Hope is not a plan

In the May, 2006 issue of PLoS: Medicine, Hotez et al argue for a substantial targeting of neglected "tropical" diseases in their article Incorporating a Rapid-Impact Package for Neglected Tropical Diseases with Programs for HIV/AIDS, Tuberculosis, and Malaria.

In their article, they propose that in addition to targeting the "big three" of AIDS, malaria and tuberculosis, we should also be targeting a suite of neglected "tropical" diseases including leishmaniasis, African trypanosomiasis, Chagas disease, trachoma, leprosy, Buruli ulcer, hookworm, ascariasis, trichuriasis, lymphatic filariasis, onchocerciasis, guinea worm and schistosomiasis.

While the big three kill 5.6 million people per year and the neglected thirteen kill "only" 534,000 per year, the article notes that both cause massive impacts in terms of lifelong disability. The big three lead to 166 million disability-adjusted life years (DALYs) lost annually, and the neglected thirteen contribute another 57 million DALYs each year. Members of the neglected thirteen also negatively impact growth, development and cognition, meaning that even individuals who are not killed or incapacitated by these diseases may suffer from lost opportunities and lifelong limitation.

On top of this, members of the thirteen contribute to the effects of the big three. Thus, infection by a parasite can lead to increased infectivity of HIV, and disease-induced anemia may compound with the effects of other diseases, or limit the immune system's ability to fight disease. Vaccines may also be rendered far less effective by prior parasitic infection. Not only would it be helpful in itself to cure these conditions -- it would directly benefit the fight against the major killers.

The kicker of the article is that, for a cost of $0.40 (that's forty cents) per person, people could be treated for the thirteen, using a four-drug combo pack of albendazole, ivermectin, praziquantel and azithromycin. You could, at that price, cover all of Africa for about $300 million.

That is a good deal and, as the authors argue, would be a pharmaceutically cheap way to promote the construction of the kind of infrastructure that's going to be needed for eventual distribution of more effective drugs and vaccines that directly target the big three.

The March 3, 2006 issue of Science discusses a call by Dr. Ilaria Capua for bird flu (H5N1 avian influenza) researchers to publically release their sequencing data rather than hold onto it until publication, which can mean a delay of several months before it becomes available. From the article:

Some [researchers] have been reluctant to do so because they worry about intellectual property rights or not receiving a fair share of the scientific credit; China, for instance, has not shared any avian samples for a year...

...and from VLA lab director Ian Brown in the UK:

However, until a paper about the European outbreaks -- which he says could be submitted in a matter of weeks -- has been accepted, Brown says he needs to hold on to the European sequences. "The staff in this institute is working 24/7 to provide this service," he says. "I don't think it's unreasonable to expect...some reward for their endeavors."

Perhaps their reward could be the prevention of a Europe-wide pandemic.

I agree with Dr. Capua:

Capua counters that just isolating and sequencing a virus that comes in the mail does not give researchers the right to sit on the data -- especially not at a government lab. "Most of us are paid to protect human and animal health," she says. "If publishing one more paper becomes more important, we have our priorities messed up."

The April issue of PLoS: Medicine has a series of essays on the problem of disease mongering. Disease mongering is the practice of taking things that were previously considered normal aspects of life, or items of low-level concern, and transforming them into major medical problems. In general, this is done to market pharmaceuticals.

Moynihan and Henry provide the general context for the problem and make some suggestions about how to address it.

Lexchin takes on the example of Viagra and how it moved outside of the "medically necessary" box and into the bigger world of "lifestyle drug." To begin with, Pfizer pushed the most extreme statistics on impotence, when many, many other studies suggest that not only were fewer (and older) men facing any issues, not so many of them cared so much about it. Then, to move themselves out of the relatively limited market of men facing impotence from medical reasons, Pfizer pushed the idea that -- to quote their advertising -- "Even if erection problems happen only once in a while, VIAGRA can help." Notably, they've also pushed the dubious concept of "erection" as the desired outcome, because Viagra is notably more successful in promoting erections than in promoting successful completion of intercourse. All of this is a problem both in terms of pure financial strain and because it avoids other, major issues. Perhaps you're having temporary issues because your relationship isn't solid, you're too tired from an overly busy schedule or you're hooking up with someone you really don't like? Pfizer has successfull marketed itself to cover all these cases.

Phillips looks at the role of teachers as identifiers of ADHD. Teachers are a formal part of the diagnostic process for ADHD, per the DSM IV. In taking on this task, they're faced with "educational" websites that advertise for ADHD drugs and pharma-funded advocacy groups that lobby teachers on ADHD issues. Phillips recommends training for teachers to critique and pick apart pharma-funded resources, as well as distinct avenue for teachers to report and document their interaction with ADHD and ADHD treatments.

Tiefer looks at a particularly egregious example of disease mongering in which women are told that if they haven't been interested in sex for a couple months, they're sick and need medication. She opens with Lynn Payer's checklist of disease-mongering indicators, which includes such notables as "taking a normal function and implying that there's something wrong with it" and "defining as large a portion of the population as possible as suffering from the 'disease'." After this, she moves on to trace the current development of "female sexual dysfunction" as a diagnosis. Following the early successes of Viagra, a move was made to apply that model of sexual "function" (getting an erection) to women, with little initial success. The idea has moved on to other medications, notably testosterone patches, but the basic problem is that there isn't anything as obvious to latch onto in women to convince them that something is wrong with them. Of course, there's already a huge culture that does just that, so pharma still has hope. A good quote from the essay:

The public finds medicalization attractive because the notion of simple but scientific solutions fits in with a general cultural overinvestment in biological explanations and interventions, and promises to bypass sexual embarrassment, ignorance, and anxiety. This wish will inevitably end in stories of personal disappointment, but media promotion, advertising hyperbole, and an active pipeline will create continuing hope for the next new drug along with a neglect of other models of sex and ways to deal with sexual discontent.

Though Tiefer does not make this analogy, I'll note that the idea of "simple solutions to deeper concerns leading to disappointing outcomes" pretty much defines any given issue of Cosmo.

Healy looks at the dramatic expansion of various diagnoses of bipolar disorder in the United States, focusing initially on the fact that many current treatments for bipolar disorder that use antipsychotics are based on little to no clinical evidence, and may in fact increase certain bad outcomes such as suicides. From there, he touches on the dramatic increase in diagnosis of childhood bipolar disorder, including clinical trials on kids roughly in the kindergarten/preschool age range. This is especially worrying:

Massachusetts General Hospital in fact recruited trial participants by running its own television adverts featuring clinicians and parents alerting parents to the fact that difficult and aggressive behavior in children aged four and up might stem from bipolar disorder. This does more than recruit patients with a clear disorder; it suggests that everyday behavioral difficulties may be better seen in terms of a disorder. Given that bipolar disorder in children is all but unrecognised outside the US, it seems likely that a significant proportion of these children will not meet conventional DSM criteria for bipolar I disorder. And given that it is all but impossible for a short-term trial of sedative agents in pediatric states characterized by overactivity not to show some rating scale changes that can be regarded as beneficial, the outcomes of this research are likely to appear to validate the diagnosis and increase the pressure for treatment.

Applbaum and Heath round out the essays by looking at pharmaceutical marketing and efforts to oppose disease mongering.

Overall, good essays. Though being skeptical of newly identified diagnoses always runs the risk of ignoring a genuine health problem, it is just as dangerous to let companies convince people that they are sick solely to sell product -- especially when the product itself can represent not only a financial, but also a medical risk.

In an earlier post, I cited a push for treatment of a set of thirteen neglected diseases in addition to the big three. Part of this push was the note that it's not just deaths, but years lost to disability, that matter.

In the 12 May, 2006 issue of Science, Emanuel and Wertheimer advance a similar argument for vaccinations in case of a flu pandemic.

The traditional vaccination model is "save the most lives." By this model, medical personnel are vaccinated first, then those who are expected to be most vulnerable -- the sick, elderly and very young. They argue that instead of this approach, the most ethically sound approach is what they call "the life-cycle principle." I'll present it in their words:

We believe that a life-cycle allocation principle based on the idea that each person should have an opportunity to live through all the stages of life is more appropriate for a pandemic. There is great value in being able to pass through each life stage--to be a child, a young adult, and to then develop a career and family, and to grow old--and to enjoy a wide range of the opportunities during each stage.

...and...

Death seems more tragic when a child or young adult dies than an elderly person--not because the lives of older people are less valuable, but because the younger person has not had the opportunity to live and develop through all stages of life. Although the life-cycle principle favors some ages, it is also intrinsically egalitarian. Unlike being productive or contributing to others' well-being, every person will live to be older unless their life is cut short.

They then modify this with an "investment refinement" that says that having invested in life -- developing hopes, dreams and interests -- also adds priority. This yields a final model in which people in the midrange of age, say 20-40, have the highest priority for vaccinations. As a final adjustment, they do agree that medical personnel should be vaccinated first, to maximize the total return on the vaccines.

As Tim correctly pointed out, the concept of seemingly putting babies and old people last won't fly with a lot of people, but as the authors point out, at least part of this model is intuitive. When a twenty-year old dies, it's a tragedy. When a ninety-year old dies, you think they lived a good, long life. Why shouldn't vaccination follow our intuitive, human model?

Standard, commercial bleach is a marvelous, widely available antiseptic that will kill most anything, given enough time. In the June, 2006 issue of Microbe, Norman Miner of MicroChem Laboratory explains a simple method to maximize the value of bleach as an antiseptic by lowering its pH.

Commercial bleach is sold as an alkaline solution in the pH 11-12 range (read an explanation of pH here). In this state most of the bleach is present as chlorite ion; however, the hypochlorous acid form of bleach is "80 to 200 times more antimicrobial than the chlorite ion." Fortunately, the conversion from standard bleach to "acid bleach" is straightforward:

To one gallon of tap water, add 2 ounces concentrated bleach and 2 ounces 5% distilled, white cooking vinegar.

The sole downside to this process is that this is not a stable solution, so you'll need to make a fresh one for each day of use. The component parts store easily, however. Also note that you want adequate ventilation whenever you're cleaning with bleach.

Thanks to Dr. Miner for this simple method to maximize antimicrobial power with commonly available items.

UC Berkeley professor Justin Brashares and volunteers tracked down trade in bushmeat to several markets in Paris, Brussels, London, New York, Montreal, Toronto and Los Angeles.

For the uninitiated, "bushmeat" refers to meat from African wild animals, including gorillas, chimpanzees and other primates. While this is traditional fare for locals in Africa, apparently it's a black-market delicacy for idiots in America and various European nations. For the record, in addition to contributing to the destruction of endangered species, bushmeat is the route of transmission for such diseases as HIV from animals to humans.

Africans traditionally eat bushmeat because it's the only meat available, and then they catch horrible diseases and die. They have no choice. It is personally, environmentally and epidemiologically irresponsible to choose to eat bushmeat when you have other options, especially when eating it involves transferring it from one continent to another.

The CNN story

At the end of last week's AIDS conference in Toronto, UN special envoy for AIDS in Africa Stephen Lewis went on the attack against the insanity of the South African government's approach to HIV/AIDS. In a misplaced attempt to distance themselves from perceived colonialism and make their own way, top-level South African health officials have alternately denied that HIV causes AIDS and embraced folk remedies in the place of anti-retroviral medications. Senator Obama mirrored the envoy's criticism this week:

South African AIDS activists say Health Minister Manto Tshabalala-Msimang has created confusion by pushing traditional medicines and a recipe of garlic, beetroot, lemon and African potatoes to combat AIDS while underplaying the role of anti-retroviral (ARV) drugs.

"It is not an issue of Western science versus African science, it is just science and it's not right."

Mr. Obama is right on. It is possible that African traditional medicine, just like Asian traditional medicine, is pretty good at maintaining basic health. I don't know enough to comment. But "Western" medicine excels at treating diseases, especially when the exact cause is known. HIV biology is not a mysterious black box -- it has been hammered on for decades. Yes, basic nutrition is important -- but even the healthiest, fittest person in the world will die unless given antiretroviral therapies. The first wave of deaths in America hit people who were often in excellent shape, watching their basic health and nutrition assiduously.

The government of South Africa is displaying callous irresponsibility in using AIDS as a venue for a debate about colonialism. Anywhere else but there.

The Reuters story

The BBC story

As it happens, certain parts of world ecology continue to trend in bad directions.

In an article in the August 18 issue of Science magazine, Westerling et al report that wildfires appear to have increased dramatically starting in the mid-80s due to warmer weather and an earlier spring snowmelt. As discussed in this perspective, this isn't simply a matter of "another problem caused by global warming." Forest fires currently contribute atmospheric carbon equivalent to 40% of fossil fuel emissions. This is what's known as a feed-forward cycle -- warmer weather yields more fires, which yield more carbon, which yields warmer weather, which leads to more fires, and so on.

On the disease side, tuberculosis is rapidly developing into an unkillable bug. For many years now, multi-drug resistant (MDR) tuberculosis has been a big problem, forcing doctors to rely on second-line drugs that are expensive, more toxic and less effective than the now ineffective first-line drugs. Since 2004, however, surveys of patients with MDR tuberculosis have found that from 5-15% of them have extensively drug-resistant (XDR) tuberculosis, which is immune to both first-line drugs and at least half of the six classes of second-line drugs. As the MMWR says: XDR TB has emerged worldwide as a threat to public health and TB control, raising concerns of a future epidemic of virtually untreatable TB. New anti-TB drug regimens, better diagnostic tests, and international standards for SLD-susceptibility testing are needed for effective detection and treatment of drug-resistant TB.

The culprit in this case is poor implementation of proper drug treatment, bolstered in many areas by HIV clearing out the patient's immune system ahead of time.

It's likely that TB won't be effectively treated short of a completely novel approach. In the mean time, traditional public health measures will have to be taken to try and limit the spread of this deadly and untreatable TB variant.

The BBC article

This is a clipping from this CNN report on the President's press conference today. Note the advertisement on the right. There's nothing wrong with life insurance, nor insurance ads, but it's quite the commentary that instead of the usual "is your family's future secure?" kind of pitch that life insurance uses, it has the very fear-based image of the child actually asking, "Dad, what would happen to me and mommy...if you died?"

Which words is this ad keyed to? Terror? Enemy?

The president's rhetoric of fear and uncertainty is being reflected in our national mood, and in how companies try to sell their products. He has instilled in this country the message that nowhere is safe, and that the future is ever in doubt.

As reported in this BBC article, the organization M'lop Tapang has started a program called ChildSafe in the Cambodian city of Sihanoukville, in hopes of preventing sex offenses against their children. They're recruiting motorbike taxi drivers to watch for and report suspicious situations. The hope is that aggressive community policing will protect children directly as well as indirectly, the latter by shifting the balance of tourism toward legitimate tourists.

This should complement the official Cambodian effort to prosecute sex tourists (an effort that also appears to be on th upswing in Vietnam).

I think this is the right approach. Developing a culture of protectiveness at the grassroots level has the potential to make Cambodia and other countries inhospitable for child abusers.

After being approached by one Michael Hart Jones, actor Richard E. Grant alerted the BBC show Newsnight to Jones's AIDS-medication scam. Jones, ostensibly fronting for Commercial African Resources and Development (CARD), was looking for money for an "AIDS cure" based on goat serum.

This is not unlike the old practice of implanting goat glands into men to cure impotence. That didn't work, either.

Assuming Jones, who along with CARD has already been implicated in a money laundering scheme in Sierra Leone, actually believes in his product, there are still problems.

As the article notes, the claim that goats were injected with HIV to generate antibodies, then those antibodies cured the disease, runs straight up against the fact that this method using antibodies hasn't worked. As a bonus, if you really did inject someone with goat antibodies, they'd also have to deal with their body mounting an immune response against those antibodies (being, after all, from a goat).

However, let's say we're flatly empirical, and imagine something is different this time. The specific claim made:

We posed as investors and secretly filmed him as he claimed that CARD had used it to save the lives of dozens of soldiers in Tanzania in 2001 "they were stretchered in virtually dead - as far as I was concerned they were dead". After the miracle cure "in two weeks they were up and about and back on track".

No. If you are near-death from AIDS, you have nearly no helper T cells, you probably have AIDS-related dementia and your body is wracked by one or more diseases. Even if the virus goes away instantly (like magic), your immune system would take time to recover enough to even start addressing whatever diseases you have, and the dementia is a done deal -- that's damage that's not growing back.

For a host of reasons, ranging from desperation through a desire for a "home grown" answer (that doesn't come with the expense of Western medications), Africa is especially susceptible to lies like this. It's unpleasant to watch them coming from users like Hart Jones appears to be.

The BBC story

Faced with pandemic HIV/AIDS in Africa, it's easy for a lot of people, especially Americans, to take a moralistic stance and assume that everyone "over there" is just being promiscuous. "If we could just teach them abstinence..."

Of course, the truth is everyone already gets the concept of abstinence. Your kids who are off hooking up when you think they're at the mall get it. The you who hooked up without your parents knowing (and about whom you've conveniently forgotten now that you are a parent) gets it.

As it happens, that's probably not so much the problem in Africa. In fact, it's almost certainly not, since a recent survey of 59 countries by researchers from the London School of Hygiene and Tropical Medicine showed that Westerners are far more likely to have multiple partners than Africans.

In a study in this week's issue of Science magazine, Abu-Raddad et al have modeled the effects of a known interaction between malaria and HIV and determined that each makes the other one much worse. During episodes of malarial fever, HIV viral loads spike by almost ten-fold, and it's been previously shown that the chance of spreading the infection directly relates to this viral load. HIV, in turn, beats the immune system down and makes one more susceptible to infections such as malaria. Abu-Raddad et al modeled this outcome and showed that, in the Kisumu district of Kenya (population 200,000), this HIV-malaria interaction has probably, since 1980, led to an additional 8,500 HIV cases and a whopping additional 980,000 malaria cases.

You can read the Science article here, and the BBC overview article here.

Intuitively, it makes sense that conditions that lead to immune cell proliferation would increase HIV viral load. Given that, the researchers are now looking for additional interactions between HIV and other endemic Africa diseases (of which there are quite a few).

So, it's not promiscuity. Instead, the spread of HIV in Africa has likely been powered by co-infection, inadequate detection, gender imbalances in power, inadequate education, and out-and-out lies such as those propagated by Michael Hart Jones and South African Health Minister Manto Tshabalala-Msimang.

In an earlier post about how other endemic diseases are major drivers for the spread of HIV, I wrote this:

"Of course, the truth is everyone already gets the concept of abstinence. Your kids who are off hooking up when you think they're at the mall get it. The you who hooked up without your parents knowing (and about whom you've conveniently forgotten now that you are a parent) gets it."

Even truer than I knew.

As reported in this CNN article, a new survey of Americans shows that 95% of us engaged in premarital sex, and that this percentage has been stable since the 50s.

So for the 5% of you who are leading by example when you promote premarital abstinence, good job. For the other hypocrites who are so afraid of their own pasts that they don't want to promote safer-sex education to prevent unwanted pregnancies and the catching of deadly diseases, give it a rest. It's pretty decisive that harm reduction in the form of safer-sex education beats abstinence education cold, but if you do want to promote abstinence, you at least have to own up to your own failure to abstain when doing so.

I do think that promoting abstinence instead of safer-sex methods is a losing proposition. Food, water and sex are the three things that keep a species going, and it's awfully hard to talk people out of any one of those three.

Promoting abstinence is great. But you have to teach the backup plan, too.

While other companies are working hard to convince you that there's something wrong with you, the Institute for OneWorld Health has quietly been addressing real conditions that actually matter.

At the end of August of 2006, this nonprofit drug company (the only one!) received its first drug approval for Paromomycin to treat visceral leishmaniasis. Visceral leishmaniasis, also known as kala-azar or black fever, is an unpleasant condition that attacks bone marrow and internal organs, leading to death. Even survivors can be marked by a leprosy-like skin condition. With half a million new cases a year, visceral leishmaniasis is a big deal.

IOWH has an agreement with Hyderabad-based Gland Pharma to produce Paromomycin at a price point of $10 per cure.

So, for maybe the price of a movie ticket, a life can be saved. For a paltry $5 million per year, every new case could be treated.

That's just amazing.

You can donate to the nonprofit Institute for OneWorld Health right here.

And treatable, too.

Nearly three thousand people have died of cholera in Angola since last February.

Cholera, bane of the developing world, is depressingly easy to treat. All you need is gatorade, time, and attention -- but naturally, these are all in short supply in a very poor country recovering from a civil war.

There have been 69,000 total cases, which can't be helping recovery in a country of only twelve million.

BBC article

President Yahya Jammeh of Gambia claims he can cure HIV/AIDS in three days using special -- secret, naturally -- herbs. In a mirroring of South African government foolishness, he's backed by the health minister:

Gambian Health Minister Tamsir Mbow says the herbal medicines are taken orally and applied to the body.

"We cannot actually tell you the type of herbs we are using presently, it will be known to the whole world later on," Dr Mbow told the BBC.

This reads exactly like every bit of Internet crackpottery on any topic that's been circulating since Usenet was popular, at least. They "cannot actually tell you" about the herbs, and the trials are in secret, but they're willing to make an announcment right now about efficacy. As a researcher interviewed in the article points out, this is the opposite of science. Heck, it's even the opposite of slightly-cooking-the-books big pharma science.

It's more crap that's going to get people in Gambia killed. Maybe Jammeh and Mbow believe in their stuff and are just misguided, or maybe they're operating from a misguided sense of anticolonialsim, or maybe they're planning on selling this crap, regardless of whether it works or not. As I've said before, I'm not a blanket disbeliever in traditional medicines -- however, they naturally work best at dealing with things that were known when they were developed. HIV is not one of those things, but it is firmly within the territory that "western" medicine excels at -- acute, infectious disease.

BBC article

In other HIV misguidings, Dr. James Chin, who was head of the WHO Global Programme on Aids from 1987-1992, has declared that:

people in the general population outside Africa are unlikely to contract HIV/Aids, as it is restricted to certain high-risk groups.

Furthermore:

Dr Chin says HIV prevalence is low in most populations throughout the world and can be expected to remain low.

Dr Chin says it is only in sub-Saharan Africa, where unprotected sex outside marriage is common, that the risk of heterosexual HIV transmission is high.

What does Dr. Chin's bit of wisdom tell us? Chiefly that he's still stuck in 1987-1992, when AIDS was the public property of gay men and drug users. He's been forced to amend that by adding Africa, so he hacks on the idea that unprotected sex outside marriage is only common there.

Tough luck, Doc -- the 95% of everyone in the West not practicing premarital abstinence don't back your claims, especially since Westerners are far more likely to have multiple partners than Africans. The real kicker is that, to the extent that protected sex outside marriage is more common in the West, it is because of those prevention efforts he rejects.

But Dr. Chin says:

"By refusing to accept the fact that HIV is very difficult to transmit sexually without the highest levels of sexual risk behaviours, Aids programmes have avoided labelling some populations as being more promiscuous than others.

"It is a much more socially and politically correct public health message to say that sexual promiscuity exists in all populations and thus the risk of epidemic heterosexual HIV transmission to the general public, or to ordinary people can be prevented only by aggressive programmes directed at the general population, and especially to youth."

I agree with Dr. Chin here. Some populations are more promiscuous than others -- chiefly, Western populations are more promiscuous than African ones.

This all suggests that Dr. Chin's racism might be pointed the wrong way.

BBC article

The GAO recently issued a report titled "Food Stamp Program: Payment Errors and Trafficking Have Declined Despite Increased Program Participation." You can read it by clicking here.

I think this one is worthwhile because programs such as food assistance and welfare in general are frequent targets for people looking for an "easy" place to cut funding. In addition to high-handed claims about making people into "welfare queens," the thought is that these programs are rife with corruption and misspent money.

Of course, the scale of Federal food stamp money in the U.S. is nothing in comparison with the money lost to poor military procurement procedures, corporate welfare and such novel ideas as destroying the estate tax.

The GAO reports that the error rate -- a rate that combines over- and under-payment of food stamp recipients -- has dropped from 9.86% in 1999 to 5.84% in 2005. This amounts to prevention of $1.1 billion in payment errors in 2005.

The food stamp trafficking rate -- that is, fraud involving food stamps -- has also declined. It ran at about 3.8 cents per dollar of redeemed benefits in 1993, versus 1 cent per dollar in 2002-2005. New electronic benefit management methods and other tools have helped reduce food stamp fraud. Law enforcement agencies are now targeting high-volume traffickers in hopes of further reducing the fraud rate. To put the trafficking figures into actual money, an estimated $812 million in benefits were trafficked in 1993, versus $241 million in recent years. Still big money, but that's $571 million less lost to unscrupulous people.

Maybe we can send the auditors from the USDA's Food and Nutrition Service over to DoD to audit all those lovely no-bid contracts given out to our friends at KBR.

In Spring of 2006, Kaiser Permanente got caught dumping a patient in downtown Los Angeles, well over ten miles from the medical facility she'd been in and from her own home.

Now, Hollywood Presbyterian Medical Center appears to have done Kaiser one better, dumping a paraplegic patient on the street. Apparently, Hollywood Pres has been accused of this before. This time, witnesses actually recorded the license plate number of the truck from which the man was dumped.

It's good to see increasing intolerance for this kind of behavior.

In light of the recent problems at Walter Reed, I was very interested in hearing what the GAO had to say about the VA. In a report titled Veterans' Disability Benefits: Processing of Claims Continues to Present Challenges, the GAO tells us that the VA has actually improved its procedures over the years, but that filing claims and appeals is still an arduous, overlong process, and that the VA's disability policies are probably out of step with the modern world.

As the following chart shows, the VA actually reduced its pending claim backlog in the early 2000s.

However, following a commendable low in 2003 -- the year of the Iraq invasion -- the backlog started to pile up again. By the end of last year, initial compensation claims took an average of 127 days to be processed, up 16 days from the year before, and appeals resolution took an average of 657 days.

Consider that this means that our veterans are currently waiting just over four months to have claims processed, and potentially another two years if they try to appeal a rejected claim. That's a long time to hang out, disabled, waiting for help.

The VA notes that they're receiving quite a few more claims than they used to, due to our pair of wars and other causes:

The increase in VA’s inventory of pending claims, and their average time pending is due in part to an increase in claims receipts. Rating-related claims, including those filed by veterans of the Iraq and Afghanistan conflicts, increased steadily from about 579,000 in fiscal year 2000 to about 806,000 in fiscal year 2006, an increase of about 39 percent. While VA projects relatively flat claim receipts in fiscal years 2007 and 2008, it cautions that ongoing hostilities in Iraq and Afghanistan, and the Global War on Terrorism in general, may increase the workload beyond current levels. VA also attributes increased claims to its efforts to increase outreach to veterans and servicemembers. For example, VA reports that in fiscal year 2006, it provided benefits briefings to about 393,000 separating servicemembers, up from about 210,000 in fiscal year 2003, leading to the filing of more original compensation claims. VA has also noted that claims have increased in part because older veterans are filing disability claims for the first time.

Newer claims also take longer to process because they involve harder-to-substantiate conditions, all neurological -- post-traumatic stress disorder (PTSD) and brain injuries (the latter a notable consequence of near hits by IEDs). In processing PTSD the VA runs into specific roadblocks based on the need to substantiate the causative incident(s):

Additionally, claims-processing timeliness can be hampered if VA cannot obtain the evidence it needs in a timely manner. For example, to obtain information needed to fully develop some post-traumatic stress disorder claims, VBA must obtain records from the U.S. Army and Joint Services Records Research Center (JSRRC), whose average response time to VBA regional office requests is about 1 year. This can significantly increase the time it takes to decide a claim.

The VA, aware that its improving outlook has taken a retrograde turn since the invasion of Iraq, has a number of plans to fix the situation. Their fiscal year 2008 staffing request is a 6% increase over 2006 levels. They intend to bring the additional staff up to speed quickly using overtime from regular staff and training led by retired VA employees. They also want to capture more of a servicemember's military records electronically at discharge, so they can cut down on problems such as that one-year wait time from JSRRC. They're also trying to cut down on problems that lead to appeals.

The GAO applauds these efforts, but points out that the VA may have an antiquated idea of just how disability works these days:

Specifically, our research showed that the disability programs administered by VA and the Social Security Administration (SSA) lagged behind the scientific advances and economic and social changes that have redefined the relationship between impairments and work. For example, advances in medicine and technology have reduced the severity of some medical conditions and have allowed individuals to live with greater independence and function in work settings. Moreover, the nature of work has changed in recent decades as the national economy has moved away from manufacturing-based jobs to service- and knowledge-based employment. Yet VA’s and SSA’s disability programs remain mired in concepts from the past, particularly the concept that impairment equates to an inability to work.

If I'm reading that correctly, GAO is pushing in a good direction here. The ability to work in some capacity should not, alone, be a metric that a veteran is no longer in need of assistance and care. We want our injured veterans to return to a real life, not just to survive.

A combined WHO/UNAids/Unicef report indicates that despite some impressive increases in availability, 72% of people who could benefit from antiretroviral medications still aren't receiving them. This isn't just a matter of buying additional life for people -- although that should be enough -- it's also important for stopping the spread of AIDS and avoiding the continued economic devastation of areas struck by the disease.

As I've mentioned before, diseases don't just shorten lives, they also lead to many years of disability, which in turns reduces quality of life and removes the sufferer from the economic equation for their country. Antiretrovirals can chop away years and years of disability.

Even more critical is the need for antiretrovirals for pregnant and nursing mothers. In this context, not only do they curtail the AIDS orphan problem now seen across Africa, but they also prevent vertical transmission of HIV. Unfortunately, the report indicates that only 11% of infected pregnant women receive antiretroviral therapy. This is going to be an especially bad problems in North Africa and the Middle East, where overall access to meds is just 6%.

Pharma companies have argued against wider availability of affordable "second generation" AIDS meds based on the idea that they're "too complex" for poor, third-world countries to distribute properly. The report calls them on this classic racist trope, pointing out that where they've been deployed, the third world is handling the new drugs just fine, thanks.

BBC article

Russia has begun construction on floating nuclear power plants, based initially on the low-end nuclear plants currently used in their icebreaker fleet, and then moving on to midrange plants based on the reactors used in their nuclear subs.

"This is a unique potential in both Russian and world power engineering. We have unique competitive advantages: no other country in the world had so many reactor-years and such a unique nuclear fleet as we did."

Greenpeace, naturally, is freaking out about this.

They're not unjustified, either. As Sergey Kiriyenko, head of the Russian nuclear energy agency Rosatom, said above, the former Soviet fleet has many "reactor-years" of experience. Some of that experience involves ditching nuclear reactors in the sea around the Kola peninsula. Given that the same people who cavalierly scrapped nuclear reactors by simply sinking them are now in charge of making these floating reactor platforms, Greenpeace is right to be concerned.

al Jazeera article

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.

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.

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.

It is often nigh-impossible to deconvolute preconceived notions and moralistic (but neither moral or ethical) ideas from good public health practices. Many Americans are still opposed to sex education that includes safer sex practices, despite the fact that 95% of those Americans engaged in premarital sex. Similarly, people in the porn industry are at great risk of disease because they don't have assistance from powerful unions. Another moralistic stance is taken despite the fact that some large chunk of Americans are right out there, consuming the products of that industry.

My own home state has taken matters into its own hands, moving to repeal a ban on state funding of needle-exchange programs. Laudably, the state legislature was able to distance itself from the moralistic argument that all drug users should be punished, and from the unfounded belief that needle exchange would lead to a massive boom in drug use, to recognize the proven facts that needle exchange programs massively reduce HIV prevalence and save billions of dollars in public health costs.

In their PLoS Medicine policy forum article titled The US Anti-Prostitution Pledge: First Amendment Challenges and Public Health Priorities, Nicole Franck Masenior and Chris Beyrer tell us about a substantial, problematic hiccup in the President's Emergency Plan for AIDS Relief (PEPFAR). Started in 2003, PEPFAR was an appropriation of $15 billion to be disbursed globally to fight HIV/AIDS. This program expires in 2008, and the president has called for a renewal and an increase in funding to $30 billion over the next five years. The hiccup, however, is this:

In order to receive AIDS funds from the US, all grantees must have (1) a policy explicitly opposing prostitution and sex trafficking and (2) certification of compliance with the “Prohibition on the Promotion and Advocacy of the Legalization or Practice of Prostitution or Sex Trafficking,” which applies to all organization activities, including those with funding from private grants [1,3]. “The Prostitution Pledge,” as this requirement is often called, has evoked strong and mixed reactions. It has led some grantees, most prominently the government of Brazil, to reject US AIDS dollars altogether [4]. But it is the breadth of the requirement and its application to privately funded activities that has led to legal challenge of its constitutionality.

In short, if you accept any PEPFAR money, then you must promote the idea that all prostitution must be eradicated -- even in efforts that use your own, private money. Two groups challenged this ruling as an unconstitutional limitation of free speech, and a district court agreed, despite the opposing argument that government money is allowed to come with policy strings attached.

The greater issue here is that, once again, of evidence-based harm reduction versus intuitive, moralistic arguments. Intuitively, prostitution is a problem. This makes natural sense -- sex with multiple partners is an HIV transmission risk. However, as the authors of this policy piece point out, conflating sex workers with sex traffickers -- the latter being the human traffickers, pimps, and others who organizationally promote sex work -- is a big problem. They point specifically to the example of the Lotus Project in Cambodia:

The Lotus Project began by offering a range of services to sex workers, from primary health care to English and computer lessons, while receiving funds from USAID for operations research. Within two years after the project's launch, Médecins Sans Frontières handed it over to a local organization, whose funding came primarily from USAID, in an effort to ensure sustainability. Around the same time, the Lotus Project had come on the radar of US activists working on human trafficking issues. After a number of raids on brothels in the area by US-funded anti-trafficking groups, sex workers experienced severely restricted mobility, resulting in limited access to health care and a reduced ability to earn a livelihood. The project's ability to respond effectively to the new situation was hindered by fear of being seen as promoting prostitution. Their freedom to deliver services based on best practices was limited. Eventually, funding from USAID diminished and the Lotus Project closed [24].

In short, an effective harm-reduction tool was driven out of existence because of the explicit demonization of prostitution in the PEPFAR pledge.

One of the key steps in understanding the value of harm reduction is in understanding that it plays a slightly longer game, but it plays a game that wins. It's natural to imagine that if you could magically end prostitution right now, then that route of HIV transmission would end. That's also complete nonsense, since you can no more magically end prostitution than you can magically end the need of those women to eat food. Here, as in other contexts, the "traditional" American approach is fast, direct, and utterly ineffective.

It's time for our avowed capitalist-in-chief to take a cue from an investment banker and help to end prostitution by empowering women, keeping them safe and healthy, and attacking the sex trafficking trade. It makes moral sense. It makes financial sense. There is no downside.

In a recent paper in PLoS One, Lenoir, Serre, Cantin, and Ahmed make the startling discovery that sugar and artificial sweetener are both more addictive than cocaine.

In previous studies, it's been shown that animals will consistently choose cocaine over food. However, that worked used conventional feed for the animals in question -- in other words, healthy food. Lenoir et al did a head-to-head comparison between intravenous cocaine and the artificial sweetener saccharin, and found that over 90% of animals choose saccharin. They then repeated this test using the natural sugar sucrose. Once again, the sweetener won over cocaine.

This result -- that has not yet received any significant publicity -- suggests just why the abundance of high-fructose corn syrup and other sugars in our food products is so destructive. It may not be a simple matter of abundance that leads to obesity in developed nations, but instead a matter of exactly what we put in our foods. This could also help explain why obesity has not been as much of a problem in developed Europe, Korea, and Japan, but is a problem in other nations ascending to developed status.

Chinese state media reports that sexual transmission has, for the first time, overtaken other methods of transmission for HIV within China. China officially saw 70,000 new HIV cases in 2005, with about half due to sexual transmission. This is especially problematic in policy terms, as it moves HIV transmission out of somewhat neater "high risk" boxes such as intravenous drug users and into the "general risk" population. The epidemiological difficulty this represents is enhanced by decades of policy and even older social traditions that stand in the way of having an open discussion about sex. Sexual transmission of HIV is also likely to accelerate in the face of a large, migrant bachelor population and a concomitant pool of sex workers.

The high degree of stigma associated with HIV - and a lack of confidentiality - can also deter people from being tested at all.

China, like the United States, has serious issues with accepting the value of harm reduction.

BBC article

In their paper titled Marburg Virus Infection Detected in a Common African Bat, Towner et al describe an extensive evaluation of bats collected in Gabon and Republic of Congo that turned up Marburg virus infection in a common fruit bat, Rousettus aegyptiacus.

Marburg virus, like its cousin Ebola, causes incredibly deadly outbreaks of hemorrhagic fever in both human and ape populations. Given their near-absolute lethality, it's a given that these killers don't just reside in the human and ape populations and then "go nuts" every so often. This research by Towner et al finally points the way toward understanding the natural reservoir for hemorrhagic fevers in Africa. In so doing, it may also point the way toward mitigating future epidemics or even wholly preventing them in the first place.

And, as befits the inherently dual-use nature of all pathogen research, it also tells you where to go if you want to collect some Marburg virus and can't convince USAMRIID to give you any.

This summer saw an outbreak of the economically devastating foot-and-mouth disease among livestock in the United Kingdom. Thanks in large part to a rapid and concerted response by the government, it was of relatively limited scope -- two farms, $100 million in economic harm.

(Let that sink in for a moment, that a well-handled FMD outbreak hit the UK for $100 million.)

Now, the infection has been traced not to a natural origin but to accidental release of FMD virus from a vaccine facility run by the Merial corporation and housed in a building managed by the UK government's Institute for Animal Health. Here's how it happened:

A two-step chemical strategy is used at Pirbright [the IAH facility] to prevent FMD from escaping in liquid waste. Both Merial and IAH first treat wastewater at their own buildings with a disinfectant such as citric acid. Then, a complex system of pipes takes the water to a shared effluent treatment plant, managed by IAH, where caustic soda is used to raise the pH to 12 and kill off any remaining virus during a 12-hour holding period. Finally, the liquid is released into the sewer.

As it happened, construction crews were digging holes around the leaks at the time, and heavy trucks--without proper IAH oversight--drove through the presumably virus-laden mud. Some of these vehicles later took a road that went very close to the first infected farm. From there, the farmer may have carried the virus to his herd.

Quoted from this article in Science magazine.

It's just these kinds of problems that are the big fear about facilities that work with pathogens. As the Science article discusses, a number of well-known pathogen research centers are also on the older side, and there are concerns that their infrastructure may also lend itself to these kinds of accidental releases. Add to this the possibility for procedural errors -- whether it's letting trucks drive through areas they shouldn't or forgetting to put in a new air filter in your anthrax research lab's exhaust system, and the worry is that an incorrectly managed research center may accidentally spawn the next pandemic.

It is not particularly comforting then, that Texas A&M has recently been gigged in a big way for substantial failings in their own biosafety procedures, including losing several vials of Brucella, the causative agent of the hard-to-treat Malta fever, and accidentally exposing a number of workers to Q fever. Texas A&M interim president Eddie Davis lamely defended TAMU's record by saying that "institutions under that same level of review would probably have findings that would be reportable to the CDC." He then praised the now-former biosafety compliance director for being "very loyal and competent." Competent would be good, but I don't see how loyalty to TAMU helps the rest of Texas if they're not maintaining proper safety.

It's common for people to shrug and move on in the face of regulation, doing just enough to comply. We have to remember, however, that screwing up the safety compliance in a pathogen lab is not the same as failing to maintain a piece of heavy machinery. The latter may result in a massive work accident, but the former might wipe out a city or all agriculture in the midwest.

As a lead-in its participation in the Council of Science Editors' Global Theme Issue on Poverty and Human Development, PLoS Medicine asked a number of commentators which single intervention would do the most to improve the health of those living on less than $1 per day? Popular responses included generally increasing socioeconomic status, securing food supplies, and empowering women. Here are a few other standout answers:

Jeffrey Sachs, Director of the United Nations Millennium Project and Special Advisor to United Nations Secretary-General Kofi Annan on the Millennium Development Goals, Earth Institute, New York, New York, United States of America

In tropical Africa, a mass distribution of free long-lasting insecticide-treated bed nets to fight malaria accompanied by free access to artemisinin-based combination anti-malaria medicines. In other parts of the world, the situation will be different. I should add that I've spent years objecting to posing the question this way, since at low cost we could achieve major health advances through more comprehensive approaches.

Davidson Gwatkin, Consultant on Health and Poverty, Washington, D. C., United States of America

The health of the world's poor would be best served by a series of revolutions that bring into power national leaderships that are centrally concerned about the well-being of disadvantaged groups within their borders.

Kelley Lee, Centre on Global Change and Health, London School of Hygiene and Tropical Medicine, London, United Kingdom

A genuine commitment by industrialised countries to fair trade and, in particular, to end the destructive impact of agricultural subsidies on the livelihoods of the poor, would greatly enhance household incomes, food security and thus widespread improvements in the health of the poor.

Solomon Benatar, Professor of Medicine, University of Cape Town, Cape Town, South Africa

Only when (and if) the “haves” develop genuine empathy for the “have-nots,” and come to acknowledge their own long-term interdependence with all other humans, will the global economy be improved to any significant advantage for the desperately poor.

In their essay Child Rights and Child Poverty: Can the International Framework of Children's Rights Be Used to Improve Child Survival Rates?, Pemberton, Gordon, Nandy, Pantazis, and Townsend promote the idea that bolstering human rights for children -- specifically by following the framework of the UN Convention on the Rights of the Child (UNCRC) -- is a viable method of addressing the millions of child deaths each year that can be directly attributed to poverty. They challenge the notion that human rights issues are a distraction from greater public health concerns -- while acknowledging that not all rights are equal, when viewed from a public health viewpoint:

We argue that a rights-based strategy will increase child survival, in part by reducing child poverty, but only if some rights are prioritised over others. UNICEF, under Bellamy, adopted a position in which all the rights in the UN Convention on the Rights of the Child (UNCRC) were regarded as of equal importance, and both developed and developing countries were urged to realise these rights progressively (i.e., one after the other) [5,10]. This position has become hard to defend, since some rights are clearly more important than others and/or contingent on others. For example, whilst UNICEF recognises that children living in poverty are more likely to experience non-fulfilment of other rights [5], the right to vote is little use to a child who has died in infancy as a result of a lack of medical care due to poverty.

The "Five Core Principles of the UN Convention on the Rights of the Child" are as follows:

• The right to life, survival, and development
• Non-discrimination
• Devotion to the best interests of the child
• The right to an adequate standard of living and social security

That first right is most key. Although people can quibble over what constitutes and adequate standard of living and what are a child's best interests, the right to life and survival pretty much rules out letting children die prematurely. That, at least, seems straightforward...yet this problem is not addressed as a rights issue. Why is this?

A third question about human rights is whether the “non-justiciability” and non-enforcement of certain economic, social, and cultural rights makes the development of anti-poverty policies difficult. It is often argued that “rights”, as they have been defined in human rights conventions, are imprecise or are moral claims that are not legally enforceable [20]. Many “rights” have so far been largely ignored by national courts, and the realisation of economic, social, and cultural rights is particularly difficult. Domestic courts have been adept at arriving at complex decisions in cases relating to civil and political rights, but they have tended to dodge issues of poverty, access to health care, and non-fulfilment of other economic and social rights. They cite the non-justiciability of such rights and have not been aided by international jurisprudence, which is currently lacking in this area.

I think we can distill this divergence between civil and political rights and all the other social rights down to one thing -- civil and political rights are easier to resolve. As much as humans are willing to die for rights such as freedom of expression and religion, clearly people are just as willing to fight to avoid starving to death -- yet we often treat the former as a crucial human rights issue and the latter as a problem of governance -- like making sure the street signs are all freshly painted. Fundamentally, to not oppress someone or to allow them some amount of freedom of expression has a very low financial cost. On the other hand, vaccinating every child in Africa against a major disease carries a substantial financial burden. Between the two, we choose to resolve the rights problem that is easily atomizable and has end states that don't seem daunting. If we were to fundamentally admit that an individual's civil liberties are completely abrogated when they die from dysentary, we'd be forced to resolve problems of public health with the same vigor with which we attack problems of public expression.

Viruses, in general, are highly adaptive. One of the big concerns in active antiviral therapy (where a drug is given to an already-infected patient to stem the tide of a viral infection, as opposed to preventing it in the first place with a vaccine) is that the virus will very, very quickly outmaneuver the antiviral medication, resulting in a more resistant virus. This tendency of viruses to evolve their way around treatments is why HIV is treated with a combination of multiple antivirals with differing targets (you can read more about Highly Active Anti-Retroviral Therapy, or HAART, here).

In a study titled Antiviral Oseltamivir Is not Removed or Degraded in Normal Sewage Water Treatment: Implications for Development of Resistance by Influenza A Virus, Fick et al test the effects of conventional sewage treatments on Oseltamivir -- a drug you might know better by its trade name of Tamiflu. Tamiflu is, as manufacturer Roche reminds us on the product site, "the number 1 doctor-prescribed flu medicine," used for both prevention and treatment of flu.

...and recently, patients have been showing up with Oseltamivir-resistant strains of flu. Critically, those patients have not been treated with Tamiflu. So where does the resistance come from? As Fick and colleagues report, it looks like Tamiflu makes it through normal sewage treatment processes intact. This is significant, since each seasonal burst of Tamiflu use (preventative and in treatment) will lead to a concomitant burst of Tamiflu into our sewers. If the antiviral then passes through sewage treatment intact and en masse, then influenza strains running around in natural reservoirs stand a decent chance of being exposed to Tamiflu. This, in turn, means a head start on development of resistance.

The punchline is that Tamiflu may start "wearing out" sooner than we expect, leaving us back where we started with flu vaccines and "drink plenty of fluids and get some rest."

Following the model of HAART and other successful antiviral regimes, the hope would be to develop and deploy additional anti-flu medications with completely orthogonal targets, to slow down the rise of resistant strains. Failing that, we can hope that abundant vaccines this year (and going into the future) will keep flu levels low enough to limit exposure of the virus to waste antiviral meds.

Items produced in China are once again turning out to contain problematic bonus ingredients. A batch of Bindeez beads -- little beads meant to be arranged artistically and then sprayed with water to fix them in place -- was found to be coated with gamma-hydroxy butyrate, the anesthetic and date-rape drug. Apparently, the manufacturers of this batch went "off formula" and decided to mix some GHB into the surface fixative on the Bindeez, a fact that was discovered when several children were hospitalized after swallowing Bindeez beads (note that a bunch of little swallowable beads is already probably not the best kids' toy).

The manufacturers insist that this is a batch-specific issue.

Naturally, there's a lot more vigilance about products imported from China in the last year, but this brings up an interesting question about the hit rate in successfully identifying items that are, one way or another, "off formula." If pet food causes kidney failure and toys knock kids out, the adulteration is apparent. But how long will it take to discover that a product simply lacks a necessary active ingredient. If toothpaste contains poison, that's clear. If it lacks fluoride, then that's an incremental increase in cavities over a large population, and that is not amenable to product-linked surveillance.

It's hard to say if there's a ready solution to this issue, or not.

BBC article

Among recent NIH program announcements was RFA-CE-08-006, "Feasibility of Acute Concussion Management in the Emergency Department."

As part of the "Healthy People 2010" program's injury and violence prevention component, NIH is putting funding into empirically evaluating the worth of different approaches and treatments to traumatic brain injury (TBI), with an emphasis on mild traumatic brain injury (MTBI) -- that is, getting a concussion.

Few studies have investigated the impact of interventions during the acute recovery phase on outcomes of mild TBI. However, one study in children (Ponsford et l., 2001) and a similar study of adults (Ponsford et al, 2002) conducted with patients recruited from emergency departments during the acute recovery phase reported that one-time provision of an information booklet outlining symptoms associated with mild TBI and suggesting coping strategies reduced anxiety and lowered the incidence of ongoing problems compared with a control group of patients who received standard care. Although to our knowledge, no published studies have investigated the impact of serial follow-up of MTBI patients, preliminary results from an ongoing CDC-funded study suggest that receiving multiple episodes of telephone counseling may decrease the negative impact of MTBI-related symptoms (Kathleen Bell, personal communication, July 2007).

Already important for youth athletes and people in general, MTBI treatment -- including treatment of recurring MTBI -- is obviously and particularly relevant for members of our armed forces who may be hit repeatedly with IEDs while in theater in Iraq, and who will then return home to VA or civilian medical care.

If you're a physician, the CDC provides Heads Up: Brain Injury in Your Practice, a free toolkit of materials to help in assessing and treating brain injuries.

I donated blood today -- a double-red donation. The sign outside the blood center indicated that "all types" are needed. With the exception of the week immediately following the September 11th attacks here in the U.S., there's always a need for blood donations. If you're eligible (and your local blood center probably has a website that will let you know if you are), I urge you to go in and donate blood as often as possible. Although we're still working on it, blood is one of those biomedical products that we just can't replicate or manufacture.

For normal whole blood donations, you're eligible every eight weeks. If that feels too often for your busy schedule, you can do what I did today and do automated blood collection, for a double-red donation. In a double red, they collect a double dose of red blood cells from you without a double dose of blood volume. It leaves you a little more tired, but has you coming in every sixteen weeks instead of every eight. If you have more time, you can also do apheresis to donate other key blood products -- this is independent of other blood donations, and can be done on a fairly regular basis.

You have lots of options, and if you're in the U.S., probably have a blood center full of competent, helpful staff somewhere nearby. If you're eligible, please go and donate.

You can learn more about blood donation in general, and find a nearby donation center at the AABB website.

Delegates from over a hundred nations are meeting this week in New Zealand to prepare a treaty banning the use of cluster munitions. These weapons, described here at fas.org, comprise hundreds of bomblets contained within an overall case. The intent is for the device to open up in midair, spreading bomblets over an area, where they are meant to detonate immediately. When they work, the explosions are impressive, and clearly lethal to any infantry or soft-skinned vehicles unlucky enough to be in the strike zone.

The move to ban cluster munitions comes because they often don't work, littering an area with unexploded munitions that can be triggered months and years later by unlucky civilians. For example, a 2001 cluster bombing of the Shomali Valley during our campaign against the Taliban in late 2001 left 17% of the bomblets unexploded on the ground. A good third of those were buried more than a few inches deep, meaning that large metal detectors would be needed to find them -- and that they thus present a huge risk to children at play and farmers plowing their fields. You can read the abstract of that study here. A second, more in-depth study in Afghanistan showed that over 80% of the casualties from unexploded devices were civilians, with children being most likely to be hurt specifically by unexploded ordnance (which includes cluster munitions, but excludes landmines). You can read that study here.

The big three arms distributors -- the U.S., China, and Russia -- are not participating in the conference.

The conference has been organised by the Cluster Munitions Coalition (CMC), a global network of 200 civil society organisations including leaders from the Nobel Peace Prize-winning International Campaign to Ban Landmines.

According to the CMC, France, Germany, Japan and the UK have been stepping up diplomatic pressure to weaken the draft treaty by excluding certain weapons, including a transition period and allowing the use of cluster bombs in joint military operations with countries that do not sign the treaty.

It's hard to find empirical evaluations of the relative worth of cluster munitions versus conventional munitions when addressing the same targets. The claim is often made that cluster bombs reduce immediate collateral damage by being far less destructive than conventional munitions, but again, there are no publicized evaluations to back this up. This Human Rights Watch background paper from 2001 addresses the claims that have been made, but concludes that very little solid data exist on this topic.

On the face of it, I find it difficult to believe that there are many targets for which a cluster munition is a better choice than a conventional weapon. There are probably no targets that a cluster munition can kill that a 500-pound bomb can't, and the unconfirmed potential for reducing collateral damage is at best mortgaging future civilian casualties to potentially reduce immediate civilian casualties, which given the persistence of unexploded ordnance almost certainly isn't a good deal.

al Jazeera article
BBC article

A CDC study released this week reports that on average, one in four teenage girls in the United States has some form of sexually transmitted disease.

The demographic breakdown brings some grim news for African American teens, as about half of girls in that ethnic group had an STD, compared with 20% among white and Latino teenagers.

The predominant infection is human papillomavirus, which can cause cervical cancer. The next three runners up are chlamydia, trichomoniasis, and herpes.

The CDC's Devin Fenton said it was a serious issue because the diseases could lead to infertility and cervical cancer.

The CDC is recommending annual chlamydia screening for all sexually active women under 25, and HPV vaccines for girls aged 11 to 12, followed by booster injections.

Of course, that last recommendation was greeted with some amount of horror when it was suggested last year, on the basis that somehow vaccinating young girls against one STD would give them license to engage in sexual activity. As the current studies show, that is already happening. And it's no surprise, what with nearly all Americans having engaged in premarital sex. The extremely low 5% abstinence rate has been steady since the 1950s, meaning that if you're in your 40s or younger and you're explaining how abstinence education would totally prevent this and we don't need to screen our kids or vaccinate them, you're lying.

Or you have a terrible memory. Your kids are sexually active, and they, being just like you, will go on doing that whether or not their teacher, pastor, or parents tells them to "just abstain." I'm by no means suggesting that's a great thing -- abstinence is a good thing, and I personally believe that it would have a lot more weight if we allowed a healthier public discussion of sex in this country. However, the idea that removing the tools to have safer sex or to be informed about or screened for diseases will somehow keep kids from getting involved in sex is ridiculous, dangerous, and unfair to our kids.

BBC article

The High Court in Cape Town, South Africa ruled this week against German Matthias Rath and American David Rasnick after a case was brought against them by Treatment Action Campaign and the South African Medical Association.

The short of it is that they are no longer allowed to conduct "clinical trials" of vitamin treatments for HIV among the desperate sick in South Africa.

"It is declared that the clinical trials conducted in South Africa are unlawful," Judge Dumisani Zondi said in his ruling.

But critics say such trials had led to unnecessary deaths when HIV-positive people stopped using anti-retroviral drugs.

Rasnick has worked previously as an adviser to South African president Thabo Mbeki, which can' t have helped with South Africa's history of science-denying, people-killing approaches to the HIV/AIDS epidemic in that country.

Notably, Rasnick has also incorrectly claimed to be associated with UC Berkeley, following a short time there working with HIV-denying kook and tenured faculty member Peter Duesberg. Rasnick and Duesberg collaborated as recently as 2003 on this paper that refuses to acknowledge a link between HIV and AIDS, instead trotting out their favorite, Occam's Razor-denying idea that AIDS is actually caused by recreational drugs, anti-viral therapy, and malnutrition. This never adequately explains, of course, why targeted protease inhibitors that are completely specific to HIV manage to push AIDS symptoms into remission. Duesberg has made a career, in the past decade and a half, of being contrary just to be contrary, and in so doing has enabled the kind of cruelty that Rath has been perpetrating on the unsuspecting in South Africa. Duesberg has, however, restrained himself to making the case for his kooky ideas. Others, like Rath and Rasnick, have gone and actually killed people in promotion of ideas that are not merely unorthodox, but actually ignore the hypothesis-driven science they claim drives their contrariness.

It is, in a word, criminal.

Good on the High Court for stopping it.

BBC article

With upwards of 24,000 people displaced and the loss of most of the potable water in Cedar Rapids, the destruction in Iowa is hard to legitimately comprehend. It's hard to actually visualize 1,000 city blocks being under water.

More problems may be on the way, on the order of the recent levee break in Des Moines or worse. Downriver, we have to hope that cities and towns can be reinforced to avoid even more disastrous flooding.

Beyond the tragedy for us, however, this natural disaster is going to be extremely relevant for the rest of the world, as the flooding has canceled out this year's soybean and corn crops. In 2007, Iowa produced 2.37 billion bushels of corn and 439 million bushels of soybeans. That's more corn than we export annually.

This may be an even hungrier year than the rest of the world expected.

BBC article
Washington Post article

In 2006, I commented on an article series in PLoS: Medicine covering the general practice of disease mongering -- that is, taking a reasonably normal part of the human condition and trying to convert it into a diagnosable disease for the purpose of selling a drug.

In short, if you've developed a drug, you want to maximize its use. In some cases, that involves convincing people they need to treat something that they previously thought of as normal (and which, in all likelihood, often is completely normal).

The companion to this need to expand your potential market by convincing people that they're patients is the need to expand your market reach by convincing doctors to prescribe your drug.

Over on the Science-Based Medicine blog, David Gorski brings up a recent article in the Annals of Internal Medicine about internal Merck documents that prove that Merck was engaging in a "seeding trial."

This is the first confirmation of a practice many doctors have believed pharmaceutical companies were engaging in, in which a compeletely unnecessary pharmaceutical "trial" is started at the level of individual medical practices, with the sole intent of increasing the exposure of doctors to a new medication ahead of its official approval by the FDA and commercial release. In this way, the pharmaceutical company accelerates uptake of its new drug and reduces a non-money-making "cold period" following the official commercial release. Here's the conclusion from the Annals paper:

Documentary evidence shows that ADVANTAGE is an example of marketing framed as science. The documents indicate that ADVANTAGE was a seeding trial developed by Merck's marketing division to promote prescription of Vioxx (rofecoxib) when it became available on the market in 1999.

The documentation supporting this came out as part of the multiple ongoing lawsuits against Merck in the wake of the discovery that Vioxx was responsible for an estimated 28,000 heart attacks and deaths over a four-year period.

Here's a key quote, as also quoted in the Science-Based Medicine blog:

The ADVANTAGE (Assessment of Differences between Vioxx and Naproxen To Ascertain Gastrointestinal Tolerability and Effectiveness) trial is the largest ever initiated prior to the launch of a Merck product. The objectives were to provide a product trial among a key physician group to accelerate uptake of VIOXX as the second entrant in a highly competitive new class and gather data important to this customer group. The trial was designed and executed in the spirit of the Merck marketing principles, as described below.

First, the trial was targeted to a select group of critical customers. The clinical trial program for VIOXX focused primarily on specialists. While they would be critical to early uptake and advocacy for VIOXX, the large majority of prescriptions in the A&A market (~60%) come from primary care physicians. The ADVANTAGE trial utilized this important group of prescribers as investigators. In addition to gaining experience with VIOXX, many of these physicians gained a highly coveted introduction to clinical research.

So, in other words, the marketing department at Merck devised a fundamentally unnecessary medical trial (the "largest ever" for a to-be-released Merck product) with the sole intent of accelerating uptake of their drug.

Medical trial as market research.

In June of this year, the High Court in South Africa ruled against mass killer Matthias Rath, refusing to let him kill large numbers of South Africans by convincing them to switch off of highly effective anti-HIV drugs and instead buy into his ineffective vitamin profiteering effort.

This week, the happy news came out that Matthias has dropped his libel case against the Guardian and its columnist, Ben Goldacre. Matthias initially sued Goldacre and the Guardian after Goldacre called him out on his pandemic profiteering, and the fact that Matthias was actually hurting and killing HIV-positive people in Africa by pushing a massive ad campaign of lies about the effectiveness of his vitamins over known HIV treatments. From the Guardian:

The Dr Rath Foundation focuses its promotional activities on eight countries - the US, the UK, Germany, the Netherlands, South Africa, Spain, France and Russia - claiming that his micronutrient products will cure not just Aids, but cancer, heart disease, strokes and other illnesses.

The collapse of the case will have repercussions around the world. International authorities on Aids welcomed the outcome. Prof Brian Gazzard, one of the UK's leading HIV/Aids experts, who advised the Guardian on its case, said he was delighted at the result. "The widespread provision of anti-retrovirals in sub-Saharan Africa is one of the most important public health measures of this century," he said. The confusion caused by suggestions that giving undernourished people vitamins and minerals was an alternative to taking Aids drugs was "extremely harmful".

One clear hallmark of a medical scam -- the suggestion that the magical cure is a cure-all. Cancer, HIV, heart disease, and stroke? Impressive.

The court case pulled up some scary material from Matthias, including the text of a complaint made by his companion Anthony Brink against Treatment Action Campaign founder Zackie Achmat in the Hague, in which Brink tried to have Achmat charged with genocide, suggesting that it would be appropriate to torture him as a consequence.

Had the case proceeded, the court would have been presented with details of Brink's complaint to The Hague, which called for Achmat to be permanently confined "in a small white and concrete cage, bright fluorescent light on all the time to keep an eye on him" and force-fed his Aids drugs or, "if he bites, kicks and screams too much, dripped into his arm after he's been restrained on a gurney with cable tied around his ankles, wrists and neck". The complaint was described by the Rath Foundation in January last year as "entirely valid and long overdue".

Trying to get someone charged with genocide is a pretty extreme corporate tactic. Notably, if someone did ever catch Achmat and dose him up with modern anti-HIV meds...well, he'd be okay. As much as liars like Andy and Matt would like to give people the impression that HIV meds are all AZT, modern HAART therapy is effective and has relatively mild side effects, with its major drawback being its expense -- a problem that Achmat effectively challenged and has helped resolve in South Africa. In fact, it was Achmat's efforts to make HIV treatments highly affordable that threatened Matthias Rath's vitamin profiteering, which in turn prompted the attempt to attack Achmat with a genocide charge.

We'll give the last word to columnist Ben Goldacre:

Rath is an example of the worst excesses of the alternative therapy industry; UK nutritionists make foolish claims on poor evidence - they can make your child a genius with fish oils, or prevent heart attacks in the distant future - but Rath transplanted these practices into the world of HIV/Aids, where evidence really matters.

Now that AIDS profiteer Matthias Rath has dropped his harassing libel suit against the Guardian and columnist Ben Goldacre, the Guardian is once again free to report on Rath's malice in Africa and in general on the shocking failure of the South African government to deal appropriately with the AIDS pandemic.

As the Guardian reports, South Africa was ripe for infestation by scam artists like Rath based on the government's AIDS denialism and its unfortunate view that the choice between drugs that work and other practices that don't was somehow an extension of old anticolonial battles. I'd like to once again quote something very important that Barack Obama said in 2006:

"On the treatment side the information being provided by the minister of health is not accurate," he told reporters outside an AIDS clinic in Cape Town's Khayelitsha township.

"It is not an issue of Western science versus African science, it is just science and it's not right."

Indeed.

Unfortunately, the South African government has been letting its people die by using this, of all things, as a venue to shrug off "Western" influences. Curiously, this has meant repeated intrusions by Western scam artists -- apparently, you're accepted as long as you're promoting nonsense. Consider folks like Michael Hart Jones, who was trying to set up a goat-serum AIDS cure scam. And, of course, Rath, who used incredibly unethical methods to screw up AIDS care in South Africa:

In time, MSF learned that Rath Foundation workers had infiltrated Aids clinics in Khayelitsha. A nurse and the manager of the bustling Ubuntu clinic, Nompumelelo Mantangana, says she discovered that some of the foundation's employees were paying health staff to pass on the names of HIV-positive patients: "We stopped that but not before it did a lot of damage."

She says the Rath Foundation played on the fact that many people came to the clinic only once they were sick, and that ARVs tended to make them feel worse before their health began to recover. "They said, come off the ARVs and take the multivitamins and you will feel better. And you do - but it doesn't mean you are getting well. Eventually you get sick again," she says.

But then, if you're already unethically leading people away from life-saving treatments, it's hard to imagine it being a big stretch to take the extra step and actually steal them away from effective clinics.

For more, read the full Guardian article on the topic, and applaud the Guardian for standing behind Goldacre in the face of this harassing and frivolous lawsuit.

NBC chief medical editor Dr. Nancy Snyderman interviews Dr. Paul Offit on the Today show:

I recommend watching through to the end, where Dr. Snyderman refuses to back down when Matt Lauer suggests that the belief that vaccines cause autism is "controversial." As Dr. Snyderman correctly points out, it is not controversial -- the evidence says that vaccines do not cause autism, no matter how many people believe that in the absence of any evidence. Much more can be found on this topic elsewhere, but the short version is that those who promote the idea of vaccines causing autism have moved the goalposts several times to accommodate their beliefs, even as the evidence remains the same.

The suggestion that there's some kind of vast "vaccine industry" at work manipulating results is especially noxious, as vaccines are notoriously poor money-making propositions for a pharma firm (wouldn't you rather make an erectile dysfunction drug and make serious bank?). And, as infectious disease doctor Mark Crislip points out, if it was all about the money, you'd let these epidemic diseases run wild. After all, why get paid once to vaccinate some kid for polio when you can hook them in for a lifetime of expensive care once it paralyzes them?

Obviously, that "logic" is not at work in the real world, where pediatricians encourage vaccinations precisely because these childhood diseases are so devastating.

Dr. Snyderman is arguing from evidence, evidence for the safety and efficacy of vaccines, evidence that keeps popping up in well-designed research studies, including this one from a former proponent of the autism-MMR vaccine link, who actually tested her ideas and found that there was no support for that association.

It's been suggested that vaccines are the single most important discovery of modern medical science. It makes little sense to trade those in for pandemic disease and a life of hardship.

The Today Show article

As I've discussed before, abstinence-only sex education is clearly ineffective, with up to 95% of Americans engaging in premarital sex and a concomitantly high rate of teen pregnancy and sexually transmitted diseases. Despite the lack of good empirical support for any value in trying to tell kids to act the way their parents didn't, abstinence-only sex education has nonetheless been the Federal mandate for the past eight years, a mandate that bleeds unhelpfully over into the restrictions we place on public health money we donate to other countries.

So, if abstinence-only is a bust, what can we do?

In a recent study published in the journal Pediatrics, Rand researchers Chandra et al find that teens exposed to very high levels of sexual content on television are significantly more likely to get pregnant or get someone else pregnant. Specifically, those in the 90th percentile for amount of sexual content watched on television were twice as likely to end up involved in a pregnancy as those in the 10th percentile. Although this study doesn't show causation, it does point to a potential problem and mirror other concerns about how sexual behavior is modeled in the media.

Note that the point is not necessarily "sex bad," but rather "sex portrayal bad." If you catalog the sexual material you've been exposed to on television recently, how much of it involves the use of safer sex items (e.g. condoms) and sexual interactions between healthy, long-term adult couples, and how much of it involves wild, seemingly spur-of-the-moment sex between people who don't really know each other? In the wake of a recent proposal to alter how sex education is done in England, much discussion ensued about how lower teen pregnancy rates in many Western European countries probably have a lot to do with open, healthy discussion of sexuality between teens and their parents -- giving the teens good models to work from.

He thinks the real problem is cultural - teens wanting to lose their virginity fast and sociable girls having nothing to lose by getting pregnant.

Professor van Loon says in Holland parents are more likely to spend time talking to their children and the emphasis is more on the romantic side of sex.

Rand summary of the study

Back in February of this year, delegates from over a hundred nations met to discuss the banning of cluster munitions. Early next month, these nations will sign the proposed treaty into law, and hundreds of nations will eschew the use of persistent warfare methods that cripple and kill civilians long after the conflict is over.

As I described in this earlier post, the major arms distributors -- the U.S., China, and Russia -- didn't attend the original conference and are highly unlikely to be signatories to the treaty. However, as Thomas Nash from the Cluster Munition Coalition points out, getting this many countries to sign on, including NATO members, will help to preclude the use of cluster weapons in future operations:

"What you are going to see is a comprehensive stigmatisation of the weapon," he says.

"You're going to see this weapon becoming a thing of the past."

Lacking its own facilities to decommission these munitions, the United Kingdom has contracted with Nammo Demil to destroy 28 million bomblets. Pleasingly, the bomblets are largely recyclable:

The bomblets are extracted, the fuses are cut off and the copper inners are removed.

The copper, aluminium and other metals are sold for scrap. The packaging for the bomblets is burnt for heating.

This is a hopeful sign for the future.

BBC article

Pope Benedict is headlining his upcoming visit to Africa by claiming that distributing condoms will make the HIV problem worse, and that abstinence education will honestly work this time. Really.

Also, Africa needs a great, big hug:

Pope Benedict said on the eve of his trip that he wanted to wrap his arms around the entire continent, with "its painful wounds, its enormous potential and hopes".

The United States is a very faithful country - if you travel abroad you'll notice how much more overtly religious we are than many other areas. Regardless, our rate of premarital sex is 95%, and it has been for the last half century. If our country, a country that is about 85% religious nonetheless manages to screw up abstinence 95% of the time, why do you expect other countries to do better?

The Vatican is naturally a faith-based institution, but I can't recommend its current faith-based approach to public health.

BBC article

One of our collaborators from Mexico was unable to travel for a meeting today as he has a cough, and thus is banned from flying out of the country.

There are now about 150 deaths attributed to the current wave of flu in Mexico. Cases have also been identified in Spain, Scotland, and, naturally, the United States. So far, there have been no deaths in the United States. The World Health Organization is rating this flu at an alert level of 3, which means they don't think it is readily transmitted between humans. You can read more from the WHO about this influenza outbreak here. WHO is not yet recommending restrictions on trade or travel; the U.S. government has suggested that nonessential travel to and from Mexico be avoided for now.

al Jazeera article
BBC article

I strive to be a good citizen. This includes being aware of local and world affairs, voting in each election, giving to local and global charities, and, notably, giving blood.

Giving blood is a remarkably simple, low-effort way to actually save someone's life. This is an opportunity most of us aren't accorded in our daily lives or in our workplaces. By putting aside roughly one hour every two months, you give one of your fellow Americans a chance at something more concrete than simply "a better life" - you give them a chance at life.

Many blood donation centers are run by the American Red Cross. You can find a nearby donation center by going to their site. You may also have non-ARC centers nearby. I personally give at the Stanford Blood Center.

Giving blood is super easy. One hour every two months, and they give you cookies and juice at the end (along with t-shirts, movie tickets, and all sorts of other stuff, really). It's by far the easiest and laziest way to save a life and be a good citizen, and other than that hour, it doesn't cost you one dime.

Give blood, save a life. Easy enough.

The RNC is in full-on shill mode at the moment, pushing a heavy duty ad campaign against health care reform. This is a topic I've been discussing with a lot of friends lately, as we think that people who object to health care reform fundamentally don't understand what's at risk here. The risk is not so much "I'll have to wait longer for a doctor if health care reform passes" as it is "I will be killed by a young man whose wife needs an operation they can't afford if reform fails."

Just to put that in stark terms for those of you who aren't necessarily motivated by altruism toward your fellow Americans.

Over at factcheck.org, they've taken a look at the latest RNC ad campaign that tries to scare Americans into thinking an attempt to generate affordable health care is a horrible, horrible thing. Consider these hilarious excerpts:

In “Ad Facts” released with the TV spot, the RNC states that the plan “Could Drive Doctors Out Of Business” in rural areas, but supports that claim with a news article that quotes a handful of doctors stating their personal opinion. It also cites a July 14 estimate by the Congressional Budget Office (updated July 17) that the House bill would leave 17 million without health insurance. Is that really a risk? About half of those 17 million would be illegal immigrants, according to the CBO, and nobody is proposing that they should be eligible for coverage, least of all the RNC. And anyway, the same estimate projects that 37 million otherwise uninsured persons would gain coverage.

That is to say that the RNC is complaining that we'd be preventing illegal immigrants from getting government-funded health care. Who knew they were so interested in handing out federal money to illegal immigrants?

The RNC is also noting a potential drop off in some coverage but not a massive contrasting gain in coverage. Or, even more briefly, you're looking at a net 30 million-person gain here.

What about this lovely bit?

Similarly, the “Ad Facts” also claim that the Obama plan “Could Lead To [an] Estimated 113 Million People Losing Private Health Insurance.” But they wouldn’t “lose” coverage altogether. The RNC cites House testimony by John Sheils of the Lewin Group. What Sheils actually said is that if a proposed new federal health insurance program is opened to everybody (which is permitted, but not required in the House legislation) then 122.9 million Americans would sign up for it, including 113.5 million projected to switch over from private coverage.

Basically, the advertisement looks at 113.5 million people switching from private coverage to more affordable federal coverage and count that as "lost" coverage.

Nothing could more clearly show that the RNC are full-on shills for health insurance companies. If you switch away from Blue Cross to more affordable coverage, they count that as "lost" coverage? That's like saying that people who choose to ride the bus have "lost" their cars.

If you have a Republican representative or senator, it's time to give them a talking to. Their party is representing companies that revoke coverage from cancer victims rather than representing you, and that's a bad, bad deal for you.

A recent CNN survey finds that a majority of Americans over age 50 oppose the current health care reform proposal, and a majority of Americans under 50 support it. What does this tell us?

Mainly that if you choose to target your false advertising toward a demographic, you can help sway their opinion. For example, you could show scared old people learning that their surgery isn't covered, but abortions are. Which is, of course, a lie. Or that your health insurance premiums will double. Which is, of course, also a lie.

Why lie to the elderly? Well, as the survey reminds us, that's an age demographic that is far more likely to talk to its representatives, and also generally more likely to vote. This is why it's important that you, regardless of your age, speak to your representatives and let them know you support health care reform. Click here to connect to your Congressional representatives.

I had the opportunity recently to randomly acquire a staph infection from a cut. It was ably handled by my local hospital, which I like quite a bit, and it was significantly reduced in cost by my health insurance, which (now) comes from a provider I also like. If I hadn't had insurance? $2,000+ right off the top. Consider what that would do to a low-income family, and that's for a condition that wasn't particularly preventable and that could actually kill you if untreated.

Shouldn't we make it so that our fellow Americans don't have to choose between eating and, say, having a staph infection eat them?

But now I sound like I'm trying to scare you. With that in mind, let's leave you instead with this highly relevant ad for Old Glory insurance:

CNN article

The current debate on healthcare seems to be boiling down to an argument between people who think health care for all Americans is vital and those who have bought into a pathological fear of the Federal government doing anything on a large scale. Given the ideological basis of most modern Americans as "not Communist" - something I can relate to having grown up in the 70s and 80s - it's not surprising that there's a fear of government programs even as we've already adapted to and become used to many large-scale programs such as farm subsidies, Social Security, and Medicare. Considering how many people think it's critical that we fix the latter two programs so they continue to operate, it's a little fascinating to see how many people have bought into the idea that health care for everyone - not just older people - will be a horrible thing.

There's a tendency among the more fanatic opponents of anything the Federal government does to point to the United States Constitution, try to read into its authors' intent, and treat it as a religious text. While it clearly is not a religious text, being instead a compromise document that was meant to be changed from time to time, it's still worth considering some authorial intent every so often. The best marker of Constitutional intent, much more so than reading the actual Articles, is the preamble. Let's take a look:

We the People of the United States, in Order to form a more perfect Union, establish Justice, insure domestic Tranquility, provide for the common defence, promote the general Welfare, and secure the Blessings of Liberty to ourselves and our Posterity, do ordain and establish this Constitution for the United States of America.

In order to "provide for the common defence" and "promote the general Welfare." Those are two of the key founding points of the Constitution, and by extension, our nation. Clearly, universal health care has a lot to do with the general Welfare (we'll capitalize it like they did), but consider what it has to do with the common defence as well (note the "British" spelling of defense there).

The estimated rate of excess deaths among uninsured adults in the United States is 22,000 people per year.

22,000 people.

We haven't lost that many civilians to any war since the Civil War. If we were losing that many Americans per year to terrorists, we would pull out all the stops in hunting down and eliminating that threat. Although it's much easier for us to miss this threat to America, because it doesn't happen with bombings and splashy attacks, it is nonetheless a tremendous death rate that is, at its core, preventable - and we don't even have to kill anyone to defuse the threat.

When people buy into the message of fear that says that "government health care is evil," they are fundamentally buying into propaganda pushed by people who are willing to sacrifice 22,000 Americans a year to support their own financial gain. If we really want to cleave to the ideals of this nation, we must provide for the common defense, and in so doing, promote the general welfare.

22,000 American lives a year depend on our good decision right now.

Given finite resources, healthcare and medical treatment is a matter of continual cost-benefit analysis. Consider, for example, concerns over whether or not regular mammograms actually reduce breast cancer deaths, or the debate over how to spend our current healthcare dollar.

Compared to how relatively flush America is - flush enough to horrendously misspend a lot of healthcare money - other regions must take a more parsimonious approach to health care. In this vein, Nickerson et al have evaluated Factors Predicting and Reducing Mortality in Patients with Invasive Staphylococcus aureus Disease in a Developing Country (in this case, in Thailand).

What's exciting about this study, from a cost-benefit perspective, is the authors' ability to discern between factors predicting mortality and those reducing it. Specifically, they discover that while the presence of genes encoding the Panton-Valentine Leukocidin (PVL) factor is predictive of significantly greater mortality, it makes no difference in how you treat the disease. The only value, at present, of running a PVL test on a new patient is to have this conversation:

"The Staph is PVL positive, so you're much more likely to die."

"That sounds terrible. What does it means in terms of treatment?"

"Nothing. Treatment efficacy is the same whether you're PVL+ or PVL-."

That is, it's a waste of time and, more importantly in this context, money. So instead of spending money on this test, we instead want to spend our third-world healthcare dollar on draining pus and applying immediate antibiotic therapy.

One potential concern in the United States is that a test like the PVL test would be run purely to protect against litigation. It's hard to say how to handle that; harder still because the law does not intersect with scientific, empirical evidence nearly as often as it might.

Citation: Nickerson EK, Wuthiekanun V, Wongsuvan G, Limmathurosakul D, Srisamang P, et al. (2009) Factors Predicting and Reducing Mortality in Patients with Invasive Staphylococcus aureus Disease in a Developing Country. PLoS ONE 4(8): e6512. doi:10.1371/journal.pone.0006512

Pfizer was recently pegged for fines to the tune of $2.3 billion (that's billion) following their admission of guilt in misbranding drugs with an intent to defraud or mislead. The Federal investigation came with whistle blowing by John Kopchinski, a former Pfizer sales rep who (quite naturally) could not reconcile his personal ethics with the requirement by Pfizer that their sales reps promote untested, off-label uses of their drugs, as well as uses above the tested doses - up to eight times higher than those doses.

Kopchinski, a Gulf War veteran and West Point grad cited his military background, and West Point specifically, in discussing how he was unwilling to be a "team player" and push doctors to prescribe Pfizer's drugs inappropriately and in large quantities. You can read more about his personal experience here.

Compare and contrast the official Pfizer line with, well, reality:

Amy Schulman, the senior vice president and general counsel of Pfizer, said: "We regret certain actions taken in the past, but are proud of the action we've taken to strengthen our internal controls."

Authorities called Pfizer a repeat offender, noting it was the fourth such settlement of government charges in the last decade.

Of course, it's not all down to Pfizer committing fraud. It's also down to doctors accepting free handouts and more from pharma reps. For a front against this kind of "close collaboration" between sales reps and doctors, check out the American Medical Student Association's PharmFree program, which includes this pledge:

I am committed to the practice of medicine in the best interests of patients and to the pursuit of an education that is based on the best available evidence, rather than on advertising or promotion.

I, therefore, pledge to accept no money, gifts, or hospitality from the pharmaceutical industry; to seek unbiased sources of information and not rely on information disseminated by drug companies; and to avoid conflicts of interest in my medical education and practice.

Seems good.

BBC article
al Jazeera article

A frequent discussion I have with friends concerns the difficulty people have in evaluating risk. Consider, for example, your relative risk of ending up on an airplane that terrorists attempt to hijack versus your risk of randomly picking up flu from another traveler on that airplane. We estimate the influenza-induced death rate in the U.S. as ballparking at around 30,000 people per year, which is rather higher than the death rate from terrorism of any kind. Naturally, there are other reasons why the United States maintains a policy of terrorism prevention, but at the personal scale this suggests your risk mitigation behaviors should focus significantly more on avoiding disease transmission and rather less on reprising Kurt Russell's role in Executive Decision.

Do you wear a mask to avoid flu? Should you? Does it work?

As it happens, many public health agencies have policies requiring the use of surgical masks as an infection barrier, but until this month there were no randomized, controlled trials on whether that policy makes sense.

As reported at the 49th Interscience Conference on Antimicrobial Agents and Chemotherapy, a randomized, controlled trial of nearly 2,000 health care workers in Beijing has given us our first real information on the value of masks in blocking transmission of respiratory infections. The upshot? Surgical masks are bunk, but there are real benefits from N95 masks.

The first randomized controlled clinical trial comparing surgical masks to fit-tested and nonfit-tested N95 masks in at-risk healthcare workers has found that the respirators were "clearly superior" in guarding against viral and respiratory infection, lead author of the study, C. Raina MacIntyre, PhD, from the University of New South Wales in Sydney, Australia, told meeting attendees.

"Given the logistic difficulties of fit testing, particularly during an infectious-disease emergency, this is an advantage for public-health control," the authors say in their abstract.

This is good news from many standpoints. First, it's always useful to know that your current policy directives don't have any evidence, as that lets you discard them and spend your resources more effectively. Second, it means that off-the-shelf N95 masks work just as well as custom-fit ones, which means you can get the full benefit during a pandemic using pre-stockpiled inventory.

The benefits from the N95 masks are fairly significant, and provide clear direction for future pandemic policies as well as personal decisions about wearing masks on airplanes and in other situations where it's hard to avoid respiratory contacts.

Note that this study was supported by 3M, which manufactures one brand of N95 mask. That said, the results are so significant and clear-cut that I'm not very concerned about conflict of interest (presumably they would have declined to report on the results if the N95s had turned out not to be effective).

From this Medscape article (free signup required for access)

Edited to add: Unfortunately this study has been retracted, with no word on why. The only remaining study does not show increased efficacy for N95s.

We try to drive safely. After all, with some 35,000 fatal crashes per year, we really need to. And we try to prevent crime in our communities, hoping to cut down on about 16,000 homicides per year.

It's probably worth our time and effort, then, to try and prevent 8,000-50,000 deaths per year from influenza.

This year's flu season is making the news rather more dramatically than in years past by dint of our facing the combined challenge of "conventional" seasonal influenza, responsible for those tens of thousands of deaths already described, and the H1N1 pandemic strain. The added drama of H1N1 has highlighted both honest questions about vaccination (e.g. "I've never been sick, do I need to be vaccinated?") and straight-up, bad citizenship crankery.

Vaccination is good citizenship. Here's why:

• Even if you've never been bedridden by influenza, you might have had a mild case and passed it onto someone vulnerable
• ...who may have then died
• Maintaining a high level of general influenza vaccination in a population reduces overall mortality
• Normal influenza tends to kill infants and the elderly
• H1N1 switches this up by killing children and young adults

It is, indeed, plausible that you could go years unvaccinated without getting the flu, much in the same way you might go for years not wearing a seatbelt and never be injured or killed in an accident. Unlike that seat belt example, however, you may have entirely accidentally contributed to the illness or even death of someone more vulnerable than you by being unvaccinated during that time.

Yes, the vaccine provides imperfect protection - but then, so does your seat belt, but it's still a good idea. More to the point, it's not just your life that's at stake here, but the lives of all the babies, kids, and grandmas and grandpas in your community.

For more on the truth about flu vaccination, you can read Mark Crislip's article on vaccine efficacy, listen to his podcast about the vaccine, read this rebuttal to flu vaccine fear mongering, or check out this Wired article that covers the whole thing reasonably well.