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Bad medicine is NOT better than no medicine

Adult Intensive care ward at the Hospital for Tropical Diseases, Ho Chi Minh City, ©Chau Doan/Getty Images
Adult Intensive care ward at the Hospital for Tropical Diseases, Ho Chi Minh City, ©Chau Doan/Getty Images

Recently, I have spent a good deal of time working on the issue of anti-microbial resistance. I was set on this path by the discovery, nearly a decade ago now, that the drugs we were using to treat STIs among sex workers in Indonesia didn’t work. Sending the bugs off for resistance testing, we found that 100% were resistant to one of the medicines recommended by national guidelines, and over 60% were resistant to a second medicine. Despite that, we went on treating people with these largely useless drugs for the FOUR YEARS that it took to change Indonesia’s national guidelines for STI treatment. Welcome to the fiercely political world of drug procurement and prescription (and the ethically appalling behaviour it promotes).

Recently, I’ve been focusing on one of the most political and (therefore) most neglected drivers of drug-resistant infections: poor quality medicines. Essentially, the pressure to increase access to drugs for everyone who needs them (a good thing) has created all kinds of loopholes that allow lazy, unscrupulous and criminal manufacturers of very bad drugs to prosper without proper oversight. Every time someone tries to raise the issue of bad quality generics, the companies that make them, the governments of countries where they are made, and a number of very shouty NGOs simply accuse the critics of being in bed with Big Pharma. There the conversation ends. But it is simply not true that access to bad drugs is better than no drugs at all, because bad drugs breed resistant bugs, and then even the “good” drugs are, well, no good.

There’s a very detailed report on the interaction between drug quality and antimicrobial resistance over at my day-job site. But for a shorter and better read on the subject, check out Why we are losing the war on bugs over at Prospect Magazine. (January 21, 2016). An archived .pdf of the article is available here

01/02/16, 02:29. Comments Off on Bad medicine is NOT better than no medicine

A good year for Whores, say the BBC and I

The BBC welcomes the Year of the Horse. Sort of.

The BBC welcomes the Year of the Horse. Sort of.

Last week I found myself at the House of Lords in London, discussing what the BBC World Service means to the world. The World Service stands for accuracy in reporting, a lot of very clever people said, it represents fairness and impartiality, it tells it like it is. So I was thrilled to see that the Beeb welcomed in the Chinese New Year with a celebration of Whores.

Other signs that it might be a good year: this peculiarly sensible opinion piece about sex trafficking hysteria from Kate Mogulescu of the Trafficking Victims Advocacy Project. I have to say that when I read the headline on the op-ed page of the New York Times on Saturday:

The Super Bowl and Sex Trafficking

my heart rather sank. I always find those “where there are sports fans, there will be sex-slavers” stories particularly hard to swallow at the breakfast table. This piece, though, points out not just the data-free hysteria-by-rote that we’ve become accustomed to, but the harm that it does to sex workers in general, and trafficked sex workers in particular.

新暗 娼 的 年 快乐!

Thanks to The Independent and Don Dickerson.

03/02/14, 04:51. Comments Off on A good year for Whores, say the BBC and I

Elizabeth Pisani’s next project – “Indonesia Etc. – Exploring the Improbable Nation”

UK cover Indonesia Etc. - Exploring the Improbable Land by Elizabeth Pisani from Granta UK                                         US cover of Indonesia Etc Exploring the Improbable Land by Elizabeth Pisani from WW Norton

In late 2011, epidemiologist, writer and adventurer Elizabeth Pisani granted herself a sabbatical from the day job and set off to rediscover Indonesia, a country she has wandered, loved and been baffled by for decades.

The journey forms the backbone of a book (and a multimedia BookPlus), which includes also reflections on her earlier incarnations in Indonesia. The first of these was as a foreign correspondent for Reuters in the late 1980s and early 1990s. Ten years later she was back in the very different guise of epidemiologist, helping the Ministry of Health better understand Indonesia’s HIV epidemic. That work contributed to her first book, The Wisdom of Whores, published in 2008.

The new book that will emerge in June 2014 will be called Indonesia Etc: Exploring the Improbable Nation. It will be published in the UK by Granta, in the US by WW Norton and in Indonesia by Godown, an imprint of always-inspiring Lontar.

The title Indonesia Etc is taken from Indonesia’s declaration of independence, which reads, in full:

We the People of Indonesia declare the independence of the Republic of Indonesia. The details of the transfer of power etc. will be worked out as soon as possible.

As Indonesia gears up for the 2014 elections, it is still working on its political “etc”. “Democracy by trial and error” was how one retired company head described it to me with a mirthless laugh. How far will decentralisation go? Will independent candidates and local parties be allowed? Much is still up for discussion or re-discussion. And yet the improbable nation muddles along remarkably well for such a young country. Re-reading Abraham Lincoln’s Gettysburg Address today, I was reminded that the United States, at a similar stage after its own declaration of independence, still had a bloody civil war ahead of it.

Though it looked touch-and-go for a few years at the start of this century, few people now expect Indonesia to face that kind of chaos in any of its vast territory (except, perhaps, Tanah Papua).

“Indonesia Etc. – Exploring the Improbable Land” is a vibrant mix of travelogue, history, cultural observation and analysis.

The blurb:
One in 30 of the people on this planet is Indonesian. The 13,000 islands of their homeland, scattered along the equator, stretch the distance from London to Tehran, and the residents of the capital, Jakarta, tweet more than those of any other city on the planet. By any standard, Indonesia is a global hub, one of the most dynamic and diverse countries of the 21st century. But you don’t have to look far from metropolitan Jakarta to find poverty, superstition, ancient rituals and black magic. Travelling from volcanoes and jungles to reefs and snowy peaks, investigative reporter Elizabeth Pisani sets out to capture the real Indonesia. On the way she meets the Sultan of Jogjakarta, a former presidential candidate who keeps a posse of albino dwarfs in his court, visits one of the largest red light districts in Asia, joins protesters trying to ban Lady Gaga from their homeland, and takes tea with a recently deceased grandmother. Written with Pisani’s trademark wit and brio, this is an entertaining and indispensable guide to a fascinating country we can’t afford not to know more about.

16/01/14, 07:20. Comments Off on Elizabeth Pisani’s next project – “Indonesia Etc. – Exploring the Improbable Nation”

The good side of homophobia

It’s not often that proper reporters put their own reaction to the story they are working on front and centre, but it can be revealing. Have a listen to this wonderful From Our Own Correspondent from gay BBC journalist Paul Henley reporting from the frontlines of Russian homophobia.

Without whining, Henley gives a wonderful flavour of what it is to be hated by people who don’t even know that they hate you. For me, the encouraging thing about this story is that the wall of hostility that Henley is obliged to bang his head against in Russia is new to him. Had he been born even 30 years earlier in the UK (and maybe still now in many parts of the United States) the blanket of homophobia would be woven, consciously or not, willingly or not, in to his life and his soul.

It’s not at all encouraging if you are Russian, of course, or Ugandan, or from one of the many other countries where self-appointed moralists like to stick their prurient noses into other people’s bedrooms. But the fact that Henley can broadcast his sexuality to the 180 million people who listen to the BBC World Service and make many of us feel proud of him means that in some countries, at least, we have come a very long way in the right direction.

The good side of homophobia is the vanishing side.

14/03/13, 05:29. Comments Off on The good side of homophobia

Indonesia’s health minister shocked by her own failure

A typical HIV prevention poster with no useful information.

The always provocative Unspun asks how it is that Indonesia’s minister of health is shocked at the country’s HIV prevention failure. It’s a good question, most especially since before becoming minister of health just a few months ago, Nafsiah Mboi spent six years at the helm of the National AIDS Commission.

The failure was highlighted in the new UNAIDS report on the state of the epidemic. They estimate that the rate of new HIV infections in 2011 was more than 25% higher in Indonesia than it had been a decade earlier. That raises some questions for me: is an increase of more than 25% in HIV incidence (i.e. new infections) over 10 years really so shocking? Is the rate of new infections in Indonesia still increasing today? How do we know?

1) How shocking is an increase of 25%?
It rather depends on what the original rate was. The fact is, Indonesia had virtually no HIV epidemic in 2001, except in drug injectors and waria sex workers. In other words, the baseline rate of new infections in the largest risk populations (female and male sex workers, their regular clients, and gay men) was extremely low. If you go from four new cases a year to five new cases a year you increase by 25% but add only one new infection. If a high prevalence country goes from 11,000 incident cases to 10,000 cases, it has decreased by nine percent but added 1000 new cases. Which is the bigger prevention failure? I’m not saying that HIV prevention in Indonesia is a great success story; quite the reverse (see below). I’m just reminding people to beware of relative measures.

2) and 3) Is the rate of new infections in Indonesia still increasing now? How do we know?
The fact is, we don’t. Indonesia, which in the early 2000s built up quite a strong surveillance system, has seen that system break down rather badly, in part because of the effects of decentralisation and in-fighting between government departments which means that people who should be running the system are busy squabbling over project funding, and in part because of the small-mindedness of some of the donor-funded NGOs, who cared more about measuring their own little efforts and sucking up to their own pet partners in government than about supporting strong and transparent national systems. We can’t measure new infections directly, so incidence estimates are based on models that use information about overall infection rates (prevalence) from several years for several different population groups, together with information on risk behaviour, in some case. I’m frankly surprised that UNAIDS even published an incidence estimate for Indonesia, given the shockingly poor quality of the data available in the last 5 years. I note that they shied away from giving estimates for many of the other large countries with similarly diverse epidemics and patchy data: Brazil, China and Russia.

That HIV prevention failed in Indonesia is indisputable. The failure was totally unnecessary, but sadly inevitable given the choices the country and its “development partners” made. When infection rates were still low we measured very high levels of risk behaviour in key groups. We did very little about it, and what we did was more often driven by institutional needs and development fashion than by the needs of the people at risk. We kept measuring risk and infection and saw that risk was not falling and infection was rising. We spent lots of time and energy getting more money, then threw the money at the same failed approaches (including, in the most iniquitous example, treating people’s STIs with drugs we knew didn’t work because the Ministry of Health, the WHO, the drug companies and their various cronies couldn’t get their shit together to change the outdated national guidelines on treatment).

If what data we have are to be even remotely believed, there does appear to have been some success reducing new infection rates among drug injectors. But by 2009, three years into Nafsiah Mboi’s tenure as head of the KPA, Indonesia had sucked 60 million dollars into its HIV coffers, for that year alone. How much of that was spent on HIV prevention for gay men, a sizeable group in whom infection rates had rocketed from under 3% in Jakarta when I did the first study in 2002 to over 8% in 2007? A princely US$ 23,000. It’s not at all shocking that HIV prevention doesn’t work if you are simply not doing it. Or if you are doing the kind of thing Indonesia is mostly doing, pictured above. The poster reads: “Don’t ruin your life for just a moment’s pleasure. HIV/AIDS. You can get it, you can prevent it.” Does it tell you HOW you can get it, HOW you can prevent it? No. And there are even worse examples out there.

Here’s something that I found shocking: UNAIDS chief Michel Sidebe was in Jakarta just a couple of months ago. What did he talk about? Not the gay men, junkies, waria, rent boys and clients of hookers that make up four fifths of the Indonesian epidemic (the majority of other cases being in female sex wokers). Or at least not according to newspaper reports of his visit. No, he talked about the importance of protecting innocent women and babies through sexual education for young people, most of whom are at practically zero risk. (Reminder, you can’t get HIV by having sex, even unprotected sex. You can only get HIV by having unprotected sex with an infected person. As long as they stay away from the trade, most young heterosexuals in Indonesia can have as much sex as they like without risk of HIV infection.)

The highest UN official for HIV comes to Indonesia and stresses the importance of prevention for people who are not at risk, and Ibu Naf wonders why infections continue to rise in the groups that are at risk. Please deh! Someone should write a book about this.

Oh wait, I already did….

Note: This is a cross-post from Elizabeth’s Indonesia blog, tales and observations from my current project. Though I planned to be back in the public health business round about now (November 2012), Indonesia has rather swallowed me up and I won’t be back in the day job for a while yet.

23/11/12, 10:08. 3 comments

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