Margaret Thatcher: harm reduction heroine

Cross-posted with TCF.org….

I’ve been following my left-liberal friends’ reaction to Margaret Thatcher’s death. I take it they’re not huge fans of her historical legacy. I’m not such a big fan myself. But one aspect of her legacy deserves some notice. The Thatcher government responded rather effectively and humanely to the HIV/AIDS crisis. Embracing harm reduction measures such as syringe exchange and methadone maintenance, it saved thousands of lives. Indeed the words “harm reduction,” anathema to American drug control policy until the Obama administration, were official watchwords of British drug policy. As Alex Wodak and Leah McLeod summarize this history:

By 1986 the Scottish Home and Health Department concluded that ‘the gravity of the problem is such that on balance the containment of the spread of the virus is a higher priority in management than the prevention of drug misuse.’ and recommended accordingly that ‘on balance, the prevention of spread should take priority over any perceived risk of increased drug use.’ This approach was strengthened by the influential UK Advisory Committee on the Misuse of Drugs asserting in 1988 that ‘the spread of HIV is a greater danger to individual and public health than drug misuse…accordingly, services that aim to minimize HIV risk behaviour by all available means should take precedence in development plans.’

Thatcher-era British policies provided a damning contrast to the Reagan and George H. W. Bush administrations, which so disfigured their legacies by allowing HIV policy to become yet another front in the culture wars. More than 600,000 Americans have died after being diagnosed with AIDS. An unknowable number of these deaths would not have occurred had our government moved with greater speed, resources, and humanity to contain a deadly epidemic.

The HIV epidemic struck at the weakest points of American society and our political life. The centrality of homosexuality and drug use guaranteed that HIV prevention would spark bitter ideological and moral fights. Within the British system, these fights occurred in a context in which experts at the National Health Service and related public health bodies commanded real legitimacy and respect within the political process.

Things played out rather differently here. In September 1985, President Reagan prepared to make his first, very-late public comments on AIDS. Responding to unfounded fears, health authorities proposed to include the following words in his speech: “As far as our best scientists have been able to determine, AIDS virus is not spread through casual or routine contact.”

These words were never spoken. A young White House aide redacted them. This story is telling, not because that young aide—now Chief Justice of the United States—got the science wrong. It’s telling because the medical and public health consensus was casually over-ruled by a young lawyer who knew little about AIDS. Public policy is not only about making the right decision. It is also about creating the right organizational capacities and the right norms of decision-making so that judicious analysis is performed and is then given a proper hearing. That didn’t happen.

The Reagan presidency ended twenty-five years ago. That was a different time. Public attitudes have changed—not least because of what we all witnessed in the HIV epidemic itself. Maybe it’s unfair to judge American public policy of the 1980s by our values three decades later.

Still, it’s still worth remembering that one of the English-speaking world’s greatest conservative politicians faced the same crisis, at the same moment, just across the Pond. And the Iron Lady did much better.

Two steps forward, one step back fighting HIV in Chicago

Last week, one of my twitter followers called me to task for writing an entire column on HIV and AIDS without focusing on the huge disparities by race/ethnicity. She was certainly correct about the critical role of such disparities. Yesterday–again on twitter–Chicago commissioner of public health Bechara Choucair drew my attention to an especially pertinent report on such matters.

Little by little, Chicago is making progress in addressing rising HIV incidence, non-diagnosis, and late treatment among young men who have sex with men. Thing’s aren’t great, or even remotely acceptable. Epidemiological data from the Chicago component of the National HIV Behavioral Surveillance (NHBS) System indicate that HIV prevalence among men who have sex with men (MSM) continues to rise. At least a higher proportion of men know their status and are getting treatment.

In 2008, 67% of surveyed (and tested) Black MSM found to be HIV-positive were not aware of their infection. By 2011, only 33% were similarly unaware. These numbers remain far too high. (The comparable figures among non-Hispanic White MSM were 23% and 9% in the same years.) Yet awareness is moving in the right direction. MSM who tested positive in 2011 were also more likely to be receiving appropriate medications than was found in 2008. Among African-Americans, the percentage of HIV-positive MSM reporting being on HIV medications increased from 44 to 84 percent. Among HIV-positive Hispanic MSM, there was a similarly large increase from 50 to 82 percent. (Again–among surveyed non-Hispanic white MSM, the comparable figures were, um, 90 and 100 percent.) These data are hardly airtight; epidemiological data concerning stigmatized behaviors seldom are. The basic story here seems consistent with other sources.

If you are still wondering why there is such urgency concerning African-American MSM, read the accompanying report. In particular, compare the top two lines from Figure 2 (below the fold). Both the level and the disparity remain really concerning. So any sign of progress is especially heartening. Continue reading “Two steps forward, one step back fighting HIV in Chicago”

Covering ex-prisoners: Another quiet benefit of health reform

This won’t matter politically, but the Affordable Care Act quietly improves public health by expanding coverage for hundreds of thousands of ex-prisoners and others under the control of the criminal justice system.

I began my public health career on a Yale postdoc. One of my formative experiences there was to accompany colleagues on the Community Health Care Van, a needle exchange-based mobile clinic for street drug users.

Tagging along with the staff, I helped some patients complete basic paperwork. A weathered middle-aged guy stepped on. When I asked what brought him there, he pulled back his shirt to reveal a chalky-white oozing crater in his shoulder. That festering infection was my rude introduction to the life realities of injection drug users.

Most of these women and men suffered greatly with addiction and a variety of complex illnesses. Most were uninsured, yet still consumed enormous health system resources as they cycled through correctional facilities, became emergency department frequent-fliers, and required heavy use of other safety-net services.

The CHCV reduced patients’ emergency department use by about twenty percent. We could have done more if we could have provided reliable primary care, appropriate drug treatment, and other services requiring insurance coverage.

This won’t matter politically, but the Affordable Care Act will quietly improve public health by expanding coverage for hundreds of thousands of ex-prisoners and others under the control of the criminal justice system. Most of these men and women are on parole or probation. A nice Health Affairs paper by Alison Evans Cuellar and Jehanzeb Cheema runs the numbers. Roughly half of the 700,000 people released every year from correctional institutions will gain coverage or improved care under health reform.

More here, in my latest column for healthinsurance.org.

Screening for hepatitis C in jail

Hundreds of thousands of people could be helped through opt-out hepatitis C testing in correctional settings.

Every day thousands of Americans with treatable physical or mental health problems are locked up in jails and other secure facilities. Work by Theodore Hammett and others makes clear that a surprisingly large fraction of Americans living with HIV, tuberculosis, and a variety of psychiatric disorders pass through the correctional system every year. All too often, men and women with these disorders pass through criminal justice facilities relatively quickly, their illnesses undetected and thus unaddressed.

Hepatitis C is a particularly prevalent and serious condition, which infects a huge fraction of injection drug users. In an important JAMA commentary this week (in print, but apparently not yet posted on the web), Anne Spaulding and David Thomas note that between 29 and 43 percent of all Americans infected with this disease are estimated to pass through the criminal justice system every year. Hundreds of thousands of inmates have no idea that they are infected. That’s just a huge missed opportunity.

Rapid testing technologies can now provide good results within about 20 minutes. Opt-out HCV testing in correctional settings could easily identify hundreds of thousands of people who could then receive timely medical interventions.  Given the increasingly effective array of new treatments, this could make a huge difference.

As we learned in the case of HIV, one must reach patients where they are. Injection drug users and others at-risk for this disease won’t always come to us. That means getting into our jails, detention centers, and substance abuse treatment facilities and making them work for public health. Physician-public health experts, such as my friend and co-auther Frederick Altice of Yale University, have been doing this for years, with good results. In many places, this is long overdue.

More bad news–needle exchange

Another bad development in public health

With everything else going on, some very bad news has slipped by without a lot of public attention.

As most RBC readers know, every major public health expert body from the Institute of Medicine to the Centers for Disease Control and Prevention to UNAIDS and the World Health Organization, to the White House Office of Drug Control Policy endorses syringe exchange as an effective and cost-effective strategy to prevent HIV and other blood-borne infection among injection drug users.

Despite this evidence, Philip Smith and Maia Szalavitz report, Congress just restored the ban on federal funding for syringe exchange after the Senate took the final votes to approve the 2012 federal omnibus spending bill. 

I’ll have more to say when I get a change to learn more about the practical impact. It’s especially regrettable that the bill hinders support for evidence-based international programs that support syringe exchange. There is a fight for life against AIDS around the world. This is very detrimental.

The below press release from the AIDS Foundation of Chicago tells the basic word:

Continue reading “More bad news–needle exchange”

AIDS Day

President George W. Bush deserves much credit for PEPFAR. Republicans (and others) are tarnishing this legacy with punishing cuts to HIV/AIDS services around the world.

I put up a piece this morning under the perhaps-surprising title of George W. Bush brings his awesomeness on AIDS Day. I’m, um, not a huge George W. Bush fan. But PEPFAR was a genuinely great thing. Of course there’s a Nixon-to-China aspect of a Republican president taking leadership in the fight against AIDS. Many others deserve credit. The bottom line is that Bush cared about it and was able to get this done. He’s also doing a great service advocating for sustained global health aid when so many Congressional Republicans (and, shamefully, some Democrats too) have supported and enacted punishing cuts to programs that save literally millions of lives around the globe.

As New York Times reported: “America’s budget crisis at home is forcing the first significant cuts in overseas aid in nearly two decades.” House Republicans propose deep cuts in the State Department and in foreign aid. Many of these cuts fall on evidence-based health and development assistance. As the Washington Post’s Michael Gerson described these cuts earlier this year: “If the goal of House Republicans is to squander the Republican legacy on global health, they are succeeding.” The same thing is happening in other wealthy democracies facing hard economic times.

My TIE post left one thing out: the immediate consequences of donor cuts to HIV programs. Alanna Shaikh at UN Dispatches provides a powerful column on this:

In the face of [great scientific and clinical opportunities], the global community responded in one voice, “Forget it. We don’t care.” Things are hard all around, you know, and foreigners with HIV don’t vote in domestic elections. The Global Fund to Fight AIDS, TB, and Malaria just canceled its next round of grants. The WHO is laying off staff. Bilateral donors are cutting aid to global health. Instead of breaking the cycle of HIV transmission, developing nations will be lucky if they can protect the people they already have on treatment.

That may sound dramatic, but look at the numbers. The Global Fund asked donors for $20 billion. It received $11.5.  Everyone from Germany to the USA reneged on their pledges of support.

What a predictable, infuriating, and short-sighted development. Shaikh notes that we’ll be apologizing to our children for this. The people to whom apology is really owed won’t hear it. Many will soon be dead.

Rock Hudson’s Best Movie

Anne Helen Petersen has written an intriguing, sad article about Rock Hudson and the gay agent who packaged him and other gay men as movie stars. She argues that Hudson’s sexuality actually made him more attractive to a certain segment of heterosexual women in the 1950s and 1960s precisely because he was handsome, charming, kind and at the same time (from a straight woman’s viewpoint) asexual and therefore unthreatening. Petersen closes the piece with well-deserved praise for Hudson’s handling of his HIV infection and subsequent wasting away, which galvanized public sympathy for AIDS victims.

Hudson wasn’t a top-notch actor, but he was a great movie star. He will probably be most remembered for his massively popular films with Doris Day (who at the age of 87, has a new album out! Check out her chat yesterday with her pal and fan Paul McCartney). But what is Rock Hudson’s best film?

Some movie fans would argue for Giant, which remains highly watchable today despite it’s staggeringly long running time. But the scenes in that film which stay with you are mainly those with James Dean and/or Elizabeth Taylor rather than Hudson, whose character is much flatter than theirs.

So I am going to go instead with Seconds, which very few people even remember today. It features an atypical role for Hudson and he does well with it, maybe because he could identify with the main character, who had to pretend to be someone he was not in order to “pass”. My all-time favorite cinematographer, James Wong Howe, goes over the top with strange lenses and moving shots, starting with the Vertigo-esque opening titles, which amplifies tonally the weird story that that the film tells.

Elizabeth Taylor, HIV/AIDS activist, 1932-2011

I’ve only seen one or two Elizabeth Taylor movies. I can only identify a few of her eight husbands, and that’s double-counting Richard Burton. I do know that Elizabeth Taylor did a lot for gay rights and for honoring the humanity of people living with HIV and AIDS. She is missed.

Taylor caught some criticism and resentment from segments of the gay and HIV/AIDS activist communities who deserved more of the limelight that she immediately received because of who she was. There was no way she was going to match the intensity or the boldness of (say) many ACT-UP participants and supporters. Desperate, abandoned, often fatally ill, these men (and some women, too) lacked the time for some usual niceties of coalition politics. I can’t blame them for that. They also lacked the recognition and the social acceptance they deserved. In different ways, both ACT-UP and people like Liz Taylor did much good.

Taylor also provides a chastening reminder of something else. She could have followed the path of most other self-indulgent celebrities: being quietly decent to affected friends, otherwise keeping her head down about the epidemic. She did a lot more than that.

I myself was in my early 20s when Elizabeth Taylor really stepped forward on this issue to lead amfAR. Like most people at some remove from this epidemic, I watched passively, saddened by the scale of the catastrophe, but having a million reasons for doing…not much to help out. Elizabeth Taylor’s contributions stand as a rebuke to those of us who could have done more when it most mattered, especially in those early days when HIV advocacy was a politically marginal cause.

Phoebe Connelly has a nice piece in the Awl with more.

Postscript: This Frontline piece is great, too (h/t Andrew Golis).