By Peggy McInerny
UCLA International Institute, February 2, 2017 – Dr. Ippolytos Kalofonos (ip•PAW'•li•tōs ka•LAW'•fa•nōs) joined UCLA in 2016 with a joint appointment to the UCLA International Institute and the Semel Institute for Neuroscience and Human Behavior. He will teach his first course in the Institute’s global health program in spring 2017: “Living with HIV/AIDS in Africa” (Gbl Hlt 191 17S).
Kalofonos didn’t set out to become a psychiatrist working in global public health. As a pre-med undergraduate at UC San Diego, he was studying biochemistry and working in a lab, but as he describes it, “I became interested in the broader issues relating to local, state-wide, national and global forms of inequality that were swirling around me.
“Affirmative action was repealed while I was a student and I participated in UCSD and UC-wide activism to advocate for continued attention to racial and economic disparities in California public education,” he says. “I began volunteering in a Red Cross emergency room in Tijuana on the weekends and was really struck by differences and similarities on either sides of the border.”
View of Tijuana, Mexico. Photo: Nadavspi_commonswiki/
Wikimedia Commons, 2004; cropped. CC BY-SA 1.0.
Finding a like-minded community
Kalofonos discovered anthropology when he heard a guest lecture by a medical anthropologist in an undergraduate seminar. “I was really excited by the idea of medicine as a social and cultural system, rather than as just a technical skill set,” he says. “It seemed to be a place where my interest in health, medicine and social context came together.
“I left the lecture and went straight to the store and got the book that the lecturer recommended, Melvin Konner's Becoming a Doctor,” he recounts. “Eventually, I changed my major to anthropology.” He also went on to do a study abroad program in southern Mexico, where he worked with traditional healers and was introduced to critical development studies.
The UCLA professor’s undergraduate thesis, which addressed how Proposition 187 affected the access of immigrant Latina women in California to prenatal health care, foreshadowed his interest in medical anthropology. The proposition prohibited the provision of non-emergency health care, education and other public services to undocumented immigrants in the state. “The thesis research got me really interested in political economy and health — how health is structured by forces beyond the realm of individual choice,” adds Kalofonos.
After finishing his undergraduate degree, he attended medical school at UC San Francisco. Initially, he was interested in infectious diseases and completed an MPH in epidemiology through a joint program with UC Berkeley. While at Berkeley, he met and got to know a number of MD students who were also pursuing PhDs in medical anthropology and realized, “These are my people — this is what I want to do.”
He first completed his medical school coursework and MPH, then did a PhD in medical anthropology. He then returned to med school to complete a year of clinical rotations and, finally, did a residency in psychiatry at the University of Washington in Seattle.
How a global health intervention can succeed and fail simultaneously
Kalofonos’ dissertation examined access to HIV treatment in Mozambique, following a cohort of patients who received anti-retroviral treatment just as a major treatment program was being launched in the country (and throughout southern Africa).
“I spent a lot of time following people through the process of making the decision to get tested, getting treatment and learning how their lives were changed,” he says. “I also spent a lot of time with community home-based health volunteers.”
His research yielded surprising results. The health of HIV-positive patients in the program improved, but they complained of an unusual side effect: overwhelming hunger – an effect his UCSF medical school professors had never encountered.
Kalofonos started by contextualizing the hunger of HIV patients: central Mozambique is extremely poor, with high rates of malnutrition and hunger. But as he contemplated the condition and discussed the issue with people further, he said, “They were saying that they were getting better — they were getting their health back — but they still lacked livelihoods.” His ethnographic research indeed showed that as people got better, rather than embarking on the classic quest for treatment taught in medical anthropology, they instead went on a quest to procure food and material sustenance.
“What really surprised — if not blindsided — me,” he comments, “was how people in Mozambique felt betrayed by the program. They were grateful for their medication, but they felt just getting pills was not enough.” To these patients, it made no sense that Western organizations would come halfway around the world to help them overcome HIV, only to let them die of hunger.
The biological focus of the treatment effort — getting drugs into bodies — was ultimately seen as falling short of the care many Mozambicans sought. This was articulated by the phrase he heard repeated from people receiving treatment for AIDS: “All I eat is ARVs.” He explains, “I understood this as a critique of an intervention that exacerbated hunger without adequately addressing it, even as it saved lives.
AIDS awareness street art in Machaze, Mozambique. Text in Ndau (left) and Portuguese (right):
“Think of the consequences, change behavior, prevent HIV/AIDS.” Photo: Ton Rulkens/
Wikimedia Commons, 2007; cropped. CC BY-SA 2.0.
“From the perspective of people being treated for AIDS in Mozambique, hunger infected and altered the therapeutic experience,” continues Kalofonos. “The hunger expressed both a painful embodied reality and a powerful moral metaphor for antisocial accumulation and inequality.” These dynamics, he explains, highlight the narrow scope of the vision of care of this global health intervention, a vision structured by ideas of scarcity and sustainability.
“I think there are a lot of lessons to be drawn from [the project],” reflects Kalofonos. “One is that it’s a mistake to go in with a narrow technical approach and think you are addressing a health problem by only providing technology and not [looking at] the bigger picture.”
But he cautions, “The AIDS epidemic is a social and political problem, not simply a biological problem. There is never a magic bullet. It’s really the process that’s important. There needs to be a reflective process where communities can respond to issues like these,” he remarks.
(All I Eat is ARVs: Surviving the AIDS Economy in Central Mozambique, the tentative title of the book based on his dissertation, will be published later this year by University of the California Press.)
From anthropological research to psychiatry
When Kalofonos returned to UCSF to complete his med school clinical rotations, he was drawn toward psychiatry. “Coming out of anthropology, where I spent a lot of time listening to people, paying careful attention to their language and their words, I found psychiatry had this obvious appeal that it hadn't had before,” he says.
As a psychiatrist, he remains interested in issues related to social determinants of health, the role of inequality in the distribution of illness and in the highly stigmatized chronic illnesses in underserved communities. While a UCLA Robert Woods Johnson Clinical Scholar, he worked on a project looking at how Latino patients experiencing symptoms of psychosis for the first time and their families understand and respond to those experiences.
He notes that some research indicates that people with severe mental illness often do better in some developing countries, where close family and community networks in subsistence economies ensure that the mentally ill perform a valued social role. By contrast, similarly ill people in more advanced, highly competitive capitalist economies with smaller family networks frequently do not function as well in their societies.
“There’s a lot we could learn from what’s happening in the developing world,” he comments, “and as much as we in the Global North can provide some important therapeutic approaches, we can also think about creative ways to bring out the relative strengths of the two approaches in both contexts.”
Pursuing diverse intellectual interests
After completing his fellowship, Kalofonos became a faculty member at both the Semel Institute and the UCLA International Institute in summer 2016. He currently oversees residents and medical students at the psychosis clinic and the homeless integrated care program (HPACT) in the Veterans Affairs hospital in Westwood. At Semel, he works with a cohort of MD-PhD students while continuing to do his own research. And he continues to follow the intersections of AIDS and hunger in Mozambique.
Skid Row, Los Angeles. Photo: Airman Magazine, U.S. Air Force Staff Sgt. Andrew Lee/
Flickr, 2015; cropped. CC BY-NC 2.0.
Kalofonos’ clinical work in the U.S. with severe mental illness has led him to develop an interest in working with this marginalized and extremely vulnerable population. “People with severe mental illness in the United States have a life expectancy, on average, 20 years less than the general population without severe mental illness,” he remarks.
“Globally, including in the United States, people with severe mental illness are more often the victims of violence than the recipients of care. Ideas of what constitutes care, however, are contested,” he continues. “Anthropology has a lot to bring to this discussion with nuanced and sophisticated perspectives of subjectivity and social relations.”