David Morley, hero for MCH

This is a eulogy written by my friend and colleague, Nick Cunningham, who worked with Dr. Morley throughout the past 60 years. In this summer of losing artists and heroes, I hope you'll join me in adding one more icon to your list of mourning.

Dear friends: 7 July, 2009

David Morley's death reminds us that truly creative minds almost always die too soon at no matter what age.
Dr Waterston cites some of the uniquely useful ideas that kept springing forth from his ever curious cerebrum. Here are a few comments on those that he cited and on others that he didn't:

1. The growth chart: it was far more than that. He sometimes called it the "under fives card" or the "road to health to health" chart because, as used by his colleague and co conspirator: nurse midwife Margaret Woodland, at the original "under fives" clinic at Imesi Ile, it encorporated a brief family history, at - risk factors for that child (tbc, sickle cell etc), immunizations, breast feeding duration, inter current illnesses like measles (written next to the growth curve so that family and staff could see and come to understand its often fatal impact on growth!), and family planning reminders for the mother. David realized that the mothers were far less likely to lose it than the clinic or hospital and that it could serve as an integrative tool for the mother , the family and health personnel to view and treat the child as a whole rather than as a disease or statistic.

2. Teaching Aids at Low Cost: Like all his innovations "T.A.L.C." operated non profit so that the materials, translated into multiple languages, could be available and accessible to those in greatest need. Many of the staff were local St Albans folk, so inspired by David's generosity of time and effort that they worked as volunteers or for almost no wages. Sometimes his altruism had a paradoxical reverse effect. By refusing any royalties on his (and Hermione Lovel's) seminal work, His Name Is Today (written in 1986 with the prize money he won from the King Faisal Award in 1982, and insisting that it be published in paper back at low cost, book stores realized little incentive to stock it, so that it soon became widely unavailable! But this and many of his other books remain classics in tropical child health to this day.

3. "Child to child" education curricula: David wanted school age children to learn about health by teaching, so he developed materials from which children could learn in school but also take home to their siblings (and perhaps parents). At first he envisaged the siblings as younger, but later realized that often they were older,(perhaps because girls drop out sooner?), after which he changed the name to Child to Child. This program worked so well in disparate cultures all over the world that it won a UNICEF Maurice Pate award in 1991. .

4. David spent years working on a simple low cost, tough scale, such that any community health worker anywhere could carry it along on outlying village or home visits. He also wanted it designed to involve the mother in the growth monitoring of her child. The TALC scale depended on a spring calibrated so that 1 kilo of weight translated into 1 centimeter on the growth chart. A hole in the pointer allowed the mother to affix the weight directly on her child's chart. The scale itself was made of plastic, with the instructions imprinted on the back, and so tough that, as he used to boast, a truck could drive over it without detriment, unlike the usual the UNICEF "Salter" model or later battery or solar powered types. Like the Salter, it was made to hang from a door jam or tree branch, but cost 1/5th as much. The only problem was that the growth charts had to be exact replicas of the TALC chart which was made of resistant (to both tearing & urine) plasticized paper and calibrated to fit exactly onto the scale itself. David realized that for growth monitoring to be effective, it had to be made as simple as possible and extended to entire target populations, and not just offered to those who turn up at clinics or health centers.

5. Though having started in Nigeria, where it's mostly warm, he realized in his travels that newborns were widely suffering from hypothermia and espoused the widespread distribution of small low cost disposable skin thermometers for primary prevention: another T.A.L.C. product.

6. Even cheaper was his pebble & (calibrated) string pendulum for the watchless village health worker to use in screening for tachypnea indicative of pneumonia... so simple... but he thought of it!

7. Perhaps David's most remarkable achievement came early on when he went out to work at the Wesley Guild Hospital in Nigeria. Having trained under Donald Court at Newcastle on Tyne, David knew the value of longitudinal prospective research. Before undertaking the design of his seminal "Under Fives Clinic" at Imesi Ile, he set up and, with Margaret Woodland carried out a five year study of the lives, morbidity and deaths of all babies born in that village. As the study was progressing services were designed to meet the observed needs:

Home visits and highly accessible ("twenty four seven") primary MCH care by locally recruited and trained semi professional ("grade 2") midwives ensured 95% compliance. Mothers were encouraged to bring all their children on every visit. Good weaning nutrition was built in via prolonged breast feeding and home grown chick peas & beans, careful growth monitoring and supervised feeding for those who "faltered" (failed to gain weight for 2-3 months). Immunizations were available daily & coverage was over 90%! Measles deaths dropped precipitously after every child got the new vaccine (David was friendly with Krugman and so Imesi was the first village in the world to be protected!) Basic medications and supplies were always available thanks to weekly restocking by the Wesley Guild.

The main innovation was success. How many simple low cost primary care services actually work... in the sense that 0-5 mortality is demonstrably and significantly lowered? Imesi worked but why? Besides the above features,

- the small maternity/clinic (but with a large covered waiting area against sun & rain) was built by the locals,

- most of the mothers were delivered there by the midwives,

- Margaret Woodland stayed around and learned Yoruba,

- the services (curative and preventive) met community needs and reached every child, and mainly because

- the trust needed to engage the entire population was established by the integration of all services under the same roof, by the same personnel and at the same time!

Zero to five mortality dropped in ten years from over two hundred to under fifty per thousand at a cost of less than $5 per child per year! I doubt that this achievement has ever been duplicated!

David was also an inspired teacher. Despite working for years in rather traditional academic environs, and with varying degrees of support, he maintained an active role, an optimistic attitude and the unbridled energy that fueled his countless forays leading teams of students out in the field to study nutrition and demonstrate how it underlies so much of health and disease in the tropics.

I am but one of many whose whole careers were directly inspired by his mentoring. Many of these mentees presented highly innovative work at the London festschrift in his honour in 2003.

Two memories characterize David Morley for me:
his labeling of (supernumerary) hospitals in developing societies as "disease palaces", and his cartoon (in My Name Is Today) of carrots a) unhappily planted too close together and b) contentedly spaced, as a metaphor for the benefits of spacing child births!

Respectfully and reverentially,
Nicholas Cunningham MD Dr PH,
Emeritus Professor of Clinical Pediatrics & Clinical Public Health,
Columbia University

Good bye, June and I'm taking July off

I'm disengaging from the world. I am voluntarily leaving behind all those sticky issues like paychecks and air conditioner installment and showers and days of the weak, er/and week.

At one point we wanted to be in New York for the summer. It's our favorite time of year here, after all, with the free concerts and fireflies, and empty sidewalks. But this June was the second coldest on record for the city, and the forth rainiest. In truth, it was no June at all. I have a lot of summer to make up for.

I have secured the kindest, sweetest subletters, a couple from Vancouver, and John's taken leave from his research. My grants run out tonight at midnight and the two I applied for to replace them both did not come in. I would have preferred to spend July in Uganda, but it seems the whole world is ready for me to take a vacation.

I got a new tent for my birthday and we're going to call that home for a while. We are still trying to work out how to get to our old car in Denver--my mom's been taking care of it since it's so darn hard to have a car in NYC. We tried to take the bus or the train, but they are actually very, very expensive. We are now trying to drive someone else's car west. Wish us luck.

We should meet up with Vivi and the car sometime late next week at my mom's house in Colorado. From there, who knows. We'll see which way the wind blows.

new Moby

Children's Special Health Care Needs Can Bankrupt Families

Children's Special Health Care Needs Can Bankrupt Families - Say Ahhh! A Children's Health Policy Blog:

"Because the current system is designed to address acute episodes rather than chronic or long-term health issues, many families just like mine raising children with special health care needs are financially overwhelmed - the promise represented by their little plastic card has been broken. According to the National Survey of Children with Special Health Care Needs, approximately 96% of children with chronic illnesses and disabilities have either private or public health insurance. But the survey also tells us that 20% of families of children with special health care needs spend more than $1,000 out-of-pocket per year on their care and that 18.1% of families report that their child's condition has caused them financial problems. This is direct evidence that just having access to coverage is not enough. The Catalyst Center has recently released a publication which explores and expands on the causes and consequences of this entitled 'Breaking the Link between Special Health Care Needs and Financial Hardship'. Through our work, we have identified three pathways to serious hardship, including:

* Higher health care costs (co-pays, deductibles, uncovered expenses, limits in coverage, caps on coverage)
* Higher costs for expenses every family has (child care, electricity, transportation, food/shelter/clothing)
* Loss of employment income and access to private insurance (the majority of care for children with special health care needs is provided by families, resulting in fewer opportunities to work)"

Vivi's summer vacation

Lazy afternoon
Originally uploaded by lnfenter

a shocking image

Neither John nor I can remember the last time we've seen something like this...

No Woman Should Die While Giving Birth

No Woman Should Die While Giving Birth - Blog 4 Global Health:

"The expression of these issues has resulted in the birth of the Newborn, Child, and Mother Survival Act of 2009 (H.R. 1410), which requires the U.S. Government to develop and implement comprehensive strategies, establish guidelines, invest and fund international and maternal health programs with an intentional focus on 60 countries which maintain the highest newborn, child, and maternal mortality rates. For more information on H.R. 1410 or to support it, contact the two offices leading this effort:

Lina Choudhry, Office of Rep. Betty McCollum
202-225-6631
lina.choudhry@mail.house.gov

Marhall Reffett, Office of Rep. Dave Reichert
202.225.7761
Marshall.reffett@mail.house.gov"

Aidan's most recent stories

The War

It was 1709, there was a war. It was dark. The clock said 12:00. All the other clocks were broken. This was where the chief general of the war lived for tonight. He was sleeping soundly when a deafening scream woke him up. He jumped out of bed, grabbed his gun, and ran downstairs just in time to see his wife and daughter get carried away by five soldiers. He ran but they got into a tank and shot the house down and then drove away. His five guards outside his house had been killed. His ten guards insider were fine except for some scratches. He sighed. Then he and his guards crept into the wreck and slept on some wood. In the morning they woke up, startled. A pot was on a fire cooking. They looked around and saw… The daughter and mother of the general next to a fire cooking. This was strange… Thought the general. They ate breakfast and had a talk. Later that day, the mother and daughter snuck off. The dad saw and snuck after them. When he came back he was squeezing his stomach with terror!!! My wife and daughter are evil! He said. His guards killed them (the wife and daughter) Then they used a nuclear bomb to destroy the other side of the war. The end.


[Aidan explained that he went through a draft stage at school where he translated the general to the Star Wars character, Palpatine. The next story follows:]


Surviving the Forest of Endor (Preview)

As you might have seen in the first book, there are two sides to the war: the Republic and The Dark Side. Last book the Dark Side had and lost an ability. Then the Republic had and lost a, well, let us say, explosive ability.
The ship was drifting towards Endor when Dark Side ships attacked. They turned on the energy shield. They went into an asteroid field and the Dark Side ships were destroyed. The one Republic ship came out of the asteroid field and flew through hyperspace and landed on Endor. They traveled through the forest until they got to a clearing in the woods. They were tired and hungry. Their only comfort was their two droids. One was an astronomy droid named R-4. The other was a protocol droid named C-3PO. There was a piece of meat hanging by a rope. A foolish guard ran up to it and pulled at it. All of a sudden, a huge net hidden in the ground scooped them all up so they were trapped in the net. “I should ‘ave known,” said Palpatine. Everyone looked where Palpatine was pointing. In the distance, there was a humongous tree house. “Ewoks,” said a guard. The End.

perfect solstice, albeit with very little sun

Blue Hill at Stone Barns is an organic farm just a half hour drive up the Hudson valley from Manhattan, near Sleepy Hollow. We spent the day there to celebrate my birthday and the solstice. We had to rent a ZipCar to get there, so after a fun breakfast of heart-shaped homemade waffles, we took the subway to the Bronx to find what was apparently the last available ZipCar in all of Manhattan. I have to share that ZipCar is so very friendly that when I called them to say we were running late due to the trains, they voluntarily moved our rental back an hour, so we didn't have to pay for the hour we didn't use and we got an extra hour tagged at the end of our slot.

Leaving the island is dramatic. Aside from Uganda, I haven't left Manhattan since December. Somewhere around the Cloisters the air feels alive and fresh in a way I did not know I missed until I smelled it. The farm itself is a dream. If I could take myself from just five years ago to see this, I would not have believed the green movement would go so far in so little time. Blue Hill embodies the legitimate ethic of sustainable environmentalism: they reduce, reuse, and recycle, and they do it in such an attractive way that people pay boatloads of cash to come take part in that experience.

The interesting aspect is the way people self-sort upon arrival. Some go to the tie and coat mandatory restaurant, where the menus begin at $96/person and some go to the cafe where sandwiches, pastries, and quiches run around $7. Both offer fresh-grown ingredients from the farm. Some take pay-tours, picking their own vegetables and nabbing their own eggs out from under the hens. We opted for lunch in the cafe followed by wondering through the fields and barns, then hiking in the state forest that borders the farm. It has rained so much this June that New England already has more than twice the monthly average, but we dodged the rain for most of the day--only getting doused once toward the end of our hike.

We left with fresh-butchered lamb, fresh picked snap peas and strawberries, and fresh-cut wildflowers for the table and we're preparing a feast tonight to enjoy the fruits of our day. The children had all the appropriate mixed feelings about killing the farm animals through the day, but I guarantee the taste will override the guilt tonight!

in honor of fathers day

Even though Willie the Whale is my favorite Justin Roberts song, this one befits the day best:

Vivi's new mobility

Vivi's new mobility
Originally uploaded by anniem

The girl flew off again to Colorado. We miss Vivi, but we're loving the respite her brief absences give us from Vivi's accoutrement. You know: the doctors, the therapists, the feeding and medicine regimens, the night wakings, the therapists. Her grandparents are in baby Heaven!

Sadly, this is the last trip for which Vivi is a free lap baby.

Aidan's school

Aidan's school
Originally uploaded by anniem

Next week we expect to receive Aidan's lottery results for City Wide. We're hopeful for Anderson, which is amazing _and_ close. Aidan's kindergarten teachers first pegged him for Anderson 3 years ago. I like to think that was a good sign that Aidan is widely understood to be a great student for this school. Other possibilities are significant commutes away, and they have busing, but I don't like the idea of Aidan being an hour away, even if it's only a couple of miles.

His school has been a wild mix this year: crazy bullies, under-resourced teachers and principles that do more with a few resources than you would think possible, and fledgling gangs that _still_ haunt us. But it's also been a joyful mix of dance, jazz, and chess teachers that merit an arts magnet school in NYC. They draw a lot of attention from idealistic arts organizations. This past week Aidan was selected to join an elite afterschool ballet program _with_ scholarship. The program has the possibility of feeding into the NYC Public School for Dance in the coming years. If we're still in NYC in a few years.

As you can see, lots of things on the horizon, but nothing is really known. Crossing our fingers? Sitting on our hands? Pick your metaphor: we're hopeful and watchful... of the mail.

El and the guitar

El and the guitar
Originally uploaded by anniem

She has to keep playing, she looks too pretty holding a guitar!

Taking a Close Look at Trash

Taking a Close Look at Trash

"Kindergarten teacher Joyce Tsang writes: For Earth Day, KD parents John and Annie Feighery spoke to the class about what we can to to reduce trash in landfills. After talking about the three Rs (reduce, re-use, and recycle) we examined KD's trash bin, sorting the contents into three categories and weighing each: food scraps (to feed Ms. Rothman's worms), paper,and plastic."

Researchers First To Document Early Signs For Diabetes In Kids As Young As 7

Researchers First To Document Early Signs For Diabetes In Kids As Young As 7:

"'This means that if the mother has a healthy weight gain during pregnancy and the child is breast-fed and physically active, the fat may not accumulate in the skeletal muscle and/or liver and the child may not experience an impaired fat burning ability in the muscle. All of these factors are significantly associated with poor insulin sensitivity that may eventually lead to type 2 diabetes in adolescence or young adulthood. We hope to conduct future prospective studies in this cohort of healthy children to confirm this finding,' notes Dr. Melinda Sothern, LSU Health Sciences Center New Orleans Professor of Public Health and study leader."

Next Test - Value of $125,000-a-Year Teachers - NYTimes.com

Interesting idea.. will be interesting to see if it works:

Next Test - Value of $125,000-a-Year Teachers - NYTimes.com

message in a bottle, thrown thru some sort of space-time porthole

To my 1990s self: things get better.

In Recognition of Gay and Lesbian Pride Month 2009

the pony ride at the birthday party

To surprise a group of squealing six-year-old girls with a pony at a birthday party in Frederick Douglas Park, modern-day, mid-gentrification Harlem was sublime. But it was a Shetland pony. As I explained to my children on our walk homeward to the 137th Street subway stop, this is a breed of pony that is famously ornery. I once had one, as a child, that learned to kneel down on his knees and shake its booty high in the air so that I, his rider, would tumble over his neck and he would be done with me. Or so he thought. Until my parents would howl from afar: "Get back on!" Maybe Shetlands aren't so much ornery as smart. Would I want someone riding me in an unseasonably warm park all day? It should have come as little surprise when our sweet El got on this pony's back and, just out of arms reach of her daddy, was bucked off. By accounts, it was a gentle bucking. The pony kicked his back heels once and she was so light that she flew up and slightly over before either of the pony attendants could catch her. She landed on her hip, where tonight a deep purple bruise is already shining.

Frederick Douglas Park is on a steep hill that marks the northern edge of Hudson Valley, just before Manhattan gives way to the Bronx. While the children ran after the announcement that the pony had arrived, I was waiting with Vivien in the shade just a short bit away, but down the steep bank of the park. I saw John carrying a crying El back from the pony line when I said, what's wrong, did she fall off? But I really thought he was joking when he said yes. Until I realized he wasn't and my next response could only be what was programmed into me years and years ago: did she get back on?

In our house, the children are addicted to Little House on the Prairie. It's horrifying sometimes, especially when that song for Uncle Ted comes along, or the stories of how Pa's daddy disciplined him with switches. Aidan read the whole series at least once, and El is on book 3 for her first pass. Often, they listen to the stories on audio as they fall asleep at night. They've been to the Little House museum online as well as the Wikipedia sites for Laura Ingles Wilder and the series. Know that it was in the spirit of Little House that I told the children about all the times I fell off horses. I told them about the time I was bucked off of the tall appaloosa, Bandy, in the 4-H Quay County playday and my mom was the announcer in the booth so as I laid on the dirt in the middle of the arena I heard her voice in the loudspeaker say, "Is she ok?" and then, "get her back on." They know about my horse that was struck by lightening and the one that drowned. And, even though they have not grown up with horses, they have grown up with the analogy of horseriding turned onto everything from piano recitals to bike riding. When you get bucked off, you get back on. Nomatter what.

John handed me the crying El and said I should take care of it. I asked him later if he was shocked by my response and he said no. I walked her back up the very steep hill to the pony line, skipped ahead at least ten little girls looking forward to their rides, and put El on top of that little horse--with a helmet on, albeit. As we were walking I said lots of things about being brave, showing the horse who's boss, not teaching bad habits, and finishing well. But when she was on I was fantasizing about putting a tie-down on this horse for the rest of the morning. If only NYC wasn't so darn sensitive to animal cruelty. A few parents told John if it were their child they would be cussing out the horse owner. One mom said, should we give a hip-hip hooray yell for El? To which I quickly said, No! It would spook the horse and she'll get bucked off again, then we'll never get her back on. Her second ride was without incident as she came around the bend, back to my waiting arms. Then, I walked her back down the hill and she had pizza and got her face painted.

As it turned out, El wasn't the only one to be bucked off by this little pony today, just the first. But she set an amazing example of how to handle it.

fingers crossed, shoes laced

We decided not to risk the $6,000 mandatory donation to charities if we couldn't raise the money before November 1. We're risking the one in four chance of the New York Marathon lottery. I would still love to run for a charity, but I owe my student loan debtors enough money already. When I put the question up to my Facebook buds about pitching in, I had a very generous 8 or 10 friends say they would donate $25--which means I am still far from $3K.

I'm going to be very hopeful about our chances in this lottery. I believe we'll both get chosen. Believe with me.

ten years ago today

ten years ago today
Originally uploaded by anniem