February 2006 Archives

Misdiagnosis

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The New York Times has an article on misdiagnosis in medicine. Doctors misdiagnosis patient conditions 20% of the time, the article says, because there are no incentives for doctors tied to correct versus incorrect diagnoses. One doctor quoted in the NYT article notes that "doctors don't go down with their planes."

The article points to products like Isabel Healthcare's disease diagnosis software that can help doctors to identify diseases. It is especially useful for conditions that are rarely seen in clinics -- many doctors see the same symptoms and diseases over and over again. The company was started by a businessman whose young daughter was in the hospital for months with Group A Streptococcus that causes symptoms of necrotizing fascitis and toxic shock syndrome. Orginally diagnosed with chicken pox, "only when her organs began shutting down did her doctors realize that she had a potentially fatal flesh-eating infection". (Group A strep is actually a well-recognized secondary infection associated with varicella).

According to the Wall Street Journal only 2% of doctors use software to help them diagnosis illness, sometimes because hospitals won't pay for it, others because medicine is considered "an art". This comment seems more applicable appropriate to a different era. It has become less of an "art" and more of an assembly-line in the U.S., where doctors are forced through insurance incentives (low paying office reimbursements) to see as many patients as possible in a day. Yet if software would benefit patients hospitals also balk at spending $80,000 or so to aquire the licenses.

There aren't tremendous repercussions to this business decision. Malpractice lawsuits tend to occupy the news and high settlements are headlined as though they are common, but it is not malpractice insurance that's driving up the cost of medicine. Regardless, significant action has been taken to limit insurance liability, which provides more (perhaps indirect) incentive for doctors to focus on things other than double checking their work. One trend in care is doctors who treat patients on the condition that they sign away their rights to trial jury. Medical malpractice caps, common in some states, were recently re-introduced in congress to limit "non-economic damages".

The NYT article suggests that doctors are motivated to process patients, order tests and prescribe medicine, and that legislative action is needed to change the priorities in medical care: "For a politician looking to make the often-bloodless debate over health care come alive, this is a huge opportunity.". I'm not sure politicians like Clinton, who have gone that route and been defeated to cries of that "there is 'no healthcare crisis'" would agree. More intuitively, the article asks why patients continue to pay for "wasted procedures and pointless drugs". Because that's business and patients aren't yet poised to protest?

Antibiotic Resistance: A Tragedy of The Commons?

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PLoS Medicine published an article in their Policy Forum this month, provocatively titled "Do We Need to Put Society First? The Potential for Tragedy in Antimicrobial Resistance", by KR Foster and H Grundmann. The article positions global antibiotic resistance as a proverbial "tragedy of the commons" and the authors propose that the accessibility of antimicrobials results in widespread antibiotic resistance. Although various parties try to curb the overuse of antibiotics by patients, they say, "current policies may only partly solve the problem". As they put it, these efforts:

"do not address the conundrum at the heart of antimicrobial resistance: the solution may ultimately require us to put society before the individual. That is, halting the rise of resistance may only be achievable if some patients go untreated. We defend this uncomfortable conclusion using the logic of the well-known social dilemma "the tragedy of the commons."

So the glut of antibiotics causes antibiotic resistance, which we should solve by restricting antibiotics? Perhaps we should call it: "The Tragedy of the Commoners"? Their stunning conclusion comes in the first paragraph, and is only dwarfed by the photo on the right, of an oozing sore on the dark knee of a person inflicted with methicillin resistant Staphylococcus aureus (MRSA).

As if an afterthought, the next sentence reads: "More data on the societal costs of resistance are required to evaluate the potential for a tragedy of antimicrobial resistance and the moral dilemma that it would present." One would have hoped that the "more data" part would come before the publishing part but perhaps tenuous commentary is the purpose of PLoS's "Policy Forum".

Though the topic sentence may affront the reader, the theme of the article is more or less drug allocation and management, a vital concern to national and international drug and health programs. The proposal PLoS publishes may seem draconian but it is not foreign. Drugs are routinely made unavailable to some people, inadvertently or by design. For instance, various drugs for infectious (and other) diseases can be priced above what many patients can pay. Patents or trade regimes limit drug use and usefulness to allow pharmaceuticals to maximize profit. Governments and businesses hoarding drugs. Recently, governments and corporations identified of subsets of people who will receive Tamiflu (whether it works of not), if and when bird flu becomes epidemic.

So yes, drug production, allocation, distribution, and management are well discussed in public health, policy, and economics circles. Antibiotic resistance is certainly on the rise and problematic. But is the "tragedy of the commons" a useful metaphor to analyze the problem?

Tragedy or Dismal Science?

Garret Hardin's 1968 essay, "The Tragedy of Commons" (available online at Science: Vol. 162. no. 3859, pp. 1243 - 1248 and here), describes how resources in the public domain tend to get overused and depleted. According to Hardin's views which stem from neoclassical economics, private ownership offers individual owners incentive to conserve a resource so as not to detract from its future value. "Common" resources by comparison, offer no such incentive. Therefore individuals tend to overuse "commons" because they only recognize the immediate value of what 'to their mind' seems like an endless resource, whereas any loss of value or burden due to depletion is shared by many other individuals. Therefore for each person, the rewards are greater for taking than for conserving.

Hardin's essay popularized a general phenomena described by Aristotle and others in easy to grasp, simplified terms. It's most frequently applied to environmental problems: fisheries, water resources and pollution, and it may adequately describe these situations where many individuals have access to these resources. The simplicity, popularity and malleability of the parable make it easy to apply to other problems such as internet usage, university education, and public radio.

The parable is also used inappropriately. For instance in a case of asbestos litigation¹. , the lawyer wrote "What we have here is a failure to cooperate", citing a line from "Cool Hand Luke" and meshing that with the tragedy of the commons by advocating curtailing payments to "asbestos plaintiffs,...[who are] arguably 'overgrazing' the accessible financial assets...". Private financial "assets" are not commons and injured plaintiffs looking for compensation for asbestos lung injuries are not "overgrazing.

So while the simple "commons" metaphor can useful, it can also be used for dubious intention to effectively blame individuals for complex societal problems, to erode individual rights, or to promote legislation that privatizes natural resources (even when it is clear that privatization does not necessarily solve common resource problems).

The PLoS authors chose to use the tragedy of the commons parable for the problem of antibiotic resistance based on an article about the Spanish national health care program: "Baquero and Campos recently argued that this dilemma mirrors what Hardin termed "the tragedy of the commons". But if you read the article, you would know that the Spanish authors write specifically about the public health program in Spain where doctors prescribe drugs to patients based on a national formulary. Baquero and Campos outline incentives that could be used for the pharmaceutical companies, doctors, and patients to curb excessive prescription use in the Spanish system.

Although the Spanish case isn't a good example of the "commons", as we'll see below, the PLoS authors seem to discount the Spanish authors' solutions while taking liberty to extend the Hardin parable in a vague way to global public health and antimicrobial resistance: "Protecting the antimicrobial commons, and hence the collective best interest, may require society sometimes to act against an individual patient's best interests. The Spanish authors weren't arguing to limit necessary drugs, only to prevent overuse. There are no "antimicrobial commons", and why come out of the gate acting "against individual patient's best interest"?

To be fair, what the authors try to do, integrate antibiotic resistance and economics and public health via a framework borrowed from the 1960's, isn't an easy feat. Hardin himself warned in an article in Science (vol. 280: May 1, 1998):

"A final word about interdisciplinary work -- do not underestimate its difficulties. The more specialties we try to stitch together, the greater are our opportunities to make mistakes -- and the more numerous are our willing critics."

Though Hardin's original essay gained tremendous popularity, it also attracted criticism both for its methods and subject matter. The original essay addressed the overpopulation "problem". Hardin proposed that the "right to breed" could never be resolved or managed by government and the implications were disastrous. However, history doesn't support the catastrophe he predicted. Population growth was controlled via individual family planning. Virtually all developing countries' populations decreased with development that resulted in better public health, female education and increased wealth. But the "problem" still has it's staunch supporters in Malthusian circles, and Hardin recently said (1998) (Science:162): "The reality that underlies all the necessary curtailments is always the same -- population growth."

The failure of Hardin's predictions about population growth doesn't rule out use of the "commons" framework. It has been applied to great effect for conceptualizing environmental problems. But any model, no matter how popular, needs to be measured against the historical record and applied only with care to contemporary problems.

The authors claim: " Hardin's tragedy of the commons has proved to be a powerful analogy for understanding the problem of protecting the benefit we all receive from public goods". We argue that it is not the best analogy. As privatization has become the norm, the concept of a "common" resource becomes almost anachronistic. In the case of antibiotic resistance, it is neither powerful nor an applicable. There are more powerful models that provide better framework to analyze the problem.

Antibiotics are Private Goods

Different disciplines have different vocabularies for the same phenomena that are equally valid, but in the case of public goods economists can do better then the simple "commons" parable. Economists define "public" goods and distinguish them from from "private" goods. A public "good" benefits society and can counteract a "bad". The definition is refined by considering concepts of "excludability" and "rivalry". Lighthouses are the prototypical public good, with non-excludability and non-rivalry, as is national defense. No one can be excluded from using a lighthouse or public defense, and one person's use does not hamper another persons use. For a non-rivalrous good the marginal cost of consumption is zero -- it doesn't impose on society. Non-excludability of a resource, whether it's a light from a lighthouse, national defense, or a broadcast on public airways, is a requirement for a "public good", as is non-rivalry.

Economists further refine these ideas by distinguishing between pure and impure public goods, and pure and impure private goods. A lecture in a public auditorium is an impure public good. Although many people can listen, each person who listens limits the future number of other people who can listen in the space, and is in this way rivalrous. Ocean fisheries are similarly impure public goods, because they are rivalrous, although people for centuries imagined the oceans as a limitless resource.

Club goods such as health clubs and churches are excludable. All private goods, like clothing and haircuts are both excludable and rivalrous. Such services and manufactured consumer products are considered pure private goods. Medicines are considered private goods, however private medicines can be distributed by public programs - but they're still private goods. Exceptions include world wide polio vaccination program, which could be considered a public good.

This framework is not perfect for determining whether a good is public or private. Close examination of such a complex problem is still difficult, but the framework makes it easier to discern whether a problem has more public features or private. Perhaps in a case of nationalized medicine like Spain, antibiotics are not purely private or public, however from a global perspective, antibiotics are private goods. Antibiotic resistance is a global problem.

Antibiotics are sometimes extremely scarce and sometimes abundant. In rural areas throughout the world people die of simple infections that could be cured by antibiotics. In other places like some cities in Asia, antibiotics are priced at steep discounts and used with utter abandon in combination with various other traditional and allopathic medicines. But in both cases private industry determines the scarcity or glut.

An article written by Steve Stecklow and the late Daniel Pearl, from the Wall Street Journal, August 16, 2001, available here at essential.org, illustrates the extent to which privatization determines the supply of antibiotics. The article describes the influence of various players in the pharmaceutical industry in India. It details some of the profit incentives of pharmacies (which often stand in for doctors in India). The pharmacists' relationships with pharmaceutical companies become arguably more important than the individual patient. The incentives of the pharmacists influence drug sales and in turn affect the use and misuse of drugs:

"Mr. Patil [a pharmacist] also didn't disguise his motivation for recommending certain brands. 'The ultimate decision is based on what the margins are," he said. For fevers, he usually recommended a generic version of the antibiotic Ciprofloxacin; a recent incentive deal from an Indian manufacturer offered him a 250% profit margin and a chance to win a motorcycle..."

Pharmaceutical companies refuse to develop drugs for markets that can't afford to pay, and pharmaceutical companies supply drugs cheaply when there are surpluses. The ethical quandries with this model abound, but pharmaceutical companies consistently act as rational for-profit private entities.

What Are Our Values? The Commons, Individuals, Life & Economic Costs

Antibiotic resistance could be considered a global public "bad". It hasn't always been seen this way. Doctors in the U.S. have been cognizant of antibiotic resistance for decades and have counseled American patients about conservative use of antibiotics. But they ignored or were ignorant to egregious misuse of antibiotics overseas and for the most part failed to conceive how this might effect the US. Antibiotics are not a global public good because they are privately developed, manufactured, sold and managed according to the profit motives of pharmaceutical companies. Pharmaceutical companies influence politicians to pass laws favoring the sale of drugs. The participation of lawyers and politicians is as instrumental to the problem as the prescribing habits of doctors.

This is not a simple dynamic between some individual herders and a pasture. Antibiotics are not a free resource open for public consumption, but a private product sold to consumers by pharmaceutical companies for profit. Yet surprisingly, the word "pharmaceutical" does not appear in the PLoS article. Neither do the words "industry", "company", or "business". The word "drugs appears twice:

  • 1) "Most worryingly, some bacterial strains are resistant to multiple classes of drugs"
  • 2) "...development of new drugs...comes at considerable economic cost."

It's telling that pharmaceutical companies remain unidentified in the article as playing a role. It's their market! It's also telling that "economic cost" makes the potential solution of research and development of new antibiotics unpalatable to the authors, even when they compare it to the "moral dilemma" of not treating patients.

The authors run through many possible solutions to the problems -- curbing prescriptions for viral infections, limiting antibiotic use in agriculture, government incentives for drug development. But they seem to toss these valid solutions aside because they don't fit the text of Hardin's original 1968 essay. Indeed the authors note at the beginning of their essay:

"What is most important for our discussion, however, is Hardin's key insight that a tragedy of the commons lacks a technical solution, which he defined as 'one that requires a change only in the techniques of the natural sciences, demanding little or nothing in the way of change in human values or ideas of morality.'"

Since their article hinges on Hardin's assertion that there is no "technical solution", it's as though they fixate on an answer that seems most likely to satisfy the 1968 article; the one that most emphatically challenges notions of "human values or ideas of morality." They seem to recognize all the misuses of antimicrobials in exhaustive lists in their essay while at the same time recognizing the international disparities in prescription guidelines, but then they toss these key issues aside in favor of their histrionic proposal that we: "face up to the reality of a tragedy of antimicrobial resistance".

It seems that to these authors, contemplating the loss of individual life is less horrifying than contemplating a change in the paradigm of how antimicrobials are distributed. Similarly, when the U.S. government contemplates climate change, it dismisses any proposal that might alter the economic incentives for the entrenched fossil fuel industries. Have privatization and sustaining business profits become subsumed as "human values", and taken precedence over other "human values" that we used to claim such as individual lives and liberty?

Brave Policy Decisions

It is difficult to take seriously proposals that omit important pieces of the problems they claim to consider and discard solutions that they claim to seek. An obvious snag in the logic of the PLoS author's solution, leaving selected patients untreated, becomes clear when imagining the difficulty of imposing such a broad solution successfully, given their assertion that none of the other smaller scale government solutions they considered seemed to suffice.

The biggest problem with applying the metaphor of the "tragedy of commons" to antimicrobial resistance is that it's too vague and amorphous an analogy. There are more cogent and analytical frameworks for contemplating the problem of antibiotic resistance, and by comparison, the "tragedy of the commons" only invites criticism. At best it seems like cultural shorthand that stands in lazily for a more clear-eyed, rigorous, nuanced delineation of a problem.

Such an analysis might question the contention that individuals are best served by international patent regimes that strong arm countries into limiting development of essential medicines -- a view that the authors endorse. This patent protection purportedly motivates pharmaceutical companies to develop new drugs. But if this were true, than why continue excusing companies from not developing drugs because of "economic cost"? If this "...careful use of patents", did indeed encourage drug development, than why would the profit reinvestment need to be further augmented by "government investment" -- especially when governments already provide the means for basic research upon which most drugs are developed?

We could also question how individuals could possibly be culpable for antibiotic resistance: "every herdsman knows that putting too many cows upon a pasture will eventually destroy it by overgrazing. Who "knows" more? The patient in India who walks into the pharmacy as in the WSJ article, hoping to cure their illness? Or the pharmaceutical company that sells them the drugs? Furthermore, does the right of a company to spare "economic cost", trump the right of an individual to spare his own life with medicine that he pays for either with cash at purchase or with taxes he pays to support national healthcare?

While the authors readily acknowledge many features of the antibiotic resistance dilemma, they do no service in forwarding the notion that individuals should bear the brunt of inefficient antibiotics distribution. For years pharmaceutical companies have propagated antibiotic resistance with greedy business practices like dumping pharmaceuticals into markets where their cheap price practically guarantees overuse. Whether the individual is an MRSA patient in a London hospital, an AIDS patient with an opportunistic infection in South Africa or India, an ill aunt in Spain, or a child with strep throat in the U.S., the individuals with infectious diseases are not plundering the drug supply, nor are they responsible for the problem of antibiotic resistance.

The authors conclude that "difficult choices" are in store that may "require brave policy decisions". If governments enacted policies that sacrificed individual treatment via antibiotics would this really be "brave"? This seems routine, business as usual. However, what if governments chose instead to contemplate aspects of the current for-profit paradigm of pharmaceutical companies, the issue that the article published by PLoS; "Do We Need to Put Society First? The Potential for Tragedy in Antimicrobial Resistance", tries to ignore? Wouldn't that be "brave"?

¹ Francis McGovern; "The Tragedy of The Asbestos Commons", Dec. 2002; Virginia Law Review Vol 88, No. 8.

Rebuilding After the Tsunami

Temporary Optimism For Temporary Housing

Following the tsunami there was quite a lot of media coverage focused on the outpouring of support for rebuilding communities demolished by the sea. The waves killed hundreds of thousands of people across Southeast Asia. In Aceh, an estimated 120,000 houses needed to be rebuilt.

The tsunami has long lasting human tolls, not only in deaths, disease, ruined livelihoods, and material destruction. It also eats away at optimism. Following the tsunami proposals for temporary housing in Aceh poured out. But not Indonesia's rebuilding is bogged down in the harsh realities of bringing the project to reality.

At one time, it seemed like arrangements for temporary shelter would quickly emerge from the many proposals highlighted by the media....

  • Harvard/MIT's "Sri Lankan house", touted as not only economical but "built with local materials and engineered to withstand a tsunami".
  • Architecture for Humanities' structures, designed specifically for use in India and Sri Lanka.
  • World Vision's project of 139 houses, lauded "as 'best practice' in post-tsunami rebuilding".
  • Projects NPR noted were low-cost and framed with cheap, flexible, strong bamboo.
  • Homes by architectural wunderkind Daniel Libeskind, who worked pro bono to rebuild a town in Sri Lanka.

There were a plethora of architecturally innovative ideas from universities and architects for sustainable projects and innovative solutions. But now building progress on temporary housing stalled because of a shortage of wood, according to a Financial Times. 67,000 people still living in tents and "only 800 of the planned 20,000", temporary homes are finished in Aceh. What happened?

Sourcing Lumber From Canada

Materials for rebuilding turned out to be the sticking point. Concrete used in many places isn't a sound seismic choice. Steel and tin were initially used for temporary shelters in the Andaman and Nicobar Islands, turn out oven-like structures which are uncomfortable for the climate. Solutions poured in but wood was the most practical building material. therefore reconstruction depends on lumber sourced from foreign countries. (Still, illegal logging in places like Gunung Leuser National Park by industrious entrepreneurs threatens to destroy local forests.)

Conservation International wrote that they successfully advocated for the use foreign wood . By May of 2005, donations had been offered from US, Australia, Belgium, Finland, Sweden, New Zealand, Germany, and Denmark. British Columbia wooed Indonesia with their ideas of wooden prefabricated homes, cut from Canadian forests, shipped to Aceh, then trucked to villages and assembled.

Getting timber from places like Canada however, ties progress to shifting environmental standards, the "inexperience of many aid agencies in sourcing large amounts of wood.", and promises like: "a UK-based timber broker was expected in coming weeks."

In addition to the challenges of sourcing timber from far flung places such as Canada and Sweden, organizations coordinating rebuilding efforts must also get clearance from the bureaucratic Indonesian government. So, along many NGO's have neat press-ready plans to show and tell, but scaling those plans and coordinating all the agencies to meet the epic challenge of the massive reconstruction effort of the tsunami isn't easy.

Little Cardboard House Models

The challenge of affordable, sturdy emergency housing has been solved over and over again by innovative teams of architects, at universities and via the dedication of non-profits and lots of generous support. But the problem remains historically unresolvable. An article in Slate last year described the issue:

"Architects in the past have proposed a variety of ingenious shelters, including prefabs, inflatables, geodesic dome kits, sprayed polyurethane igloos, and temporary housing made of cardboard tubes and plastic beer crates. As Davis [the author refers to Ian Davis, who wrote the book Shelter After Disaster (1978)], points out, not only are these often untested 'universal' solutions generally prohibitively expensive, their exotic forms are usually ill-suited to local conditions. That may be why such shelters, when they have been deployed, have frequently been rejected by users, and why historically the most common temporary shelter is the tent. Emergency housing sounds compelling, but it almost never works."

This wouldn't be a surprise to citizens of the areas hit. Six months after the crisis, many areas had already tired of the slow, spurious progress. In India the Habitat for Humanity proposed one model for a house for Tamil Nadu. Prompted for a reaction when shown "the little cardboard house model", a lady from Killai commented:

"People have been here before talking about houses; now they are gone. You are here now, but how do I know you will come again?"

Temporary housing is not the only rebuilding issue. Aid organizations overseeing the rebuilding of thousands of boats that were also destroyed in the tsunami report conflicts size and technology of the boats being built; many are smaller than the larger trawlers they are replacing, which may lead to over-fishing in shallow waters. The boats are also apparently made of unseasoned wood, because of the timber shortage, which is far less seaworthy the seasoned wood.

Though many of the problems are expected given the scope of the disaster, life remains on hold for thousands of Indonesians on Aceh still living in "rotting" tents while agents track down millions of cubic feet of lumber half a world away.

Schatten in Stem Cell Controversy

Gerald Schatten of the University of Pittsburgh, senior author of a now retracted stem cell paper in the journal Science, has cited for "scientific misbehavior" by an ethics panel at the University according to media reports today.

At issue was his endorsement of the paper as senior author, without fulfilling the duties of that honor by verifying the accuracy of the research. The panel also took issue with his shifting accounts of his responsibilities. According to the New York Times:

"He told the Pittsburgh panel that he had written most of the text of the 2005 paper. Three weeks later, he told Seoul National University that he had not written the paper, the panel said."

In other news of the investigation in Korea, Science reported that about 2,221 eggs were used from 119 women, not 427, as the paper initially reported. Science covered more issues with the research this week in "Investigations Document Still More Problems for Stem Cell Researchers."(311: 5762 p. 754). Korean researchers have requested that Schatten travel to Korea according to the article. Schatten remains silent.

Climate Change

Berkeley Open Infrastructure for Network Computing ("BOINC") put distributed computing to use again for studying climate change in the summer of 2004. The first project employed by the Berkeley system was the project to Search For Extraterrestrial Intelligence (SETI) and has been used for several other problems that require vast computing resources. The latest, climatepredition.net, is an Oxford University application simulating climate change from 1920 to 2080. There are about 12 participating institutions and about 95,000 users from 139 countries are currently participating. Climateprediction.net has descriptions of the experiments users will be running, as well as initial results, information about classes and user forums.

WTO, the EU, the US, and GMOs

In August of 2003, the U.S. asked the World Trade Organization (WTO) to step in to force the hand of the European Union in a disagreement over the EU's ban on genetically modified organisms (GMOs). Europe has long resisted using genetically modified crops and foods, much to the consternation of the U.S., home to several corporate giants who sell their products world-wide. The case involved the purported "moratorium" on GM imports and Argentina and Canada backed the US.

Yesterday the WTO issued a preliminary ruling saying that the EU had effectively barred the products and the action conflicted with the WTO trade regime. Businesses and the US Department of Agriculture (USDA) reported vindication. However the EU is claiming that the WTO ruling does not effect its current bans, and that it never had a "de facto moratorium".

Acronym Required previously wrote about transgenic crops, the EU v. US, in another case here.

Zimbabwe: Hopeful News for HIV/AIDS Prevention?

Progress in halting the deadly progression of HIV/AIDS takes concerted effort led from the tops of governments. We have examples in Thailand, Uganda, Brazil, and Senegal, which have periodically decreased HIV infection rates through behavior change. In Thailand it was through education and condom promotion, and in Uganda via their "ABC" program -- for abstinence, "be faithful", and condoms, implemented in the early 90's. The governments that showed progress made slowing the human and economic toll of the disease a priority of their administrations and poured tremendous resources into the effort. But even with these efforts success has been sporadic. Uganda undermined its program last year by collaborating with the U.S. world AIDS project that promotes abstinence only. The new campaign does not support condom use, in fact promotional material was distributed declaring condoms to be porous, along with the "new" message that pre-marital sex a form of "deviance", reports Human Rights Watch (HRW).

Thailand's program has sometimes wavered, but after an up tick in infections Thailand in recent years the country is reporting decreased deaths in 2005 due to the new availability of anti-retroviral drugs (ART). Senegal has an infection rate of about 1%, compared to rated of 25-30% of some African countries. This is attributed to strong government intervention and concerted longtime measures at education and prevention. Brazil's comprehensive program includes prevention and treatment. The latter goal was attained only through Brazil's fierce perseverance in manufacturing drugs and providing free treatment to all citizens despite obstructive international politics around patent and trade regimes.

Public health advocates studying HIV/AIDS epidemics are experienced enough (in grim, close-up, heartbreaking terms), to acknowledge that long term success requires consistent intense effort. To date, any level of "success" includes political activism from the highest levels of government (and as in Brazil's case, from activist citizens), participation and leadership by women, access to medication, public campaigns (for instance via churches and radio) and community education to de-stigmatize the disease and promote testing and monitoring. This is in a addition to supporting behavior modification, building vital public health infrastructure, having financial resources and trained medical staff. This isn't necessarily an exhaustive list.

Brazil's success in particular is instructive and hopeful, however that country has clear advantages because it is one of the world's largest economies and has some historical idea of what public health infrastructure looks like. Most countries where AIDS rampages are extremely disadvantaged by comparison.

Contrary what most public health advocates agree makes as effective prevention policy, the Bush administration pushes an "abstinence" only message that lets a lot of these success factors slip through the cracks. For example, abstinence until marriage without condoms leaves women, who have 40% infection rates in some countries, tragically vulnerable. No access to drugs or treatment gives some people little incentive to be tested. The policy flies in the face of decades worth of scientific experience and leaves many who are engaged in preventing and controlling HIV/AIDS sputtering with frustration.

Yet to confuse matters perhaps, researchers reported last week that in a province in Zimbabwe called Manicaland, HIV infections decreased between 1998 to 2003 from 23 percent to 20.5 percent by delaying when they first have sex and having fewer casual partners. The research by scientists at the Imperial college of London showed that people had modified their behavior over the years resulting in the "first" reduction of HIV infection in sub-Saharan Africa, the region most stricken by the spread of the virus. The study; "HIV Decline Associated with Behavior Change in Eastern Zimbabwe", was published in last week's Science: (Gregson et al.: Vol. 311. no. 5761, pp. 664 - 666).

The news is hopeful and confirms reports by the World Health Organization last year. Yet many are warning that these research findings are open for interpretation and could possibly undermine the fight against the disease. If some of the factors assumed to be necessary for success, like political leadership and public health infrastructure, are important to the mitigation the disease, as public health advocates almost uniformly concur, Zimbabwe's current government has the opposite profile. This study takes place against a backdrop of political depravity, violence, eviction, forced migration, a depressed economy and international isolation, a situation that seems to only worsen.

In addition there is inherent difficulty interpreting these types of studies. For instance Bush's abstinence idea is purportedly based on Uganda's erstwhile successful ABC program. But a study last year from Uganda concluded that HIV infection rates had actually decreased because of condom use and high mortality rates (C and D (death)), not (A and B) of the "ABC" program. Acronym Required wrote briefly on this last year. Increased death rates would lead to spurious results because individuals with multiple partners would die off and distort the distribution patterns of the population and the interpretation behavior-infection link over the course of the study. The authors of the current study seem to address this: "given the relatively small numbers of individuals who died, AIDS-associated mortality explained only 6.3% of the observed reduction in sexual partner change in men and 8.6% in women.... They add: "It cannot be discounted as an important long-term factor." (Does their death rate seem low?)

In addition, the number of changing variables within the data make it hopeful but challenging to believe that the results (even assuming reliable data) represent long-term success. So perhaps the study is good news, anything that implies a positive change in the HIV/AIDS situation is good news, however only time (or a more nuanced understanding of the data) will tell.

Circle of Trust

Our last commentary touched on lying, a familiar topic. Today the New York Times magazine publishes a general overview of the science of detecting lies. Author Robin Marantz Henig, reviews the research of catchily coined "credibility assessment" - including magnetic resonance imaging (MRI) and electroencephalography (EEG). As we would surmise in this epoch of top-secret government, reliable lie detection technology is coveted but elusive. Since many areas of the brain are involved with different types of lying and the recruitment of different areas is often unique between individuals, no technology so far - however sophisticated - is quite trustworthy enough. In fact they often have the same downfalls as the polygraph, for instance they give results that are sensitive to a variety of emotions or states of mind that aren't always indicative of lying.

There are several agencies in the U.S. government developing lie detection technology including the Department of Defense Polygraph Institute and the Department of Homeland Security. The author discusses some of the implications of using the available technology and quotes the DOD Polygraph Institute research head who notes that they only "develop the science", while "other people" decide how it's used. Cliche and familiar, but also a controversial stance in the evolving theme of science, society and responsibility.

According to the article some regard lying as an evolutionary step to intelligence -- maybe those who can outwit those inside and outside of their clan are more clever. It's an extensive article apropos (naturally) to current events.

Groundhog Day

We're quite accustomed to lying. Some may feign shock - as they did when a slump-faced, shifty-eyed, quivery-lipped Frey confessed to Oprah, the arbiter of truth, that his book was a pack of lies. It seemed like more genuine disbelief when the stem-cell myth slowly unraveled and the legacy of Hwang did a landslide shift from "supreme scientist" to he who would have had a street named after him, could have had a museum named after him, or would have been forever revered by his countrymen. Really, all this shock can't be more than an act. Maybe all jurors should be chosen from Oprah audiences; but lets be honest about the pretend "surprise" of it all. The routine deceptions are no more surprising than Groundhog Day (the movie). With all the Enrons and WorldComs and Katrinas and Iraqs, isn't it just the same day all over again?

Cut to Bush's State of the Union address. People recoiled at his proclamation about banning any sort of cloning research, "human cloning in all its forms; creating or implanting embryos for experiments; creating human-animal hybrids; and buying, selling or patenting human embryos". It has been widely pointed out that animal-human chimeras are a not so very scary part of health research. What Bush proposes also pertains to infertility treatments used by thousands of couples today to have families. People speculate about what he really means.

On energy, Bush said we were "addicted to oil" and that we would reduce our dependence on mid-east oil by 75% -- "through technology". There were arguments about this out of the gate -- the reductions weren't realistic or feasible and only 20% percent of our oil comes from the mid-east anyway. Indeed, say Bush's aides according to the Philadelphia Inquirer today, the President did not mean any of this literally. "This was purely an example", Energy Secretary Samuel Bodman said.

So is the cloning rhetoric also just an "example"? If the administration knows what they say, perhaps they don't really mean it? Outside of the most obvious (and at the moment unfeasible) human cloning and therapeutic cloning "examples" that Bush wants banned, there are some technologies that are essential for the scientifically advanced, humane, non-isolationist nation he promotes. Unfortunately, since the administration has already gone to great lengths to curtail stem cell-like researh, indications are that they will be invigorated by their new court appointees and will continue down this path.

While the intention is certainly there, it seems ideologically distorted. The stated impetus of "a hopeful society...that recognizes the matchless value of every life", rings false. As a small example, why say "no cloning", then merrily "clone" these troops for speech props in this Photoshop picture. Isn't that disrespectful?

The good thing about Groundhog Day (the date) is that one way or another you know that the season or term or trend or silliness will eventually end.

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