After I Left AIDS - Part II (Thesis)

So, after I left AIDS, I got thinking about how homophobia, as a societal norm, affects health. Not just queers' health, but how it also affects the health of the whole population.

In my last post, I talked a bit about my journey through thinking about health disparities, and how nobody seemed to be measuring the causes of these disparities. That leads directly to my doctoral thesis, which was about how to measure normative heterosexuality, and from there, estimating the impact of it on suicide. Not just on "gay" suicide, but suicide in the whole population, and also in various sub-populations defined by sex, age, and race/ethnicity.

So, following the lead of thinking about residential segregation by race/ethnicity, and income inequities, I began thinking about how to measure normative heterosexuality, the presumed cause of the health disparites that epidemiologists had begun to document with greater and greater precision.
How do you measure the degree to which a group of people (a large group of people) share a rigid set of beliefs about sex, gender, who ought to be having sex with whom, and how? My first thought was that the frequency of hate crimes directed against gay men would be a good measure. If this set of rigid beliefs dominated a social setting, then the informal "enforcement" of those beliefs would be enacted through the commission of bias-motivated crimes, presumably mostly by young men with "something to prove".

When I pulled the data down off the FBI's Uniform Crime Reporting (UCR) System, I quickly realized something was amiss. San Francisco had by far the highest number of anti-gay hate crimes in the country, and several Southern and Mountian states reported not a single one.

I've put more recent statistics by state in a table, based on numbers from 2004 to 2008, the five most recently reported. Basically the same trend holds - bias-motivated crime tends to be higher in places we think of as gay-friendly, and extremely low in the deep South. Then there are also strange jurisdictional oddities - Pennsylvania for example appears to have an extraordinarily low rate of bias-motivated violent crime.

The way I've come to understand this data is that it represents not the phenomenon of crime occurring, but rather on two phenomena: 1) how comfortable victims feel about reporting a bias-motivation to law enforcement, and 2) local law enforcement customs and legal constraints about recording and validating these reports. If it was just the first of these, then one could use the reporting of hate crime as a measure of homophobia at a societal level, that is the more hate crime reported in an area is evidence of how little homophobia there is there, as perverse as that sounds. But alas that second factor, particularly the bit about jurisdictional quirks in how different local law enforcement agencies deal with the reports that are made to them, really throws the whole thing off.

So, I couldn't use hate crime statistics. But maybe I could use the presence or absence of a law for reporting hate crime statistics that specifically included sexual orientation. Or, how about the presence or absence of a law prohibiting discrimination on the basis of sexual orientation?

So, the next thing I looked at was which states had gay rights laws, and when they were enacted. Various of the states have enacted gay rights laws over the years, the first being Wisconsin in 1981, a few more in the late 1980's, and a lot during the 1990's. Recently, state-by-state gains have slowed considerably, as gay activists have pressed for a national law (ENDA), or been distracted by the marriage thingy.
The point for my purposes is that the enactment of state-wide gay rights laws has been a pretty hotly-contested issue, debated for years within each state's legislature, rather than by a small cadre of legalistic judges, or the flash of public opinion of a referendum. As a result, the enactment of a gay rights law represents something of a local watershed, the point in time at which the balance of adverse consequences for elected officials switches from a net negative to a net positive.
So, looking at the enactment of gay rights laws seemed to hold promise, at least from a theoretical perspective, as a good measure of the broad social environment of a State in regards to the level of normative heterosexuality.

Another potential measure of normative heterosexuality to be considered is public opinion polling. The gay rights law thing seems a bit crude - a yes-or-no variable to measure something which I claimed varied by degree from one place to another, and one time to another within those places. Public opinion polling, on the other hand, offered the promise of a finely-tuned measure of normative heterosexuality. There are some relevant questions that have been asked the same way for decades. For instance, Paul Brewer has examined the time trends in how Americans feel about the "wrong"-ness of same-sex sex, which increased during the AIDS years, followed by a precipitous drop recently, the majority of Americans now saying it is not "always wrong" (small consolation that!).
So, public opinion polling looks like it might be a better "thermometer" to gauge how people feel about homosexuality. And there is longitudinal data to work with, so I could look at changes over time.
On the other hand, public opinion polls, by design, ask the smallest number of people possible in order to get accurate results. Thus a "large" national poll might have only 500 respondents. The GSS from which the data above is generated is a good bit larger than that, but still it is only a few thousand in any given year. A few thousand sounds like a lot of people, but what I needed to do was compare across places, not just time. So a few thousand breaks down into a few dozen in some states, and in others, fewer than ten. It would be a stretch to characterize the whole State of Connecticut based on how 15 randomly chosen people answered a question (for the record, I'm pulling that number out of thin air, but that's about what it comes down to).

So I was stuck with public opinion polling, too. Good temporal trends, but lousy in terms of geographic specificity.

A related idea was to look at how people voted on anti-gay referenda, such as the Briggs Initiative in California in 1978, Measure 8 in Oregon in 1988, and Colorado's Amendment 2 in 1992. These explicitly anti-gay referenda had the advantage of high geographic specificity, presumably accurate down to the precinct level, but represented a snap-shot in time. Also, they represented a small number of states, and the questions addressed in each one were quite different.

While I was working on my thesis, though, another opportunity to think about voter referenda came up. The issue of same-sex marriage cropped up. Although same-sex marriage has been contested in U.S. courts since 1970, it had never gotten much notice one way or the other - the Christian right didn't feel threatened by it, and most gay acitivists thought marriage was a non-starter politically, or at any rate a horrid reminder of heterosexuality run amok that should not be emulated.
But in 1998, Hawaii and Alaska voters chimed in on same-sex marriage, a few more did in the 2000 and 2002 elections, and then the 2004 election was swamped with voter initiatives to restrict marriage, in part a cynical manipulation by Republic Party operatives in order to keep their guy at the helm.

These referenda share the problem that opinion polling data have, in that they are a snap-shot in time (except for a few states which have had multiple referenda on this issue), but there were major advantages. For one thing, the question being asked was nearly identical in every state, some slight variation on whether legal recognition of marriage should be restricted to "one man and one woman". As an aside, no state has yet offered to restrict marriage to "one woman and one man" - something to consider when thinking about marriage as a forum for liberty and equity. And, the geographic scope was huge, with most states chiming in on the issue one way or another. The map I made here shows how different areas voted, from strongly in favor of restricting marriage (red) to being against restricting marriage (dark green).
On the whole, this map comports more or less with what one would expect, there's more red in the rural areas, more green in urban centers and on the Pacific coast, and there seems to be a trend towards more green in the Northeast. But there are some unexpected spots, too, such as South Dakota, which was substantially less in favor of restricting marriage than its neighbors Nebraska and North Dakota, And Arizona, which was the first state to reject restricting marriage in 2006 (alas, they went to the dark side in 2008).
So, there are some tricky issues to deal with in using this data. I haven't quite figured out how to make it comparable across time periods.

The final method I've thought of for measuring normative heterosexuality is using counts of same sex couples. The number of same sex couples was counted (albeit inadvertently) by the U.S. Census in 1990. For the 2000 Census, they did a better job of it, and the upcoming 2010 Census is expected to do better yet.
In any event, the number of people who identify themselves as married same-sex partners and un-married same-sex partners in the Census is probably mostly a factor of three forces: 1) How comfortable people in same-sex couples feel identifying themselves as such on the Census forms; 2) The degree of selective in-migration and out-migration of people in same-sex couples (or destined to join one), and 3) The degree of confusion by people in mixed-sex couples who inadvertently identify themselves as same sex partners.
The first two of these factors (net migration and comfort identifing as a same-sex couple) are related to what I want to measure - how accepting an area is of homosexuality. The third factor is a pain in the butt, not in a good way. I've discussed that issue at length before.

So, counting same-sex couples has two huge advantages: it uses the same methodology for the entire United States, and you can get comparable data down the the neighborhood level (census tracts). On the other hand, the data itself has some big caveats - it doesn't identify young people, single people, or couples living in separate residences, and it is essentially useless when considering older people (for reason 3 above). And although there will soon be three time points to compare, the methodology has changed in each Census, and it remains to be seen if the 2010 Census data will be comparable to the 2000 Census data (probably not, but for the reason that the methods are becoming more accurate).

So, in the end, I decided to pursue three measures of normative heterosexuality further:
1) The enactment of gay rights laws,
2) How people voted on referenda to restrict marriage to one man and one woman, and
3) The proportion of same-sex couples identified in the Census.

More to come...

After I Left AIDS - Part I

About a month ago, I wrote about Why I Left AIDS, but didn't get around to what I'd moved into.

While I was working in gerontology, and started taking classes again in public health, I was trying to figure out what I wanted to do research on. I knew it wasn't HIV/AIDS, and most of the other health outcomes related to gay men (suicidality, depression, substance abuse) were kind of downers. The depression bit hit close to home, and the substance abuse felt completely foreign to me, so I didn't really know where to go.
At the time, in gerontology, I was working on a variety of measures of regional variation in social conditions to try to explain health disparities. We had noticed a big difference in the occurrence of pressure ulcers (bed sores) by racial identity. While it was interesting for me to crunch large datasets, and to work with colleagues to figure out a narrative that might explain the health disparity, documenting the disparity and theorizing about why it occurred seemed unsatisfying. I wanted to measure the cause, not just the effect.
I had also been a teaching assistant for the epidemiology class at Brown for many years at that point, and we always chose an article about the link between residential segregation along racial lines and some health outcome or another, usually birth weight or premature delivery. The idea was that racial segregation, the separation of people in space, reflected social segregation, or the history and current strength of racial hierarchical ideology.
So it was a natural connection to say, hey let's look at whether the health disparity in bed sores is larger in cities characterized by high levels of racial segregation than it is in cities where people are more evenly distributed.
Unfortunately, we never got around to writing that paper (I don't think we even got to the analysis stage before I moved on), but the point is, I spent long hours figuring out how to measure, in a quantitative sense, the racial segregation of where people live, and also the levels of economic disparity (gap between the rich and poor), and how these measures vary across the U.S.
Roughly at the same time, I began to think that I wasn't so interested in documenting the extent of health disparity there was between gay men and straight men, lesbians and straight women (and there was almost no literature on bisexuals, and even less on gender identity), I was interested in measuring what causes the health disparities that do exist.
At first, I tried to think about measuring homophobia in high schools. In my own life, high school was definitely the most homophobic environment I had survived, after all.
I figured that one way to do it was to ask a wide range of students who had graduated and gone on to college to rate their high school environment with regards to homophobia. Having gone to college, they would have at least one other environment to compare to, some perspective. And by asking them about the school environment, rather than their personal experience, then queer kids and straight kids would both have valuable and relevant insights and perceptions on the issue.
I developed a 20-some odd page questionnaire and tested it on maybe 40 or so Brown undergrads, queer, straight, and in-between. At that point, it was an exercise for a survey design class I was taking, so I wasn't particularly interested in scientifically important questions like inter-rater reliability, I had a much more mundane purpose - did recent high school graduates feel like these questions made sense? Were they salient? Were they getting at what I intended them to get at? and was I missing anything?
It was a great experience (for me, anyway). And the questions did make sense (most of them), they were on target (most of them), and there were a few things I had missed. I was convinced that it was worth taking it to the next stage.
I began thinking about how to use it. It was one thing if one could describe the social environment, it was another to use it to predict health or health behaviors. In conversation with a student (Marc), we had an idea - which was to measure the homophobia at a series of high schools where more than one student had died of self-inflicted injuries to high schools where no student had died of self-inflicted injuries in many years, and to measure the extent to which the school social environment was infused with homophobia in both sets of schools.
And here's an important point - whether the students were queer, straight, or in-between was not relevant to our plan. It wasn't going to be a study about who had killed themselves, but about what sort of environment drives people to the point of ending their lives.

So maybe you're seeing a thread here already - the vast majority of research literature on queer health is about documenting the bad things that queers (and usually gay men specifically) are at higher risk for. But I wanted to take a different tack - I wasn't so concerned with what the specific health outcomes were, but the cause of them, and specifically, the cause in the sense of the social environment.
And this opened up a new possibility - examining the influence of the perfusion of homophobia in social environments not just on queer people, but on the whole population, on straight people too.
My involvement with ActUp/RI was highly influential in getting me to think about homophobia as a health hazard, but in that context, I thought about it as the reason the government was letting gay men die without saying a word, literally. Or when words were spoken, they would be words of condemnation, threats of quarantine, of judicial prosecution for having an infections disease, of punishment for exposing the "general population" to a scourge that we deserved but they did not.
Instead, I was now thinking about homophobia as a threat to the whole population.

More to come...

Breast Cancer Screening Controversy

I'm going to be teaching two sections of epidemiology this Spring, one for grad students, one for undergrads.
The grad student version I'm pretty confident about, but I want to change a few things, especially the cumulative paper that I ask the students to write throughout the semester.
The other thing I'm thinking about is pulling in the breast cancer screening controversy, which seems to have long legs, re-appearing in the news on a regular basis. I had been thinking about H1N1, but to be perfectly honest, it hasn't been able to attract my attention (not the way the 1918 war-fueled epidemic did anyway).
For the undergrads, I'm trying out a new textbook (new to me, anyway), which has more pictures. I haven't been able to find a good textbook for undergrad epi, and the worst are the ones that say that that is their target audience.

Anyway, back to breast cancer screening. I think it's a great issue to tussle with. It has a lot of emotionally laden content in addition to "the science". The science itself is complex and fascinating, and really engages all forms of epidemiologic study designs, from case-control studies to massive experimental trials, and concerns epidemiologists have about sources of error and misleading results.

Also, one of the pioneering epidemiologic researchers was Janet Lane-Claypon, who did a case-control study comparing 500 women with breast cancer to 500 women without breast cancer, and confirmed most of the risk factors that we now know have a large influence on the development of breast cancer, in 1926. I like having a historical focus in my class, and it bugs me that that means reading exclusively male writers in a class that's predominantly made up of women.
I'd also like to include more of the large corpus of early writing from Spanish language authors, but I'm not familiar enough with it, and the few pieces I have seen translated just wouldn't fit well into my curriculum. (Perhaps it's time to expand my curriculum, then!)

But back to screening. I myself didn't think much about breast cancer screening, until my mom got a positive mammogram. It pretty well freaked her, and me, out. Weeks of anxious anticipation were not erased after minor surgery removed what turned out to be perfectly benign calcified lumps. But still, what if it had been cancer, wouldn't it have been good to know earlier rather than later?
The more I've thought and read about it, the more I've come around to a different point of view - it probably wouldn't have been better to know about it earlier. I know that sounds harsh to anyone with breast cancer, and easy for me, given that it wasn't breast cancer. But I don't say it glibly. The unnecessary anxiety, the unnecessary (if minor) surgery, these are not benign side effects. They may be mild inconveniences compared to mastectomy, chemo and/or radiation. But really how many unnecessary side effects are we generating with screening mammograms compared to how many treatable breast cancers that get detected (and wouldn't be equally treatable after they grew a bit and became diagnosed by other means)? How many breast cancers are detected and treated with highly toxic and invasive methods that, left alone, would never have caused a problem? Those are complicated questions that are technically challenging to answer.
Then, there's also an issue of where we, as a society, spend money. I don't think that costs should be a determinant of what health care people get. In a previous post, I lampooned the idea of doing a cost-benefit analysis of vaccination against HPV. The more effective a vaccine campaign is, the less cost-effective it would be, so it's just silly to do a cost-benefit analysis in the first place.
But at the same time, one wonders if all the attention paid to promoting mammograms as the one thing you can do to prevent breast cancer has crowded out other means of preventing breast cancer. Methods that may be less sexy, and less under an individual's control. Why does preventing breast cancer have to be something each woman does for herself? What about pesticides and environmental pollutants that probably have a very small influence on any one woman's risk of getting breast cancer, but by increasing all women's risks somewhat, have a large societal impact? What about the disparities in the levels of these pollutants that often mimic disparities in class and race in this country? What about addressing the structural poverty and disenfranchisement that keeps women from having symptomatic breast cancers dealt with early on when it's more treatable? These methods at least give men something to do!

Why I Left AIDS

I left AIDS in the mid-late 1990's.

I made a conscious decision to stop working on HIV/AIDS, and to stop referring to HIV/AIDS when talking about gay health.

In short, I was over AIDS.

I wanted to force myself into a new idiom, a new way of thinking. I had no idea what it would be, but I had come to the conclusion that continuing to work on HIV/AIDS would be detrimental to me personally, and might well not be helping anyone else either.

I wish I could say that I had some inspired moment, that I had some vision of the future of queer health, some goal in mind, some grand theory. But in truth I had none of those things. Gradually, I began to realize that working on HIV/AIDS felt increasingly distant from my personal experience I noticed that it was harder and harder to interest my friends to get active, it was even hard to know what to get active about.

But maybe I should start a little earlier.

I was a little fagling in 1987, a momentous year in queer history. In 1986, my freshman year of college it began to dawn on me that it was not a passing œdipal phase, that my attraction to other guys was not merely admiration of their physical form, to be replaced at some point in the future with an attraction to the voluptuous female form, marriage and children.
This was distressing to me, because my only image of an adult gay man was not what I wanted to become. Don't get me wrong, I didn't want to be "normal", I just didn't want to be lonely, depressed, and ridiculed for the rest of my life.
I quit the crew team, partly because I was not going to be competitive at the level required, but mostly because I just didn't see any possibility of being happy, healthy, and vibrant as a gay man.

I slowly began meeting other gay men, particularly Chris Bartlett and Stephen Gendin. Then in October 1987, Chris invited me to vanpool down to DC for a March on Washington. It totally blew my mind. For the first time in my life I saw happy, healthy, vibrant gay men. I kissed one of them, for about six hours, while driving around from one spectacularly lit patriot monument to another.

I came back to Providence transformed. I realized that I could do this gay thing after all.
My then (and current) roommate calls it my militant phase. I painted pink triangles on the back of my hands. I gave out "queer fries" at the snack bar to anyone who would publicly say they were gay or lesbian. I proselytized to anyone and everyone.

In early 1988, Stephen invited me to "come get arrested". I said "sure" and then it took me a week to ask "what for?" He told me it was about gay rights, and only during the civil disobedience training did I learn that it was really about AIDS, about trying to keep the Health Department from doing widespread mandatory HIV testing, and compiling a list of everyone who tested positive for some as yet to be determined intervention. I kinda freaked out. I had begun to come to terms with the gay thing, but I was scared to death of AIDS and didn't want anything to do with it.

But Stephen was inspirational, and I stuck with it, becoming one of six people arrested in H. Denman Scott's office on the fourth floor of the Health Department. I'm the one in the purple shirt with a green knapsack.


Thus began a long and industrious career with ActUp/RI.

We never needed to get arrested again, it just doesn't take much of a fuss to get on TV in Rhode Island. We disrupted Ed DiPrete's gubernatioral candidacy announcement, we protested the high price of AZT, we joined in national actions at CDC and FDA. I started writing a weekly summary called Bill's News Headlines, a 'zine about all things HIV/AIDS, with a few spicy pictures thrown in for interest.

Under the Reagan Administration, AIDS was largely ignored, until it wasn't. In the late 1980's all kinds of scary talk was coming down, including threats of quarantine. We had a clear and obvious enemy. Those of us young enough and pissed off enough rose up in anger and began a confrontational style of political action that the generation before us was too overwhelmed to undertake.
But when George the first took office, things began to lose traction. Many of our initial demands were being met (AIDS drugs cost less, mandatory testing and quarantine were mostly averted, some government resources began to flow into aid programs, some of the egregious ethical violations inherent to clinical trials of new medications were being abated). The newer issues we were grappling with (needle exchange, anonymous HIV testing) just weren't as sexy. We had a few more big demos (notably a big coalition bash at the Providence Journal, and a fun hootin' and hollerin' when Dan Quayle came to town), but things were starting to taper off. We started meeting with the Health Department, in addition to chastizing them. I even worked there on an internship one semester.
And by the time Clinton came along, all the air got let out of the balloon. Don't get me wrong, Clinton the first did as little as possible to advance the cause of people with HIV, and was arguably one of the worst presidents we've had on gay rights. But the community had had enough. It just wasn't possible to gather a crowd of pitchfork-wielding townspeople any more.

By this time, I was working in HIV/AIDS clinical research. Doing some statistical presentations of data from clinical trials, and medical record abstractions. I began keeping a list, for the medical researchers, of everyone that had been treated for HIV in Rhode Island, what major infections they had had, when they started treatment, etc. I felt pretty conflicted about that, and at the same time fascinated by the stories I was reading between the lines of lab reports and hospitalization records.

The job took me to an AmFAR conference in San Francisco. I fell in love with the city instantly, despite having an earthquake knock my hotel bed around the room my first night in town. I loved how it smelled. I loved the hills and the views. It seemed impossibly magical.

I vowed to move to San Francisco at the next opportunity, quit my job in HIV clinical research, and had all but bought the plane ticket when I got invited to take a job with the tuberculosis and HIV basic immunology lab at Brown. The pay was good, very good. And I figured, what the heck, I can do this for a couple years more, then go out to San Francisco. In the meantime, for several years I got in the habit of taking a month-long vacation in San Francisco every January, staying at the YMCA on Golden Gate & Leavenworth. Everything I needed to pack for a month fit in one bike messenger bag.

Well, I worked on that stuff for a few years, developed a mathematical algorithm for predicting amino acid sequences that would be likely to trigger an immune response, and had a lot of fun while doing it. Got to work with some very motivated and bright undergrads. Got to travel to a bunch of conferences. Even got a pat on the back from Tony Fauci at one point.

But at some point, I realized I needed a break from the frantic pace of HIV research.
HIV/AIDS was the most important thing in the world, or so it seemed. Everything was urgent. HIV/AIDS was an exception to every rule. But after the better part of ten years on the cutting edge, I got weary of being cut. I needed a break.

I began looking for another job, and quickly found it, in the much tamer field of gerontology. I got to work with incredibly bright, talented, and caring people. People who were interested in getting things done carefully, slowly, correctly, not living in a state of perpetual emergency. I had an amazing boss, who really helped me work much more effectively with other people (do you remember the 7 habits of highly defective people - I had probably 4 of them - I was not an easy person to manage).

So at first, I was just taking a break, not really thinking about HIV/AIDS, except about how futile it seemed to be to think about it.

At some point, though, I did make a conscious decision that I would not work on HIV/AIDS again. I wanted to force myself to think differently, to force myself to be more creative, to develop a new language and vocabulary, and whole new mindset.
As I was struggling to do that, I put together a forum at Brown about the Post-AIDS phenomenon. I invited Chris and Stephen as panelsits, after getting re-connected with Chris at the Boulder Gay Men's Health Summit, and also invited Justin Smith, a next-generation activist. It was a fantastic discussion, and there was plenty of passionate but respectful argument.
I made an analogy at the outset that Post-AIDS, in my mind didn't mean that AIDS was over, any more than Post-Modern means we are no longer modern. But the shock of modernity is largely over. The automobile has gone from being a bizzarre new sight on our city streets, crowding and running over pedestrians and cyclists, to being banal, a fact of life (though still running over pedestrians and cyclists - I've got the chronic pain to prove it - it's just banal and mundane now). Electric lights are no longer a showy extravance. It is not that modernity is done modernizing, but rather that the progressive development of wonderful, exciting, and dangerous new technologies is expected and welcomed.
My analogy to the term Post-AIDS was that the shock of AIDS was over, that we were now living in a world where AIDS is part of life, and that public health prevention efforts revolving around HIV as new, threatening, and catastrophic may have worked in the past, but would no longer work in the future. We needed to find new language, new ways of thinking about public health's role in prevention, because the tools of fear and hyperbole have run their course. We are in Post-AIDS now, but HIV prevention has yet to catch up to that reality.

Some ten years later, there are some exciting new developments on the gay health promotion front, such as Chicago's How are you Healthy? campaign, which is all about tying the three words "Gay. Sexy. Healthy." together in new and interesting combinations. The I Am Gay And... campaing in New York City is another one I like a lot. But these two are exceptions.
We're still bombarded with ad campaigns like this one, this one, this one, and this one that either play on fears and negative imagery, or treat us like we're just not knowledgeable enough to know what's good for us.

Well, I've wandered and rambled quite a bit here, and I'm not sure that I've adequately answered the original question - why I left AIDS. But it's a start.

I'm really curious about what some of the stories of the thousands of gay men who have left AIDS work - what did it feel like? What are you doing now instead? Do you, like me, feel conflicted about abandoning the AIDS work, even if what you're doing now is much more productive and forward-looking?

Quick Trip East

Went back East for a week to see my parents. Here they are walking through a small orchard of apple trees planted a very long time ago (probably about 100 years or so) that I've been pruning. The apples used to taste awful but now they're pretty good. They are varieties that are not commercially viable (too small and bumpy), so you can't find them in stores, even specialty markets.
My mother says that one of them is called a "banana apple" which she recognizes from her father's farm in upstate New York. It's true, it's an apple with a faint whiff of banana as you bite into it.

Also stopped into Providence to try to do some work on my house. Got a bit frustrated because the windows I wanted to replace I have to special-order, so mostly I frittered around with some electrical work and painting instead.

I've come to the solid realization (yet again) that I need to work tirelessly towards getting a full-time teaching job. Not only do I love teaching (and I'm getting pretty good at it if I may say so), but I need to be connected to the land in Vermont that I've put so much time and effort into, and the best way to do that is to have the summers off.

HPV Vaccine for Boys? No (and Yes)

The news about HPV vaccine for boys lately has been mighty confusing.

An FDA panel approved the use of an HPV vaccine in boys to prevent genital warts in September with a 7-0-1 vote.

Then an article came out in early October, sponsored by the CDC and others, suggesting that vaccinating boys to prevent cervical cancer in girls would not be cost-effective (more on that later).

And then today, a CDC advisory panel chose not to recommend HPV vaccination in boys. Apparently, the CDC-funded study weighed heavily in the committee's deliberations.

The upshot is that a doctor can write a prescription for HPV vaccination for a boy, but because it is not recommended, very few doctors will bring it up as an option, and no health insurance plan will pay for it.

Benefits of Vaccinating Boys Against HPV
1) The vaccine prevents getting genital warts. Sure, genital warts are mostly a minor nuisance, but tell that to someone who's had a few hundred warts cauterized up in his butt. Ouch!

2) The vaccine probably prevents anal cancer. No study is ever likely to prove that the vaccine prevents anal cancer. It is too rare, and takes too long to develop. But it doesn't take a genius to figure out that if the vaccine prevents getting the HPV strains that cause anal cancer, it will prevent anal cancers. Interestingly, this benefit is often dismissed as not a real problem, because most anal cancers occur in gay men (and nobody's son will grow up gay?).

3) The vaccine probably prevents a bunch of other, though rare, cancers - penis cancer (yes, there is such a thing), and cancers of the head and neck, primarily. Admittedly these are pretty rare. But if they can be prevented, why not?

4) Vaccinating boys prevents cervical cancer. Huh? But only people with a cervix (born female) can get cervical cancer. OK, but how are they getting HPV? From "Immaculate Infection"? No, from men and boys (for the most part). So, vaccinating boys is crucial to having a successful strategy for reducing the prevalence of these HPV strains in the population, thereby reducing the chances that a woman or girl will get infected, either because she didn't get the vaccine, or because it didn't work.

Lousy Vaccine Policy
The problem with contemporary U.S. vaccine policy is two-fold. Vaccination policy is strictly limited to worrying about individual risks and benefits, and vaccination policy is couched in terms of cost-efficacy, a framework that doesn't make sense.

Individual Benefits Only
So first, the individualized approach to vaccination strategy assumes that nobody else benefits from you getting vaccinated. So, if there is not an immediate benefit to you, don't get vaccinated. Because the individual, albeit miniscule, risk to you outweighs any potential benefit to others. And since men can't get cervical cancer, it is irrelevant that men and boys can infect women and girls with the virus that does cause cervical cancer in them.
That's not how vaccination policy has always been done. Smallpox vaccines were given to lots of people who had a next to zero risk of getting it, because the risk to society of having smallpox come back was too high. Same with polio. Today's vaccines are a lot safer than those vaccines were. The shift came with the HBV vaccine, when individualized risk-assessment was used to guide vaccinations, a policy that largely failed for the first two decades, and thousands of Americans are paying the price with HBV infections they didn't need to get, because a safe and effective vaccine was bottled up in a bureacracy of risk-assessment.

Cost-Efficacy. You're Worth $50,000 a Year.
Second, cost-efficacy is the wrong framework for evaluating vaccination strategy. For one thing, it is fairly arbitrary to say that a year of healthy life is worth $50,000, but not $100,000. By that logic, it wouldn't make sense to treat many forms of cancer, or advanced HIV infection, etc. Because if your treatment costs more than $100,000 in a year (which is not hard to do if you get surgery, chemo and radiation therapies), it exceeds the 'value' of your life for that year.
But that's exactly the logic of the CDC-funded article I linked to above. At $50,000 per year of healthy life saved, vaccinating girls is worth it. But at a little bit higher than $90,000 per year of healthy life saved, vaccinating boys isn't.
The study was also funded by the American Cancer Society, which recommends cancer screening programs that cost many times higher than that, and some of which (mammograms in women under 50, PSA tests), may well cause more human health harm than good, so could not be considered cost-effective at $10 billion per year of healthy life.

More fundamentally, cost-efficacy ignores any societal benefits acheived through reducing the prevalence of HPV infections. There is no space in the calculation for the benefits to society from reducing one's exposure to HPV because fewer people in the population have it. By the logic of cost-efficacy, if the vaccination strategy were somewhat effective, and reduced the prevalence of HPV infections by half, then the cost of a year of healthy life saved would rise to $100,000, and this logic would dictate that we should stop vaccinating girls at that point if the vaccinations are successful.
If we had pursued that strategy with smallpox and polio, we would have vaccinated people when the prevalence was high, but as soon as it got down to an acceptable annual cost to just let people get sick, we would have stopped the vaccinations, and we would not have eradicated smallpox from the Earth, or polio from almost everywhere.

Gloomy Predictions for HIV Vaccination Strategy
All the signs point to these forms of illogic being applied to the HIV vaccine, when it becomes available. First, vaccinations will be targetted only to "high risk" individuals, meaning that doctors won't think to ask if you want it, insurers will not pay for it, and you'll be hard-pressed to find it in-stock anywhere, meaning that you'll need to visit your doctor to get the prescription, go to a pharmacy to pick it up, and make another trip to the doctor's office to have it administered. Second, the logic of cost-efficacy will almost certainly exclude recommending any HIV vaccine - which will be expensive, require multiple shots, and be only partially effective (maybe 1/4 to 1/2 of people would be protected).
Getting a vaccine that works, my friend, is the easy part of this battle.

So forget what's recommended. If you can afford to get your boys vaccinated for HPV, please do it. For them, and for the girls.

Environmental Success Stories

Global warming. Air pollution. The ozone hole. Nuclear winter. Acid rain. Deforestation. Pesticides. Extinction. Industrial waste.

Poisons are everywhere, undetectable, and have unknown risks.

Everything you hear about the environment leaves you feeling threatened and helpless. Not only that, but usually you are personally culpable unless you spend a huge amount of money buying your share of the problem away with (insert environmentally chic and expensive food/clothing/transportation/lifestyle item here).
A pretty insurmountable trio of adjectives, threatened, helpless, and culpable.

Believe it or not, there are actually a lot of environmental success stories. Successes that are the direct result of the political action engendered by making us feel threatened, helpless and culpable.

Acid Rain
When I was a kid, everybody talked about acid rain, how it was killing the fish in the lakes, burning the trees. And it did. And it does still, but to a much lesser extent. Did anyone tell you that acid rain has gotten much better? That your outrage led to actions that severely curtailed the emission of the pollutants responsible for acid rain? That progress has been made even faster than what Congress anticipated?
Clap yourself on the back. We did it. Or, more correctly, we're doing it. Keep up the good work!

Air Pollution
You never hear about it, but the air is easier to breathe. Not everywhere, but in most cities, particularly in California and the Northeast, air quality has been getting better and better, thanks to some of the same measures that were taken for acid rain, but mostly because cars and trucks have become less polluting.

Deforestation
Deforestation is a huge problem worldwide. But not everywhere!
New England used to be about 80% de-forested. Now it is about 80% re-forested. Those new trees are a lot smaller than the old trees that got cut down. And the demand for wood in New England is largely met by exporting the problem to other parts of the world.
And yet, New England is rapidly re-growing a valuable renewable resource.
And nobody talks about what a huge success that is. How can we learn from what happened in New England and export that success as well?

The Ozone Hole
The ozone hole was first recognized in the 1970's, and by 1978, the main agents responsible were banned in most countries. We changed the propellants used in spray cans, and the refrigerants used in refrigerators. And although the ozone hole hasn't been shrinking, it has stopped growing quickly, and is expected to recover over the next few decades.
Problem caused. Alarm raised. Problem addressed. Let the healing begin.

Lead Poisoning
A huge success story is lead poisoning in children. You've probably heard about kids getting poisoned from lead paint. Too much lead causes brain changes that are not good. It's still a big issue in areas with older housing stock (but rapid progress is being made).
Not too long ago, virtually every child had potentially toxic levels of lead in their body, due to the lead additives used in gasoline that we all breathed in. That's gone now. And there's a huge generational shift in blood lead levels.

And there's more. The Nashua River used to stink to high heaven, it's banks were scorched clean. Now you can eat the fish you catch there. Bays have gotten cleaner. Alternatives to pesticides are gaining ground. Eagles are laying eggs that hatch. Wild areas are being protected. And so on and so on.

I remind myself of these stories now and again because I think feeling threatened, helpless and culpable is a pretty big waste of time.
I'd like to think that there's a way to motivate the public to address the serious environmental threats facing us that doesn't resort to backing us into that uncomfortable corner. And can we celebrate the successes, for once?

When faced with the newer threats - like global warming - and the old threats - like nuclear waste - I take heart in the fact that we've been able to make real progress on a lot of fronts in the past. I don't necessarily think that there's a technological fix to every problem, that there's a progressive inevitability to cleaning up after ourselves. But I also don't think we're living in a world that is on the verge of total collapse, either. And I vehemently disagree with the stance that the only real solution is to reduce the human population. We may cause the problems, but we're also the ones to fix them.
I think we can make a difference. We already have. Let's keep doing it.