Baird's CMC -- Blog

The 27th of July provided the starkest contrast imaginable between the French tradition of rationality and the Anglo Saxon one of putting together a few random bits of information and hoping a pattern emerges.

Le Monde carried a masterful editorial on Living With Terror. Ten closely-reasoned sub-points argued that “Islamic terrorism” (as I suppose we must get used to calling it) was:

• here to stay
• had no single cause
• could not be reduced to being the direct consequence of any single, long-standing regional conflict (although many fed volunteers to terrorist groups)

The editorial went on to say that:

• the US / British invasion of Iraq has, as many Europeans said it would, exacerbated tension and found limitless volunteers for radical groups
• Westerners do not hold all the keys to the solution: we desperately need progressive and reformist forces in the Islamic world to lead
• the struggle against Islamic terror is not a “war”: in wars, one side wins and there is a surrender or a negotiated cessation. That will not happen here: “Al Qaida” is more a brand than an organisation
• the hatred that drives the terrorism may be more of a European issue than an American one; it has been nurtured in communities in Europe where we have failed to make the ideas of Western democracy alive or appealing enough

Le Monde concluded with two suggestions:

• Pakistan is the epicentre of this terrorist movement. Overall American policy to Pakistan is inexplicable but its failure to target extremism there may be the most serious American foreign policy error.
• what the terrorists group want is for us to abandon our values and to resort to torture, internment and sanctioned state-killing. A first step to this “barbarisation” of our society would be abandoning habeus corpus and other traditional liberties.

I haven’t done justice to this exceptionally lucid and compelling piece of writing. Look at the original in the Le Monde archives for the 27th of July (http://www.lemonde.fr/web/recherche/0,13-0,1-0,0.html)

On the same day, the lead editorial in The International Herald Tribune, also published in Paris, was on Zimbabwe. Its leader writers had noticed that the UN report critical of slum clearance in Zimbabwe had been written by a woman. It showed, said the IHT, that she was “not one of the boys”. “Maybe that’s why she did not mince her words about the horrors ... that Africa’s male establishment seems so afraid to talk about.” This was it, the whole of the point. She was a woman; she had been critical; some men had not; ergo the problem in Africa is a male establishment sticking up for a male president. Presumably simple ignorance meant that the leader writers did not know that Mugabe’s designated successor (and an enthusiastic advocate of slum clearance) is a woman. Or maybe it was just a fact that didn’t support the conclusion. (See if I'm being unfair to them at www.iht.com)

You can see the common pattern in Anglo thinking. The people who blew up the World Trade Centre were Arabs who didn’t like America; Saddam Hussein is an Arab who doesn’t like America; ergo Saddam must be responsible for 9/11.

Maybe we should leave any serious thinking up to the French.

A good deal of my consultancy involves convincing governments, elites, the great and the good about the value of public health interventions in the developing world. Last week, I was working with a group of demographers at the International Union for the Scientific Study of Population meeting in Tours. One asked, very politely, if we were really sure that good communications had any impact on policy. I did have a moment of self-doubt. The world is full of press kits, dossiers, briefing notes and – heaven knows – resolutions. Do any of them make any difference?

Look at what happens when communications specialists don’t try to get science to policymakers and opinion formers. For example, for the last three or four years, it has become clear that many – maybe most – of the new HIV infections in sub-Saharan Africa are passed on during the first eight to twelve weeks of an individual being infected himself or herself. That’s to say that if a Kenyan man becomes infected tomorrow, half of the infections he causes in other people during his lifetime are likely to happen in the next two to three months. (Most of the rest, by the way, are likely to happen in eight to ten years time when the man is visibly ill with HIV).

It’s not actually that new a theory. Christopher Pilcher of UNC Chapel Hill outlined most of it in a very elegant paper in 2002 (http://www.natap.org/2002/9retro/day27.htm). In hindsight, it seems almost obvious. When a healthy individual is infected by HIV the virus runs wild producing tens of thousands of copies of itself in every millilitre of blood. It takes the immune system a few weeks to bring the HIV under control. Once the immune system kicks in, the number of copies of the virus circulating in the body drops dramatically (often by a factor of 10 or 100). The less virus there is, the fewer opportunities there are to pass it on in body fluids. After eight to ten years, the virus starts to wear down the immune system and the number of circulating copies increases again but, by this time, the person with AIDS is usually displaying clinical signs and symptoms.

Since 2002, Pilcher and others have gone about testing their thesis in very high-quality work in Africa. In one study, he looked at the viral load (the amount of virus) in semen in recently-infected men with HIV (tragically, the sober write-up fails to explain just how Pilcher and his colleagues were that persuasive). It then matched these findings to what we know about transmission from men with high and low viral loads (from a study of couples in which one is HIV positive and one is negative in the Rakai district of Kenya) and concluded that up to 60% of onward infections happened during this initial viral peak.

This work has caused quite a buzz in science circles and is part of the reason why the US National Institutes of Health have just invested another $350 million looking at issues related to this early viral peak.

But amongst policymakers, journalists and the chattering classes of the international health community, you hardly hear a mention of Pilcher and early viral peaks. Why? Well, it’s not a conspiracy but it’s not really in anyone’s interest to talk about it. Those who favours counselling and testing above all else (and aren’t too bothered about the niceties of it being voluntary) are clearly a bit unsettled: during this early peak of primary HIV infection (the few weeks after getting infected), a few people will have slight flu-like symptoms but most won’t feel anything and won’t test positive on the standard HIV antibody test kits used in testing programmes. So, if the theory, is right, testing will have no impact on stopping 60% of infections. Actually, it’s worse than that because most of the rest of the infections will happen when an individual is already showing signs of AIDS so testing will, at most, confirm something he probably suspects.

It doesn’t fit the neat myth of the abstinence crowd or the women-are-totally-blameless squad.

The vaccine and microbicide campaigners are, frankly, too lost in their own little world of failed monkey models to have registered the implication: only a vaccine – or a surprisingly- effective microbicide – can stop this epidemic. It’s particularly amazing that none of the vaccine advocacy groups has grasped it because they know that the first generation of AIDS vaccines is unlikely to prevent infection by HIV but may make the body better able to contain the disease if a person is vaccinated before he or she becomes infected (meaning that the initial viral peak would, potentially, be much lower in vaccinated individuals who subsequently became infected.)

For the prevention industry, any finding that focuses attention on a small group is bad news. The big money comes from "awareness raising" campaigns with their glossy brochures, clever PR, long-running radio series and, above all, advertising. We have lots of evidence that small, community-based campaigns reduce AIDS transmission but almost none that the multi-media extravaganzas do any good. (For example, the World Bank's David Wilson noted that many of the most successful campaigns against HIV he had analysed were, "rapid, endogenous, inexpensive, and simple. They were based on the premise that communities, however disparate, have within themselves the resources and capital to reverse this epidemic. They preceded large scale exogenous assistance and occurred largely without the involvement of specialist agencies." BMJ 2004;328:848-849). It is the communities that have been ravaged by unprotected sex with multiple partners which have responded by measures which, unknowingly, reduced the numbers who would be infected by someone in this early, highly-infectious phase of HIV.

So, these findings about transmission during acute infection go largely ignored by policy makers.

What international public health really needs is a few more good spin doctors.

Sky News is so good that we often forget it is part of the same media family as Fox, The Sun and The New York Post. Friday was a good reminder that a struggle goes on between News International values and many of the journalists at Sky. A particularly inane poll was breathlessly reported. "46% [of British Moslems] said they thought of themselves as Muslim first and British second". How many blond-haired accountants think of themselves as blond first and accountants second? How many Big Mac-eating taxi drivers think of themselves as Big Mac eaters first and taxi drivers second? The questions are silly because there's no conflict between being a taxi driver and a Big Mac eater. If a polling organisation asked the question, you would expect about half to pick each answer. Surprise, surprise, about half of British Moslems picked one answer and half picked the other.

The question is based on very interesting market research work in the UK over the past few years which has tracked changes in the whether people think of themselves as "English, Scottish or Welsh" first and "British" second (or, for a depressingly small number of us, as "Europeans" first, "Welsh" second and "British" third -- but that's another story). These are all questions about nationality so you can ask people to make valid choices.

How would Christians answer if you asked if they thought of themselves as "Christian" or "British" first? Probably, with our traditional view of Anglicanism as a sort-of Shinto, you would get quite a few who would answer "British". It would be an odd view: "the Creator of the Universe has taken the trouble to personally communicate with me about timeless, unchanging ultimate truth but I think this is less important than being a citizen of a country that's existed for about 200 years and probably won't exist in another 100". Fortunately, no-one is about to commission the polling.

Still, Sky is positively responsible compared to The Times (of course, another News International outlet) which on the 12th of July reported, "stark divisions in attitudes between people living in London and the South East, and those in the rest of the country. The further away from London respondents lived, the stronger their support for tough new [security] measures." Read a bit further on and you will see that the biggest difference is actually about 11% ("While 95 per cent of Scots support security checks and baggage inspections at stations, 84 per cent in London and the South East back this measure.") In a survey with about a thousand respondents across the UK, margins of error in comparing regions and countries must be pretty broad. Maybe 11% is significant at some reasonable level but it is hardly "stark". Most of the "stark differences" were not remotely significant. How did Populus, the market research group commissioned by The Times, ever allow this copy?