Walk together, talk together
O ye people of the earth,
Then and only then
Shall ye have peace. --Sanskrit proverb

John Shepherd, M.D., a family physician from Colorado, U.S., spent part of 2003 in Tobanda Camp in eastern Sierra Leone working in a Liberian refugee camp.

When I returned from Sierra Leone in mid-2003, I expected to fill a notebook with comments on the differences and stark contrasts between West Africa and the United States. But after trying to provide primary health care in Sierra Leone to Liberian refugees fleeing an unimaginably cruel civil war -- a continuation of the mayhem that infested Sierra Leone for a decade -- I found innumerable similarities. Admittedly, our technologically burdened American society does not lack dialysis machines or advanced radiologic equipment and chickens don't patrol our examination rooms for insects nor does wood dust fall from the termites feeding on the wooden poles supporting the roof on the tables and chairs. On a daily basis parents in the U.S., unlike those in Sierra Leone, don't carry their children into a clinic on their backs or in a wheelbarrow to die of cerebral malaria, herbal poisonings, malnutrition, or Lassa fever. The American expected life span of 78 years, exceeds the 38 years of Sierra Leone, fewer than 18 out of every 100 women expire during childbirth in the U.S., and in most populations in the U.S. more than 20 percent of children live beyond five years of age.

Yet I recognize the shoeless man dressed in torn tee shirt and rope-belted frayed pants, because he walked into the homeless clinic in Denver where I have worked. Some people seek care only when they can no longer tolerate the pain, while others whimper and exaggerate the slightest ill -- a range from unbelievable restraint to quaking fragility. Adolescent boys with diabetes skip meals in defiance of authority and don't come for medication even though the insulin has added an additional five kilograms of weight to strengthen their sparse frames and increased their energy. Some people ask for too much and some refuse to demand enough. All seek enough uncontaminated water, protection from the weather, adequate food, and freedom from fear. Individual diversity melds into the same spectrum of behavior.

Neither country has an organized national health care system that would treat every citizen with the same dignity and quality of care. The Minister of Health in Sierra Leone cares as little for the individual as the insurance company executive in the U.S. People are denied health care because they lack the fee of 5000 Leones (less than $2.10) or because they have no insurance. Complacency and Neglect in the U.S. and Europe ignore the annual death of 11 million children from diarrhea, malaria, and measles. The World Health Organization estimates that $7.5 billion would eliminate malaria which kills a child every 30 seconds. The U.S. expects to spend over ten times that amount for the Iraq war and the U.S. and Western Europe spend $17 billion each year on pet food. Malaria kills more people every 2.5 hours and TB every three hours than the total mortality due to SARS, yet inequities in income distribution and power allow the latter to receive the press coverage.

Functionally, the U.S. legal administration ignores our Constitution just as the magistrates in Sierra Leone demand bribes for favorable rulings. Insidiously contradictory government behavior leads the U.S. to lecture the world about the need to prohibit the proliferation of weapons of mass destruction while seeking Congressional authority to develop nuclear tipped "bunker buster" missiles and leads West African governments to post billboards warning of AIDS, measles, and hemorrhagic fever without offering them condoms, vaccines, or vector control and mechanisms to protect food from rat urine.

The major U.S. political parties fail to cooperate enough to legislate policy needed to assist the poor, while non-governmental organizations have inadequate oversight to guarantee the delivery of goods to people seeking refuge from mutilation. Cultures of greed deter cooperation, and economic systems assure self-perpetuation leading to irresponsible attempts at humanitarianism or "philanthropic pretense" as author Joseph Conrad labeled it. Wealth lies concentrated under the control of a few privileged people, while "conflict minerals" (valuable minerals that are mined and sold) buy guns and not public health, schools, or food for the vast majority.

The same color as the Los Angeles sun falling through the exhaust fumes into the Pacific, the West African sun sets round and orange through the dry-season dust and the smoke of the jungle burning to open land to plant cassava. Unable to see beyond tomorrow or their own village or city, people tend to focus on themselves, their children, their clans and discriminate against outsiders or any foreign element. A perversion of reason provides a pretext for despising, humiliating, and oppressing others. Even survival requires a conquest of human spirit.

Unable to conceptualize beyond the chiefdom or county, poor planning and lack of sustainability dooms good intentions to ultimate insignificance. Antinomian criminals drag a man to death chained behind a truck in Texas, while West African rebels amputate the limb of a child with a machete. Animists, Muslims, Christians, Jews, Buddhists and atheists all live within meters of each other yet can't recognize the similarities of their beliefs.

The official language is English in both countries, yet many people know little or nothing of it and speak in numerous other languages. Refugees struggle to obtain 2100 kcal per day while obese westerners accustomed to consuming twice that amount strive for this goal. In the U.S., some children go without meals because poverty denies them and in Sierre Leone children go without meals because there is no food. Mothers cry or ululate over the death of their children.

Africa is not just an allegory, but a reality that metaphors can't capture.

One thought ever at the fore -
That the Divine Ship, the World, breasting Time and Space,
All People of the globe together
Sail, sail the same voyage, are bound to the same destination.
-- Walt Whitman(19th century American poet)