Americans take bitter pleasure in speculating about the consequences of their country’s decline. But how might the immense, energy-rich, and nuclear state of Russia respond to the wane of U.S. power? On February 21, Calhoun College, in association with the Yale International Relations Association and the Poynter Journalism Fellowship, hosted Paul Starobin, contributing editor to the National Journal and author of After America: Narratives for the Next Global Age, to discuss what Russia might be like in four potential post-American worlds.

Whatever its future context, the Russia of today—and likely of tomorrow—is in a sorry state. With a shrinking population, “abysmal healthcare”, rampant corruption, an unruly and inefficient military, and an economy dependent on resources extraction, “Russia has been a declining power for over 20 years”. The regime of Vladimir Putin—led by him as Prime Minister for 12 years, and as President for 6—has financed its doings with a vast oil revenue, a product of sustained high oil prices.

Paul Starobin gave his audience the choice of four futures; of course, given chaos theory, a butterfly flapping its wings in Brazil today might completely rupture Russian policy in 2050. Or something like that. (Courtesy of Facebook).

However, as Russia has declined, so has America. This post-American world, to which Russia will have to adjust itself, will take on one of four forms: either a return to Westphalian multipolarity, a Chinese Century of Sinic preeminence, a Ancient-Greece-like world of city-states, or a homogenized universal civilization.

In the first of these, the Russian establishment would thrive. Without a global policeman to resists its moves, Russia would see few challenges to how it treated its “near-abroad”. Intriguingly, such a world could see stronger relations between Europe and Russia, as the threateningly expansionist policies of NATO—largely spearheaded by the United States—would recede along with the US.

Although it might be somewhat taken aback, Russia could manage in a Chinese Century. Having traditionally looked to Europe for cultural guidance, it would feel uncomfortable submitting to the Chinese, towards whom the Russians harbor a largely “condescending and racist attitude”. Combined with Russian fears over Chinese expansion into Siberia, this scenario would be tough to manage—but Russian energy exports to China would surely dominate the relationship.

Russia could almost be said to already inhabit the age of city states; in Starobin’s words, “everything that is happening in Russia … is happening in Moscow”. This is nothing new, as dominance by a single city—going as far back as Rus and Novgorod—is a hallmark of Russian history. In a world of city-states, Moscow’s preeminence would only be reinforced.

The final and most novel option is that of the universal civilization, which Starobin describes as a “Davos world, if you will, on steroids”, referring to the annual globalization-celebrating fête. This would be the world most foreign to Russians, as nationalism rather than cosmopolitanism colors the thinking of both the elites and the public. In a world dominated by well-enforced global standards of justice and commerce, the Russian instinct would be to resist vociferously.

How Russia engages with the world of tomorrow will have consequences not only for its own 180 million inhabitants, but also for those it might choose to trade with, imitate, or even invade. Though divining the future will never be a perfect science, it is a necessary (and fascinating) task.

Fil Lekkas ’14 is an Economics major in Calhoun college. Contact him at filippos.lekkas@yale.edu.

On February 21, the Boris Kapustin, professor of Political Science at Yale, and Paul Starobin, veteran Russia correspondent and contributing editor to the National Journal, addressed a packed lecture hall in WLH. Organized by the Yale International Relations Association, their talk discussed the nature and future of the Putin regime in Russia, especially in light of the widespread protests organized in response to widely recognized electoral fraud.

Though intrigued by Russia’s current protests, Starobin emphasizes that liberalism and democracy remain very elusive. Vladimir Putin played a major role in creating the current situation, having “monopolized the assets of the country, eliminated opposition, and defanged the media”. However, a deeply ingrained tradition of “strong-man” autocracy combined with a national ethic defined by Orthodox obscurantism (the restriction of knowledge from the people), creates a public that is more willing than others to tolerate such practices. Furthermore, the disdain Russia’s educated elite and downtrodden poor feel for each other keep these two important parties tragically divided. In the light of all of the above, Starobin considers the likelihood of this “fractious” movement’s success slight. Despite that, he finds this attempt by ordinary Russians to “advance a kind of democratic possibility” (and resist their strongman) encouraging.

Boris Kapustin lectures in Harkness Hall. Kapustin and Paul Starobin split over Russia's splits, but both agreed that Putin remains unsplit. (Lekkas/TYG).

Where Starobin saw the deep forces of tradition combined with elite snobbery, Kapustin identified a deeply antidemocratic “peripheral capitalism” as the prime agent of the failure of liberalism. Unlike Starobin, he sees in Russia a liberal public waiting to break free of a “collusion of dominators” consisting of the “top brass of the police and military” and the oligarchic super-class. Intent of protecting their plunder, Russia’s elite are “foxes that are pretending to be lions”: bourgeois and decadent, but eager to appear imperialist to threaten their neighbors and beguile their people. In his view, Putin—though by no means a puppet—is entrapped by their maneuvering despite being the figurehead of “Kremlin Inc.”. As such, today’s Russia is not an “authoritarian state” run by Putin, but “to quite a large extent, a failed state”. Kapustin has little hope for the protest movement; even if the current protests were to elect a new Prime Minister, that person would be similarly “entangled in the collusion of the elites”.

However one interprets it, the situation in Russia looks grim. Deep structural factors—whether cultural, historical or economic—constitute a significant obstacle for those Russians discontent with their lot.

Fil Lekkas ’14 is an Economics major in Calhoun College. Contact him at filippos.lekkas@yale.edu.

A signature foreign policy initiative of in the early days in President Barack Obama’s Administration was a “reset” of relations with Russia after years of cyclical mistrust and cooperation. Yet, as Thomas Graham, a Senior Fellow at the Jackson Institute for Global Affairs explains, the reset “ended at the moment when it reached its highest point” – the ratification of the New START Treaty 2010. Graham’s talk, part of a lecture series sponsored by the Jackson Institute drew a crowd of approximately 60 students, faculty, and members of the community and focused on the future of U.S.-Russian relations. As a managing director at Kissinger Associates, Inc., where he focuses on Russian and Eurasian affairs, Graham provided insight while also engaging his audience.

Graham began his talk with two related assertions. First, former and likely future President of Russia, Vladimir Putin will continue to lead Russia and second, the “reset” is dead. Much of this has to do with the fact that Mr. Putin symbolizes the negative images Americans hold in regard to Russia. With Dmitry Medvedev, Russia’s current President, both President Obama and the nation as a whole could better relate to his style, ideology, and love of technology. Yet, with the imminent “re-election” of Mr. Putin—which Putin recently revealed had been planned since his first term, with no other option for Russia’s people—the U.S. shows no signs of seeking a warmer relationship and has in fact increased its rhetoric against Russia to highlight our differences.

Thomas Graham speaks in the Sterling International Room. Given his topic, the nationless map behind him is bitterly ironic, don't you think? (Williams/TYG).

Ultimately, Graham sought to explore the question of whether or not “the U.S. and Russia can sum up the imagination to launch a new constructive page beyond the reset” or will we “continue within a cycle of hope and disappointment.” Indeed, it would seem as if we are presently within the disappointment stage: discussions relating to missile defense are stagnant, U.S. has denounced human rights abuses in Russia, and Russia has countered U.S. positions on Libya and most recently, Syria. But another reset is not enough. Like a slow computer that needs a restart, the current framework of relations needs to be scrapped in favor of a relationship defined by meeting new strategic challenges and interests.

Establishing such a relationship, Graham explained, is no easy task. The United States faces a world that is more globalized than ever before, in which it is no longer a “rising” power, and in which we can’t use traditional approaches to foreign policy (such as isolationism or the single threat framework such as containment or unconditional surrender) that defined much of 20^th Century American foreign policy. At the same time, Russia, for the first time in three centuries, is not the dynamic core of Eurasia. It is surrounded by stable, more dynamic power in China and Europe. Both countries, the U.S. and Russia continue to see each other as competitors rather than partners—but in reality, Graham notes, “neither poses a strategic threat to the other.”

Still, audience members left the talk without much hope for the warming of relations. A new constructive phase is unlikely to materialize under a renewed Putin administration in Russia and if both parties continue to view the relationship without considering both short-term and long-term goals. History and petty political differences will continue to prevent us from acting in a cooperative manner, even though this would be to both our interests—as in so much of world policy today.

Matt Williams ’13 is a Global Affairs major in Berkeley College. Contact him at matthew.williams@yale.edu.

The girl I am to interview sits down across from me – sharp and stylish in gold earrings, a bright teal sweater, and shining black leather boots. Her name is Marina Filiba, and she’s been wearing the same t-shirt for eight months.

Marina is participating in the I Am Challenge, a youth-led initiative that asks young people to commit to wearing a t-shirt with their name on it for 365 days while raising funds for causes they care about. Marina gave a talk on the I Am Challenge at the TEDx Yale conference this February 4^th. When I ask Marina how she found such an exclusive opportunity, I’m surprised to hear that she didn’t start out wanting to give a talk. A self-proclaimed “ TED junkie,” Marina was thrilled to hear that TED was happening at Yale and approached   TEDx Yale curator Diana Enriquez Schneider about helping to organize the event. By then, TEDx Yale had enough organizers, but Diana suggested Marina sign up for the student speaker competition. Though the idea made her nervous, Marina auditioned, became one of the most popular candidates in the online competition and won a spot on the stage.

Marina is currently the international director of the I Am Challenge, overseeing two to three regional directors of Challenge projects around the world. While the projects change depending on the region, the t-shirt remains the same in each country, establishing a connection between participants regardless of cultural separation. To Marina, that makes the world seem a little smaller—and this feeling is one of her favorite aspects of the Challenge.

Dozens of young people around the world have taken up the Challenge; those with long names might have some trouble, though. (Courtesy I Am Challenge).

In the beginning, the I Am Challenge consisted of Dan and Ben— two friends in New Zealand who dared each other to wear the same t-shirt for one year. Co-founder Dan Cullum says that he and Ben realized they “weren’t going to be able to get through the whole year if they didn’t have a cause.” So they contacted the New Zealand branch of World Vision, a humanitarian organization, and began a project to raise funds to build wells in water-deficient Tanzania. Soon after that, their friends asked to get involved, and the larger organization was born.

Since 2008, the Challenge has spread to 11 countries around the world, and over 300 young people have participated. Today, groups have adopted the challenge in Hong Kong, Marina’s homeland of Argentina, and my hometown of Atlanta. In New Zealand, a seasoned group of Challengers is working to sponsor arts programs in Christchurch, a city leveled by an earthquake last February. In 2012, they will launch a project in which each Challenger is paired with a child in a developing Asian country with the goal of raising $550 for that child. After completing the year-long Challenge, each participant gets a second assignment—to find someone to take up the Challenge and continue raising money for the same child.

In Kuwait, a team led by a regional director named Hiba is focusing its efforts on environmentalism. They plant trees and run a market where they sell goods made with recycled materials (like purses crafted from grocery bags). Marina has never met Hiba in person but says that she is “amazing.” Rather than letting their project fizzle out, Hiba’s team already has new leadership lined up for when she leaves for university. Marina says the group in Kuwait exemplifies the kind of commitment the Challenge aims to foster.

When I ask Marina whether she knows Dan and Ben personally, she tells me that Dan is her boyfriend—a detail they keep under wraps. The two met in London two years after Dan star TED the Challenge and have been dating ever since. For two years, Marina has never seen Dan without his “I Am” shirt. “I don’t know what my boyfriend looks like without that shirt,” she says, we both laugh. Dan never pressured Marina to take up the Challenge, but Marina tells me about times on her visits to New Zealand when she and Dan would be shopping at the grocery store, and Marina would see people wearing the t-shirt who didn’t even know Dan. It was this evidence of the Challenge’s impact that made Marina want to get involved.

Marina outlines the Challenge’s objectives for me: one is “getting rid of excuses”—the Challenge aims to refute the stereotype that today’s youth are commitment-challenged. Through “I Am”, kids our age show the world that we are passionate, that we can devote our lives to something. Marina and the other Challenge directors don’t try to sell their mission as an easy one—they know every participant will face days when they wake up, go to their closets, and regret their decision to wear the t-shirt. But as Marina said in her talk, “When you think back on this year, you’re not going to remember moments of hesitation, but rather the 365 days of genuine commitment to a cause much greater than one’s wardrobe.”

Another of the Challenge’s objectives is fundraising. As Dan says, the t-shirt is just a tool that Challengers can use to raise money for and awareness about causes they support. Marina points out that sponsorship is a great way for people to get involved in the Challenge if the t-shirt isn’t their style. She says, “My sister told me, ‘I’m past the age where I can wear some t-shirt and be an activist and all that, but I want to support you.’ So she became a sponsor and gives $25 a month to the Challenge.”

The Challenge’s third objective addresses fashion. This was an especially interesting part of Marina’s I Am Challenge story. She hails from Buenos Aires, Argentina, one of the fashion capitals of the world. When she started the Challenge, friends and family questioned her. “Are you crazy?” her dad asked when she talked about donning the t-shirt just before heading to Yale. Marina was unruffled: she saw the beginning of the school year as a great time to introduce her new classmates to the Challenge. She got some positive attention for it at the Orientation for International Students (OIS): at the end of the program, she received the award for “Best Wardrobe.”

I had to ask: doesn’t it get hard, wearing the same shirt every day? Marina answered that the longer she does the Challenge, the less she thinks about what she wears. She has become convinced that “[her] time is better spent in other ways.” She tells me that the Challenge pushes you toward this kind of self-discovery. She regularly hears stories of people who finished their long year of fashion suppression to find that they couldn’t return to life without the t-shirt. They figured if they were going to put effort into the clothes they wore, they might as well do it for a cause.

The Challenge has renewed Marina’s faith in today’s youth. Each week, she gets emails from people wanting to take up the Challenge in their communities. In New Zealand, an entire infrastructure—shirts, fundraising tools, moral support—already exists for those who wish to begin, but building project groups from scratch in other places leads to trouble with unwieldy logistics and heavy bureaucracy. But despite it all, they follow through with the Challenge. Seeing that, Marina says, is when she is most impressed.

So, are you thinking of signing up for the Challenge yet? If you are, you’ll be glad to hear that, along with a group of four fellow Yale freshmen, Marina is bringing the I Am Challenge to campus. The group includes Luis Schachner, Marina’s suitemate Nancy Xia, fellow international student Christian Rhally, and Monica Hannush, who met Marina immediately after her talk to learn how to get involved. The group is still deciding which cause they’ll adopt; one option they’re considering is fundraising for and volunteering with local tutoring programs. Marina stresses that they are open to suggestions from anyone for projects to support.

Marina is certain that even after she’s done wearing the t-shirt, the Challenge will still be part of her life—especially since she’s dating Dan. Service was a big part of her life before the Challenge and will be after it. She may even be starting an initiative of her own next year. Her studies at Yale have given her new ways of thinking about her work: last semester, Gateway to Global Affairs prodded her to examine the role of women in international activism. As for a major, she’s thinking Psychology or Political Science, or both.

Before concluding our interview, I ask Marina why her t-shirt says “I Am Maru” instead of “I Am Marina.” She explains that in Argentina, everyone goes by nicknames—if her mom calls her Marina, she probably hasn’t done her laundry. The “I Am” t-shirt allows one to present herself as she wants to be perceived, and Marina has always thought of herself as “Maru”—she’s still getting used to being called Marina in college. As the interview wraps up, another function of the shirt comes to mind—it’s a surefire way to bring about meaningful conversations with strangers and reporters alike.

Ifeanyu Awachie ’14 is in Timothy Dwight college. Contact her at ifeanyu.awachie@yale.edu.

On the eve of antigovernment protests scheduled for February 4^th in St. Petersburg, political activist Philip Kostenko was beaten on his way to work. While the evidence remains unclear, Human Rights First has held the police responsible for the attack.

The episode exemplifies how law enforcement and prosecutorial officials have exploited anti-extremism legislation to target nonviolent government critics, including journalists, independent media, human rights organizations, and artists. Kostenko is also an affiliate of the radical street-art collective Voina, which has been prosecuted in the past for its protest art.

One of Russia’s most high profile artistic protest groups, Voina most recently acted earlier in the protests. On December 31, the artists broke into a police station, placed Molotov cocktails near the tires of a police vehicle, and set it on fire, as recorded in their released video. The destruction of the tank-like vehicle, which had been used to transport prisoners, was their proclaimed “gift to all political prisoners in Russia.” The official police statement denied Voina’s involvement in the fire, saying the source was unknown and damage minimal.

A Voina activist dresses up as a cop for a protest in Voina's basement hideout. (Fred S./Flickr Creative Commons)

Voina, meaning “war” in Russian, has long stood as the symbol of the avant-garde and for the artistic resistance against Prime Minister Vladimir Putin. The group supports anarchy, renounces money, and ignores law. Founded in 2005 by Moscow philosophy student Oleg Vorotnikov (“Vor”) and his wife Natalia Sokol (“Kozlyenok”), the group has branches in most major Russian cities and supports a network of international activist artists such as Chinese dissident Ai Weiwei and those of Occupy Wall Street.

Political figures were the main targets of their earlier works. In one of their first public works, five members, including a pregnant woman four days from giving birth, had public sex in Moscow’s Timirayzev State Museum of Biology. The performance, called “Fuck for the heir Medved`s little Bear!”, protested the 2008 election of President Medvedev. Their other 2008 work, “In Memory of the Decemberists – A Present to Yuri Luzhkov,” staged a hanging of two homosexual men and three Central Asian guest workers. The work reflected the alleged homophobia and racism of Yuri Luzhkov, the mayor of Moscow by drawing inspiration from the libertarian Decembrists, who protested against the czar over 200 years ago.

Their recent art has attacked corruption of the cops. In 2010, they spray painted a 250-foot tall penis on a St. Petersburg bridge. The looming phallus, which pointed at the F.S.B., the state security service, represented the “unconquerable Russian phallus.” Their next project, “Palace Revolution,” involved flipping over parked police cars in protest of police corruption. The alleged hooliganism of their leaders led to their arrests, from which they were release on bail only last spring with the help of British street artist Banksy.

Is it art? Is there beauty in the way the flame consumed what Voina calls “a symbol of today’s repressions and human rights and freedoms”? When does activist art simply descend into vandalism or chaos? Unless the art begins to attack the apolitical, perhaps the answer depends on legally defined boundaries. But even that is questionable amidst rampant corruption.

When does revolutionary art lose its coherence? Look at the art’s fidelity to the broader ideology: Voina’s explicit artistic-intellectual goals mix tradition with radicalism in an unclear way. They want to resurrect the Romantic artist-intellectual hero who triumphs over evil, yet reject “outmodedness and provincialism,” or the deeply romantic cultural trope of the Russian peasant that represented a rich countryside folk tradition and defined a distinctly Eastern European Romanticism. They wish for an “innovative topical art language” that can accurately talk about the “new epoch” and has “no analogues in the past,” but also draw inspiration from the old Russian laughing culture of absurdity and sarcasm as well as the 1920’s futurists.

The Voina certainly names precise goals and sources of inspiration, but the most resonant common thread is the celebration of the visceral: the direct grittiness of the carnival-street, the aggressive innovation that cuts off the past, a “lively” art, and the activist artist. Above all, they exalt an ideology of spirit. Whether a mere attitude can qualify as the basis of a coherent ideology can be questioned, but there’s something to be said about the way such radicalism can jolt the public into thought or action. “If an activist secretly burns a cop truck at night, it won’t be art. It will be the revenge of an activist,” Voina representative Plutser-Sarno wrote to online publication ARTINFO. “But to burn it openly and proclaim to the entire country: ‘I am an artist. I burned down your prison, symbol of totalitarianism. This autodafe is our art action,’ then it becomes a piece of art. We made people discuss it as an artistic action.”

Sarah Swong ’15 is in Pierson College. She is a Globalist Notebook beat blogger on topics of international art and politics. Contact her at sarah.swong@yale.edu.

(Courtesy Bart Nagel)

Q: Would you mind briefly describing the work you do as a “virus hunter?”

A: My job and the mission of my organization is to decrease the global risks associated with threats from microbes of any sort. A lot of the story of these microbial threats has to do with our relationship and contact with animals, so we’re very interested in the contact between human and animal species and understanding how microbes flow into the human population. Q: Do you think that viruses that  originated in animals are becoming more significant to human diseases, like Avian Flu and Swine Flu, for example?

Q: Do you think that viruses that originated in animals are becoming more significant to human diseases, like Avian Flu and Swine Flu, for example?

A: If you think about “new viruses” in humans, there are only really two ways that you can get something because [viruses] are changing all the time, but they’re not continuing to come into existence. The only two ways you can get it are (1) that it’s been in your ancestors for some time or (2) that it comes from another species. Things that are in little pockets of humans can then emerge more broadly, but basically the entire story has to do with animals. But it has always been the case that it’s been about animal viruses. What’s really changed is the global interconnectivity of human populations. A virus that crosses into humans, that fifty or a hundred years ago would have had a really good chance of either dying out or just staying put locally, now has a global stage on which to do its thing.

HIV is a great example. HIV is a virus that’s been in chimpanzee populations for at least some hundreds of thousands of years. And humans have been hunting chimpanzees for the entire duration of that  period. So you have to imagine that the particular chimpanzee virus that jumped from a chimp to a human in the early 20th century, and then in the last part of the 20th century spread around the world to be the HIV/AIDS pandemic, was not the first one of these chimpanzee viruses to jump into humans. But one of the major factors in the late 20th century was that instead of the virus just basically burning  itself out in a little village in rural Central Africa, we had a situation where the world was completely interconnected.

Q: How do you explain your research to local hunters and other community members who might not have the same level of science background?

A: Even in places where there’s a large percentage of individuals who have no more than a primary level of education, these folks understand much more about the forest that they work in and the animals that they work with than we ever will as visitors. When we say things like, “some of these animals are going to be ill and there’s the potential that humans can contract the illnesses from the animals, and sometimes those illnesses can spread,” it’s a very intuitive thing for a lot of people that we work with. For us it’s very much a collaborative exercise. Many of the people in these communities [even] assist us in collecting specimens.

Q: How do you see the link between opportunities for disease control and economic and human development in these regions?

A: One of the things you find when you go to these villages is that most people want to be on the grid. Their first desires are for better roads so they have easier contact with economic opportunities and infrastructure. And so there’s a tremendous, and you have to assume very rational, desire to be a part of the interconnected planet.

From my perspective, one of the challenges is that these roads provide avenues for transmission and movement of diseases both from these rural biodiverse areas to the rest of the world, but also from the rest of the world to these rural communities. But the connectivity also provides us with the opportunity to understand what’s going on in these communities and to improve health infrastructure and early detection. It’s also very important that we get together and really take seriously the problems of poverty in rural regions because in some ways there’s a very clear poverty link.

Rachel Brown ’15 is in Saybrook College. Contact her at rachel.brown@yale.edu.

Salud Alarcon, 15 years old with brunette ringlets framing her grinning face, has written her favorite saying onto the first page of every fresh notebook she purchased for school: “No hay mal que dure cien años.” There is no evil that lasts 100 years. There is nothing one can’t endure.

For Salud, whose mundane high school routine in Antigua, Guatemala presents her few real stressors, this saying reminds her that she is lucky. She entered the world on a humid evening in February, barely surviving a fight against her mother’s umbilical cord, which had wrapped around her, trapping her inside her mother’s uterus.

Two Guatemalan rural midwives take a break from their assessment. NGOs test the women on their delivery procedures to determine which technologies and methods to implement. (Courtesy Marcin Szczepansk)

A woman’s first labor lasts, on average, eight hours. Salud’s mother was in labor for over twenty painful hours before hemorrhaging to death after Salud was finally extracted. The birth attendant left the house with few things to say. Salud’s father prepared a low-key funeral. Two years later, he remarried.

Of the 500,000 women’s deaths each year from complications that arise during childbirth, 99 percent occur in developing countries, where a woman’s lifetime risk of dying from pregnancy and related complications is almost 40 times greater than that of her counterparts in developed countries. A woman’s risk of dying in childbirth in the United States is one in 3,700 whereas in Latin America the risk is one in 130. In Guatemala, with its 13 million residents, a population that doubles about every 22 years, promising natural resources and mounting tourism, the maternal mortality statistics are more than sobering—they are unacceptable.

With the second most skewed income distribution in the Western hemisphere, Guatemala is split, geographically and culturally, between the rural indigenous people of Mayan descent who carve their villages in the highlands, and the urbanized Ladino population. As estimated by Hurtado and Saenz de Tejada, the Ministry of Public Health and Social Assistance in Guatemala, there are 248 deaths out of every 100,000 live births. Maternal mortality among indigenous Mayan women in certain rural areas, however, may be as high as 446 in 100,000. These statistics make pregnancy in Guatemala more dangerous than pregnancy in any other Latin American country.

The causes of maternal mortality in Guatemala, the most common of which are postpartum hemorrhage, puerperal sepsis (a bacterial infection of the blood), or eclampsia (unmitigated seizures) are all attributable to abnormally prolonged labor that is quickly detected by trained obstetricians. But the majority of rural Guatemalans who speak indigenous languages and practice centuries-old home remedies will never set foot in a hospital. Not surprisingly, the health of indigenous Guatemalan mothers and children is dramatically poorer than that of the Ladino population. Rural women will only trust their local midwives at their bedsides.

Traditional midwives attend 80 percent of home and in-clinic births in Guatemala and virtually 100 percent of births in rural areas, where drug-less, tool-less home birthing is the only option. Unfortunately, there are only 20 trained midwives for every 10,000 Guatemalans. But Western medical training might not yield lower mortality rates: Several field studies suggest that many obstetrical routines have cultural rather than medical determinants. In the mid1990s, an independent researcher hired by the World Health Organization to survey routine obstetrical practice around the world concluded that only 10 percent of all routine obstetrical procedures were scientifically based. The evidence points to childbirth as a largely cultural or spiritual event in a woman’s life.

A rural woman in labor is examined by an American doctor. If she needs a C-section, she will need to be transported two hours to the nearest hospital. Rural midwives don’t have the equipment or training to perform safe C-Sections. (Courtesy Marcin Szczepansk)

“[Some] rural midwives bring relics to the bedside,” said Dr. Jean Albright, the director of a global health project at the University of Michigan designed to expose medical students to the ethnic, religious, and linguistic barriers to equalizing rural health care access in the Guatemalan highlands. “Some of the traditional communities in the highlands don’t have what we refer to as ‘biomedical beliefs.’ They simply don’t get the point of hospitals or physicians.”

Albright had to send her first batch of student health workers back to Ann Arbor so she could spend a year calibrating the program to better suit these ethnic divides. Understanding midwifery, traditional or otherwise, precedes any attempts to build hospitals or wrestle with a corrupt and Ladino-dominated national health care bureaucracy.

A targeted global health intervention will wisely select the most instrumental player in the rural childbirth gamble, the comadrona, the traditional midwife, as the locus of progress. But do researchers and global health workers force midwives to speak their jargon of elapsed seconds, bacterial this or that, pre- or ante-natal precautions, or do they try to make room in their proposed professional and results-based interventions for the fact that childbirth is spiritual before it is medical?

Jennifer Houston, a practicing midwife in both Antigua, Guatemala and Catskill, New York, believes in the latter.

“Traditional midwives have knowledge and skills that are unique and different from the biomedical or ‘technocratic’ model,” she argues. “The unique gifts that traditional midwifery has to offer, unexposed to biomedicine, is a profound trust and belief in the sacredness of birth and women’s power.”

Nearly 15 years ago, Houston founded Ixmucane, a birthing center disguised as a quaint colonial house in the narrow streets of Antigua. The center hosted several foreign nurses each year who paid nominal fees to a local comadrona for several months worth of home cooking and for cot space. Upon arrival, the foreign nurses would shadow their midwife hosts for several weeks under a program called Midwives for Midwives. Houston, whose birthing center was forced to close after the national government dropped its promised funding, emphasizes the need to respect the sanctity of childbirth.

Midwives for Midwives still facilitates home stays, and while visiting nurses must submit reports about tools and educational methods they believe would best work in fighting prolonged labor in rural contexts, there is little mention of offering professional instruction—no “graduation” or approval system for a midwife’s skills— only culturally adapted suggestions for preventing life or death situations.

“We’re working to reverse the global trend of devaluing traditional systems, and to prevent the natural process of birth from becoming a total medical and technological procedure done to women,” said Houston resolutely. Her tone, authoritative and fearless, suits a woman who delivered all of her own children at home with only herbal medications.

Pregnant women in developed countries often enter labor under the much-appreciated spell of an epidural. Whether at the preventative stage, through the use of contraceptives, family planning, shopping for an ob-gyn, or during delivery itself, being able to choose drugs or agree to Caesarean sections, women have choices. But in countries like Guatamala, where the perspective insisting that women exist to deliver is still prevalent, birth, as Houston argues, is done to women.

By allowing rural midwives to host educated, foreign nurses, and by making room for their ritualistic or “unscientific” birthing methods, exchange programs like Midwives for Midwives aim to empower midwives by letting them know that their jobs are valued. Even if biomedical childbirth  with its blood pressure cuffs and cervix dilation readings remains a foreign concept in the Guatemalan highlands, midwives learn that their art demands skills—skills to be shared and developed—and that they possess a gift rare among women in their rural communities: an education.

But according to Daniela Adabi, exchange and cultural accommodation is not enough. Abadi’s missions as a midwife with Doctors Without Borders have taken her to Cambodia, Thailand, Nicaragua, and, most recently, back to her home in the lush valleys surrounding Lake Atitlan in southwest Guatemala. It’s there that she plans to launch a professional midwife training center. Abadi, a French-educated Argentinian, speaks slowly about her experiences with maternal mortality, enunciating her syllables above the rapid metronome of raindrops on her corrugated metal roof.

“The responses from the local women have been good. Most of them accept the idea that things need to be improved,” explains Abadi, whose proposed project will recruit graduating high school senior girls and offer them professional obstetric training, the kind dispensed to home birth attendants in the United States. Abadi’s model replaces home stays with on-site instruction, and will collaborate with local universities to provide some sort of initial certifications for its first graduates.

“This will be a model where you don’t just impose on the women where to give birth, how to give birth but also [provide] workshops, classes around nutrition, around child care.” Abadi, unlike Albright or Houston, is a local. Health workers dream of places like Lake Atitlan, with its lush climate punctuated by the occasional intense rains and its hushed Mayan tradition tucked into all hours of the day, but Abadi knows the local school systems, some of the local midwives, and has faith that her proposed model has calibrated itself to fit the culture.

For the few women who complete their high school education in the Atitlan highlands, there are few skills-based jobs. The only other alternative in the health professions is assistant nursing, which tends to be less appealing than marrying young and rearing children. And while Abadi concedes that “there [will be] a lot of challenges” to her model, the biggest challenge will be to have trained midwives recognized by the community they serve and by the national health system. But by reinforcing technical education and offering a program that a midwife can say she graduated from, women can find confidence in their skills and status. And the introduction of professional midwives could be empowering in new ways, too.

“[Women] choose the traditional birth attendant because that is all they know. That’s the tradition. But if you have trained professionals, women can ask for what they really want and what they really need … not just feel like they have to say ‘yes’ to anybody.”

Childbirth is spiritual and empowering. But it sometimes involves no choice for the women involved. Childbirth is, for many women, a celebration, a milestone. But childbirth can be deadly.

In Xelaju, Salud Alarcon is studying to become a doctor. She regularly complains about her homework and often procrastinates by playing soccer at the gimnasio downtown. Her urban upbringing affords her the opportunity to study in school and pursue higher education. It even has her considering an unlikely path to medicine.

“Maths is so hard,” she mumbled. “But it will be worth it. I want to make people feel good.”

Over the years, Salud’s voice has developed an undeniably warm, maternal timbre. Despite harboring the usual teenage anxieties about boys and fashion, she speaks to her younger step-siblings and shares her career dreams with a mature inflection. One day, she will live up to her name and might even, as a physician, help propagate what it represents. “Salud” in Spanish, after all, translates to “health.”

For women in the rural highlands, the legitimization of existing female roles, as midwives and valued homemakers, is the closest thing to female professional development. Whether the process will involve ritual exchange or diploma exchange is unclear. But a woman’s agency rests at the center of every movement to fight maternal mortality. These movements offer the promise of education, of cultural understanding, and of advanced medical methodologies. Above all else, they offer women the ability to choose health in the face of tradition.

Cathy Huang ’14 is in Morse College. Contact her at cathy.huang@yale.edu.

The pungent scent of cinnamon lingered on my clothing for days after I left the dense forest of northeastern Brazil’s National Park, Chapada Diamantina. I can remember waking up as the sun began to rise and falling asleep to the nightly rain. The air in the chapada was purer than it was in Bahia’s capital, Salvador, and the people spoke more softly and with less urgency than big city folk. Everything in the chapada hummed with life, but a quieter, more peaceful life than the hustle and bustle of Brazil’s biggest cities.

People from all over South America flock to the Chapada Diamantina to experience the mystical powers the jungle has over its visitors and residents. Many come for the hikes or the chance to escape into the wild, but all are struck by the sense of rejuvenation that comes from living in a sustainable community with roots in holistic healing. The communities of the chapada pride themselves in supporting a philosophy and way of life that attends to the health of not only the body, but also of the mind and spirit.

When I arrived, I was surprised by the unwavering faith these people placed in holistic medicine—so different from my modern lifestyle. Herbal tea and salves were valued above fast-acting pills, and a combination of yoga and meditation was believed to fight off future diseases like cancer. It sounded absurd. I wanted to understand, but I also wanted to make them understand how unlikely it was that a meager cup of nine-herb tea was going to cure the hideous cough that was plaguing me. As a foreigner unversed in the subtleties of local language and culture, though, it seemed safest to be still and listen.

Seu Santinho conducts an earwax removal used to prevent infection and to improve hearing. (Cruzzavala/ TYG)

For just over a week, I spent my days working in Horto Vale Flora, the community garden. There, nestled in the park alongside other students, biologists, nomads, and the local medicine man, I met some of the people responsible for the preservation of the community’s holistic healing practices.

Emiliano Evangelista Neto, or Seu Santinho as he is fondly called, is a stocky man with leathery hands, slurred speech, and the ability to identify nearly every plant in the national park. Born in Conceição dos Gatos in 1955, Seu Santinho inherited the duty of medicine man from his father, and for over 30 years has worked with medicinal plants native to Chapada Diamantina. With his volunteers, Seu Santinho maintains an expansive medicinal garden teeming with plants that do everything from soothing a sore throat to exhibiting antiviral properties. When he is not assisting local midwives with births and postnatal care, Seu Santinho collects plants to make his famous nine-herb tea, which he freely distributes to anyone experiencing flu-like symptoms. It was this very tea that became the topic of many of our conversations over dinner: He was eager to have me try his method before turning towards the nearest box of antibiotics. I was hesitant, but there was no harm in trying, and his esteem in the community certainly didn’t hurt.

Along with this attention to physical health, Seu Santinho and the other residents of the Chapada Diamantina dedicate just as much time to the betterment of the mind and spirit. To complement the tea that was supposedly healing me, I was encouraged to meditate once a day and to devote my mornings to the community garden. As Reuben, a Bolivian nomad who works alongside Seu Santinho, told me, “You must be willing to walk into nature knowing that every living creature or plant can teach you something new about the world. When you listen and learn, your mind is healing… and your spirit thanks you when you find connection with nature. These are the things that will cure the world.”

Perhaps the philosophies behind holistic medicine are outdated or lack sufficient scientific support to hold true in today’s culture of fast-acting pills and treatments. But in a society discredited by modern medical standards, it is a discovery to find a group of people who are healthy, strong, focused, and connected to the natural world around them. I found myself feeling calmer, more energized, and even happier after only a few days in the chapada. And by the time I left, my month-long cough had miraculously subsided.

Alexis Cruzzavala ’13 is an Anthropology major in Davenport College. Contact her at alexis.cruzzavala@yale.edu.

It was barely 8:00 in the morning on Saturday, Oct. 30, 2010. I stood in line with a group of other Yale and Harvard students for President Obama’s afternoon speech in Bridgeport, Connecticut. Before proceeding through the wall of metal detectors and into the stadium, we stuffed banners into our pants  and jammed signs and chant lyrics into our jackets, wallets, shoes, and anywhere else we could hide them.

Following several speeches by Representative Himes, Senator Blumenthal, and a host of other politicians, Obama took the stage, galvanizing an energy and applause which thundered throughout the arena. In two separate groups on either side of the stage, we slowly unfurled the banners beneath our feet, stood up, and began shouting, “Broken promises kill, fund global AIDS. Broken promises kill, fund global AIDS.”

“Excuse me! Excuse me, young people!” the president responded. “We’re funding global AIDS, and the other side is not. So I don’t know why you think this is a useful strategy to take.”

“You promised more! Fifty billion.” We shot back in perfect unison, anticipating his evasion, drawing attention back to the promises he had made in 2008.

After several more minutes of back and forth with the president, we were spat on, kicked, and shoved. The signs were ripped from our hands as we were escorted out by security.

The decision to protest the president was not an easy one. Most of us were and continue to be staunch Obama supporters and cringed at the thought of harming his public image. But after fierce debates andcareful calculation, we found ourselves protesting the administration’s waning health equity to new heights.

In a twist of fate, merely two weeks later, the architect of Obama’s global health policy, Dr. Ezekiel Emanuel, paid a visit to Yale for a guest lecture on global health ethics. At the heart of Emanuel’s plan for Obama’s global health policy lay the belief that AIDS occupies too much of our national attention and budget. He emphasized that there are a host of other ailments and concerns, such as childhood respiratory and diarrheal diseases, which affect more lives in the developing world and can be treated more cheaply than fighting HIV/AIDS. Over the course of the day, I met face to face with Emanuel, along with Jared Augenstein and Nick DeVito, two students at the Yale School of Public Health and co-founders of the Student Global Health and AIDS Coalition on campus.

Over breakfast, Emanuel shared a few nasty words about AIDS activists, including many whom I had worked with or befriended over the preceding months. He chastised me for joining an outdated  movement that had selfishly hijacked U.S. global health policy.

“It’s always AIDS, AIDS, AIDS. Why do you guys all waste your time yelling at me about my AIDS funding? Why aren’t you out there fighting for maternal and child health and neglected diseases?”

His brow furrowed in contempt as he embarked on a verbal tirade mocking my criticisms of his policy agenda. He scoffed at my accusations in a self-confident and smug tone well-known throughout Washington.

The truth was, I was immensely uncomfortable with Emanuel’s accusations. I still fundamentally disagreed with his claims that AIDS treatment was too expensive and cost-ineffective, but I, too, began to wonder why AIDS activists weren’t doing more for other diseases. The AIDS movement had become so prominent in the United States largely because the disease affected Americans on a scale that  malaria, tuberculosis, and other infectious diseases simply do not. As part of the new generation of AIDS activists divorced from any personal history of HIV, why wasn’t I doing more for global health equity  broadly?

Even within the AIDS activism movement, there was considerable divergence. In conference calls with AIDS activists around the country, meetings in D.C., and mass list-serve emails, we, the new, younger generation, often struggle with the title “AIDS activists.” We come from a different world than the older generation of activists, who fought for their own lives and the lives of their loved ones as HIV/AIDS tore through the nation in the ‘80s and ‘90s. The vast majority of us have never truly known HIV. We were barely infants at a time when the epidemic was sweeping violently through this country, a dismal era when HIV was a death sentence and entire communities—homosexuals, African Americans, drug users, and others—were being decimated. Our generation, having learned about global health largely through travelling and working in the developing world, is less HIV focused and more interested in the broad issue of global health.

This past summer I found myself replaying my debate with Emanuel in my head. I was in the U.S. embassy in Maseru, Lesotho, on a short vacation after two and half months working on a Zulu youth empowerment project in South Africa. During the trip, I had the opportunity to meet with the President’s Emergency Plan for AIDS Relief (PEPFAR) and Center for Disease Control (CDC) teams in

Lesotho that coordinate the United States’ AIDS treatment and prevention programming in the country. As we sat down in the board room, the first thing they began telling me about was a new “mother-baby pack,” a kit of maternal and child services for pregnant women in remote Lesotho who have no access to any obstetric or post-natal care. The pack, they explained, allowed community health workers to provide comprehensive pre- and post-natal care in the women’s homes, offering a wide range of both diagnostics and treatments for these women.

“And who pays for these?” I asked, confused as to why a PEPFAR official, rather than a maternal and child health expert, was proudly showing this kit to me.

“PEPFAR does!” she shot back, equally confused about why I was asking such an obvious question.

As it turns out, among the cohort of tests and diagnostic tools included in the mother and child kit is a rapid HIV test. This HIV test was enough, the PEPFAR official explained, for PEPFAR to cover the entire cost of the kit and visit to the woman. An AIDS relief program was shouldering the entire cost of what was at most 10 percent HIV/AIDS and 90 percent maternal and child health.

The real question, however, was: Why was PEPFAR, an AIDS program, funding the mother-baby pack in the first place? Why is there no President’s Emergency Plan for Maternal Health Relief?

For years, ever since President Bush announced PEPFAR in his 2003 State of the Union Address, the U.S. government has been captivated by the narrative that AIDS funding is a vital part of American foreign policy, a crucial program not only for humanitarian reasons but also for national security. As the narrative went, AIDS was decimating a generation of young adults in Africa, many of them in the prime of their lives, and it was leaving a vacuum of social unrest in its wake which terrorism was primed to fill. If nothing was done to stop AIDS, millions of children would be left without parents or stable economies; governments would deteriorate, and organizations like al-Qaeda would capitalize on the social unrest to recruit from the dregs of a desperate African population.

This argument still reigns today. Last December I found myself face to face with Senator Pat Toomey’s (R-PA) national security advisor, a man of military background. I entered the meeting with apprehension, convinced that my calls for global health funding—40 cents for a day of antiretrovirals and pennies for neglected tropical disease treatment—would be trounced by $150 million fighter jets and over $3 billion in monthly spending in Afghanistan. I sat down and began my well-rehearsed AIDS lobbyist script, calling on Senator Toomey to promote the extremely bipartisan cause of PEPFAR for its public health, humanitarian, and national security benefits.

Before I could continue, his national security advisor interrupted, “You know, people just don’t realize that this PEPFAR is so important for our national security. Without it, AIDS is gonna leave a vacuum  which the terrorists are gonna fill.”

Just months prior, at the Wild Irish Breakfast in New Hampshire, I had a remarkably similar conversation with Newt Gingrich while calling on him to include strong AIDS policy in his presidential campaign platform.

“People just don’t realize that fighting AIDS is important for our national security,” Gingrich lectured me. “I actually have a call tomorrow morning with Bono to discuss just this point.” Friends, others from the Yale Global Health and AIDS Coalition, and fellow global health political activists at colleges across the country have reported similar comments from senior Republican Congressmen, Mitt Romney, Rick Santorum, and others.

David Carel ’13 is an Economics major in Pierson College. Contact him at david.carel@yale.edu.

A chest X-ray hangs in Mr.  Mkoko’s door. The cavity in the upper left corner confirms what his constantcoughing already indicated: He has contracted tuberculosis.

Mineworkers in South Africa, used to frequent terminations due to occupational lung disease, colloquially say that their coworkers have been “sent home to die.”  Though Mkoko was personally unsuccessful in fighting through the tangled web of legal statutes to obtain care or compensation, those who succeed him may have more luck.

An X-ray of a lung infected with tuberculosis. (Courtesy Jonathan Smith)

South African miners are in a particularly fatal position because they are exposed to both some of the highest concentrations of silica dust and highest rates of HIV in the world. “Gold mining in otherparts of the world does not have this problem,” said Jonathan Smith, a professor at the Yale School of Public Health. “It’s not like it is in Peru, where mining is something more akin to industrialized panning for gold. Ore in South Africa is surrounded by silica dust.”

Immune cells in the lungs are predisposed to attack silica dust particles in the same way that they would react to true viral vectors. So the immune system becomes paralyzed in the battle to engulf a ceaseless supply of new silica particles. Continued exposure to silica dust eventually scars the lung tissue and results in silicosis, a permanent condition that cannot be treated. Given the rates of HIV in South Africa, particularly among miners, the combination of these two immunodeficiency disorders increases the risk of contracting tuberculosis by about 15 times.

It is no surprise, then, that tuberculosis prevalence among South African gold miners is the highest among any demographic population in the world, and 28 times the level of declared emergency by the World Health Organization.

But these facts and figures have been known for years. Not only do effective methods of controlling silica dust exist, but the world has also had an affordable cure for tuberculosis for half a century now. Ultimately, complexities of South African law, coupled with the legal power of mining conglomerates, have been the biggest obstacles to resolving this epidemic.

”Be prepared for a mess,” Smith warned as he began a discussion of why mining companies are able to flaunt existing compensation laws. The mining companies’ legal power has stymied governmental attempts to improve safety conditions. A 2008 government audit of the mining industry stated that the list of safety violations committed by mines “goes on and on.”

The first major legal obstacle is that the mining industry operates under a complex third party labor contract system. Third-party agencies, not the mining conglomerates themselves, go into remote villages and recruit men to work. “As such, the miners can’t sue the contracting companies because they are simply an intermediary,” said Smith. “The contracting company didn’t expose them to high levels of dust or disease, the mining company did.  There is no legal claim there.”

This loophole aside, South African law also contains two conflicting compensatory schemes for occupational lung diseases.  The first, the Occupational Diseases in Mines and Works Act (ODIMWA), was enacted in 1973 and provides disabled miners with a small lump sum. “But the bottom line is that the compensation payable under ODIMWA is particularly low, around R16,000 [or $2,062]” said mining law expert Warren Beech of the South African firm Webber Wentzel. The second scheme, enacted in 1993, is the Compensation for Occupational Injuries and Diseases Act (COIDA). Under COIDA, employees receive monthly compensation in exchange for signing away their right to sue employers.  Payments are determined on a sliding scale based on disability level, similar to American Social Security Disability payments.

”Keep in mind, though, no one gets this compensation anyway,” said Smith.

A Deloitte audit of the mining industry found that only 400 out of 28,000 miners who filed ODIMWA claims in an 18-month period were granted awards. When they sign their contracts with the mining company, miners essentially give up their right to sue, Smith explained. Thus, former miners like Thembekile Mankayi are considered lucky if they can even get an ODIMWA award.

In March 2011, Mankayi’s groundbreaking case against AngloGold Ashanti was brought to the South African Constitutional Court, after the High Court rejected his right to appeal. “For the first time, a miner was asserting that he was entitled to damages outside of the four corners of the ODIMWA act, [that] he was not precluded from a common law claim because of COIDA,” said Bonita Meyersfeld, associate professor of law at the University of Witwatersrand, Johannesburg.

Mankayi’s case, which held that his occupational lung disease was a result of his exposure to harmful dusts and gases, was effectively a test of COIDA’s section 35(1).  Though he died two days before he could see the Constitutional Court rule in favor of his case, the judgment “opened the door for claims against employers on a civil basis even in the case of coverage by ODIMWA,” according to Beech. Given the 300 to 500,000 former mineworkers who suffer from occupational lung diseases, mining companies would stand to lose a substantial sum if more cases are successfully brought to court. Collectively, these settlements would be worth up to R700 million (about $85 million), according to Beech.

Though the Mankayi case cements the legal right for miners to bring civil claims against mining corporations, it may yet be unrealistic to expect a tide of change.

”Again, you have the implementation problem. It is great in terms of an abstract right, but in terms of bringing actual justice, it’s going to be easier said than done,” said Gregg Gonsalves, former program coordinator for the Aids and Rights Alliance for South Africa’s tuberculosis campaign. Civil cases in the High Court typically last four to five years, involving litigation costs far out of reach of individual miners’ ability to pay. Since most of South Africa’s constitutional litigation is done through NGOs, progress in litigation really depends on whether NGOs are willing to recognize the potential in these mining cases.

Early indications of interest are encouraging. Sayi Nindi, a lawyer working with the nonprofit Legal Resources Center, currently has funding from Legal Aid South Africa to proceed with litigation in the Blom et al v. Anglo American group claim. The scope of the Blom case is even more ambitious than Mankayi’s, aiming to hold mining conglomerates like Anglo American responsible for the dangerous safety conditions and silica levels in their mines. If successful, the decision will hopefully arrive by the end of this year, Nindi believes that mining companies will be forced to form a compensation scheme that can be applied to the all the affected ex-miners.

Even considering all the recent legal progress, it is possible that the exasperating impunity under which mining companies operate may continue. Nindi points out a central difficulty of her own litigation: “On paper, everything seems fine. AngloAmerican reports that the silica dust levels in their mines adhere to the legally required maximum. But if that were true, every year we wouldn’t have thousands of miners being diagnosed with silicosis and dying.”

Indeed, big mining companies like AngloAmerican are also quick to call attention to the fact that they have programs to give workers access to medical treatment and drugs. But Gonsalves makes it clear that these programs make little practical difference. “First off, no one notices that many of the smaller mines don’t have these programs. And miners only get six months of treatment. They also have to get sick while they’re on the job in order to get the treatment—an issue if the disease contracted is silicosis, which is permanently incurable and only later leads to life-threatening tuberculosis.”

The Mankayi and Blum cases undoubtedly comprise an important first step towards forcing mining companies to be accountable for their role in the silicosis-tuberculosis epidemic. Laws in South Africa that mandate mines to provide basic safety equipment and limit the level of silica dust already exist. Perhaps, faced with evidence that occupational lung diseases are developed as a direct result of work-related conditions, the closing of the COIDAODIMWA loophole, and the possibility of paying group claims worth millions of dollars, mining companies may finally have the incentive to comply with these laws.

Ashley Wu ’15 is in Morse College. Contact her at ashley.wu@yale.edu.