Posted tagged ‘Policy’

Some Mostly Stolen Thoughts On That Old Politics Vs. Revolution Thang

May 25, 2016

So this morning I’m reading a diary on the Great Orange Satan about political doings over in Bagdad By The Bay.  Though I grew up in the San Francisco area, I’m not really current on what’s happening, aside from the fact that I couldn’t afford a shack in SF itself anymore — notamidst all those Twitter-, Apple-, and Google-erati.  So I gobble down the story, assume/accept the big-city, big-money corruption narrative, and move on.

Sucker!

I do have friends and relatives back by the Bay, as it turns out, and one of them has worked in city government for a long time.

Turner_-_Dido

He’s got first hand knowledge of San Francisco’s allegedly lost progressive mindset as it works within local government, and he weighed in.

I’ll excerpt his comment below, but first I just want to say this was an object lesson for me, a reminder of how easy it is trip up in the way that I’ve criticized some of the most extreme of the Bernie camp for doing.

That is: there’s a ton wrong with our politics, our society, and our engagement with each other.  It’s so tempting to leap from a clear problem — the impact on middle and low income residents of the gentrification of San Francisco (and elsewhere!) driven by extreme income inequality — and assume that political actors are obviously complicit.

The reality?  Sometimes they are, sometimes they aren’t, and it takes some effort to figure out the five Ws and the H in each case.  Worse yet — if the problem is truly complex, then political action is at best an incomplete tool to deal with the issue.

Which is why, in the end, I think Obama is a truly great president: he gets all of that.  The need for policy and politics; the insufficiency of politics on its own; the agonizing difficulty of addressing any truly major problem — which translates into rage-inducing slowness to see the change take shape; and the need to keep plugging away.

I feel that rage often enough, and I know that I don’t have the qualities of character our president does, the off-the-charts focus and persistence required to make sh*t happen, and to wait — years if necessary, decades — to see the results.

I have high hopes for Hillary on this score.  Not that I’ll agree with her on everything — I don’t and won’t, just as I haven’t always with Barack Hussein Obama.  But I trust her (yes, that word) to pay attention, to know her stuff, to hire good, smart folks, and to soldier on and on and on — as the job and the world requires.

Here the sermon endeth…and an excerpt from my old Bay Area companion’s comment takes over:

I’ve worked on the financial administration side for the City of San Francisco for many years, and the truth is that under successive mayors and Boards, San Francisco has put more money behind progressive goals than almost any other city in the country.

The City spends billions of dollars a year on its amazing public health programs, including a universal health access program for City residents that predates and goes well beyond Obamacare, and many hundreds of millions of dollars on programs to help the poor and homeless, including thousands of units of housing for the poorest of the poor and people with severe mental illness and other health problems.  The City spends hundreds of millions a year subsidizing its transit system and setting aside funds for children.  The City spends hundreds of millions a year subsidizing its transit system and setting aside funds for children. 

Mayor Lee …supported not just measures to attract and keep higher-paying tech jobs but also continued one of the largest and best City subsidized jobs programs in the country…

These are great progressive achievements….

You can read more at the link. The writer goes on to acknowledge that despite all this, the reality is that San Francisco’s housing costs put enormous stress on too many, and argues that the drivers of that are at best barely subject to direct political control — and that policy responses offer very tricky alternatives.  The challenge for progressives, among whom he numbers himself is thus to..

examine what housing policies we should we be pushing for that can help the most people of different income levels that need housing (not just the poorest of the poor).

TL:DR:  electioneering — and definitely punditizing —  is easy.  Governating is damn hard, which is something to be mindful of at this and every season.

Over to y’all.

Image:  J. W. M. Turner, Dido Building Carthage, 1815.

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.

And on the other hand (Easterbrook edition)

September 9, 2008

Update: See Shiv’s comment below for an alternate view of the wisdom, or lack thereof, in Easterbrook’s argument.  I think he has a point — though the notion that simply good design could do a lot to reduce oil consumption even absent significant technological change seems to me to be valid.

Below, I excoriate sportswriter and sometime pundit Gregg Easterbrooks’ willed no-nothing stance on the LCH startup.

Here, I acknowledge his wisdom, further down in the same column that earned my ire.  Talking about fuel economy, US policy and the amazing foolishness of the current horsepower race on the American roads, he concludes

Federal legislation to regulate the horsepower of passenger vehicles, perhaps by establishing a power-to-weight standard, would reduce petroleum consumption, cut greenhouse gas emissions, lower U.S. oil imports, strengthen the dollar, and take some of the road-rage stress out of driving. So what are we waiting for?

He’s right, and the rest of his analysis is on the mark. So skip the physics nonesense, ignore the football stuff, (nothing much happened last weekend anyway), and scroll down to just past the half way mark if you want to get the whole of the argument.

Image:  Start of the 1915 Indianapolis 500, published in the New York Times, June 13, 1915.  Source: Wikimedia Commons.

Bad Science Kills, take two: Bush admin. fears sex, other people die edition.

February 19, 2008

From 365Gay.com via No Capital by way of Eschaton comes this reminder why it really hurts when we are led by those who fear not just sex, but facts.

The Bush administration and Congress are arguing about the renewal of the African Aids initiative. At issue: whether or not to preserve the rigid requirement that one third of the funding must go to abstinence programs.

Bush argues (Sunday, February 16, in Tanzania) that there should be no problem with his approach. Why, says he? Because

My attitude toward Congress is, see what works…PEPFAR is working. It is a balanced program. It is an ABC program – abstinence, be faithful and condoms. It is a program that’s been proven effective.

Except, of course, that it is not, for two reasons — both captured in (let’s be kind) two mistatements in the brief quote above.

Does abstinence education work? Not in this country. See this post for my earlier take on that issue. In Africa? Not so much there either. From Britain’s The Independent comes a report from Uganda, once the poster child for successful government-led HIV/AIDS prevention policy.

Aids activists and development officials point to the 130,000 Ugandans infected with HIV last year alone – up from 70,000 in 2002 – and say the recent obsession with abstinence is handicapping the country’s once-successful fight against the virus.

How successful was that earlier approach? Try this:

Under the previous “balanced” strategy, condom distribution grew from four million a year to 118 million by 2001. Thanks to the abstinence message, teenagers lost their virginity about 18 months later than before. People with several partners realised they needed to stop sleeping around so much. In 1992, one in five Ugandans had Aids. By 2001 that dropped to one in 20.

Not bad. Damn good, in fact. To take the Talmud’s view that to save one life is to save a world, here’ s a public health intervention that has preserved a human multiverse.

But what of the claim that Bush’s policy is balanced? Not so much there, either. On the ground where services are actually delivered, the mandated requirement to promote abstinence has squeezed the condom message out of what was supposed to be a program that worked by enabling individuals to exercise choice and responsibility for their own actions. Instead…

What has changed in Uganda is that condoms are no longer promoted to the general population. In line with US Aids policy under Mr Bush, condoms should be promoted exclusively to high-risk groups such as truck drivers, soldiers and “discordant” couples (where just one of the partners is HIV-positive). Everyone else should hear the rubber-free virtues of abstinence and fidelity only. Yoweri Museveni’s government hungrily devoured the American abstinence policy and the attached cash. It is dependent on foreign donors for half its budget.

“We have worked so hard to get people to understand HIV and that there are three options open to them: A, B or C,” says Dr Henry Katamba. “That’s Abstain from sex, Be faithful or use a Condom, whichever is the one for you. That’s what our government used to say – and everyone understood. The message recognised that it wasn’t realistic to ask for abstinence from everyone who’s not married.” Dr Katamba is health co-ordinator of the Uganda Protestant Medical Bureau, an umbrella of churches providing clinical help in the absence of government hospitals.

“Because of the US, our government now says Abstain and Be faithful only,” says Dr Katamba. “So people stop trusting our advice. They think we were lying about how condoms can stop Aids. Confusion is deadly.”

“Deadly.” Let that word sink in.

I’ve written elsewhere on this blog about the way that some of our leaders, at least, choose death before dishonor, as long as it is someone else — someone negligible, like an anonymous heroin addict, or some distant African at risk for HIV/AIDS — who actually does the dying.

The usual analysis of this disgraceful division of labor turns on the political calculus of interest groups and the Rovian tactic of keeping the literalist evangelical “base” calm and happy. But whatever the truth of that argument (and who knows whether Bush argues for abstinence out of calculation or genuine belief), such mind reading misses the larger point.

Scientific illiteracy is not ignorance of any given fact. George Bush does not need to know the curve that fits the data on the rates of infection in different sub-Saharan countries. He does need to pay attention, though, to the fact that such knowledge exists, and says something important about the world and the consequences of US action.

Instead, in the government we have now, facts and the process of inference from facts are subordinate to pre-existing certainties.

Among them: Sex is bad in and of itself, except in certain, tightly defined circumstances. If you choose to go ahead and do the nasty in defiance of that moral “truth,” then be prepared to take the consequences. (Even if you didn’t choose – of course, but I’m not even going to go down that sewer just now). You made your bed, man or woman (or unborn child) … now die in it.

This is how science matters in public life. It’s not, to my mind, the question of funding choices – should physics get more than chemistry; neuro more than endocrine biology or what have you. It’s not about Obama liking NASA and the manned space mission less than Clinton. It’s whether or not our leaders understand the idea that facts have consequences.

When someone makes a claim about material events in the world, scientific thinking provides the only reliable method to test that claim. You have to get the data, analyze it, and expose the tools of your analysis to scrutiny as well. If you don’t you get what we have: policies that defend ideological purity, literally to the death.

I’ve written this before; I’m sure it’ll come up again. That’s what makes the practical consequences of bad science not just tragic, but criminal.

Images: Nicholas Poussin, “The Plague of Ashdod.” 1630-31. Source: Wikimedia Commons
Special costume to be worn by medical men confronting the plague. Germany 17th century.  Licensed under a GNU free documentation license Ver. 1.2 or any later version published bythe Free Software Foundation.  Source:  Wikimedia Commons.

Bad Science Kills People: Bush administration/heroin edition.

January 27, 2008

I don’t know how much attention this post by Mark Kleiman is getting around the blogosphere, but it should be getting more. (h/t Kevin Drum in this post.)

Kleiman picked up on this story from NPR, which reported two facts:

Fact 1: public health officials around the country, including those in Cambridge, MA, the city where I now sit, are distributing rescue kits that save heroin users from overdoses. The kits cost $9.50, and they are credited with reversing 2,600 overdoses in 16 such local programs around the country. For context: NPR reports that “overdoses of heroin and opiates, such as Oxycontin, kill more drug users than AIDS, hepatitis or homicide.”

Most people would think that a cheap, simple tool that allows those on the sharp end of the drug wars to save lives would be an unalloyed good.

But then there’s fact 2: I’m just going to quote here the same comments Kleiman cites:

Dr. Bertha Madras, deputy director of the White House Office on National Drug Control Policy, opposes the use of Narcan in overdose-rescue programs.

“First of all, I don’t agree with giving an opioid antidote to non-medical professionals. That’s No. 1,” she says. “I just don’t think that’s good public health policy.”

Madras says drug users aren’t likely to be competent to deal with an overdose emergency. More importantly, she says, Narcan kits may actually encourage drug abusers to keep using heroin because they know overdosing isn’t as likely.

Madras says the rescue programs might take away the drug user’s motivation to get into detoxification and drug treatment.

“Sometimes having an overdose, being in an emergency room, having that contact with a health care professional is enough to make a person snap into the reality of the situation and snap into having someone give them services,” Madras says.

Read that again.

People in dire straits should not be empowered to help themselves (in a way shown to work). Instead, a dying person should hope to have the luck to make it to the E.R.

It gets worse. The essential claim Madras makes is that improving a user’s chance of surviving an overdose will encourage further drug use, while avoiding death under the care of medical professional will induce the lucky survivors to seek drug treatment.

These are at least nominally empirical claims. They can and should be tested. But as far as we can tell, Madras pulls these statements out of her gut (I’m trying to be polite here). To the extent that there is any real data, NPR’s story also reports that “one small study suggests that overdose-rescue programs reduce heroin use and get some people into treatment.”

That is, the Bush Administration’s point person on drug policy simply ignores the inconvenient knowledge that exists about the effect of this cheap, life saving program.

R

Why?

Why doesn’t the fact that readily available cheap (and cheaper-for-the-state) alternatives to life-destroying events exist affect this view? Because of a commitment to an unexamined assumption: Exemplary suffering helps focus one’s mind, it is claimed (how else can you read Madras’s comments) and so anything that might defuse the power of the demonstration is to be avoided. Science be damned.

This is, of course, precisely why the idea of good science matters. I’m going to post later on the debate at the Science Blogging Conference about why science has such problems articulating itself in the public square (see this post at Terra Sigillata for a run down of the state of play in that conversation.) But this story tells us why the issue is vital. Real science demands that theory be ratified by observation and defensible interpretation of the data. Bad science allows ideology to determine what facts, if any, are admitted into the conversation. Right now, bad science is winning.

I’ll stop here. I’m trying to stay reasoned in the face of my own mounting rage.

Update: A commenter over at Matthew Yglesias’s thread on this topic points out that the same reasoning that Madras uses above to reject distribution of overdose rescue kits applies to the right wing orthodoxy’s opposition to giving HPV vaccines to pre-sexually active girls. (See this or read this analysis for a more comprehensive public health introduction to the question.)

Update 2: See also this post and embedded link at commenter Lovable Liberal’s blog: he’s right — this whole thing is disgraceful, but unsurprising — which is, of course, the point. If repeated blows can overwhelm the public’s capacity for outrage, then the unforgivable becomes routine.

Update 3: Drug Monkey has taken this story and run with it here. Aside from the kind comments about this blog, the key idea I drew out of the post is what happens even to good scientists when they get absorbed into an institutional culture of politicized bad science. Madras is hardly the first scientist to face the worse-or-worser fate that comes whenever you have to weigh personal reputation vs. your job of putting makeup on ever uglier pigs. But she does provide one more object lesson in why an understanding of real science at the very top actually matters.

See also Tara C. Smith’s writing at Aetiology. She sees the Narcan/HPV vaccine connection and raises it by the anti-needle exchange folly. The take home from all of the above: this story cannot be read as single outrage. It is one more thread that leads into a much larger scandal, one that should be treated as such by both the science and the political blogosphere/press.

Update 4:  Click on this link to commenter Elizabeth Pisani’s blog for an amplification of her remarks below.  She’s been on the front line.  Reality does make a difference to one’s outlook, no?

Images: “Opium Smokers in the East End of London” Illustrated London News, 1874.

Franz-Eugen Koehler, “Opium Poppy” in Koehler’s Medicinal Plants, 183-1914. Both sourced from Wikipedia Commons.