Friday, July 27, 2007

HIV: the Invisible Cure

A new book by Helen Epstein uncovers the Invisible Cure for HIV: behavioral changes. She documents the impressive decline in HIV in Uganda during the 1990's. She discovered the seminal paper by Maxine Ankrah that showed that reductions in the numbers of sexual partners were crucial in containing the spread of the disease. This paper was downplayed or overlooked completely in UN reports. This book sounds like an important breakthrough in the discussion about AIDS prevention, when even the NYT is willing to read it objectively.
While I'm glad that she has done this, I must say that I remember reading about the success of the Ugandan program well before this. The Weekly Standard did an article on the subject, back in 2005, by Edward Green, also an AIDS researcher. He wrotes:
Our secret was that the country that had best succeeded in curbing the spread of HIV--Uganda--had achieved this result without following the formula the experts had been pushing for over 20 years, namely, condoms, drugs, and testing. Instead, Uganda had achieved its unparalleled decline in the prevalence of HIV with a home-grown, low-cost program built around something offensive to conventional experts: promotion of sexual abstinence and fidelity, with condoms promoted only quietly, to high-risk groups and those already infected.
Not surprisingly, information about what was actually working in Uganda was unpopular. Condoms have been regarded as the first line of defense for everyone, everywhere, and anyone who disagrees with this orthodoxy has been dismissed as a religious fanatic with "an agenda." Hundreds of millions of dollars have been spent on condom social marketing (a field I myself worked in for several years) and on related medical-pharmaceutical solutions. How infuriating that an approach not funded by the big donors and scoffed at by foreign experts should prove to
be the very thing that worked best.

This "follow the money" logic only partially explains the reluctance of the AIDS establishment to give full credit to the Ugandan model. They don't really beleive that "partner reduction" is a realistic stratgey. Green tells this story:
CONSIDER THIS VIGNETTE, from the global AIDS conference in Bangkok in July 2004. When Simon Onaba, a 22-year-old Ugandan university student, told an audience of AIDS experts that he had abstained from sex for three years and intended to continue doing so until his wedding night, he was loudly jeered. "Oh, how nice for you!" went one reaction. "You may be able to abstain, but what about a 13-year-old Somali girl forced into marriage and subjected to genital mutilation? She doesn't have the luxury to abstain!" (As if, by choosing abstinence, Simon were somehow failing to take a stand against genital mutilation.) The experts also hurled hostile questions at Simon: How often do you masturbate, and with whom? What's your real agenda for trying to make people believe you are abstaining?
These critics seem to believe that since abstinence and fidelity may not be workable options for 5 percent of the population, they should be rejected altogether, even if they are the best option for 95 percent of the population. These numbers are not arbitrary: By 1995, only 5 percent of Ugandan males and females were reporting casual sex.

As that last figure suggests, reality is very different from the Western experts' perception. Surveys today suggest that more than half of African males and females between the ages of 15 and 19 are abstaining from premarital sex, and increasing proportions of adults are having sex with only one partner. Yet few who work in AIDS prevention have called attention to these important trends, perhaps because they contradict the image of the hypersexed African that Western AIDS experts have been selling since the beginning of the AIDS pandemic. They depict Africans as "polygamous by nature," and supposedly so driven by hormones and poverty that commercial and transactional sex, and the inability to make responsible decisions about sex, are simply part of what it means to be African. If you accept this condescending view, condoms seem to be the only realistic solution to AIDS.

The trouble with the image of the hypersexed African is that it was never true for most Africans. Meanwhile, sexual behavior in Africa has changed. Not only in Uganda, but also perhaps in Senegal, Kenya, and elsewhere, abstinence and faithfulness have worked better than condoms. I document the evidence for Uganda and Senegal
in detail in my 2003 book Rethinking AIDS Prevention. I also show that in about 1999, Kenya switched to a Uganda-style approach. In the past four to five years, casual sex on the part of Kenyan men and women has declined by about 50 percent, and HIV infection rates have fallen.

I wish Helen Epstein every success with her book.

Health Care Costs

John Goodman has an outstanding article on the proposal to expand the SCRIP program to cover the middle-class. Hi comment: most of the people who would be covered by the expansion ALREADY HAVE HEALTH INSURANCE. This proposal is a way to crowd out the private sector and expand the public sector. At the same time, it will contribute to the bankruptcy of the Medicare system. Not good, in the long run.

Why am I interested in health care, in this blog devoted to family policy? Because the high price of health care for people outside large companies is, in my opinion, a significant financial barrier to fertility, along with college debt and the high cost of housing. We need to do something about these burdensome costs for the young.

Foster Care Horror Stories

My article about the death of little Malachi McBride-Roberts prompted this response:

Very good article. If you want more proof look into Washington State DSHS (Department of Social and Health Services).

Tyler DeLeon is the most recent in the news, he was seven years old, weighed 28 pounds and broke out a window the day before he died to try and get snow to ease his thirst.

Washington State residents are treated to a numbing routine of dead children under DSHS supervision.

I am a Washington State Foster parent, our three foster kids under age 3, are legally free and will adopt them sometime before the end of 2007.

Our kids came to us in a program that identified high risk children and placed them in a foster home identified as the future adoptive home.
This program was an attempt to minimize the children's bouncing through the system. The program has been terminated. It was successful in 1 out of 7 DSHS districts and thus a failure. Instead of looking at what worked, the bureaucracy looks to the failures.

DSHS's budget has increased 12% in the last budget cycle. However services to the children and their parents has been cut. Cut services to the parents means court ordered treatments are not available. When the parents do not receive court ordered services the cases is delayed until the parent succeeds or fails in the treatment programs. Worse case is the court finding DSHS in contempt and the child being returned to the parents.

Our kids initially required rehabilitation services, with the budget cuts we had to be very aggressive getting the services the children needed. At times we paid out of pocket, fortunately we can afford such things but many foster parents cannot afford such out of pocket expenses.

Thank you for giving national exposure to this issue. If you need more grist for the mill Washington's DSHS will give you more than enough.

I also got a long letter from someone telling me that the foster care system is only interested in maximizing its budget, and that is why the kids are never freed for adoption, why the state snatches children from innocent parents and all the rest. There is plenty of bureaucratic mismanagment, and poorly structured incentives. But I actually don't think there is that much room for reform in that area. Many reforms end up with the effect of trying to micromanage the day to day work of the social workers. I think the interpretive culture around these decisions is often very skewed: sometimes by bureaucratic incentives, sometimes by fear of bein overturned on appeal, sometimes by fear of making a big mistake. But the accumulation of a lot of small mistakes can be just as deadly, as little Malachi's case shows.

Thursday, July 26, 2007

Who Killed Malachi?

My latest on NRO, tells of a child killed in foster care. The little boy was eminently adoptable, but had been in foster care for all of his two years. What would it take for a parent's rights to be terminated? I have had an interesting e-mail dialogue on this point with a couple of correspondents. More later.
The whole sad story about this child's death is here.

Friday, July 20, 2007

Get the Government Out of Sex Ed

My latest Town hall article is HERE. The contraceptive failure rates commonly reported are very misleading. I cited a couple of articles from Family Planning Perspectives, published by the Allan Guttmacher Institute, which is the research arm of Planned Parenthood. Those articles show that contraceptive failure rates depend not only on the method of contraception used. The probability of failure also depends on the demographic characteristics of the user.
Some of my critics in the blogsphere seem to think I made these numbers up, just for meaness. These are Planned Parenthood's numbers. The question is: what do we make up them? What do they mean? There are 3 demographically relevant factors: age, poverty and marital status. I think there are probably several big issues behind these demographics: fertility, maturity, commitment and amount of sexual activity.
First, age is a proxy for both maturity and fertility. For any contraceptive method, young women are more likely to get pregnant than older women. This is a function of the fact that fertility naturally declines with age. Think about people you know: among the middle-aged, middle-class married women, you probably know some who are more worried about infertility than contraception. That is what the data are picking up when they show an overall failure rate of 15.2% for women aged 20-24 and 9% for women over 30. (table 4 of Ranjit et. al.)
Maturity matters because some of the younger, and possibly less stable individuals are probably not using their contraception consistently or correctly.
Commitment is very interesting: cohabiting women have twice the contraceptive failure rate of married women overall: 21% versus 10%. And even looking at comparable age groups and poverty status, cohabiting women have much greater failure rates than married women. See Tale 2 of Fu et. al. Cohabiting teenaged poor women have a 70% failure rate for condoms, compared with only a 23% failure rate for married poor teenagers. What does this mean? I suspect that the married couples have less difficulty negotiating consistent condom use. They have a shared future, which the cohabiting couples may not.
Finally, cohabiting couples have sex frequently than single people. This may account for the relative success of singles vs. cohabiting women of comparable age and income. Again, see Table 2 of Fu et. al.: the failure rate for the PILL is 48% for cohabiting poor teens, but only 13% for single poor teens.
Of course both these rates are higher than the officially published statistics of 8% for the pill, and 15% for the condom, which was my point.
Sex ed programs should be focusing on the failure rates that are relevant to the target demographic group, not the general population. If a middle-class, middle-aged married woman has a contraceptive failure, that is a private problem for her and her family. It has no social significance whatsoever, and is frankly none of the government's business one way or the other. Contraception failure among the poor and the young and the unmarried has become a public problem because the public is likely to end up supporting their offspring. That is why the government has taken it upon itself to teach sex ed in the first place. If the government is going to get involved, it should focus on demographically relevant contraceptive failure rates, not on some failure rates, theoretically obtainable in a world of perfect use. The point of the tables in these studies is exactly to show that perfect use is not the same as theoretically perfect use.
By the way, I am certainly prepared to believe that improved education can improve the consistency of contraceptive use. I'm not prepared to believe that there is any education program that will make a 13 year old behave like a 30 year old.
By the way, the shouting and screaming in the blogsophere, complete with commentary about my likely sex life, confirms what I believe is our new social norm about sex: Sex is a essentially a private recreational activity, with no moral or social consequences. We believe sex is essentially a sterile activity, and babies are an after-thought, an optional consumer life-style extra, if you happen to like that sort of thing. Many of the discussants at Pandagon seem to feel themselves cheated if they don't obtain the results that perfectly functioning contraception would create. I'm just the messenger: contraception doesn't always work. Shoot the messenger if you must, but that doesn't negate the message.

Wednesday, July 11, 2007

Re: Three Stages of a Man's Life

Ok, folks in the comments section. These photos are meant to be funny. They represent the thought that men get tamed by their wives once they get married, and that men get fleeced by divorce. I'm not saying I condone henpecking or fleecing. I thought the photos were more pro-male, a commiseration with the sad state that too many men find themselves in.
So sorry my joyless commentators missed the joke.
While I appreciate my readers' concern for my sex life, I'm afraid that some ofyour comments were not appropriate. I had to delete them.