Archive for the ‘public health’ category

Brrrraaaaaiiiiiiinnnnssss…

February 6, 2015

Or rather…

MMMMMorrrrrronnnnns:

The reanimated corpse of Dr. Jonas Salk, the medical researcher who developed the first polio vaccine, rose from the grave Friday morning on what authorities believe is a mission to hunt down idiots.

Wiertz_burial

The usual suspects beware.

Another drive-by post, but go read the whole of Andy Borowitz’s update to his eponymous report.*  It’ll help your mood.

You’re welcome.

*Yes.  I did put this post up solely for the purpose of getting to type “eponymous.” It’s the little pleasures…

Image:  Antoine Wiertz, The Premature Burial, 1854.

Ebola Derangement Syndrome…Some Context

October 8, 2014

As of October 5  — the period covered by the World Health Organization’s latest Ebola Situation Report [PDF]  — there have been 8,033 cases of Ebola identified, with 3,879 deaths.  The one US Ebola death isn’t in that total yet — it will show up in next week’s report.

Using 2011 numbers (I can’t dig up more recent CDC data), forty weeks worth of gun deaths in the US would produce almost 25,000 men, women, kids, dead by homicide, dead in domestic battles, dead by accident, dead of the misery that leads to self-murder.

37.42

A single US Ebola case has completely deranged the Republican party and their pack of running dogs.  There have been calls for summary execution of the ill and scorched earth assaults on some of the world’s poorest; someone managed to conflate Ebola and ISIS; a truly timorous sour (when did the GOP become such cowards?) now demands panic [h/t Edoroso] in response to this (genuinely) terrible disease that has, just to go back to the numbers again, the death of one person on American soil.

None of these trembling, vicious GOP hacks offers anything remotely so…determined…in the face of stories like this.  Or these. [PDF].  Or all those documented here, until the slaughter became too much for witnesses to bear.

Ebola is a terrifying disease.  It is doing immense damage to extremely vulnerable people and societies.  We should bring all we can to bear to block further transmission, to care for those already infected, and to discover whatever there is to be found to treat or prevent it.  But as we do so, it’s worth remembering that there is an epidemic disease claiming the lives of  more than eighty Americans a day, and we aren’t doing anything to stop it.

Image:  Alexandre-Gabriel Decamps, The Suicidec. 1836.

Inequality Kills. Policy Drives Inequality. Elections Matter

March 16, 2014

Annie Lowrey in The New York Times today:

Fairfax is a place of the haves, and McDowell of the have-nots. Just outside of Washington, fat government contracts and a growing technology sector buoy the median household income in Fairfax County up to $107,000, one of the highest in the nation. McDowell, with the decline of coal, has little in the way of industry. Unemployment is high. Drug abuse is rampant. Median household income is about one-fifth that of Fairfax.

One of the starkest consequences of that divide is seen in the life expectancies of the people there. Residents of Fairfax County are among the longest-lived in the country: Men have an average life expectancy of 82 years and women, 85, about the same as in Sweden. In McDowell, the averages are 64 and 73, about the same as in Iraq.

There have long been stark economic differences between Fairfax County and McDowell. But as their fortunes have diverged even further over the past generation, their life expectancies have diverged, too. In McDowell, women’s life expectancy has actually fallen by two years since 1985; it grew five years in Fairfax. [Links in the original]

Albrecht_Dürer_013

Lowrey is careful to note that the causal connection between poverty and longevity (or its absence) is hard to establish, and the data are both incomplete and fraught with co- and confounding factors.  But such caution does not in the end distract her from the basic point of her reporting:

It is hard to prove causality with the available information. County-level data is the most detailed available, but it is not perfect. People move, and that is a confounding factor. McDowell’s population has dropped by more than half since the late 1970s, whereas Fairfax’s has roughly doubled. Perhaps more educated and healthier people have been relocating from places like McDowell to places like Fairfax. In that case, life expectancy would not have changed; how Americans arrange themselves geographically would have.

“These things are not nearly as clear as they seem, or as clear as epidemiologists seem to think,” said Angus Deaton, an economist at Princeton.

Further, there is nothing to suggest that, for a given individual, getting a raise in pay or moving between counties would mean outliving her peers.

“The statistical term is the ecological fallacy,” Mr. Kindig said. “We can’t apply aggregate data to an individual, and that’s underappreciated when you’re looking at these numbers.” But, “having said that, I still think that the averages and the variation across counties tells us a lot,” he added. “We don’t want to let the perfect be the enemy of the good here.”

Despite the statistical murk, many epidemiologists, economists and other researchers say that rising income inequality may be playing into the rising disparity in health and longevity. “We can’t say that there is no effect, just because we don’t have clear methods to test the effect,” said Hui Zheng, a sociologist at Ohio State University…

Mr. Zheng has also posited that inequality, by socially disenfranchising certain groups and making them distrustful of public systems, may have a long-range effect on health.

To some extent, the broad expansion of health insurance to low-income communities, as called for under Obamacare, may help to mitigate this stark divide, experts say. And it is encouraging that both Republicans and Democrats have recently elevated the issues of poverty, economic mobility and inequality, But the contrast between McDowell and Fairfax shows just how deeply entrenched these trends are, with consequences reaching all the way from people’s pocketbooks to their graves.

I’ll mostly pass over Lowrey’s seeming willingness to take as hopeful recent Republican rhetoric on poverty absent any policy proposals that would do anything about it, whilst continuing to propose, inter alia, the destruction of Obamacare, the one program she cites as having the potential to help.  This kind of both-sides-ism seems to be an ineradicable MSM pathology.

What matters much more is the basic point to draw from the evidence within Lowrey’s piece:  poverty kills — or perhaps better, wealth saves. Increases in inequality correlate with an increasing gap between rich and poor on the most basic of measures, how long we all get to enjoy the pursuits of life, liberty and happiness.  Policies that drive such inequality, or do nothing to mitigate, are implicated in those lost years, in deaths before time.  Those policies are the current program of the Republican Party.

Literally:  Vote like your live depends on it.

Image: Albrecht Dürer, The Death of Crescentia Pirckheimer, 1504.

This Is How Bad Ideas Become Received Wisdom: Mark Ambinder, Regulation, and Evil edition

April 16, 2010

I’m not an Ambinder hater.  He knows the mechanics of politics really well, and when he chooses, he’s got useful material to share.

But I’m no fan either — I think he’s allowed himself to play Villager too much too soon.  He’s a good reporter, I think, but his pleasure at being a member of the Washington in-crowd is palpable, and I find his site less and less interesting the more reliably conventional its wisdom becomes.

It’s kind of sad, actually.  He’s too young and too smart to make it pretty to watch him turn into a kind aspiring Broder with internet skillz.  But that’s what’s happening,  I think.

Case in point — look at this reflex in action on what would seem to be a subject pretty far removed from the usual Washington sacred cow.  Ambinder wrote a  very interesting article for the May issue of The Atlantic Monthly about  obesity, spinning of his own experience an in depth look at what can and/or should be done about the very real harm obesity is causing in this country.

Mostly, the piece is a pretty good bit of feature writing, with a clear understanding of its subject and its aims.  But even in a matter very near to his heart, and one in which he has already made the (for the contemporary Village) significant leap of recognizing a role of government action in confronting the very complex issue of obesity, he still can’t help straying into the easy, mindless tropes of elite posturing on the evils of policy action.

For example, in one passage, he describes President Obama’s choice of FDA chief, Margaret Hamburg, as “another New York City veteran with a strong nanny streak.”

That would be this Dr. Hamburg

Dr. Hamburg, who was appointed by Mayor David N. Dinkins as acting commissioner in 1991 and became commissioner the following year, was one of the few top officials asked to remain when Mayor Rudolph W. Giuliani took office in 1994. She was best known for developing a tuberculosis control program that produced sharp declines in the incidences of the disease in New York. Under her tenure, child immunization rates rose in the city.

She left New York in 1997 to become assistant secretary for planning and evaluation at the federal Department of Health and Human Services, where she created a bioterrorism initiative and led planning for pandemic flu response.

And what was Dr. Hamburg’s sin? That under her leadership, the FDA “warned 17 food manufacturers that their food labeling made misleading health claims that needed to be corrected.”

This is, if I may steal someone else’s snark, Your Liberal Media In Action.

Ambinder seems to see as a nanny — by implication, I think, an emasculating female authority figure — someone who helped roll back what many consider to be one of, if not the greatest looming public health crises around these days (TB) — not to mention someone who has tried to plan ahead for a couple of the most significant anticipatable but not predictable medical threats we face as a nation.

I’m not sure what you would call someone who has that skill set and resume, but she’s a nanny only if you think proactive government planning and decisions in the face of real dangers is somehow Satanic Mary Poppins territory.

But that, of course, is the current elite Washington chattering class consensus.  Three decades of hard, effective work by the radical right propaganda apparat — the AEIs and the rest — have produced the unthought conclusion for too many that government action of any sort is an infantalizing, illegitimate assault on the individual’s corporation’s right to lie about the effects of its products.

What’s weird — or rather, telling — is that it actually appears from the passage in question that Ambinder actually admires the FDA’s action in this case. He writes, “This was the most significant FDA enforcement action on such matters in more than a decade.”

But even so, he can’t stop himself from spitting out a cliched epithet that undercuts his own apparent conclusion — and, more broadly, the whole idea that it might make sense for the government to be active in the arena of protecting the public from deceptive practices implicated in a major health concern.

You see this pathology more bluntly in a blog post that Ambinder wrote to follow up on the article, in which he outlined in brief what he thought ought to be done about the American obesity plague.  There he writes that  we should

Accept that regulation is a necessary evil. (Emphasis added.)

Oh FSM.  Not this again.

Easy snark aside, here you have the political editor of The Atlantic Monthly taking as absolutely uncontroversial the idea that regulation, necessary or not, is bad.  It’s a truth universally acknoweledged– in his worldview —  that such government action cannot be better than the lesser of two lousy outcomes.

And this is the problem.  There is no argument that there can be good and bad regulation — as in rules that fail to achieve their policy goals.  But the idea that the tool of regulation is itself evil — now that’s the true accomplishment of the Reaganite long war on the whole idea of public governance, of a public interest.

And, of course, it’s false, a lie, told wittingly by some, unconsciously, I think, here.

This really isn’t complicated:  regulations are the tools we use to ensure that private ambitions do not trump public interests.

Ambinder even gets this, sort of.  In  his longer article, he writes of the ways regulatory change works.  Sometimes it is simply a rule that compels a change in behavior.  Other times, it is process that evokes such changes.  He writes,

There is a creative tension here, and the conversations can be difficult,” said the [National Restaurant Association] president, Dawn Sweeney, of its negotiations with the administration. “Having said that, we have to have real things to offer, because if regulation is in the offing at some point down the road, we want to be out in front of it.”

Well, yeah.

To recap:  what has Ambinder tried to say here?  One — that our current food practices have led to a deeply damaging national crisis of obesity.  Two — that the organization of  our food industry and culture are among the primary drivers of this crisis.  Three — that absent changes in the way the industries involved do business we are unlikely to resolve said crisis.  And four — that such change comes only in the context of explicit incentives to do so, and this administration is using the regulatory process to provide those incentives.

Nothing evil to see here — except, if I may hyperbolize — Ambinder’s swift and sloppy appropriation of a cliche that advances the very political interests that would derail the changes he wants to see here.

Which is to say Ambinder has to choose, as must all the rest of us, which side of this rhetorical and real divide he wants to defend.

*Ambinder himself notes this problem, writing, inter alia, that “wide evidence suggests that advertising feeds obesity, triggering what the psychologist Robert Cialdini has called the brain’s “click-whirr” response.”

Images:  James Gillray “A Voluptuary, under the horrors of digestion” (a caricature of the Prince of Wales, later George IV) 1792.

And why not two  Weird Tales covers in one day, this one, dated November 1942, vol. 36, no. 8, featuring Nursemaid to Nightmares by Robert Bloch. Cover art by Richard Bennett.

Health Care Reform and 9/11, or yet another way to demonstrate that the GOP and its allies are moral imbeciles.

January 23, 2010

I remember September 11, 2001, very well indeed.  That morning, I’d walked across 12th St. at Sixth Ave. to grab a quick breakfast at Joe Jr.’s.  I even remember what I had:  a toasted bialy with raspberry jam and a cup of coffee.  I was chatting with a couple of other guys at the counter about the Monday Night Football game the evening before — the Giants at Denver.  See — I remember.

Then a guy who looked as if he had lived way too hard during the sixties opened the door and said that a plane had just hit the World Trade Tower…and we didn’t believe him.

I walked out of the diner about five minutes later, looked to my left…

….you know what I saw.

I didn’t stay to the end.  I knew that I was watching people die, and I could not just stand there in the middle of Sixth Ave. — The Avenue of the Americas! — as that happened.

The official figure is that on that day 2,976 innocents died.

It was horrific — a disaster, a tragedy, and a crime.

For the sake of those almost three thousand dead, with the aim of preventing such a loss ever again, the United States went to war, twice.

We have committed an astonishing amount of treasure to those conflicts — about one trillion now, and counting — and  we have asked hundreds of thousands of Americans to serve in truly difficult circumstances to defend us from harm.

We have received that last full measure of devotion from thousands of those Americans — 5,344 members of the uniformed services as I write this — all in response to the loss of those three thousand  taken from us on September 11, 2001.*

Now, in January 2010, we are debating a question that seems far removed from the stark horror and terror of 9/11.

We confront once more the question of whether or not an American’s access to health care should, in this country at this moment, be something every American can expect.

We all know where we are, confronting a Senate bill that is deeply flawed.  It is compromised in a dozen different directions, and it does not deal with several of the root problems in the health care complex that the United States must some day solve.

But, but, but… at its core it does this one thing:  it provides  health insurance to 30 million Americans who do not now have it. Whether or not it can be improved by one legislative maneuver or another, it still does that.

We know one thing about the lack of coverage.  It kills people.

The latest Harvard Medical School Study estimates that 45,000 Americans die each year from lack of coverage.

You can see where this is going, I’m sure.

Thirty  million people is about 1o percent of the population of the United States. One tenth of 45,000 is 4,500.  But of course, it’s worse than that. The US Census estimates that about 46 million Americans lack health insurance each year.  That thirty million who would benefit under the Senate bill account for about two thirds of that total.

If we cannot find a way to pass the Senate bill, with or without changes…if we can’t get this through, then those thirty millions will remain uninsured.  Some of them will die each year as a result.  If the Harvard study is right, that number could be as high as 30,000 Americans gone who did not need to go.

Even if you think the Harvard study may overstate the death toll, then give the number a haircut — say cut it almost in half — and you still have some 18,o00 Americans dead each year from financial arrest.  Six 9/11s.  One every couple of months

We were willing to go to war; we are still willing to spend billions each year on the fight; as a nation we accept the necessity of sacrifice, of the loss of good women and men cut off in their prime, to respond to the criminal tragedy that was 9/11, with its 2,976 men and women killed.

We’re losing many times that many every year that we could save right now….and yet the GOP and its allies think it is more important to win a political battle than it is to prevent this annual massacre.

I don’t accuse our friends across the aisle of a willful desire to kill their fellow citizens in their thousands.  Rather, it is willed ignorance — that’s where I bring them in guilty.

Theirs is a careful not-knowing, a skill that allows them to unsee the unglamorous and unnoticed missed infection here, the unmedicated heart failure there.

But the outcome is the same, and the current attempt to derail the health care/health insurance reform measures available to us now makes those who are doing so accessories before the fact — co-conspirators — in all those unnecessary deaths.

That’s what blocking health care means.  Leave aside the compelling policy argument, all the practical reasons why this makes sense:   if you knew that there was some action you could take to prevent 9/11, what would be the moral cost of choosing not to do so?

That’s what the GOP should ask itself;  that’s what the perfection-at-any-cost wing of my own Democratic party needs to remember.  That’s what the rest of us should be dinning in our neighbors ears:  Those who for financial interest or partisan advantage are lying about health care now are committing perhaps another 9/11 every two months.

Year after year.

We need to get this done now.

*Not to mention, of course, the journalists, contractors, coalition military and above all, civilians who have lost their lives in these conflicts.

Image:  Nicholas Maes, “Christ Before Pilate” (Pilate washing his hands), before 1670.

Sexual terror kills people: a sort-of follow up to David Brooks’ sexual queasiness.

November 19, 2009

A few days ago I wrote this screed of disdain about David Brooks data-less, thoughtless complaint about the vapid sex lives of Kids These Days™.*  I have more than once commented on the evil consequences of marrying sexual queasiness to bad science, social or otherwise — and it struck me that  it is important to remember that Brooks’s queasiness about sex has a broader context and worse consequences.

The thought came to me as I was reading my pre-pub copy (what used to be called a galley) of Rebecca Skloot’s marvelous new book The Immortal Life of HEnrietta LAcks.  Rebecca has written a work that  is proximately the story of HeLa —  the most ubiquitous (some would say ferocious) human cell line used in modern biology — and the woman from whom those cells were derived, without her knowledge or permission.  It’s more than that, of course — an inquiry into race and its twisted history in America, family, medical practice and medical ethics, the autonomy — or lack therof — with which we all inhabit our own bodies, and much more besides.  I’ll blog about it properly closer to pub date, but put this one on your list.

Within all that, the factoid that got me thinking was Rebecca’s discussion of the particular type of cancer that killed Henrietta Lacks so swiftly and cruelly: cervical cancer, the sequel to her multiple infections with HPV-18, one of the most malign of the 100+ strains of Human Papilloma Virus.

HPV infection was and is an epidemic.  In 2008, the Centers for Disease Control reported that

HPV is the most common sexually transmitted infection in the U.S., with about 20 million people currently infected. Women have an 80 percent chance of getting HPV by the time they are 50. HPV is most common in young people who are in their late teens and early 20s.

That is:  about 7 percent, give or take, of the American population — closer to ten percent of the adult population**–are infected with a virus whose consequences range from nothing to death in predictable proportions.  The same CDC report tells us that each year 11,000 women are diagnosed with cervical cancer, and that 3,600 will die of it.

For those of you keeping score, the number of women who will die this year of the disease that killed Henrietta Lacks is about 80% of the total US military deaths in Iraq since 2003 — 4363, according to the latest AP count.  It is greater than the number of combat deaths in that period:  3,476.

There is this difference of course:  death is a necessary component of battle.  War is the imposition of national will by violence, in one short hand definition, and within that context, people will die.

By contrast, no one — or rather, within a generation, very close to no one — need die of HPV infection.  The HPV vaccine, approved by the FDA in 2006, protects against four of the strains of HPV, including those that cause genital warts and cancer.  It is effective, according to the CDC, and safe:

As of June 30, 2008 VAERS has received a total of 9,749 reports of potential adverse events following HPV vaccination. Ninety-four percent (94%) of these reports were about non-serious adverse events.

Six percent (6%) of adverse events reported for the HPV vaccine were considered serious, which is about half of the average number of serious reports for other vaccines. In comparison, the overall average in VAERS for any serious adverse event following vaccination ranges from 10% to 15%; therefore, the percentage of serious reports for Gardasil® is less than the overall average for other vaccines.

The CDC goes on to caution that the number of adverse events actually caused by the virus vaccine is almost certainly lower than that number, due to the post hoc ergo propter hoc problem.

The virus vaccine is recommended for girls aged 11-12.  Why?  Because this is before the age of likely infection, given that HPV is a sexually transmitted pathogen.

We all know where this goes.  The notion of protecting girls from a deadly disease transmitted in the context — oh get the fainting couch ready — of the sexual lives of their older selves is terrifying, at least to some.

So much so that  those terrified of especially female sexual appetite and expression (see for an allegedly respectable example, Chunky Reese Averse Ross Douthat) would rather kill people than acquiesce in the possibility that human beings might on occasion make the beast with two backs.

Recall:  Texas secessionist Governor Rick Perry wasn’t always 100% crazy.  Back when the loon quotient was down to no more than 95% or so, he actually, in a moment of clarity in 2007, signed an order that all require all sixth grade girls in Texas to receive the HPV vaccine.  The response?  As you’d expect.  Texas legislators “rushed to file bills that would override the governor’s order, which they said revokes parental rights and could encourage young girls to be promiscuous.”

To his credit Perry stood up for modern public health:

Providing the HPV vaccine doesn’t promote sexual promiscuity any more than the Hepatitis B vaccine promotes drug use,” Perry said Monday. “If the medical community developed a vaccine for lung cancer, would the same critics oppose it, claiming it would encourage smoking?”

Soon, though — damn soon — in fact, he lost.  Though he complained — accurately, that the legislators who had voted in favor of the bill overturning his executive order would rather tell women that  “We could have prevented this disease for your daughters and your granddaughters, but we just didn’t have the gumption to address all the misguided and misleading political rhetoric,” he lacked the votes to prevent his veto from being overturned, and allowed the bill, unsigned, to become law.

Perry, it should be noted, still defends this decision.  I have no time for just about everything Perry stands for  — but on this one, he has it right.

So let’s recap:  we face a disease that kills more women in this country each year than have died in battle in the last six in our war in Iraq….

…that will be allowed to persist in the lives of our daughters because to some people it is more important to pretend that human beings don’t have sex with more than one person in their lives than it is to prevent wholly avoidable suffering.

So, finally, to return to why I find David Brooks’s maundering about the sex lives of New Yorkers so pernicious is not just because of the gaping crater of intellectual shoddiness at its heart:  it that he offers a well-spoken version of the attitude that declares, whatever may actually happen in real human experience, women shouldn’t have the temerity to uncross their legs.  Remember the corollary of that belief as well:  if they do, then, by gum, disease, distress and death are merely the appropriate consequences for such sin.

Last note:  when ever I hear the term “value voters” I throw up in my mouth.  The single central value of just about any ethical system, including those advanced by the sages of traditional religion, is that it is wrong to use other people as objects, rather than subjects, individuals of intrinsic value.  Requiring others to die to avoid unpleasant contradiction with one’s own value system is not a virtue.  It is, in the only true sense of the word, the very definition of a sin.

A pox upon them.

I mean that literally.

Oh — and one more thing.  If anyone wants to draw the obvious connection to the current health care debates (Joe Stupak, are you listening?  Senators?) then I think that is an entirely appropriate link.  The entire anti-health care movement is in the end a decision to allow innocents to die in large numbers in order to achieve other ends; it sacrifices individuals in the service of either or both abstract “values” and the financial interests of various elites.  Mere sin hardly covers the case; evil is more like it.

*I later found out that Brooks’ silliness was deeper than I thought, for I chanced across the original article in New York magazine in which the editors described the process by which they accumulated the sex diaries that so confounded the gentle Mr. Brooks.  These were, which I’m sure will surprise no one, wholly selected for maximum effect.  Producing social commentary on the basis of sought-and-found soft porn purveyed to prop up an at-risk publishing model is something only the credulous or the contemptuous-of-their-readers would attempt.  Consider this an exercise for the readers to decide which it might be.

**and yes, I know that plenty of under-18s will have HPV infections.  This is numerical shorthand here — an attempt to express scale.  It is not, as I hope the language makes obvious, a precise claim.

Update: minor but crucial edits above (for “virus” read “vaccine” twice) thanks to the eagle eye of  Lovable Liberal.

Images:  Albrecht Dürer, “The Revelation of St John: 4. The Four Riders of the Apocalypse” 1497-1498

Berthe Morisot, “The Balcony” 1872

Poverty and Aids: Who Does What To Whom/Elizabeth Pisani edition.

December 4, 2008

So, to get back to business, a little follow up on the MIT talk by Elizabeth Pisani touted below.

Elizabeth, whose book, The Wisdom of Whores I admire both as a ripping read and as a powerfully argued polemic – with – the -facts, is a passionate advocate for clarity in our description of and response to HIV and AIDS.  A journalist, and then an epidemiologist, as well as a self-admitted member of the AIDS mafia, Pisani emphasizes that HIV is a virus that is transmitted by a few well known pathways: basically unprotected sex, unprotected anal sex, and needle sharing among IV drug users.

In her book and in her talk at MIT on Monday, Elizabeth admitted her own complicity in what she sees as the original sin (my phrase, not hers) of the public health community’s response to the epidemic.  In order to secure funds to fight the disease, public health folks and epidemiologists de-emphasized in public the central roles of commercial sex, homosexual sex and drug use in the dissemination of the virus, choosing instead to highlight more broadly sympathetic and politically acceptable potential victims:  children, “innocent” women, and the ultimately, the public at large.

That spin worked, Elizabeth said, attracting a torrent of money. But there was a catch:  a ton of that new cash was restricted to taking care of the politically attractive categories, leaving the problems at the core of the epidemic — sex and drugs — still drastically under-addressed.

That’s the broad stroke argument, very broad — so don’t blame Elizabeth for my shorthand and no doubt inaccurate attempt at a gloss on her talk. Among her caveats:  much of what she had to say applied not to the two thirds of the epidemic taking place in southern and eastern Africa, but to the one third spread out over the rest of the world.  But the discussion that followed raised two crucial points of contention that are worth thinking about.

One was a reaction to Elizabeth’s complaint of what she did not call, but I will, AIDS whoring.  By this I mean the habit that Elizabeth pointed out of all kinds of (presumptively) well-intentioned organizations trying to claim some connection to the fight against HIV/AIDS, no matter what they actually do, just to take a sip or two from that river of money flowing towards the disease.

In particular, the trope that HIV is a disease of poverty got Elizabeth’s goat.  No, she argued. HIV is a virus, and to the extent that it is a disease of anything….wait for it…it’s one of sex and drugs.

Money spent on projects to alleviate poverty, or to increase women’s economic power, or any of the other entirely important and necessary development goals someone might have will not, in this view, do much of anything to deal with the problem of HIV and AIDS.  If you really want to deal with the disease, she argued, attack the problem directly. Needle exchanges work.  Proper prison HIV projects work.  Condoms work…that’s where the emphasis should lie.

Not so, argued one member of the audience in a conversation after the talk.  Too reticent to push the point during the q. and a., this person argued that Elizabeth was too much the epidemiologist.  From where she sat — a physician with experience in the Middle East, now studying the interface between technology, culture and history in the context of health and medicine — poverty was indeed a significant part of the equation.

That is hard won knowledge, and I’ve heard the same from other people up to their elbows in responding to the epidemic.

And yet, stripping down the question to its core — what will save lives most directly, right now — it’s hard to ignore Elizabeth’s central point:  the argument that addressing HIV/AIDS head on is not the same thing as saying that one should not attack poverty, the evils done to women and or children and so on.  It is just that improved sanitation installed over the next months or years; a new micro-loan program, even one laptop per child is not going to affect the infection being transmitted right now on a thin mattress in a brothel, in the passage from one arm to the next of droplets of blood mixed with heroin, in the late night, alcohol and dance fever-fueled “decision” to forget the damn condom after all.

In this view diseases are not — or at least not only — social phenomena.  From the point of view of someone actually about to be infected, they involve specific pathogens moving through known pathways to inflict harm on identifiable individual people.  And there are methods available, were political and moral will strong enough, to find both those people already suffering, and to reach those near them at risk. Given that capacity, what should the course of action be?

Look at another example:  Paul Farmer has achieved a justifiable fame (some would say apotheosis) through an approach that says you do what you have to do to make sure the miserably poor, no-hoper ten miles away across three mountain ranges takes his or her damn TB meds.

All the medical interventions that Farmer’s approach has generated have not transformed the fundamental conditions of poverty and oppression in Haiti or in other communities where his efforts have been directed.  But they do, of course, save lives — and I’m comfortable with the claim that basic health is a necessary pre-conditions to any such change. Even if you argue that there is an intimate connection between social pathologies and the medical ones associated with AIDS, there is the brute fact of a feedback loop:  poor and oppressed communities, marginalized and reviled groups (think junkies and whores) do not improve their ability to press a claim on the society or polity as a whole when they are mired in the struggle with a spreading infection.

All this, of course, is open to dispute on points of principle.  It is certainly true that absent structural change, the poor and the marginalized have more or less unlimited paths to suffering and death.  Hence, any given amelioration of suffering can be seen as the rearranging of the deck chairs on the Titanic. There is every reason to argue that what is needed is transformative change that addresses blighted lives and communities across the range of problems confronting them.

Fair enough — but in practice, as Elizabeth has described with potent fury in her book, the dilution of AIDS efforts into generalized anti- this or that has does not prevent infections, nor does it, so far at least, seem to have transformed the world of the poor.  There are the usual problems of aid:  those who live well off doing good are always with us, for example.

But more deeply, this seems to me to be a case of the best being the enemy of the good:   There is the blunt fact that structural change is slow and uncertain, and HIV infection and its consequences often are neither.  It is my hope that come January 20th, the worst diversions of effort and emphasis in US global HIV/AIDS policy will be reversed.  Just dumping the abstinence-only set-aside would be a major step forward.  Here’s hoping.

Of course — this begs the question of whether any policy involving culture, society and behavior can work, given the freight that comes with anything involving sex, drugs, conceptions of sin and purity and all the rest…and that came up too in Elizabeth’s talk.

But this post has gone on long enough.  I’ll write up the debate on this point that came out of Elizabeth’s talk in another one.

Jean Agélou, “French nude smoking opium” c. 1910.