Hope is not a plan

This week brings some contrasting efforts to change the world, two happening in the courts, the third ending up in the courts.

In the Netherlands, relatives of people killed in the 1995 Srebrenica massacre are suing the Dutch government. While the Dutch governmental response is that all claims should be made against those who committed the massacre, the plaintiffs in this case argue that the Dutch government is at fault for refusing to provide air support for Dutch troops in Srebrenica. Certainly, it's true that people flocked to Srebrenica as a safe haven, only to find that is really wasn't. You can read more in this BBC article.

Elsewhere, the government of Nigeria, as well as the government of the Nigerian state of Kano, have filed suit against big pharma company Pfizer, claiming that it carried out improper trials for a meningitis drug, and in so doing caused deaths, as well as mental and physical problems. Pfizer holds that it did everything properly, and obtained "verbal consent" from parents of children who were involved. you can read more in this BBC article.

Finally, a plot to violently overthrow the government of Laos was busted up in California. Nine people, led by former Hmong general Vang Pao, were trying to buy weapons en masse to equip an insurgent effort in Laos, with the goal of taking out several government buildings. The Hmong, who you may never have heard of, are ethnic minorities in Laos who were backed and equipped by the CIA during our larger war in Southeast Asia. When we pulled out of the effort, we mostly abandoned the Hmong, although some have filtered over to the US, and others ended up lingering in refugee camps in Thailand for years. The BBC has an overview of the state of the Hmong in Laos here. You can read the full article on this abortive insurgency here.

Harm reduction is the notion that public policy should be aimed at saving lives and keeping people healthy, rather than moralizing at them at the expense of everyone's public health. A classic example of harm reduction at work is needle exchange programs, in which people can bring in used hypodermic needles and acquire brand-new, sterile ones.

The California State Assembly this week moved toward greater harm reduction with a vote to repeal a ban on funding needle exchange programs with state money:

Despite opponents' assertions that needle exchange programs promote drug use, they have been legal in California since at least 1999, if authorized by a city or county. Local and state funding of the programs is also legal, but California law prohibits the use of state grants to pay for the needles themselves. The federal government does not fund the programs.

On Friday, the Office of AIDS in the state Department of Health Services approved $750,000 a year for three years to 10 needle exchange programs to cover staff costs, program expansion and purchase of any materials except needles. They include programs in Berkeley, Oakland, Hayward, Santa Rosa and Santa Cruz and an organization in Alameda County.

People who say that needle exchange programs promote drug use like making baseless assertions without bothering to check in with the public-health benefits of these programs. Consider the case of Australia, which moved into needle exchange programs in a big way in the early 90s. A recent study looking at the return on investment in Australian needle exchange programs showed that cities with such programs saw an annual 18.6% drop in HIV prevalence, compared with an annual 8.1% increase in cities without such programs. In other words, the total HIV burden on cities actually drops when needle exchange programs are in place.

So that means fewer people with HIV, and fewer deaths -- but it also means massive cost savings. Needle-exchange programs have cost various Australian governments $130 million since their inception in the early 90s...but over the course of that decade, they saved those same governments at least $2.4 billion. A 1700% return on investment would be awesome if you hit it in the stock market, and is just as amazing when it's your tax dollars being saved.

Harm reduction means setting aside the desire to punish and moralize, instead choosing to help your fellow humans first and foremost. In doing so, we usually realize that we, too, benefit from this approach -- both in compassion and in hard, empirical finance.

Abu Djana, the current military leader of Jemaah Islamiah, was captured this week by Indonesian security forces on the island of Java. Djana was wanted in connection with a number of attacks, including the 2004 bombing of the Australian embassy and others. Indonesian security officials couldn't be sure that the man they'd wounded during a raid was really Djana until they carried out fingerprint and DNA analyses to confirm his identity.

Analysts say Abu Dujana has key information about logistics and operations within JI, and his arrest will be a serious blow to the organisation.

"If he is willing to talk he will be able to tell the police about the structure, the strength, the finances and the international connection and the goal and objectives of JI," she told reporters.

"Willing to talk" is an interesting way to put it.

BBC article
al Jazeera article

When the president wants to make a temporary end-run around Congress, he uses a recess appointment to place someone in a position. This avoids any sort of confirmation hearing. This provision was not actually put in place to let the president avoid hearings, but rather to let him assign people to critical roles even when members of the Senate were, perhaps, weeks away by carriage from the capital. In the late 18th and early 19th centuries, recess really meant recess, and people weren't going to be able to come back quickly.

However, as discussed in this GAO report penned by Gary Kepplinger, Congress is well within its rights to deny pay to any recess appointee. The report was actually addressing a weird confluence of regulation and Constitutional law. Congress can deny pay to an appointee that did not receive a confirmation, and certain rules prevent unpaid work by government employees. However, it has been deemed unconstitutional for Congress to be able to deny the Constitutionally-provided recess appointment right by denying pay -- so the "no work without pay" rule is effectively waived in this case.

Or, more briefly, if Congress doesn't like a recess appointment, they can't stop it, but they don't have to pay the appointee a salary.

The specific appointee in this case was Sam Fox, entrepreneur, Swift-Boat-ad-campaign backer, and now volunteer ambassador to Belgium.

In case you missed it, Gaza has gone to hell recently. President Mahmoud Abbas has sacked the Hamas-led government by declaration, but they're having none of it, given that they've routed the Fatah security wing and overtaken the Palestinian Authority's official buildings.

For an American perspective, al Jazeera turned to Shelly Smith, a 42-year-old high school teacher who lives and works in Gaza. Her account is grim:

Our neighbour Waseem Arafat had gone to the Shifa hospital in Beit Hanoun to visit someone and when he came out a gunman shot him four times in the head.

Shortly after Ronald Reagan came into office, Iran released the sixty-six hostages it had held for over a year.

Hamas is now following Iran's example, trying to mark a political shift with a hostage release. According to a Hamas spokesman, they're calling for the release of BBC journalist Alan Johnston.

This is a clear sympathy play by Hamas, who've spent much of the last week killing random civilians as they pushed Fatah out of power. Doubtless, they do have the power to lean on Alan Johnston's kidnappers, the self-styled "Army of Islam". They almost certainly had that power two weeks ago, too -- but they didn't need to make up for deaths and mass destruction two weeks ago.

hedge, v

1. To plant or cultivate hedges.
2. To take compensatory measures so as to counterbalance possible loss.
3. To avoid making a clear, direct response or statement.

(from The Free Dictionary

According to DOD spokesman Lt. Col. Christopher Garver, the US has now finally deployed the full 28,500 troops of the "surge" and counterinsurgency operations can finally get under way.

"All the forces initially identified as part of the surge have completed their strategic movements into theatre in Iraq," he said.

"Now everyone is here, this is when General Petraeus intends the surge to start as it was envisaged, with everyone working together to bring the levels of violence down in Baghdad."

But maybe not really:

He warned it would take 30 to 60 days for the final brigade, which arrived this week, to become fully operational.

Now, while it may confuse some people like John McCain, who thought the surge was already working, apparently the surge is only now, finally ready to start working. Or, perhaps, it's ready to start working in one to two months. It's clear that the consequence aversion disease is as robust as ever, as spokespeople get stuck with the unenviable task of making rah-rah declarations about the surge while still hedging heavily so that people aren't disappointed if things don't work out. Rather than move the goalposts after the fact, the strategy now is to populate the field with goalposts in series, in the hopes of hitting a positive note on at least one of the goal lines. For the surge, we could have claimed success from good outcomes (1) at the start of the surge, (2) right now, with all the troops in place, (3), in a month or two, or (4) a month or two after that, since that's a month or two after the 30-60 days to get the final troops up and running. So if you haven't seen anything good out of Iraq by the end of August, be prepared to be told to wait another two months -- to "give the surge a chance to work," in the paraphrased words of George Bush.

The Bush strategy now is this -- if you set up enough benchmarks, maybe you'll actually hit one of them and claim success. Like a bad cold reader trying to cheat you out of five bucks, the Bush administration throws out as many goals and timelines as possible, in the hopes that one will end up smelling like success.

The hope now rests on the intelligence and creativity of our troops and General David Petraeus, because all Bush's "surge" has done is push our troop total to 88% of our 2005 level, far short of what's really needed to fight an insurgency. If our troops can't pull this one off, I don't blame them at all. Bush won't blame them either, but only because that's politically unsound. He'll blame a lack of support at home, or the Iraqis, or al Qaeda, or maybe some other scapegoat that's just a glimmer in Karl Rove's eye.

But that won't happen yet. There are still some goalposts to move.

On effectively taking power in Gaza last week, Hamas promised to free kidnapped BBC journalist Alan Johnston, in a face-saving gesture of goodwill from a group that was, until recently, shooting random bystanders in the head during their fight with rival group Fatah.

Johnston's kidnappers, a day club referring to themselves with no sense of irony as the "Army of Islam," issued a quick declaration that they were, under no circumstances, handing Mr. Johnston over.

Hamas has now indicated that if the handover doesn't happen soon, they're going to free Johnston by force. The "Army" replied that it will kill Mr. Johnston if this happens. Their own set of demands revolves around Abu Qatada, who is currently facing deportation from the UK on the grounds that he's a terrorist. Of course, given their declarations about how killing Mr. Johnston will bring them "closer to God", it's clear what their real motivation is.

Hopefully, Mr. Johnston will emerge safely from the care of this cadre of losers, regardless of what happens with Hamas or anyone else.

It's a popular pasttime in the US to point to the UN as a bloated, inefficient entity that really doesn't deserve our money. Certainly, strange decisions are made by parts of the UN, like the incomprehensible vote that put Zimbabwe in charge of the commission on Sustainable Economic Development. In a report titled Peacekeeping: Observations on Costs, Strengths, and Limitations of U.S. and U.N. Operations, the GAO addresses the issue of the relative efficiency and capabilities of the UN and the US in peacekeeping operations. In short, does it make more sense for us to send our own troops, or to give the UN money to send in a UN-led force?

This is an important issue both because the US is already stretched across quite a few military commitments right now, and because peacekeeping operations are pulling in a lot of American money.

The GAO analysis used as a point of comparison the current UN stabilization mission in Haiti (MINUSTAH), and estimated the cost of an equivalent peacekeeping mission as carried out by US forces. The punchline?

An American peacekeeping mission would cost roughly twice as much as its UN equivalent. The major cost differences come primarily in salary and housing, as we pay our troops and civilian elements much more than the UN does, and we'd put more money into housing our civilian employees in secure facilities.

Add to that something I didn't know, namely that the UN actually practices realistic budgeting:

This table shows that the UN has consistently come in somewhat under budget for the entire MINUSTAH peacekeeping operation in Haiti. In contrast, the American practice of late has been one of very unrealistic budgeting, especially for military operations. Part of the problem there may be that, unlike in our prior wars, we have not yet integrated the war into the regular budget, instead funding it with emergency appropriations.

Obviously, cost is not the only factor involved in the decision of "who to send." The GAO report addresses some of the key elements to consider for each force.

For the US:

• Rapid deployment - We have the best airlift capacity in the world, and can have troops on the ground within the critical first 6-12 weeks following a ceasefire or peace accord. No one in the world can match us on this.
• Unified command and control - Naturally, since an American force consists of troops from one nation.
• Superior training and equipment - Remember how we pay our troops more? It matters.
• Shortages of skills and equipment - As mentioned, American military forces are stretched thin right now, and we might not have people to spare from Afghanistan and Iraq.
• Perceived lack of impartiality - This is why we didn't try to directly intervene as a peacekeeping force in Lebanon in 2006.

For the UN:

• Multinational participation - This is one way to avoid the perceived lack of impartiality mentioned above. If a force consists of several nationalities, it seems more likely to be fair.
• Experienced peacekeeping officials - The UN has people whose entire job is peacekeeping operations. They have experience from earlier peacekeeping efforts that are transferable ot each new operation.
• Able to coordinate international assistance - Similarly, the UN is geared for international cooperation, and can channel aid in from donors, the World Bank, and so forth.
• Limited rapid deployment - In a mirror of the American strength above, UN forces just aren't put together and deployed quickly. It takes time to round up troops from member nations, to put a command together, and then to put people in place.
• Limiteds on command and control - As a multinational force, any UN peacekeeping group is potentially a lot more disorganized and chaotic than a one-nation force. Also, as the report notes, UN peacekeepers have been caught comitting crimes and abuses, but appear to rarely face disciplinary action.
• Varying equipment and training - Not all nations have the same standards for training and equipping their troops. Some nations have sent troops with basically no equipment, which then puts the burden on the force commander to equip them. Similarly, undertrained troops may lead to the abuses cited above.

The final conclusion is, of course, that there are reasons to go either route. If you want fast, disciplined, and expensive (and the risk of inflaming the situation due to past history), pick a US force. If you want slower, experienced, cheaper, but potentially disorganized, go with a UN force.

The real conclusion, as far as I'm concerned, is twofold. One, the UN does something we currently don't -- they make realistic budgets. Two, we can't afford to carry out anymore peacekeeping operations anyway, so we might as well ditch some of our knee-jerk, know-nothing responses to the UN and accept that sometimes, it's the right choice.

Excuse me for a moment as I dip into profanity for one sentence:

This asshole just lost his cruel, harassing lawsuit against some unfortunate immigrants who may now well hate America forever. From the BBC article:

A US judge has lost a $54m (£27m) claim against a South Korean dry-cleaning firm which lost a pair of his trousers.

Legal groups have said the case, which has dragged on for two years and involved thousands of hours of legal investigative work, has damaged the image of the US judicial system.

No kidding. The Chungs have indicated that they're considering going back to South Korea. Seriously, who can blame them? Why try at the American dream when some idiot in a position of a authority can destroy your lives because he's got nothing else going on with his? Hell. You can get that anywhere else in the world.

The National Labor Relations Board is calling for Roy Pearson to be debarred, so he can no longer be a judge.

It's kind of sad when your whole life in the legal profession results in a Wikipedia entry about you being a complete schmuck.

Although it's what I expected, I'm glad that our legal system is not so broken as to allow this idiot to win his case. It is broken enough that the poor folks he sued can only now get out from under two years of stress and legal fees.

AIDS has been devastating in Africa. Although HIV/AIDS is a problem elsewhere in the world, Africa is the only place that sees prevalence rates up in the double digits across multiple nations. So what, then, is the problem?

We know that there are still problems getting anti-HIV drugs to people, that other endemic diseases promote AIDS, and vice versa, and that there are quite a few treatment scams out there, despite our best efforts. We also know it's not about promiscuity, since Westerners are likely to have more partners.

Still, the question remains -- what's up? Did AIDS just get too strong a foothold in Africa, and now we're fighting back from a huge disadvantage?

John R. Talbott's thesis is that prostitution is the key to the AIDS problem in Africa. In this PLoS One article, he uses statistical analyses to support his hypothesis that African nations with high HIV/AIDS rates have high levels of infected prostitutes (that is, a large number of prostitutes, and a large percentage of those infected with HIV):

(CSWs are Commercial Sex Workers -- prostitutes)

The statistical analyses seem sound enough, and certainly this concept anecdotally fits with other reports I've read about 90% HIV infection prevalence in prostitutes who serve truck drivers in various parts of Africa.

You can read Talbott's pitch at his site, Africans Against AIDS. Read the PowerPoint for a bit more on his views. Although he equates HIV-infected prostitutes with drunk drivers, he quickly settles down into a rational, harm-reduction-based approach that seeks to punish enablers of prostitution (e.g. customers, pimps) and transition women from prostitution into subsidized jobs.

Talbott is a former Goldman Sachs investment banker, who has written books predicting various market crashes and pushing world democracy.

For the first time in half a decade IAEA inspectors are on the ground in North Korea, ready to begin talks about shutting down and sealing the Yongbyon nuclear facility. This step was overdue per the terms of the agreement North Korea made in Beijing, which said that the shutdown would start by mid-April. Other key points of that agreement:

• UN inspectors to be allowed entry to verify the shutdown
• North Korea to list its nuclear programs and materials derived from them to date
• North Korea to start normalizing its diplomatic ties with the US and Japan, and begin talks with South Korea

In return for all these things, North Korea will receive an initial shipment of 50,000 tons of fuel oil, upped to 1,000,000 tons when Yongbyon is completely shut down. South Korea has also said it will restart food aid now that the shutdown appears to actually be happening.

So why the action now? The likely motivation to move is our release of $25 million in North Korean funds held in a bank in Macao.

Consider just how wrecked the North Korean economy is at all levels, that this amount of money is enough to induce Kim Jong-il to hold up peace talks that he, apparently, was otherwise willing to at least pretend to move on. Obviously, the money's going straight to him, but its importance suggests that perhaps he's unable to imbezzle that money anywhere else out of the destitute economy of the DPRK. Either that, or his ego couldn't stand the prestige hit of having his funds frozen.

US envoy Christopher Hill had a few understandably cautious words about all this:

"I think the next couple weeks are going to be a very important period for the six-party process," Hill told reporters Monday. He expects the reactor to be shut down within a few weeks.

Here's the DPRK's official take on the funds issue:

Pyongyang, June 25 (KCNA) -- A spokesman for the DPRK Foreign Ministry gave the following answer to a question put by KCNA Monday as regards the settlement of the issue of the funds frozen in the Banco Delta Asia in Macao:
The funds frozen at the above-said bank were finally wired as demanded by the DPRK side, thus settling the controversial issue of the frozen funds.
It has thus become possible to use the de-frozen funds for improving the standard of people's living and humanitarian purposes, as planned.
The DPRK took a serious view of the issue of de-freezing the funds not because of that amount of money but the action taken to freeze the funds was a vivid manifestation of the hostile policy toward the DPRK.
This is also in line with the principle of "action for action" confirmed by the six parties. Now that the issue of de-freezing the funds has been settled, the DPRK, too, will start implementing the February 13 agreement on the principle of "action for action."
As part of it, the DPRK will hold a discussion on the suspension of the operations of nuclear facilities, its verification and monitoring with the working delegation of the International Atomic Energy Agency in Pyongyang from June 26.

al Jazeera article
CNN article

Police in Iraq have raided the home of Minister of Culture Asaad Kamal al-Hashemi, missing the Minister but arresting six of his bodyguards. Hashemi, a member of the Sunni Iraqi Islamic Party, is thought to be spending some time in Jordan right now.

The charges involve the early 2005 murder of the two sons of Sunni politician Mithal al-Alusi. Hashemi was not the Minister of Culture at the time.

The warrant for Mr Hashemi's arrest was issued on Monday by Iraq's Supreme Judicial Council.

"The minister was then an imam in a mosque."

The response?

Mr Hashemi's party condemned the arrest warrant as part of the "marginalising policy against prominent Sunni leaders to push them away from the political process".

It warned the Iraq's Shia-dominated government to avoid "playing with fire by continuing the policy of fabricating lies to exclude Sunni politicians and officials from the Iraqi arena".

Who do we believe? Hard to say.

BBC article

As I discussed in May, the government of Iran has spent the last year trying to figure out how to solve its gas problem. Despite its large oil reserves, Iran has very little refining capacity, and thus is forced to import gasoline. For years, the government has been subsidizing these imports, keeping the prices very low and doing great harm to the national treasury. Since sometime in 2006, they've been thinking of easing off on these subsidies while simultaneously putting in place a gas purchasing cap.

This week, they enacted a cap.

It did not go well.

With less than two hours notice, the government or Iran announced to its citizens that they are now limited to 100 liters of fuel (26 gallons) per month.

Riots broke out soon after, and twelve gas stations were torched in Tehran.

"Guns, fireworks, tanks, [President] Ahmadinejad should be killed," chanted angry youths, throwing stones at police.

Some Iranian members of parliament are calling for a relaxation on the cap, citing the improbably short notice the government gave. The government of Iran is, in turn, presumed to be trying to cut down on its fuel imports before someone (like, say, the US) decides to cut off the gas supply by way of applying pressure against Iran about its nuclear program, interference in Iraq, funding of Hezbollah, or anything else that strikes their fancy.

BBC article

Senator Richard Lugar and Senator George Voinovich, both senior Republicans, have called this week for some kind of coherent Iraq exit strategy to be developed.

Senator Voinovich had this to say:

"It's time for the United States to put together a comprehensive plan for gradual disengagement in Iraq," Voinovich said. "We're running out of time and I don't think it's fair to the next administration to say, 'Hey by the way, we're leaving this baby for you guys to figure out.' "

It's inspiring to see a partisan voice clearly call for not making this "someone else's problem", where that "someone else" is anyone other than George Bush, Dick Cheney, and friends.

Senator Lugar said this:

"The president may believe that he can simply continue on with or without the congress, but I think he is wrong in that assumption.

"My fear is that at some point we will have a withdrawal from Iraq that is very disorderly and not very well planned," he said in excerpts released by the station.

"That would be a tragedy for the troops, a tragedy for Iraq, a tragedy for us."

Again, the Senator sees the actual strategy of "failure after, but not on, my watch" that the current administration is using and refuses to go for it.

Of course, they're already being sniped at by other members of their own party. Consider this particular bit of nonsense from Lindsey Graham:

As much as I respect Sen. Lugar, I think it's unfair to the troops in the field to say the surge is not working."

"The military part of the surge is definitely working," Graham said. "There's no question in my mind that there's improvement in stability and new political alliances being formed."

It's unfair to the troops to say that the asinine, not-actually-a-surge "surge" strategy isn't working? Seriously? It's a little more unfair to them to put them continuously in harm's way to try and hide George Bush's ever-swelling shame. But Mr. Graham feels okay, because there's "no question in [his] mind" that the surge is working, and new alliances are being formed. Of course, John McCain thought it was working two months ago, but his numbers were made up. Despite the real and continuing trend of increasing violence over time and the fact that both the Iraqi military and that nation's infrastructure are largely imaginary, die-hard war supporters won't let reality stand in the way of their strong beliefs.

Curiously, reality still appears to disagree with people like Mr. Graham. Consider the fact that the Iraqi army can't hold areas cleared by American troops during our recent offensive in Baquba. But that's okay, because new alliances are being formed. Specifically, we're making deals with local militant groups to help fight al Qaeda.

Obviously, part of the pressure here comes from the pending election season. While it's sad that people need to be kicked into action by the possibility of losing their jobs, this highlights something very important -- this is why we have elections. Whether they're caring people or cynical bastards, our political figures depend on our continued good mood to keep their jobs.

This, at least, is democracy in action.

CNN article
al Jazeera article

(Notice that the al Jazeera article is willing to show a wounded American soldier in the field. This is something our own media and government bodies tend to assiduously avoid, in an act of intense disrespect for our soldiers who have volunteered to serve us around the world. It's not a good thing to pretend that our people don't pay for our choices.)

The open-access medical journal PLoS Medicine hits us on the international and the state level with two opinion and analysis pieces on the topic of disease and its prevention.

At the international level, Kouyate et al tell us about The Great Failure of Malaria Control in Africa, with a specific focus on the situation in Burkina Faso. As they remind us, the scope of malaria in Africa is epic, and its impact epicly terrible.

Malaria remains the most important parasitic disease affecting humans [1]. Every year, there are some 5 billion clinical episodes resembling malaria, some 600 million clinical malaria cases, and about 1 million malaria deaths [2]. The great majority of the malaria burden falls on the poor rural communities in sub-Saharan Africa (SSA), and most deaths occur in young children [1,2]. Malaria is considered a major barrier to the development of SSA [3].

In addition, treatment and prevention measures just aren't taking hold. Despite being tremendously effective in preventing malaria, insecticide-treated netting is still massively underutilized. In addition, treatment options for people suffering from malaria are limited. In the case of Burkina Faso, the country's entire health budget amounts to $9 per person per year. Consider that not just in light of whatever you had for lunch yesterday, but also based on the expected six fever or malaria episodes each child will suffer each year, and the $2 cost of treatment for each such episode (just to clarify, that's $12 of treatment each should should receive each year, on average...and that's just treatment, and not prevention, research, or any other function of health spending).

Drug-resistant forms of malaria are spreading, and knowledge about which drugs are now out of date, or may still work, has not been spreading to match.

The authors end by calling for a realistic approach to treatment of malaria in very poor African nations:

Unfortunately there is no ideal world. As sufficient funds for high coverage provision of ACT [artemisinin-based combination therapy -- the most medically effective approach, but also quite expensive] are currently not available, an appropriate interim solution would be to use a pragmatic combination of two affordable drugs. The obvious choice would be the combination of pyrimethamine–sulfadoxine and amodiaquine, which has been shown to be as effective as ACT in a number of SSA countries, including Burkina Faso [38–40].

However, after it became clear that Burkina Faso would not receive GFATM funds for the purchase of ACT, the NMCP of Burkina Faso asked the World Bank to use a portion of an existing US$12 million loan from the Global Strategy and Booster Program to purchase pyrimethamine–sulfadoxine and amodiaquine as an interim solution. This request was rejected with the argument that WHO recommends only ACT. As a result, chloroquine remains factually the first-line malaria treatment in Burkina Faso. These observations support the view that SSA countries continue to be victims of ignorance and lack of coordination between external donors and international organisations [41,42].

So, to summarize, Burkina Faso went to the world bank asking for money for the drugs it could afford, but the World Bank refused, being only willing to give money for the one treatment recommended by the World Health Organization (WHO). Of course, the problem here is that $12 million worth of ACT wouldn't have done the job. The authors hope that international agencies will get their act together and stop making decisions that punish poor nations for being poor by refusing them any kind of medical assistance.

Moving from the international scene to the California scene, Grudzen and Kerndt ask if it's time to regulate the adult film industry. As they point out, the adult film industry is a multi-billion dollar industry ($9-13 billion, which if you have a good memory, is about a thousand times as much money as the entire country of Burkina Faso requested from the World Bank for malaria treatment), although it formally employs a fairly small pool of people -- 1,200-1,500 performers. Throughout this article, the authors focus on an estimated 200 production companies. These latter two values feel like underestimates.

Their big issue is with the fact that pornography was legalized by case law rather than by statute, and thus is not nearly as regulated as most other industries that involve bodily fluids (such as being an EMT, for example). The performers are typically required to engage in unprotected, often high-risk sex acts, with the expected consequences:

The current practice of periodic HIV and STD testing may detect some disease early, but often fails to prevent transmission. The most recent HIV outbreak occurred when three performers who had been compliant with monthly screening contracted HIV in April of 2004 [6]. At that time, a male performer who had tested HIV negative only three days earlier infected three of 14 female performers.

Other STDs are also highly prevalent in the industry. Among 825 performers screened in 2000–2001, 7.7% of females and 5.5% of males had chlamydia, and 2% overall had gonorrhea [7]. These rates are much higher than in patients visiting family planning clinics, where chlamydia and gonorrhea rates were 4.0% and 0.7%, respectively [8]. Some might argue that this program of STD testing keeps rates of HIV and other STDs lower than in other sex-related industries, and in fact, a recent study of prostitutes in San Francisco found 6.8% and 12.4% positivity rates for chlamydia and gonorrhea, higher than rates in the adult film industry [9].

Notably, as an isolated public health issue, this is unfortunate for the people involved, but really doesn't matter nearly as much as some others. But the authors point out that it isn't just the performers who are affected:

The portrayal of unsafe sex in adult films may also influence viewer behavior. In the same way that images of smoking in films romanticize tobacco use, viewers of these adult films may idealize unprotected sex [16]. The increasingly high-risk sexual behavior viewed by large audiences on television and the Internet could decrease condom use. Requiring condoms may influence viewers to see them as normative or even sexually appealing, and devalue unsafe sex. With the growing accessibility of adult film to mainstream America, portrayals of condom use onscreen could increase condom use among viewers, thereby promoting public health.

In contrast to heterosexual adult films, homosexual-targeted productions more consistently require condoms. Due to the large number of HIV-positive performers, there is no requirement for HIV testing and condom use is the norm. Despite the ubiquitous use of condoms, homosexual adult movies are popular and profitable for production companies. In fact, there is some evidence that homosexual male audiences would not tolerate movies with unsafe sex, likely due to their proximity to many with HIV in the homosexual community. Some homosexual audiences regard watching sex without condoms as “watching death on the screen” [16].

They then cite other models of partially or wholly regulated sex industries:

Legislators can look to Nevada for a model for the successful regulation of a legal sex-related industry. Since the institution of mandatory condoms in Nevada's brothels in 1988, not a single sex worker has contracted HIV [17]. Workers must be repeatedly tested for HIV, syphilis, gonorrhea, and chlamydia to maintain a state health and work card. There are numerous other international models for condom enforcement in sex work, from Mexico City to Amsterdam. While there is no clear model for mandatory condom use in adult film, Brazil boasts an 80% condom usage rate in their adult films [18], while still maintaining a large share of the international market as the world's second largest adult film industry [18]. This suggests that condom use in adult films does not have to erode profitability.

It's worth adding that condom use is really important in the Brazilian industry, because of the HIV problem that appeared there before condom use became as prevalent as it is. Indeed, the most recent industry-wide HIV scare in the United States was spurred by American performers working in Brazil and contracting HIV.

Both articles ask us to take a practical, harm-reduction-oriented approach to a public health issue. In the case of the adult film industry, our touchiness about this topic keeps us from openly addressing the fact that we've set up a world where no one in my workplace can give me an aspirin, but a film company can mandate risky sex acts as a condition of employment. In the case of malaria, we are reminded that we shouldn't deny money for all but the "best" solutions, and should concentrate on enacting the "good" solutions that these nations can actually afford.