomachs every day. I also had the advantage of being able to pay hotel-inflated prices for a couple of pieces of bread that would absorb the aspirin and vitamin, resolve my discomfort, and allow me to go about my business.

Ato Shallo identified the challenges. People with HIV/AIDS need anti-retroviral medications to survive. For those drugs to be effective, they must have access to food – and ideally nutritious food. Maybe solutions to these challenges would be forthcoming if all of us with power and privilege experienced what many Ethiopians experience: the debilitating side affects of taking medications without food. Now, our doctors would never recommend that we do that. So, if it isn’t acceptable for us, why is it acceptable for poor Ethiopians?

The High Risk Corridor to Dijbouti

Follow any ground transportation route on the African continent, such as roads driven by long distance truckers who are transporting goods great distances, and you will notice elevated rates of HIV infection along those routes. Truckers are away from their families for extended periods of time, have money, and the opportunity to engage in sex with commercial sex workers who come to these areas knowing there will be a constant demand for their services. In the absence of AIDS education, training, access to condoms, and the ability for commercial sex workers to negotiate safer sex practices – HIV infection skyrockets.

The road from Addis Ababa to the Republic of Dijbouti is an economic lifeline for the landlocked nation of Ethiopia. Following the 1998 war between Ethiopia and Eritrea, the country of Dijbouti became the primary seaport for Ethiopia. Today, the stretch of road between Addis and the Red Sea in Dijbouti is congested with semi-trucks, mini van taxis, buses, and cars. A single lane road, drivers are always on watch for an opportunity to pass slower vehicles, though the high rate of traffic makes for very few passing opportunities that are safe. Traffic accidents are a concern as evidenced by the number of damaged trucks by the side of the road.

Congestion is not limited to the paved road. Along the shoulder, donkeys roam freely, sometimes into traffic which causes immediate slowdowns. Ethiopians walk with their goats or sheep, some carry firewood, some sell watermelons or rugs or insulated containers that keep water cold for those in transit to Dijbouti. Farmland in the Great Rift Valley is tilled with primitive wooden devices pulled by oxen. Although drought is a primary factor for malnutrition and starvation in Ethiopia, the lack of modern farming equipment greatly reduces the yield that can be obtained from small parcels of land.

The city of Adama, 100 kilometers southeast of Addis Ababa, was our final destination on what has become known as the “high risk corridor”. It’s high risk, of course, because many of the factors that can cause a perfect storm for the spread of HIV exist here: poverty, high rates of unemployment, lack of education, and truckers who can pay commercial sex workers.

The high risk corridor has been a priority for HIV/AIDS education and outreach for years. International relief organizations, many of them funded by President Bush’s PEPFAR (President’s Emergency Plan for AIDS Relief) initiative, created programs to reduce HIV transmission, provide Anti-Retroviral Treatment (ART), and improve adherence to medications. Save the Children is here, as is the World Food Program, the Clinton Foundation, and numerous other non-governmental organizations (NGO) both large and small. One doesn’t need to understand Amharic to appreciate that the billboards with a red ribbon are HIV/AIDS messages and reminders. When we check into the Safari Lodge for an overnight stay in Adama I find two condoms in a woven basket by the side of the bed. Although most Ethiopians I have talked with about HIV/AIDS primarily discuss abstinence and being faithful, the existence of coffee flavored condoms and bedside condoms at the Safari Lodge, give me confidence that the complete A-B-C model of HIV/AIDS education and prevention, (Abstain – Be Faithful – Use Condoms), is being practiced here.

But despite the efforts of NGOs, the HIV/AIDS messages, the availability of condoms to prevent infection, and medication to help control the disease, an extraordinary amount of work still needs to happen just along this one high risk corridor. And there are many corridors just like this one on the African continent, and around the world.

Tuesday, July 8, 2008

Coffee, HIV/AIDS, and Hunger

The popularity of coffee becomes even more obvious in Ethiopia when meeting with representatives from social service organizations who work on issues like hunger, malnutrition, and HIV/AIDS. At every meeting a slip of paper is presented for guests to designate their preference for a macchiato, coffee, tea, or water. Within minutes of indicating your order, a staffer presents a tray with the selected refreshments. Having already consumed enough macchiatos for one day, I politely passed on another espresso shot while meeting with Ato Gonfa, HIV/AIDS Prevention and Control Desk Head, at a sub city level in Addis Ababa. I did not pass, however, on his offer to give me a box of coffee flavored condoms.

The box of three “international quality latex condoms” are marketed under the name of Coffee Sensation and sell for three Birr a box – that’s the equivalent of 30 cents for three condoms. The box is illustrated with condoms and coffee beans and is a big seller in this highly caffeinated country. Although Ethiopia doesn’t have the high rates of HIV infection that are associated with nations like South Africa, the fact that coffee flavored condoms are manufactured in the first place indicates the seriousness of HIV/AIDS here.

Ethiopia has a population of 80 million people, the overwhelming majority of who live in rural areas. Unemployment rates are high – over 50% - and the literacy rate is only about 40%. The overall rate of HIV infection in the nation is 2.1% of adults. Addis Ababa, a sprawling urban center of five million people, has a significantly higher rate of HIV/AIDS. The disease has created a population of approximately 900,000 orphans. Although Anti-Retroviral Treatment (ART) is available for people living with the disease here, there are still thousands of people who could benefit from the medicine who do not currently receive it. Food insecurity is a major factor in the lives of many Ethiopians who suffer from hunger and malnutrition. This is especially true for people with HIV/AIDS who may have access to treatment for their illness, but are taking these powerful drugs on empty stomachs, thereby reducing the effectiveness of the medications and creating other health issues that could easily be avoided with food and proper nutrition.

The global food crisis has resulted in unprecedented increases in food costs in Ethiopia. The food crisis, combined with a drought that has diminished crop production throughout much of Ethiopia, has resulted in increasing rates of malnutrition. UNICEF estimates that there are 75,000 severely malnourished children in Ethiopia and predicts that anywhere from one-quarter to one-half of them will die without intervention. In the future, a coffee flavored condom might prevent HIV infection in these children. That is, if they don’t die of malnutrition or starvation before they reach an age of sexual maturity.

Monday, July 7, 2008

Ethiopia 101

Ethiopia is a landlocked nation in northeastern Africa. Unlike the rest of the continent, Ethiopia avoided colonialization, though the brief Italian occupation (from 1936-41) is still evident by the pastas and pastries served in most restaurants. Apparently, Ethiopians didn’t want to be ruled by Italians, but they recognized good food when they tasted it. The Italians were kicked out, but their cuisine remained.

Ethiopia, of course, is also a coffee drinking nation. Macchiato, which translates to espresso marked with milk, is the coffee of choice here. Drinking multiple macchiatos throughout the day is temporarily warding off jetlag for me.

Pasta may be prevalent, but while in Ethiopia I intend to eat as much local food as possible Рwhich means eating injera at every meal. Injera is the staple bread of Ethiopia. Made of Teff cereal, injera is pulled apart and used to scoop up whatever other food you are eating. Fillet tibs, diced beef saut̩ed in onions and tomatoes, is a popular dish. Shiro, chickpea gravy with onions and Ethiopian spiced butter, is delicious and easily sopped up with injera.

A popular bar and restaurant, the Old Milk House, is a short walk from the Hilton Hotel where we are staying. An order of shiro, along with beyeainetu – a fasting platter of various Ethiopian foods, was really enough food for three or four people. Bedele and St. George’s, two local beers, were the perfect complement to the meals. At the end of the evening, two main courses and four beers came to 82 Birr – less than $8.50. As tasty as the food is at the Old Milk House, the highlight had to be a visit to the restroom where an attendant not only presents guests with a napkin to dry your hands, but she sells packs of banana flavored chewing gum for three Birr. Who needs dessert when you can buy banana gum in the restrooms!

Sunday, July 6, 2008

Waking Up in Addis Ababa

I really am a farm kid from rural Minnesota. I rarely think about that when I’m in the United States, but when I wake up, as I did this morning, in a part of the world that until yesterday was only a name on a map, I don’t think as much about where I am as I do about how far I have come.

Where does a longing for adventure come from? Why does the travel bug bite some of us and not others?

As a young boy I remember sitting in the Lutheran church, built in the middle of a cornfield – a central location for all of the neighboring farmers – listening to missionaries talk about exotic places like Madagascar. And I wanted to go there. I didn’t want to convert anyone, even at that age, but I wanted to see a place that sounded so totally different from my world. If the Weekly Reader had a story about Alaska, that would be the next destination of my dreams. Fess Parker playing Daniel Boone on a television show sparked a desire to see Kentucky. John Denver signing Rocky Mountain High had me packing for Colorado.

Although my family didn’t travel often, aside from an occasional week at Sunset Bay Resort in Minnesota’s lake country, or a road trip to the Black Hills of South Dakota, I always suspected there was a travel gene somewhere in my DNA make-up. I mean, my ancestors had left Norway in the 1870s for the U.S. Granted, they were motivated to establish better lives for themselves, but I believe that these distant family members from Scandinavia also woke up in the New World and thought – not so much about where they were – but how far they had come.

There is a possibility that waking up, as I did this morning in Addis Ababa, Ethiopia, isn’t really as far from where I came from as one might think. Yes, it was a long trans-Atlantic flight to Amsterdam, followed by another long flight to Khartoum in Sudan, before finally arriving in the capital of Ethiopia 24 hours after leaving the airport in Minneapolis. But long before my family left Norway, about 60,000 years ago, my family probably lived here, in Ethiopia; eventually making a journey from Africa, through Turkey, and the countries of Europe, before settling in what is now Norway, and then embarking for the Americas. At least that is what the National Geographic Genographic Project, based on my DNA, believes is the history of my very extended family.

My family believes that we are 100% Norwegian Americans. My mother’s family immigrated from Jevnaker and my father’s family from Trondheim. This belief hasn’t stopped a recurring discussion within my family that we also may be part American Indian. When I heard about the Genographic Project, I hoped that by submitting a swap of saliva to a lab that we might finally discover whether or not there was more diversity in my family than we previously thought.

Just like waking up for the first time in a part of the world that is totally new triggers more thoughts for me about the past than it does the present; the Genographic Project told me less about where our family is today, than where it came from. Currently, the project only tracks my family to the shores of Norway. What may have happened to my DNA in the New World has yet to be charted by National Geographic. But what my DNA did indicate is that thousands of years ago, where I woke up this morning in Ethiopia is where most of our ancestors woke up every day of their lives. And although I haven’t lived on a farm in rural Minnesota for 40 years, it is farming – more specifically hunger, nutrition, and disease – that brings me here to Addis Ababa.

Sometimes the past, the present, and the future are all the same thing. And perhaps Minnesota, Norway, and Ethiopia are not all that different from each other either.


To learn more about National Geographic’s Genographic Project visit www.nationalgeographic.com/genographic.