Russian alcoholics, Chinese and Thai sex workers, and Congressman Darrell Issa

So many people have died needlessly of AIDS while politicians like California Representative Darrell Issa make things worse to score cheap political points. The people trying to fight this disease—not to mention those trying to avoid or survive it—deserve better than they got this Tuesday.

I identify more closely with Russian alcoholics and Thai sex workers than I do with Republican Representative Darrell Issa (R-CA). For their sake, among others, I’m dismayed by the Republican’s recent victory.

That seems like a stretch. Bear with me.

Last spring, I visited Russia to deliver some HIV prevention lectures and to learn about some of the related risks confronting injection drug users, sex workers, and others. One morning, after enjoying a sumptuous salmon buffet breakfast at my fancy tourist hotel, I visited one of the few residential treatment centers available to the large population of Russians suffering from drug or alcohol disorders…..

Housed in a large old stone building, it was a forbidding facility. The barred gates and the dark stone stairways conjure images from Dostoevsky and George Orwell. The Spartan physical surroundings and constraints were at-times misleading. Counselors and social workers provide useful services. Patients are linked to medical care and other services. HIV+ patients are linked to skilled medical care at the city’s AIDS center. Basic services are free, financed by city government. (For another $100 per day, patients can buy a bit more privacy and better food.)

The center provides a 21-day residential program for roughly 500 patients. As in many such programs, relapse is the normal trajectory. Maybe 25 percent of patients complete the prescribed treatment. Fewer successfully link to follow-up services. Some patients enter the program to clean out their systems so they can hit the street again. Most follow the common trajectory among ambivalent users trying to quit, but who face multiple barriers to successful recovery.

Climbing a few flights of stairs, I passed through another security door and encountered a doorway covered by a heavy curtain. I pulled aside the curtain and caught a whiff of that musty institutional aroma as I glimpsed rows of cots in a large room. Ten or fifteen men were there. Some were standing around talking. Some were sleeping. Others were curled up tightly in bed, uncomfortable, enduring the symptoms of alcohol withdrawal. Down the hallway was the more tidy women’s sleeping area. A teddy bear rested on one neatly-made bed alongside a few family photos.

Many of these patients were HIV-infected. Russia is struggling to avoid a generalized HIV epidemic emerging from its large population of heroin users. The estimated infected population exceeds one million. Almost of these men and women were infected over the past decade. By some estimates, eighty percent are younger than age 30. Russia has more infected people, and probably more new infections, than does United States, even though our population is twice as large. Maybe 80 percent of the infected are injection drug users, though 1/3 of recent cases are estimated to occur outside the population of injection drug users.

Until the 1990s, HIV was rare in Russia. Yet as Murray Feshbach and others have documented, Russia squandered its long head start in confronting the epidemic. Many Russians believe that AIDS is a disease of decadent Westerners, or (much worse) sub-Saharan Africans. Soviet-era policies and attitudes regarding drug users and sexual minorities were quite harsh. Soviet inefficiency produced other problems, such as condom shortages and syringe production shortfalls that prompted HIV outbreaks in hospitals that reused injection equipment. Until four or five years ago, Russian officials conspicuously avoided public mention of AIDS.

The prevention challenge is underscored by 2007 surveys. Only about 1/3 of Russian young adults and commercial sex workers “both correctly identify ways of preventing the sexual transmission of HIV,” and “reject major misconceptions about HIV transmission.” Only ¼ of Russian gay men could correctly answer similar questions. Most Russians living with HIV don’t know they are infected.

Belatedly, things are improving. Russian government and international donors have increased prevention and treatment spending. They are way behind the (non-stellar) U.S. efforts, but combined Russian government spending on HIV prevention has reached roughly $50 million. Russia and the rest of the world have much at stake in slowing this unfolding epidemic.

Not every obstacle is Russian. Here’s where Tuesday’s election was so tragic. Whatever complaints one might have about House Democrats, Nancy Pelosi, George Miller, Henry Waxman, and others are strong advocates for domestic and global public health measures: evidence-based HIV prevention, tobacco control, maternal and child health, support for state and local public health efforts. House Democrats promoted important public health measures in the stimulus and then in the health reform bill. Many of these measures died in the Senate, but important accomplishments were made.

Not surprisingly, global HIV prevention is a heavy lift. Although Republicans have supported President Bush’s life-saving PEPFAR initiative, researching and effectively implementing measures to reduce sex- and drug-related HIV risks still draws conservative ire.

An Issa amendment stripped $5 million in NIH funding from three peer-reviewed HIV prevention studies. One of these studies concerns behavioral risks among hospitalized Russian alcoholics. (The other two studies examine strategies to prevent HIV transmission among sex workers in Thailand and China—two other key sites of the global HIV epidemic.)

Issa’s office crowed that his amendment passed by voice vote. As their press release put things: “These studies are clearly not high priorities for U.S. citizens, suffering from disease here at home, who could benefit from the $5 million the NIH plans to spend on foreign alcoholics and prostitutes.” There is little political payoff in funding sound interventions that help marginalized people in distant lands. There is also little payoff in overriding scientific peer review to slam weird-sounding research projects.

That’s too bad. Russia’s HIV epidemic poses many economic, political, and security dangers. We have much to lose if Russia fails in controlling it. Modest global public health investments bring other benefits, too. The nonprofit organizations and public health agencies that perform this work are fragile pillars of pluralism and tolerance within a largely-undemocratic society. We should stand with them.

Rep. Issa is now poised to become chair of the House Oversight committee. Democrats are rightly worried that this provides an ideal platform to pursue partisan investigations and to harass the Obama administration. I worry, too, about less-visible but valuable initiatives which Issa is now positioned to thwart or to disparage.

So many people have died needlessly of AIDS while politicians like Rep. Issa make things worse to score cheap political points. The people trying to fight this disease—not to mention those trying to avoid or survive it—deserve better than they got this Tuesday.

Author: Harold Pollack

Harold Pollack is Helen Ross Professor of Social Service Administration at the University of Chicago. He has served on three expert committees of the National Academies of Science. His recent research appears in such journals as Addiction, Journal of the American Medical Association, and American Journal of Public Health. He writes regularly on HIV prevention, crime and drug policy, health reform, and disability policy for American Prospect, tnr.com, and other news outlets. His essay, "Lessons from an Emergency Room Nightmare" was selected for the collection The Best American Medical Writing, 2009. He recently participated, with zero critical acclaim, in the University of Chicago's annual Latke-Hamentaschen debate.

24 thoughts on “Russian alcoholics, Chinese and Thai sex workers, and Congressman Darrell Issa”

  1. I think it's time to move one of those useless presidents, or Franklin, who was a France-worshipping whoremonger anyways — off of our money, and replace him with Al Davis. And "Just Win, Baby" can go where E pluribus unum used to be.

    That would be so cool — and so American.

  2. Having been closely associated with a prominent Chinese national who works with the Global Aids Program that is supported by our CDC, I have a difficult time understanding why millions of CDC money is spent in China and other areas of Asia to supplement their AIDS programs. Our country is obviously spending borrowed money to help these wealthy countries. I am sure our CDC leaders take great pride in their assumed "authority" role. If the CDC has such a wealth of superiority to offer these countries, it would seem more economically prudent to hold seminars in the US and charge seminar fees. Until our government leaders wake up and realize that we can not continue to spend money we are borrowing on foreign projects which other very capable governments can manage themselves both financially and intellectually, our country will continue down this slippery slope to a unfortunately dark future for our citizens. Yes, I know the Gates Foundation is also very active in China and Asia. That is wonderful. From what I understand their staff is better paid than those of the GAP program. However, the Gates Foundation is not spending borrowed money. If they think this is a wise use of their money, then I support their decision.

  3. Issa was on Real Time With Bill Maher (HBO) this evening and spoke about the troubling size of our prison population and the need to separately treat those with drug addictions to reduce recidivism.

  4. Research dollars aren't unlimited. Money that goes to help prevent Thai whores and Russian junkies from getting a disease which has long been known to be easily preventable simply by avoiding high-risk behavior comes out of research for diseases like cancer, heart disease, diabetes, and Alzheimer's disease that kill or debilitate millions of Americans, including those who don't engage in high-risk behavior.

    Explain why we should be interested in funding these programs when there are worthy grant applications for diseases that kill ordinary Americans that aren't getting funded.

  5. What Ron and SR say. "funding sound interventions that help marginalized people in distant lands." is not a core function of government, and it's certainly not something a government deep in debt, and growing much deeper from moment to moment, should be doing. There's something deeply bizarre about the US borrowing money from China to help people in China. Though I suppose the Chinese government appreciates it.

    "We should stand with them."

    Fine, you're part of "we", and I presume you're not broke. Get to it! Charity is great. Spending somebody else's taxes on it, not so great.

  6. In 1714 the British Parliament offered a very large prize of £20,000 for a method of determining longitude for navigating ships (an entire fleet was lost in 1707 because of longitude error). Wikipedia gives the current equivalent as $4.7m; but GDP was much lower, and the order of magnitude was that of the largest private incomes in England. The prize was open to foreigners, and Leonhard Euler got an small award for a useful mathematical contribution towards the astronomical table method.

    Generally speaking, nationality restrictions will make research inefficient. There´s a free-rider problem, clearly, as commenters have pointed out in relation to China, Russia and Thailand. The solution is multilateralism, as with the IPCC, ITER and smallpox eradication. Issa wouldn´t like that either.

    What´s objectionable in Issa´s action is the mean-spiritedness. The sums are very small change not only in relation to the US Federal budget, but in that of the NIH. The message it sends to Russian, Chinese and Thai élites is that Republicans don´t care what happens to their sick compatriots. There´s every reason to think that these élites are taking notice. Smart move?

  7. Well, the trolls are really out in force today. As James says, we are talking about a real pittance in relation to the federal budget. When Issa starts investigating the Pentagon and agricultural subsidies, then I'll take him seriously. Moreover, the whole point about a communicable disease is that it's communicable. Germs don't stop at a border. Third, even a tiny effort at public support not only dwarfs charitable contributions but also galvanizes them: more people will contribute when they know that there is a broad effort. And for those who say that we owe no obligations to those across our borders, spare me any of your lectures about "conservative faith" and "traditional values".

  8. What point of "conservative faith" or "traditional values" mandates distributing other people's money to aid foreign whores and drug addicts? Was this in the catechism somewhere? "Why did God make you?" "To be taxed to support utopian globalist social programs."

    As for the pathogens coming to the US, I'm not too worried about it. The likelihood of someone with my habits getting AIDS is virtually nil. I do have a substantial risk of heart disease, stroke, or cancer. The same is true of the vast majority of American taxpayer. If it's not true for you, then reevaluate your lifestyle. I'm not going to say that it's completely without value, but there are higher priorities.

    And if you think the money is so small that this issue doesn't matter, why are YOU talking about it? Clearly it's not just about the $5 million. If you accept the principle that we have the duty to fix internal problems in foreign basket-case countries, the sky's the limit.

  9. Sevral commenters express a sadly narrow-minded perspective on several counts. Nations have a common interest in containing deadly and expensive diseases. Especially in this era of global travel, complete with sex- and drug-tourism, it's naïve to believe we are unaffected by widespread HIV infection in Russia, Thailand, or China.

    Moreover, when we help other societies confront deadly threats to their well-being, we earn something real that can't be earned any other way. When we had our own trauma on 9/11, many Americans were upset that countries around the world weren't more sympathetic. Yet we ourselves fail to help when other nations endure far more widespread threats to well-being and public health.

    Then there is the question Jesus asked: Who is my neighbor?

  10. I agree with Brett (for the record).

    We can't afford to solve national health crises and social problems for governments of other wealthy nations. How are we more responsible for their populations than they are?

    Hardly anyone I know under 35 has a job with benefits.

    Half our population earns less than $26,000 / year.

    Fix America first?

  11. Harold: pretty much everybody was sympathetic in the immediate aftermath of 9/11. I recall one anti-American demonstration in Palestine (not condoned by the Palestinian leadership) and a nasty statement from Saddam Hussein. That was about it on the negative front. Even Syria and Libya sent nice messages! If Americans remember things differently, they are projecting the subsequent worldwide disaffection created by Bush´s GWOT and especially the invasion of Iraq. It was a moment of true solidarity, a great blown opportunity.

    The particular conditions of the 9/11 attacks meant that practical international assistance would not have been useful. There was no immediate financial or disaster relief problem to be met. However, when Katrina struck all sorts of countries gave help. Albania donated $300,000 – a big sum if you think of the size and poverty of the country. Similarly, help was offered in dealing with the Gulf oil spill. It´s what normal human beings do.

  12. This is partly a basic moral disagreement. At least one side is wrong, but there's not much chance the difference will be bridged by rational means. Underlying the disagreement is a difference in character.

    But there's also a question of instrumentalities. Issa doesn't propose to end US presence in Thailand, or even all US involvement with the Thai sex industry. He's been a supporter of the religious right's anti-trafficking projects there, and the current amendment is connected with that.

    Issa's statement notwithstanding, House Republicans won't adopt SR's "I'm down on whores" rhetoric. They'll just shift the money from measures that would save sex workers' lives to ones that purport to save their souls.

  13. Maybe an economist can make a more precise contribution to this thread, but perhaps there is a common thread connecting the approach of movement conservative thought in this specific instance and in "free market" issues that are beloved of the same people. Issa seems to be blind to the concept of externalities, which are consequences of market interactions that affect people who were not parties to the particular market transaction. Sometimes these manifest as free-rider issues, and sometimes, as happened in the financial crash, people who never traded in securitized mortgages have lost jobs and life savings due to the fallout from the unregulated trade in financial commodities which the traders did not bother to understand.

    It is as if the conservatives conceived of the world in terms of isolated voluntary transactions whose consequences remain restricted to the walled-off environment in which the transactions took place. Individuals, appearing as isolated entities, are the primary reality, and their webs of relatedness are derived and secondary realities. I appreciate K's assertion that these are moral disagreements, but perhaps they are divergent perspectives on what is actually real.

  14. It's as though liberals can't conceive of the government as an absolutely unlimited force which MUST do every last thing they think is even remotely worth doing, even, as I say, if it's deep in debt, and getting deeper at a terrifying pace.

  15. "can't conceive of government as other than", I should say.

    Johnathan, if it's really is a pittance, and the goal is widely agreed to be good, seems like it would be a perfect candidate for private charity. Since you're not advocating that, I assume you think one of those conditions fails. You expressed the "pittance" part explicitly, so it it that you want government to do this because it's unpopular enough with American citizens that they wouldn't do it if given a choice in the matter?

  16. Harold is right that the value of that grant might have been non-zero for Americans, but the value is less than the opportunity cost. The probabilty of a particular American getting AIDS, directly or indirectly, from Russian junkies or Thai whores is non-zero, but low, whereas the probability of getting cancer or heart disease, among others, is quite high. It's not comparable to something like the eradication of smallpox (which I would support, not being as naive as Ed Whitney thinks).

    We live in a declining country, heavily in debt, and other researchers are having trouble getting their grants funded, including those who study the big killer diseases. This is not the time for messianic world-healing.

  17. Brett, you've been proven to be a worshiping lackey of that rogue state in the Middle East, Israel.

    We give that ungrateful pack of scum 100x the money that we spend on worldwide AIDS prevention. Money which would have a positive benefit – twice, because Israel would receive less coerced US dollars.

    So don't even pretend that you give a flying fig about the money.

  18. sr,

    If I understand correctly, the studies Issa killed dealt with prevention strategies.

    You complain that,

    Money that goes to help prevent Thai whores and Russian junkies from getting a disease which has long been known to be easily preventable simply by avoiding high-risk behavior comes out of research for diseases like cancer, heart disease, diabetes,..

    Funny thing. Type 2 diabetes is highly (not totally) preventable "simply by avoiding high-risk behavior." Same for lung cancer and, to a lesser degree, heart disease. Then there's car accidents. If we are looking for domestic benefits for these studies it seems to me that anything we learn about getting people to change high-risk behaviors would be helpful in a broad sense, regardless of the disease involved. Now, it may be that what works with these particular poplations doesn't transfer readily to the US, but do we know that? Even if we learn just a smidge, there would surely be a positive payoff. Even a small reduction in diabetes incidence over the next decade (let's say it only occurs in Thai and Russian immigrants) will be worth much more than $5 million to the US.

    So even leaving aside the altruistic reasons it seems to me that there might be some benefit. Going one step further, I don't think the "Don't spend my money on it. It's easily preventable by avoiding high-risk behavior," argument stands up well under scrutiny.

  19. My risk of being a victim of terrorism is quite small. Please don't spend my tax dollars preventing terrorism in New York, LA, and D.C. After all, it's all about me. Being concerned with my fellow Americans, much less my fellow humans, pays no dividends to my bank account.

    That is all.

  20. Those 12-year-old "Thai whores" need to start taking responsibility for their actions. Why should the hard-earned tax money from commenters here be spent providing help for something these children brought on themselves?

  21. The government is nominally taxing us for OUR benefit. That's the justification given, after all, for taking the money from us by force: It's for your own good!

    That being the case, the government is always on very shaky ground indeed when it spends that money for somebody else's good. Even if there might be some "trickle back" in the end.

    Sure, there might be come indirect, partial benefit to Americans from studying prevention strategies in Russian alcoholics and Thai sex workers. Do we lack alcoholics and sex workers here, to spend the money studying?

    Incidentally, "Until the 1990s, HIV was rare in Russia." Do we actually have independent evidence this was true? It's not like official statistics coming out of the USSR, (Which, perhaps not coincidentally, fell in the 1990's…) were particularly reliable.

  22. Brett re taxes: "…taking the money from us by force"

    Grow up. I am "forced" to pay taxes like I'm forced to work for a living; like I'm forced to pay for my groceries. It's true only in the most hyperbolic sense. Of course actions have consequences. But no one's putting a gun to your head. Stop making it sound like they are. It just makes you sound like a baby.

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