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 cityâ€™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 womenâ€™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 â€œboth correctly identify ways of preventing the sexual transmission of HIV,â€ and â€œreject major misconceptions about HIV transmission.â€ Only Â¼ of Russian gay men could correctly answer similar questions. Most Russians living with HIV donâ€™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 Chinaâ€”two other key sites of the global HIV epidemic.)
Issaâ€™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. Russiaâ€™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 diseaseâ€”not to mention those trying to avoid or survive itâ€”deserve better than they got this Tuesday.