The NYT story elicited this comment from a friend of mine, a journalist who is much more informed about HIV than most. “The trouble with this story is it doesn’t say WHY they want to do testing nor indeed WHO has HIV! So are they testing people needlessly ? Is it good surveillance or bad public health? For us lay people, v confusing!”

It’s pretty confusing for a lot of non-lay people, too. I can safely say that is it NOT good surveillance. Surveillance aims to track trends in infection, to guide prevention and care programmes. This is case-finding, which is quite different. The Bronx is trying to identify individuals infected with HIV, so that it can get them onto treatment if need be. It OUGHT to be trying to identify people in need of prevention services, too, but that doesn’t seem to be on the agenda.

So is this mass testing good public health? Not if we ignore prevention needs, certainly. But even if we don’t, I’m dubious. To me, good public health implies protecting the greatest number of people at the lowest possible cost. Mass testing doesn’t do that. In the United States, as in virtually every country outside of sub-Saharan Africa, new HIV infections are concentrated very largely among people who have pretty well-defined risks: they inject drugs or they’re active on the gay scene. People who sell sex or buy it will be at higher than usual risk, too. As is anyone who has recently immigrated from one of the handful of countries in sub-Saharan Africa where HIV prevalence is very high. The Bronx could scoop up a very significant proportion of infections by targeting its testing at those groups.

The problem is, of course, that targeted testing is perceived as “stigmatising”. The United States in general, and the Bronx in particular, has decided that it is better to test everyone than to risk making someone feel uncomfortable by pointing out that their behaviour puts them at higher than average risk for HIV infection. Fair enough, if you’ve got unlimited budgets. But this will mean spending US$ 12 a pop testing several hundred thousand people who are highly unlikely to be infected, to spare the feelings of those who might. I’d be interested to know whether residents of the Bronx who have difficulty accessing other basic health services think it’s a good investment.

While we’re on the subject, MTV is airing rap artist Common performing lyrics written by 18 year-old Jose Rivera from Ewing, Nebraska. They’re hoping to encourage young people to get tested across the country on June 27th, National HIV testing day. Watch Common bring them in for testing right here. Think of me rolling my eyes in time to the music.

Many of the people (OK, men) that rule this nation had nannies, matrons and ward sisters telling them what to do when they were young. But most of us didn’t. We can distinguish between being told what to do (don’t drive my car), and being given information that helps us decide what to do (if you drive my car and crash it, I’ll cut your pocket-money until its paid for). In other words, we can distinguish between legislation and public health campaigns. The first is Nannyish. The second is not.

Does the state have a duty to save us from ourselves? Not necessarily, though I do believe it has a duty to inform us how to stay out of trouble. If the government has dutifully told us that smoking will kill us, that we’d be really smart not to share needles when we’re shooting up, that an hour on the football field is better than an hour in front of Match of the Day, then their job is largely done. It follows that if we go ahead and do stupid things anyway, the state doesn’t have a responsibility to pick up the pieces. But as voters, we don’t buy that. We still want the NHS to treat lung cancer in smokers and make obesity drugs more easily available. The government knows it will end up picking up the tab for most human stupidity; you can hardly blame it for getting overzealous about trying to control the stupidity.

Perhaps we need to think about a regime of progressive intolerance, a sort of Three Strikes and You’re Out campaign. The idea is planted in me not by the US administration but by a little book of quotations called “Nanny says”. My all-time favourite: “Once is funny, twice is silly, and three times is to bed with a smack“.

The Africa Public Health Rights Alliance thinks the answer lies in raising salaries for health workers in African countries. Of course. But couldn’t we also take another approach, raising salaries for nurses in rich countries? Some 13,000 health workers trained in sub-Saharan African countries now practice in Australia, Britain, Canada and the U.S, and there are tens of thousands more from the Philppines, Latin America and the Caribbean.

Those jobs are on offer to immigrants because people at home don’t want to do them. Natives of Manchester don’t want to work awkward hours wiping away sick people’s body fluids for £20,000 a year. Natives of Harare do. Zimbabwe could change that equation by raising salaries to a level close enough to £20,000 a year to remove the incentive for a local nurse to leave an under-resourced hospital in a poorly governed country with chronic health problems. Or Britain could change the equation by raising salaries close enough to a living wage to encourage more Brits to train as nurses, carers and doctors, reducing demand for African staff. Zimbabwe probably can’t afford to do what it needs to do to keep well-trained staff at home. Britain (and Canada and the US) could afford to reduce the demand for overseas staff by making the health industry more attractive to its nationals.