Luck’s a chance, but trouble’s sure: HIV prevention efforts during the World Cup are being undermined

I’m very lucky. The only time I was ever up shit creek I just happened to have a paddle with me. ~ George Carlin

If you google “fifa world cup hiv” and click on the “I’m feeling lucky” button, you will find a good article from allAfrica.com about how FIFA is hindering HIV prevention in South Africa during this year’s World Cup. But luck’s a chance, and you could just as well have run across predictable propaganda in a corporate-friendly Reuters article. Reading the latter, you would think FIFA is leading the campaign with banners flying and money sacks open. The truth is just the opposite. In a sport devoted to the glorification of hard young bodies, unheard-of personal wealth, and vaunted celebrity, HIV is an image-tarnisher, an unlucky coin toss in life’s game of chance. FIFA’s neglectful attitude to HIV prevention and its lack of engagement with and support for local AIDS organizations is making headlines. Sexually active football fans will be in need of much good luck in the coming month. Their health seems to be of little concern to football organizers, who have spared no effort to make sure that supplies of beer will not run out.

When you think of the extraordinary sums of money to be made in the coming weeks and the fabulous riches of the football clubs, it is an outrage that FIFA has not donated at least the modest half million dollars (4 million Rand) required by the South African National AIDS Council to fund an HIV prevention campaign during the tournament. It is equally appalling to learn that FIFA is actively banning the distribution of condoms at World Cup stadiums and other venues.

Although the lords of football made the right noises in a public announcement earlier this year, FIFA is now being criticized by AIDS organizations, both for its action and inaction in South Africa, and for its general insouciance and ignorance about HIV prevention. In the midst of contradictory statements and corporate spin, it emerges that about all FIFA has actually agreed to is the installation of condom dispensers in toilets at the stadiums. It also claims to have encouraged health authorities to set up “fan service areas” in South African cities during the tournament. These feeble gestures come as the planet’s wildest party is about to begin in a country with the largest number of HIV carriers, with an estimated 5.7 million people infected. There are 1,400 new HIV infections every day and nearly 1,000 AIDS deaths.

“To date Fifa has not permitted any civil society organisation to distribute HIV- or health-related information and Fifa has not provided any written confirmation that condoms may be distributed at stadia and within the fan-fests,” South African AIDS groups said in a statement. “This is despite the fact that commercial sponsors selling alcohol will have dedicated spaces available.”

For the sex trade a World Cup event is like having all the navies in the world dropping anchor in your home port. Vats of alcohol are sure to be consumed as foreign fans drink to lady luck and rub shoulders with locals. But in a country where one in five adults is living with HIV, the price of throwing caution to the wind and having unprotected sex with a local, let alone a sex worker, could be extremely high.

It is estimated that 100 million condoms will be needed to meet increased demand during the World Cup. Despite some generous donations from Britain and the UN, there probably won’t be enough condoms for football revellers. That’s bad enough, but as a South African expert has said, the problem is not just the quantity of condoms available – it’s also the lack of a high-profile safer sex campaign.

FIFA is not the only one at fault. South African laws that criminalize sex work compound sex workers’ individual risk for HIV and compromise broader public health goals. A massive international sporting event like the World Cup will undoubtedly increase demand for paid sex and, particularly in a country with hyper-endemic HIV, will guarantee a sharp rise in HIV-infection rates through unprotected sex.

In a paper published last December in Globalization and Health, a group of activists called on South Africa to respond to the challenges the sex industry poses in a strategic and rights-based manner, using the World Cup events as an opportunity to attribute more weight to public health goods than to an ideology based on sexual moralism – an ideology that time and again has been proven ineffective in preventing HIV in South Africa and beyond. The authors argue for a moratorium on the enforcement of laws that persecute and victimize sex workers during the World Cup period.

The prospects are not encouraging. While the world rightly celebrates South Africa’s pride in hosting the games, amidst all the hoopla the HIV epidemic is only going to grow worse. When the party is over and the teams and their fans have gone home, as FIFA calculates its profits epidemiological statistics will begin to tick ever upward. You’ll be able to google them in a year or so.

Luck’s a chance, but trouble’s sure. It’s one thing to click the “I’m feeling lucky” button – but having sex without a condom during the World Cup is like being up the creek without a paddle.

flickr photo by dmountain

The troubling reality of sexual lubricants: while promising enhanced pleasure, they facilitate infection

New research presented at the Microbicides 2010 conference, as reported in Medscape, indicates that several common over-the-counter sexual lubricants can damage rectal and vaginal tissue, thereby increasing vulnerability to a number of sexually transmitted infections (STIs), including chlamydia, gonorrhea and HIV. These results build on previous studies with similar findings [1-2].

Rectal lubricant gels are widely used [3], but the evidence is now pretty convincing that the hyperosmolar kind (those with a higher concentration of salts and sugars relative to epithelial cells with which they come into contact) can cause significant damage to sensitive tissue and greatly increase the danger of infection. There has also been some research on the common use of saliva as a sexual lubricant, especially among men who have sex with men [4], but more studies are required to determine whether saliva use in this way contributes to transmission of saliva-borne pathogens.

According to a press release from the Microbicides 2010 conference, in the United States alone receptive anal intercourse is practised by 90 percent of gay and other men who have sex with men. Moreover, the practice is not limited to men. U.S. estimates and surveys in the United Kingdom indicate between 10 to 35 percent of heterosexual women have engaged in anal sex at least once. Globally, estimates suggest 5 to 10 percent of sexually active women are having anal sex. Despite enormous efforts to promote condom use, especially in the past quarter century, most acts of anal sex go unprotected.

All this begs the big condom question. Although the recent research on lubricants is troubling enough, it should not distract public health authorities and community-based organizations from emphasizing yet again the plain fact that consistent condom use is the best way to prevent STIs [5-6].

REFERENCES

1. Fuchs EJ, Lee LA, Torbenson MS, Parsons TL, Bakshi RP, Guidos AM, Wahl RL, Hendrix CW. Hyperosmolar sexual lubricant causes epithelial damage in the distal colon: potential implication for HIV transmission. J Infect Dis. 2007 Mar 1;195(5):703-10. Epub 2007 Jan 23. PubMed PMID: 17262713.

2. Sudol KM, Phillips DM. Relative safety of sexual lubricants for rectal intercourse. Sex Transm Dis. 2004 Jun;31(6):346-9. PubMed PMID: 15167643.

3. Javanbakht M, Murphy R, Gorbach P, Leblanc MA, Pickett J. Preference and practices relating to lubricant use during anal intercourse: implications for rectal microbicides. Sex Health. 2010 Jun;7(2):193-8. PubMed PMID: 20465986.

4. Butler LM, Osmond DH, Jones AG, Martin JN. Use of saliva as a lubricant in anal sexual practices among homosexual men. J Acquir Immune Defic Syndr. 2009 Feb 1;50(2):162-7. PubMed PMID: 19131893.

5. Weller S, Davis K. Condom effectiveness in reducing heterosexual HIV transmission. Cochrane Database Syst Rev. 2002;(1):CD003255. PubMed PMID: 11869658.

6. Mindel A, Sawleshwarkar S. Condoms for sexually transmissible infection prevention: politics versus science. Sex Health. 2008 Mar;5(1):1-8. PubMed PMID: 18361848.

cc flicker photo by Erik Pronske

Web refuseniks as second-class citizens: librarians can only do so much for the offline classes

People who don’t want to – or simply can’t – be part of the digital world are being subjected to bullying tactics.The NHS is not alone in disenfranchising, tormenting or otherwise penalising citizens who, living offline, are already defined as excluded. Employers, too, demand that job applications be submitted online; banks and shops, travel, insurance and energy companies save competitive products for online customers; even councils demand applications for social housing be made, exclusively, online.

Britain’s millions of refuseniks seem to be surviving. In public spaces all round the country, librarians help the offline classes to fill long, complicated forms with pieces of sensitive personal information. How long have they been unemployed? Have they ever been in trouble? Any problems with neighbours? Need help? For that you will need an internet address, ask your librarian.

Want to complain to someone about your new, digital designation as a second-class citizen? Tough, losers: you can only do that online.

Catherine Bennett. If you’re not online these days you’re a second-class citizen. “Comment Is Free” The Guardian, Sunday 16 May 2010

cc licensed flickr photo by sp3ccylad

Endless blather about health care coverage. But why aren’t we talking about dental care reform?

The Obama administration’s agonizingly eked out health care reform will affect the dentistry industry in the United States in some minor ways, for example, requiring insurance plans to include pediatric oral health services for children up to 21 years of age, establishing public education campaigns, and ensuring that essential health benefits packages include oral care. But without insurance, Yankee teeth are in constant danger of eventually being, well, yanked.

We Canadians like to boast about our single-payer system and universal coverage for all. But when it comes to Canadian teeth, we play the same kind of insurance game with our health as our neighbours to the south. The Canada Health Act, as explained in a typically ponderous government document, provides for coverage of “medically required surgical dental procedures which can be properly carried out only in a hospital.” But if you need a filling or root canal work, you’ll need a cool thousand or a good insurance plan.

The dental profession means well. You frequently find token gestures such as one recently announced by the Manitoba Dental Association, which will re-introduce its “Free First Visit” oral health program, beginning in April 2010. This loss leader is designed to encourage dental visits for infants and toddlers by offering a free first check-up for all children age 3 years and younger. But what about the ongoing oral health care needs of children? Where is the much-needed integration of dental care into medicare? We pay taxes to educate our children and keep most of their bodies healthy, except, strangely, their teeth. What is so special about our oral cavities – as opposed to, say, our anal cavities – that leaves their care to the tender mercies of insurance companies. Why shouldn’t complete oral health coverage be extended to all Canadians? Let’s include eye care while we’re at it.

But enter our inner Calvinist. The Atlas-Shrugged types will argue vociferously that it is wrong to use taxpayers’ money to provide a safety net for the offspring of losers and gingivitic ne’er-do-wells who think floss is pink and consumed in great quantities at county fairs. Pundits from corporate-funded think tanks like the Fraser Institute and Manitoba’s Frontier Centre for Public Policy will gnash their bicuspids in horror at such a flagrant concession to human weakness. Obviously they’ve never had to endure a twanging molar or a suppurating abscess they couldn’t spend their way out of.

The arguments haven’t changed much since the overwhelming suffering of the poverty-stricken went unheeded by those opposed to the Health Care Act in the 1960s. And their arguments are still just as specious. Let’s keep moralizing out of health policy. We need only consider the annual expenditure by the public purse on spavined hearts and riddled livers to see that this kind of supercilious cost-accounting is all that’s left of decency after the nerve has been extracted.

CC licensed flickr photo by erix!

Library renovations: tool-carrying banshees get the hurly-burly done

The true triumph of reason is that it enables us to get along with those who do not possess it. So said Voltaire, and so I have liked to think for many a year. But to a desolate soul who has been subjected for hours to the continuous whining drills and the stupendous crashings that are the leitmotif of construction work, reason quickly gives way to a kind of death-drive retreat from cacophonous reality. We all become deranged, dispossessed, and a little desperate.

When you approach the foyer of my library (the Neil John Maclean Health Sciences Library) you immediately see the “walled garden” effect that the newly erected hoardings make. Thanks to the recent largesse of the federal government, we are one of many quickly-launched funded projects that are raising dust and breeding migraines all over Canada.  During Phase I of our renovation, which will last two months, the library’s main floor will be a frantic scenario that makes the mad scene in Lucia di Lammermoor look tame. Phase II and III will continue during the later spring and summer, leaving no corner of the library untouched and no mind unravelled.

“When the hurly-burly’s done, when the battle’s lost and won”
Workers have spent most of the past week putting up hoardings to contain the dust and commotion of construction (but not the noise, unfortunately). The north, east and west areas of the main floor have disappeared. Gone are the former Circulation Desk, staff offices, our boardroom, and most regrettably, the lunch room and toilets. Both circulation staff and librarians compete for breathing space at the reorganized Information Desk.

The rest of the staff are a crowded, oxygen-starved Ellenbogengesellschaft in the adjoining computer labs, which have been repurposed for the duration of construction. Some liaison librarians like myself have been able to find temporary shelter with their respective faculties.

Having escaped the great flood of 1997, when my staff and I had to move an entire library in plastic tubs from the basement to the (thankfully) still empty fourth floor of the St. Boniface Research Centre in Winnipeg, I can be philosophical about the current disruptions. And as I work yet another dreary shift at an Information Desk surrounded by tool-carrying banshees, I will try to live up to Voltaire’s maxim, even as I shout out complex directions to the toilets over a tumultuous roar that would never respond to a shush or a shaken finger.

Academic librarians and the rhetoric of excellence

SOCRATES: What is the excellence of the art of music, as I told you truly that the excellence of wrestling was gymnastic — what is the excellence of music — to be what?
ALCIBIADES: To be musical, I suppose.
SOCRATES: Very good; and now please to tell me what is the excellence of war and peace; as the more musical was the more excellent, or the more gymnastical was the more excellent, tell me, what name do you give to the more excellent in war and peace?
ALCIBIADES: But I really cannot tell you.

Plato, Alcibiades I

As academic librarians strive for ever greater levels of achievement in our professional lives, we frequently find ourselves caught up in the fashionable discourse of excellence. Awards for excellence, endowments for excellence, excellence in librarianship, excellence in research, excellence in excelling. Like Alcibiades stuttering his way through Socrates’ relentless questioning, we have to admit that we don’t really know its true meaning except that the concept is supremely valued and sublimely variable.

We read articles by other librarians extolling accomplishment, distinction, inimitability, and overall superbness [1-2]. We hear rousing accolades to the “mutually beneficial symbiotic relationship” between business and the library as a “centre of excellence” [3]. We are subjected to peculiar perorations such as the following:

The continuous repetition of the entire excellence processes at regular intervals, including a renewed assessment, ensures a development of the library that is close to the market and meets the needs of a knowledge-based society. This dynamic leads to a continual optimisation of the library whereas the scale of the excellence achieved often corresponds to the current situation. The improvement of a library therefore knows no upper limit and new optimisation potential can be revealed continually [4].

“Centre of excellence,” “close to the market,” “no upper limit,” “continual optimisation”:  there is certainly a message here, and the language it is written in is that of the corporate communiqué and the total quality management handbook. It seems that whenever one hears of excellence, along with it there is the sound of a cheque book being snapped open.

As Elizabeth Hodgson, President of the University of British Columbia Faculty Association, writes in her recently published rant on excellence, this all-too-familiar morpheme has become “a supersaturated term like ‘patriot’ or ‘family values’, a word that means both everything and nothing” [5]. Like the Lacanian Big Other or the Foucauldian instrument of social control, it hovers over and underlies our discourse. Everyone has an idea of what excellence means, but it remains just beyond the margins of the definable. Immeasurable and impossible to grasp, its attainment is all-important, yet ever-receding. Robert Merton, the well-known sociologist of science, described it this way: “Many of us are persuaded that we know what we mean by excellence and would prefer not to be asked to explain. We act as though we believe that close inspection of the idea of excellence will cause it to dissolve into nothing” [6, p. 422].

Despite this hermeneutic panic on the part of some thinkers, for our elite groups, including university administrators, the word has become a handy shibboleth. It conveniently stands in as a universal signifier that justifies almost anything — for who could possibly object to excellence? To question the pursuit of excellence could only arise out of the envious rancour of mediocrity, the resentment of the underachiever or the subversive. As with Protecting Our Children or Supporting Our Troops, excellence allows no nuance or debate. It is absolute, inviolate, and demands uncritical acceptance.

There is a large degree of expediency in our leaders’ relentless emphasis on excellence. It provides ideological cover for power wielders, impresses those with money, and nicely papers over inadequacies. For, as has been remarked of old, often the cockloft is empty in those whom nature hath built many stories high. The bullying use of the term in the academy must further the same ends. Why else bring coals to Newcastle by pushing excellence in a setting that is already marked by an abundance of ambitious over-achievers, self-motivated, creative, and zealous of their scholarly reputations? Academic librarians have jumped on the excellence bandwagon partly to prove that we are as good as our faculty colleagues and that we deserve the resources we require to do our jobs, and partly also out of our own conformism and conceit. We should look harder at this trend. We should ask why there are so many awards for excellence in librarianship.

Where none admire, ’tis useless to excel;
Where none are beaux, ’tis vain to be a belle.  (George, Lord Lyttelton – Soliloquy of a Beauty in the Country)

A fixation on excellence can quickly go to one’s head. The way some librarians carry on, a dull-as-ditchwater meeting is made to sound as exclusive as a reunion banquet for the Ptolemies. A commonplace journal article recounting the creation of a few web pages unexpectedly and embarrassingly bursts into praise for “librarians’ persistence, performances [sic] and achievements” [7]. Are we not too familiar with unseemly preening and puffery of this sort? We enter into heated arguments and contractual battles about the measurement of excellence in research and scholarship, teaching, or professional performance. Excellence-obsessed concepts and practices such as enterprise culture, managerialism, total quality assurance, and customer care have battered the coastline of academic librarianship in successive waves. Scarcely has one subsided than the next arrives. Yet in all this commotion around excellence we can’t suck clarity out of our thumb. Right, but we can always establish another award.

While we are all scrambling in pursuit of our ideas of excellence, the cheque book reveals its true utilitarian and economic hue. Our academic centres of excellence are prodigious factories. Research excellence and research commercialization are in a tight embrace. The three drivers of research excellence are the creation of new, high-quality scientific and technical knowledge, its accelerated transmission to user communities, and the commercial exploitation of that knowledge. Achieving and maintaining excellence is now all about competing at national or international scientific frontiers, and attracting sufficient resources to maintain a lead. Striving for excellence has become of paramount importance in science policy and informs the quality assurance practices of granting agencies [8].

Universities are taking this game seriously. They look for stars to ratchet up the excellence factor, perform as big money magnets, and compete with other institutions doing exactly the same thing. In this invidious process the message becomes clear: if you are not excellent — i.e., bringing in vast grants and accumulating ever more social and professional brownie points — you are essentially worthless. Yet it is patently absurd, as Elizabeth Hodgson reminds us, to refuse to recognize that any group of people will include a normal and healthy range of abilities, levels of commitment, and measurable success rates. A bemused colleague whispers in her ear: “Do you think they know that someone has to be in the bottom decile?” Are administrators not aware that there is a natural spectrum of achievement, that more nurturing and less needling might work wonders, that an orchestra composed only of star performers does not play well?

I recommend Hodgson’s essay to stressed librarians who feel caught up in the treadmill of competitiveness and the rhetoric of excellence. She concludes her self-acknowledged rant with a call for common sense:

As it is, we spend more and more of our work energies having to prove repeatedly that we deserve the resources we need to do our jobs. We spend more and more time attempting to demonstrate, in order to keep our jobs, that we are even more excellent than we were the year before, more excellent than our colleagues and more excellent than the university across town.

The net effect, ironically, is that we are far more likely to do less of what we were trained to do, what we are genuinely gifted at. You don’t make a pig fatter by weighing it; you feed it. “Excellence,” I assure you, despite its fine sound, has no nutritional value [5].

There’s food for thought. To switch metaphors, let’s avoid the fate of the fanatical climber in Longfellow’s poem, who reaches the mountain top only to end up lifeless but beautiful, and half-buried in snow, “still grasping in his hand of ice / That banner with the strange device, / Excelsior!”

References

1. Hardesty L. Excellence in academic libraries: recognizing it. Library issues. 2007;27(4):1-4

2. Hyams E. A new impetus to professional excellence. Library + information update. 2005;4(6):33-35.

3. Reid D. The National Library of New Zealand as a Sun™ Centre of Excellence. The electronic library. 2006;24(4):429-433.

4. Herget J. Excellence in libraries: a systematic and integrated approach. New library world. 2007;108(11/12):526-544.

5. Hodgson E. A rant on excellence. CAUT bulletin. 2010 Jan;57(1):2,12.

6. Merton R. The sociology of science. Chicago: University of Chicago Press; 1973.

7. Wu L. Montreal hospital librarians’ websites: striving for excellence. Journal of hospital librarianship. 2004;4(3):101-108.

8. Tijssen RJW. Scoreboards of research excellence. Research evaluation. 2003 Aug;12(2):91-103.

Photo credit: cc licensed flickr photo by Frankenstein

Hell’s-a-poppin’ anti-homeopathy campaign stages multiple mass overdoses at pharmacy doorsteps

Johnny Carson once said that if you want to clear your system out, sit on a piece of cheese and swallow a mouse. Many would claim that a homeopath’s prescription for colonic purging would be about as helpful. In the UK activists have devised a colourful way to make their point. The Guardian reports on a series of unusual protests outside pharmacies in the UK. On Saturday, January 30, hundreds of self-proclaimed skeptics gathered to denounce the Boots chain’s hawking of homeopathic remedies, treatments that are unregulated and have little or no scientific basis. At precisely 10:23am local time protesters staged a series of mass overdoses in several cities, downing entire bottles of pills and potions to emphasize their worthlessness as medicine.

A promised sympathy demo was to have taken place in Canada, but at least according to CanadaPharmacyNews, no one seems to have braved the cold to have at it with Canuck homeopathy.

Skeptics argue that theories behind homeopathy – which relies on the extreme dilution of animal, plant, mineral as well as synthetic substances so that remedies do not contain a molecule of the original substance – are utter nonsense. Most scientists agree that the only possible impact of such remedies is as a placebo. The 10:23 Campaign, which organized the demonstrations in Britain, has created an interesting website, with a provocative collection of videos. Richard Dawkins is entertaining as he demolishes homeopathic theory in less than ten minutes.

As predicted, no ill effects were reported from consuming massive amounts of homeopathic remedies. Anti-homeopathy groups have targeted Boots because they believe its nationwide status as a long-established pharmacy retailer gives the public false confidence in such products. The sale of homeopathic pills and potions in drugstores – along with potato chips, candy and soft drinks – sends a mixed message.

The anti-homeopathy lobby believes that by diverting people with genuine complaints away from conventional medicine homeopaths can put lives at risk. They cite cases of patients who have been been warned away from vaccinations, given homeopathic preparations for serious diseases like malaria, or advised to stop taking medication for cardiac disease.

The Canadian Pharmacists Association (CPhA) has not changed its position on homeopathy since 1998, when it issued a brief on herbal and homeopathic products, making several recommendations that generally revolved around ensuring that such preparations are regulated, that their claims of efficacy are substantiated by available clinical data, and that the safety of the Canadian public is protected.

The Natural Health Products Regulations require all homeopathic medicines to have a licence before being sold in Canada. Licence holders are issued a product number which must appear on the label of their product. The Natural Health Products Directorate (NHPD), which is responsible for issuing product licences for all natural health products, uses evidence submitted by applicants to critically assess the safety, efficacy and quality of NHPs before approving them for sale in Canada.

In addition to a product licence, all businesses in Canada which manufacture, package, label and/or import homeopathic medicines for sale must also have a site licence as of January 1, 2006. For more information on Canadian regulation of natural and homeopathic products, see the Health Canada website. Despite these detailed rules, Canada’s pharmacies are full of products of questionable pedigree. Caveat emptor.

Photo credits:

flickr photo by TW Collins
flickr photo by ten23campaign

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Addiction programs in Manitoba: support is flat in the great flatlands

As a have-less province with a significant fraction of the population that is poorly educated and un- or underemployed, Manitoba has its share of drug-related problems. Manitobans with addictions (many of whom have mental health issues) do not have ready access to treatment. Resources are inadequate and there are long waits. Take the case of methadone intervention programs.

Manitoba has only one-quarter of the methadone spaces per capita as compared to neighbouring Saskatchewan, and it is a sad fact that some programs currently operating in Winnipeg are feeling oxygen-deprived. Two Ten on Maryland, in Winnipeg’s inner city, is a non-profit post-treatment program for recovering addicts run by a former meth addict, Ian Rabb. He has been requesting more support from the provincial government for years, claiming that additional funding is required to provide round-the-clock supervision of clients and improve safety.

Manitoba spends $22 million a year on addiction services. Not surprisingly, belt-tightening is going on throughout government – the province faces a projected $592-million deficit this year – but officials claim this hasn’t prevented the funding of vital programs.

In a recent Winnipeg Free Press article [1] Rabb accuses the government of foot-dragging and insincerity when it claims that money is tight. In his view the programs offered at the facilities save the government money. Clients stay out of hospital and jail, and most of them eventually get off welfare.

By coincidence, in a letter to the editor on the same day a local representative of the Canadian Mental Health Association, Nicole Chammartin, pleads for improved harm-reduction programs for those with addictions, specifically mentioning methadone treatment. “We require a comprehensive and responsive addictions system that serves everyone,” concludes Chammartin.

Existing research provides some evidence for the value of harm-reduction programs for addicts. A Lancet study published last October found that psychosocial interventions used in England are associated with reduced use of heroin and crack cocaine [2]. Outreach programs can lead to high levels of compliance, general improvement, and treatment satisfaction [3]. Feeling that treatment is appropriate, finding staff motivating, and having enough time to sort out problems are important aspects of satisfaction with treatment among users of drug treatment services who achieved positive treatment outcomes. Services should seek to provide more individualized services based on understanding of individual client needs. This may require longer treatment periods and greater client involvement [4].

However, it is difficult to demonstrate conclusively the effectiveness of programs and successful treatment outcomes. A recent Cochrane Review went so far as to say that “there is no good available research to guide the clinician about the outcomes or cost-effectiveness of inpatient or outpatient approaches to opioid detoxification” [5].

Although Manitoba’s left-of-centre NDP government makes the appropriate clucking noises when it comes to addiction problems, its record is not looking good. The Addiction Foundation of Manitoba’s Methadone Intervention & Needle Exchange Program (m.i.n.e.) [6] has shown itself to be effective, but insufficient funds are being directed at this serious problem. People with intractable addictions are waiting for help and inner-city programs are stalled, while money earned from government-run casinos is lavished on developing yet more affluent suburbs and on purchasing law-and-order fetishes like police helicopters to make suburbanites feel safer.

References

1. Owen B. Cuts at addictions centres? Director may trim services without new provincial funding. Winnipeg Free Press. 2010 Jan 23;Sect. A:8 (col. 3).

2. Marsden J, Eastwood B, Bradbury C, Dale-Perera A, Farrell M, Hammond P, Knight J, Randhawa K, Wright C; National Drug Treatment Monitoring System Outcomes Study Group. Effectiveness of community treatments for heroin and crack cocaine addiction in England: a prospective, in-treatment cohort study. Lancet. 2009 Oct 10;374(9697):1262-70. PubMed PMID: 19800681.

3. Henskens R, Garretsen H, Bongers I, Van Dijk A, Sturmans F. Effectiveness of an outreach treatment program for inner city crack abusers: compliance, outcome, and client satisfaction. Subst Use Misuse. 2008;43(10):1464-75. PubMed PMID: 18615321.

4. Morris ZS, Gannon M. Drug misuse treatment services in Scotland: predicting outcomes. Int J Qual Health Care. 2008 Aug;20(4):271-6. PubMed PMID: 18492708.

5. Day E, Ison J, Strang J. Inpatient versus other settings for detoxification for opioid dependence. Cochrane Database Syst Rev. 2005 Apr 18;(2):CD004580. PubMed PMID: 15846721.

6. Bodnarchuk J, Patton D, Broszeit B. Evaluation of the AFM’s Methadone Intervention & Needle Exchange Program (m.i.n.e.) [Internet]. Winnipeg: Addiction Foundation of Manitoba; 2005 July [cited 24 Jan 2010]. Available from: http://www.afm.mb.ca/pdf/MINE_report_final.pdf

Photo credit: cc licensed flickr photo by wysiwtf

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Bring on the mind control, please

You don’t expect to find anything funny in a book with a title like this: Breeding Bio Insecurity: How US Biodefense is Exporting Fear, Globalizing Risk and Making Us All Less Secure (Chicago, 2009). In the London Review of Books Thomas Jones writes that “Lynn Klotz and Edward Sylvester make a compelling case for a radical and immediate change in America”s biosecurity policy.”  Foreign Affairs says “the authors make a plausible and disturbing case.” Other reviewers have called it “forceful and provocative,” even “indispensable.”

The book argues that the conditions of research in bioweapons and biosecurity pose a greater risk to the health and security of Americans than do bioterrorist attacks, but that this risk can be countered and defeated with greater efforts against infectious diseases and greater international oversight and transparency. It also raises the question about the moral and legal issues around the billions spent since 9/11 on R&D into bioweapons counter-measures like antibiotics, antivirals, antidotes and vaccines. Testing them clearly requires ready availability of the bioweapons agents themselves, something that contravenes the Biological Weapons Convention, which bans the development, production, and stockpiling of microbial or other biological agents or toxins.

Ever since Hannibal’s forces threw clay pots full of snakes onto the decks of enemy ships in an ancient naval battle against the Pergamenes, nations have turned to biological warfare when it has suited them – especially when it can be claimed that massive reserves of anthrax, smallpox, plague, ricin, botulinum and ebola serve to defend the homeland. Despite the extreme unlikeliness of a large-scale biological terrorist attack, the United States, for example, has 219 labs studying anthrax alone. The number of people working in biodefence has increased twentyfold in the past decade.

A review in Science claims that the authors’ argument deserves serious attention:

Klotz and Sylvester spotlight the huge sums of money invested by the U.S. government in biodefense research. Here, they claim, secrecy is having corrosive effects. They also argue that the money pouring into biodefense research is out of proportion to the level of threat. In addition, they contend, this massive investment has backfired to create more risk because now more scientists are working with dangerous pathogens, thus increasing the chances of accident, theft, and deliberate misuse.

All weighty stuff. But, as Thomas Jones in LRB notes, Klotz and Sylvester also get carried away by what sounds like Cold War paranoia. At one point they bring up the subject of “the scariest weapons of all: mind-control agents.” These are largely the realm of science fiction, but apparently white-ruled South Africa carried out research into the use of MDMA for crowd control. Given the apartheid regime’s usual methods – attack dogs, tear gas, beatings, and shootings – a plan to use Ecstasy to suppress a revolt sounds positively benign.

“Ecstasy or smallpox: I know which I’d rather be attacked with. Bring on the ‘mind-control’, please.”

Photo credit: Flickr creative commons licence, uploaded by ClevelandSGS

A victory for common sense around harm reduction: Vancouver’s injection site wins a court battle

Insite supporters can breathe a sigh of relief. On January 15, 2010, the B.C. appeal court upheld a 2008 ruling by the province’s Supreme Court that allows the supervised injection site in Vancouver’s Downtown Eastside to stay open.

Liz Evans, the executive director of the Portland Hotel Society, which runs Insite, told The Globe and Mail: “Let’s hope [Prime Minister] Stephen Harper doesn’t waste any more taxpayers’ money by taking this to the Supreme Court.”

The debate over the future of Insite has been passionate in the two years since the Canadian government, in the face of convincing research, began questioning the validity of a harm reduction approach to injection drug use.

Thomas Kerr and Evan Wood, research scientists at the British Columbia Centre for Excellence in HIV/AIDS, accused the federal Conservatives of politicizing science in their straight-laced and passive-aggressive approach to Insite’s work with drug users. “This government may already have garnered a reputation for being the most antiscience government in Canadian history,” they wrote in a sharply worded article published online in April 2008.

Doing exactly what it was set up to do
Kerr and Wood charge the government with attempting to “cloud science” and “manufacture uncertainty.” In the Tories’ get-tough, war-on-drugs strategy, they aver, there is no room for sound public health strategies like harm reduction — despite the wealth of scientific evidence to support these interventions, including more than 20 studies by the authors which have appeared in major medical journals such as the New England Journal of Medicine, the Lancet, and the British Medical Journal. This plethora of research shows that Insite is doing exactly what it was set up to do:

• contributing to reductions in the number of people injecting in public and the number of discarded syringes on city streets,
• helping to reduce HIV-risk behaviour and saving lives that might otherwise have been lost to fatal overdose,
• achieving a 30% increase in the use of detoxification programs among Insite users in the year after the site opened,
• not increasing crime or leading others to take up injection-drug use.

Moreover, Insite appears to be cost-effective and is popular among the general public. Within the strict limits imposed on it, Insite just seems to work. Undeterred by mere facts, however, Prime Minister Stephen Harper, whose strong opposition to “deviant behaviour” is well known, claims to remain unconvinced. Neither the overwhelming scientific evidence nor Insite’s articulate defenders — not even the largely positive conclusions of the government’s own Expert Advisory Committee — seem to have swayed this staunch defender of prudence and propriety and his loyal supporters.

Ideological warfare
Given the significant disagreement on this issue, perhaps the very term “harm reduction” is the problem, as A.I. Leshner of the American Association for the Advancement of Science suggests [1]. The imprecise application of this term and its use as a euphemism for drug legalization have “sufficiently inflamed … drug warriors that they cannot have a rational discussion of even the underlying concept, let alone how harm-reduction strategies might be implemented.” Leshner advocates the avoidance of ideological intensity. “Let’s get on with studying specific strategies to protect the public health and ensure social well-being and give up this term that only gets in the way, even if it does make sense.” This well-meant and seemingly pragmatic dismissal of ideology, so characteristic of certain debates within American elites, is itself highly ideological. Excellent solutions are brought forward in print, and they stay securely in print. There are still no safe injection sites anywhere in the United States.

From a Canadian perspective, Bernadette Pauly of the University of Victoria reminds us that harm reduction, however well implemented, is only a partial solution [2]. Conceived within a broader social justice context, harm reduction strategies should be part of a comprehensive approach to reducing social inequities, providing accessible health care, and improving the health of those who are street-involved. Pauly is proposing to move from print to political project. All well and good, but then we confront the by-one’s-own-bootstraps catechism of the dogged Harperites and their extraordinary ability to mobilize the fear and petty prejudices of Canadians in support of their retrograde policies.

Scientific arguments are insufficient in themselves
In a brilliant commentary on the ideological warfare behind the war on drugs, two Canadian sociologists take on the sententious rhetoric that labels harm reduction advocates as “legalizers” in the guise of scientists and public health professionals [3]. Because the right-wing attack comes from either the intractably convinced or cleverly hypocritical stance that abstinence, prevention, and enforcement are the only acceptable and morally legitimate solutions, harm reduction’s muted stance on morals, rights and values prevents proponents from engaging criticisms of this nature in terms other than the evidence or science. The case of Insite, the authors argue, demonstrates the value of asserting human rights claims that do not rest on evidence per se. Scientific arguments are insufficient in themselves to move beyond the status quo on drugs.

They conclude, “Without commitment to ‘strong rights’ and the sovereignty of users, harm reduction sentiments are easily subverted to a technocratic governance agenda. Against the accusation that we are really ‘legalizers’ harm reduction advocates need not dispute the label but rather the suggestion that opposition to the drug war is somehow irresponsible, dishonest, or immoral. Respect for human rights moves harm reduction past the confines of a scientific project — which has not been well respected outside academic circles — toward a generative programme for replacing prohibition with policies reflecting the costs and benefits of drug use and the costs and benefits of formal intervention.”

Here, surely, is the way to proceed. Palaver and posturing should not get in the way of real progress, which will be measured in terms of real lives and the difference that intelligent and compassionate social programs can make. The decision of the BC Appeal Court in favour of Insite is a victory in what has become a culture war waged on the backs of people who have the least power in this country.

References

1. Leshner AI. By now, “harm reduction” harms both science and the public health. Clin Pharmacol Ther. 2008 Apr;83(4):513-14.

2. Pauly B. Harm reduction through a social justice lens. Int J Drug Policy. 2008 Feb;19(1):4-10.

3. Hathaway AD, Tousaw KI. Harm reduction headway and continuing resistance: insights from safe injection in the city of Vancouver. Int J Drug Policy. 2008 Feb;19(1):11-16.

Photo credit: cc licensed flickr photo by audreyjm529