Archive for the ‘public health’ Category

Promise and Caution: Assessing the New HIV Vaccine

September 24th, 2009 1 comment

It’s all over the news this morning: The U.S. Army (partnered with the Thai Ministry of Public Health and the National Institute of Allergy and Infectious Diseases) has shown a modest, but statistically significant, protective effect from a vaccine against HIV.

Here are the details. The trial, which used a vaccine that is a combination of two others that had failed, involved some 16,000 Thai citizens, and was targeted at a strain of HIV that is common in that part of the world. The result was that those who received the actual vaccine were more than 30% less likely to be infected with HIV than those who’d received a placebo.

As this BBC report (click on 9/24 show) reminds us, there’s a small chance that the disparity is a statistical glitch. In the much likelier event that the result is real (and can be replicated), though, this constitutes a major breakthrough. Even quite recently, one could read only dismal prognoses for the development of a vaccine against HIV — most scientists believed it was far off, if not impossible. It’s fair to say that this latest trial was greeted with a great deal of skepticism, too.

What will this mean? What should we do, from a public health point of view, with a protective effect of about 30%, which is much lower than the 70-80% that researchers typically look for before licensing a vaccine? It depends. Right now, the mechanism by which the vaccine works isn’t understood: For one thing, it’s puzzling that those who became infected received no protective effect from the attempted immunization. Typically, where a vaccine confers incomplete protection, those who become infected have some response to the vaccine, even if it is too weak to prevent infection. So for now, it seems the best course is to work towards better understanding of this vaccine’s mode of operation, thereby to design a better candidate that will confer immunity on a much higher percentage of the population.

If that’s not possible — if this vaccine turns out to be a dead end, with scientists getting stuck at 30% protection — then it will be time to consider licensing it, thereby gaining a significant tool in the prevention arsenal. The vaccine, which requires more than one injection, will then best be seen as part of a comprehensive prevention strategy that continues to emphasize condom use, male circumcision,  education, and the social and economic empowerment of women.  Reducing the percentage of infection by 30% has enormous ripple effects, as those in the protected group are then incapable of passing infection along. Over time, the combination of strategies — with a modestly effective vaccine as a substantial component — can be expected to significantly lower the staggering global costs of HIV; costs that have been measured, for thirty years on, both financially and in terrible human suffering.

Categories: HIV/AIDS, public health, vaccination Tags:

Zeitoun — One Katrina Family’s Story

July 21st, 2009 2 comments

In the compelling Zeitoun, Dave Eggers (best known for “A Heartbreaking Work of Staggering Genius”) has created a piece of advocacy journalism that deserves to be read and discussed. I plowed straight through the first 200+ pages on Sunday night, stopping only when I simply couldn’t stay awake. Then I finished it last night, after impatiently putting the kids to bed. Positive reviews and summaries are starting to come in, and there’s a nice interview with Eggers over at Salon.

This non-fiction work chronicles the lives of Abdulrahman and Kathy (nee Delphine) Zeitoun, a Muslim couple living in New Orleans in 2005, when the city was brought down by Hurricane Katrina.

Eggers masterfully sketches out the successful but somewhat plain lives of the couple in sympathetic detail, using the lead-up to Katrina for descriptions of and digressions into:  their successful contracting business; Abdulrahman’s ancestry and childhood in Syria (including a lavish description of his aquaphobic father and his late brother, who became arguably the greatest ocean swimmer in the world); Kathy’s Christian upbringing and her conversion to Islam; and, most significantly, the couple’s loving relationship and their warm family (including Kathy’s son from a brief, early marriage and the couple’s three daughters).

Like any good documentary work, Zeitoun ties the joys, stress, travails and humiliations of the Zeitoun family to the larger issues of our collective national failure during and after Katrina. (The story doesn’t dwell on the failures that allowed Katrina to devastate the city; for that, see this and this.)  As was typical when severe hurricane warnings were posted, Kathy and the kids evacuated the city while Abdul remained behind to protect their home and the many rental properties the Zeitouns owned and managed. The book effectively cross-cuts between Kathy’s odyssey (involving nasty relatives, interminable traffic, and — finally — escape to her best friend’s home in Phoenix) and Abdulrahman’s heroism and subsequent incarceration.

After the flood, Zeitoun (as he’s mostly called) used his canoe — which he’d bought for no real reason some time ago, but now saw as providential — to rescue people who might otherwise have drowned, and to feed dogs who would otherwise have starved. Eggers effectively reflects Zeitoun’s own sense that he was meant by God to stay, and that his actions were heroic (although Zeitoun would never have used that word himself). Yet from the start, Zeitoun and other residents are treated as annoyances by the very government rescuers who were supposed to be helping them.  At one point, two government speed boats zoom past the canoe, almost capsizing it and ignoring his plea to stop. In another inexplicable incident, Zeitoun is unable convince government workers to do anything to rescue an elderly couple that will surely otherwise drown. (Zeitoun and a friend are forced to return and improvise a risky strategy of their own.) Yet for the first two-thirds of the book, the reader is somehow buoyed (sorry!) by the can-doism of Zeitoun and his fellow residents (especially Todd Gambino, who might have rescued as many as 200 people).

Then the book turns dark. Kathy can no longer contact her husband, and, assuming him dead, falls apart by degree (It can’t get worse than this, she thinks.). But Zeitoun isn’t dead; he’s been imprisoned. Zeitoun and others (including Gambino) captured in a house that Zeitoun owned were arrested, placed in a makeshift prison at the New Orleans Greyhound station, and then transferred to a maximum security prison. For almost three weeks, Zeitoun was given no reason for the arrest (there were unofficial statements that he and one of his fellow prisoners “were al Qaeda”), not arraigned, and not even allowed to make a phone call to his wife. The conditions in the prisons made sleep or comfort almost impossible. Despite severe and disabling pain, he was never granted access to a doctor. He was given food (pork) that he couldn’t eat. This is the man Kathy found after those three weeks:

“He looked like a different man, a smaller man, with longer hair, almost all of it white….He’s so small, she thought….She could feel his shoulder blades, his ribs. His neck seemd so thin and fragile, his arms skeletal. She pulled back, and his eyes were the same — but they were tired, defeated. She had never seen this in him. He had been broken.”

Why, though?

The reasons for the treatment of Zeitoun and thousands of others (Gambino spent five months in prison, and after charges were dropped, never recovered over $2,000 that had been taken from him) are complex, but a few realities emerge:

Once FEMA was made subordinate to Homeland Security, the focus — even in a situation that was clearly a natural disaster and not a terrorist strike — changed from public health and emergency management to law enforcement. Homeland Security had thought through how terrorists might exploit the aftermath of a natural calamity and then, doubtless fueled by hysterical media reports about looting, rape and murder, worried less about rescue and provision of basic services than crime prevention. Consider the construction of the emergency prison and the vast amount of time and money that went into it; this isn’t what one does in regard to a public health catastrophe. (See pages 236-237 for a vivid account of this issue.) As Professors Wendy Mariner, George Annas and Wendy Parmet state in a recent article: “Since September 11, 2001, emergency preparedness policies have shifted their focus from public health to national security….[T]his shift is both contradictory and ineffective.” Zeitoun makes this point graphically.

Further, once the issue moves away from emergency management and public health to law enforcement, the potential for abuse soars. Law enforcement will avail itself of all available tools, and, given the opportunity, will come to reflect the worst prejudices of the society. Thus, it’s never entirely clear what impact Zeitoun’s Middle Eastern appearance had on his treatment (was it really all about looting? but then why no chance to explain, no chance to make a phone call?), but it is plain that his African-American cellmates were there at least in part because of their skin color and racial profiling.  This story is the worst:

“One man said he was a sanitation worker from Houston. His company had been contracted shortly after the storm to come in and begin the cleanup. One morning he was walking from the hotel to his truck when a National Guard truck pulled up. He was arrested on the spot, handcuffed, and brought to Camp Greyhound….He was in uniform, and had identification, the keys to his truck, everything. But nothing worked. He was charged with looting and put in the cages….” (pp. 258-59)

Don’t even get me started on the FEMA trailer debacle that forms a kind of slapstick sideshow to this extraordinary work. (It’s detailed on pages 308-310. Preview: a trailer is pretty much useless if you can’t get into it.)

The book concludes with a chapter about the Zeitouns’ life now. Abdulrahman is more of a workaholic than ever, seemingly trying to forget by rebuilding. And “Kathy has lost her memory. It’s shredded, unreliable.” Because of what happened to her husband, she’s become a fretting mother, afraid to allow her kids the freedom they need to develop.

The Zeitouns (especially Abdulrahman) emerge as particularly resilient, emblematic of the American optimism and capacity for reinvention that may have led this Syrian national here. Not even the Department of Homeland Security was able to crush that spirit.

By all means, buy this book. Eggers is getting none of the royalties, having committed them to various relief organizations that are spelled out at the end of the work. And it will keep you up late.

Sotomayor: Abortion as a Public Health Issue

July 15th, 2009 1 comment

I no longer listen or watch raptly as Supreme Court nomination hearings proceed. They’re mostly for show, and a little goes a long way.

In Judge Sotomayor’s case, the little I’ve seen —  except for the moving sight of her mother in the audience, fighting back tears of joy and pride — has been as scripted as have been recent hearings. Republicans are cautiously on the attack, recycling the few pieces of ordnance they have (will anyone ever again refer to herself as “a wise Latina”?) and at times revealing their embarrassing ignorance of all things judicial. Democrats work on the hagiography while pre-emptively blocking any efforts to suggest that the nominee might actually have a heart. (Chuck Schumer’s references to cases where Sotomayor had ruled against sympathetic plaintiffs were noteworthy in this regard, if a little…odd.) And the nominee herself, determined to give them nothing (especially since she’s reputedly such a Latina hothead!), is plodding along in a performance that is measured — at times even boring — by design.

But I did stop what I was doing and listen attentively to a brief exchange between Judge Sotomayor and Sen. Lindsey Graham of South Carolina. The discussion concerned the nominee’s work as a Board member for the Puerto Rican Legal Defense and Education Fund (“PRLDF”). Having served on the board of a legal advocacy group my own self, I can tell you that even the lawyers among us had approximately zero input on the cases the organization chose to take, and even less on the legal arguments and strategy the organization pursued.

Nonetheless, there’s something to Sen. Graham’s line of questioning, because Board members are generally committed to the goals and philosophy of the organization, even if they might have quibbles about details. If Equality Advocates, on whose board I sat, had suddenly decided, for example, not to take cases involving transgender rights, I would have known about that decision, and protested it. Sotomayor said as much, noting that Board members did care about fidelity to the organization’s broad mission statement.

So Graham pressed Sotomayor on briefs that the PRLDF had filed arguing that denying poor women the right to a government-funded abortion was the moral equivalent of slavery. Sotomayor claimed, quite plausibly, to have known nothing of this, but then she did speak to the overall goals of the organization in the same way I would have felt comfortable describing the work of Equality Advocates. She said that the Fund (which contains the word “Education” in its title) was interested in issues of “public health,” as were other advocacy groups.

Aha! Graham had what he perceived as an opening. “So you think abortion is a public health issue?” he asked.

Somehow, she managed to avoid answering the question directly — but she shouldn’t have. Here’s the exchange (beginning shortly before 4:00):

Abortion is a public health issue, and this description of it shouldn’t be seen as controversial. Graham was doubtless proceeding from the presumption that those who see abortion as a matter of public health are on the extreme end of the pro-choice side.

It’s true that one argument in favor of abortion rights has been that, on a population-wide basis, safe and legal abortions lead to better health outcomes; illegality and the lack of regulation predictably compromise women’s health. But that doesn’t mean that the argument is decisive from a public health point of view, nor does it mean that the public health perspective is the only perspective from which to consider the issue.

Recently, those opposing abortion rights have argued that abortions have their own public health consequences, including increased incidence of breast cancer and adverse mental health outcomes for women who terminate their pregnancies. There’s not a lot of evidence in support of these theories, but that didn’t stop Justice Kennedy, in his 2007 Supreme Court decision in Gonzales v.  Carhart, from reciting supposed psychological consequences in support of his ruling that a law restricting late-term abortions was constitutional.

And public health, properly understood, isn’t a purely utilitarian calculus, anyway: Properly understood, it incorporates a respect for persons and autonomy that has both long- and short-term effects on health and well-being. In short, to recognize the issue as one with a public health dimension is to add a useful prism through which to view this complex and probably irresolvable issue.

But not the only prism. Saying that an issue has an important public health dimension isn’t ruling other perspectives out of order. Questions of rights and morality can’t and shouldn’t be read out of the issue. The challenge is to hold all of these perspectives before us as we strive for some kind of legal and social rules that we can live with, if not totally embrace. That goal sometimes  seems impossible to achieve, but I’m optimistic that public health talk can take some of the heat out of the discussion and enable sensible compromise.

Repeat: Abortion is a public health issue.

Delhi Order: Equality, Sliced Thick

July 6th, 2009 No comments

As many readers know, last week the High Court in Delhi, India, sided with an HIV/AIDS services organization in ruling that the state’s prohibition on consensual, “unnatural” sexual acts violated the Indian Constitution. Nan Hunter has a brief summary of the ruling in Naz Foundation v. Government of NCT of Delhi, which apparently applies throughout the country unless and until reversed by the Supreme Court.

The long decision is noteworthy for many reasons, most obviously because it adds India to the ever-growing list of nations that have taken important steps towards recognition of the basic equality of their LGBT citizens. I recommend reading the entire decision (it’s long!), which you can find linked to The Times of India  (which also quotes some of the court’s soaring rhetoric about discrimination, equality, and dignity).

Here, I want to focus on just a couple of points. First, the two state ministries that weighed in on the law differed; the Ministry of Home Affairs supported the law, while the Ministry of Health and Family Welfare sided with those challenging the law. The conflict draws into sharp focus the question of whether “morals legislation” is valid when it’s contradicted by public health and welfare considerations. In sum, the court said “no.” Home Affairs conceded the privacy argument for throwing out the law, but thought that it should be overborne by considerations of “public safety and protection of health as well as morals….” But the evidence strongly supported the contrary view of Health and Family Welfare, to the point that public health considerations argued strongly in favor of removing the legal prohibition against consensual sexual acts.

As someone who writes and teaches about the connections between public health and law, I was surprised and heartened to see the court undertake a direct and compelling public health argument in favor of throwing out this artifactual statute.  In a ten-page section of the opinion entitled “[The Law] as an Impediment to Public Health,” the court details the high social and epidemiological cost of the closet, which is powerfully reinforced by the criminalization of same-sex relations. As we know, criminalization of same-sex relations and the accompanying stigma (as well as the potential for blackmail, apparently still real in India) drive the epidemic underground, making it much more difficult to reach people with disease prevention messages and strategies.

To the Home Affairs counter that criminalization was the right response to the HIV epidemic, the court noted that this view ran counter to well-understood views of homosexuality and the effect of criminalization. Siding with international and national public health authorities (including Health and Family Welfare), the court stated the prevailing view that criminalization doesn’t stop the behavior, but simply drives it underground. Not a good place to be, from a public health perspective. In addition to leading to preventable cases of STDs, including HIV, criminalizing homosexuality has more subtle effects. It adversely “shapes an individual’s identity and self-esteem. These laws “serve to embed illegality within the identity of homosexuals.” They “reinforce public abhorrence of lesbians and gays resulting in an erosion of self-esteem and self-worth.”

The other point worth mentioning is that the court, like many courts addressing broad issues of human dignity and civil rights, looked not only to its own law but also to the laws of other nations, as well as to international declarations of rights. Lawrence v. Texas received prominence of place, with the New Delhi court quoting Justice Kennedy’s majority decision declaring that banning same-sex intimacy violated the couple’s fundamental liberty interest, as well as Justice O’Connor’s equality-based concurrence. But decisions from South Africa, Canada, Australia, and the European Court of Human Rights were also discussed, as were the Universal Declaration of Human Rights and the European Convention on Human Rights.

I can’t resist concluding this post by remembering Justice Scalia’s dissenting screed in Lawrence, relevant to both points. First, he liked that, pre-Lawrence, the prohibition on same-sex intimacy could be — and was — used to support the unequal treatment of gays and lesbians in other areas of law. A couple of the cases he cited favorably upheld: the use of a police department questionnaire asking potential applicants about past homosexual (but not heterosexual) activity; and expanded security clearance for gay and lesbian job applicants only. He left out the worst case of all, in which a job offer to a lesbian who was set to begin working in the Georgia State Attorney General’s office was withdrawn after the AG found out about her commitment ceremony; in the view of this later-to-be-determined adulterer, her status as a lesbian was enough to presume she’d engage in illegal conduct. Begin making room in the closet.

Scalia also reddened at the Lawrence majority’s invocation of — not reliance on — foreign (pronounced: “fer’n”) sources of law. He quoted favorably from an earlier opinion by Justice Thomas objecting to the Court’s imposing “foreign moods, fads, or fashions…” on Americans.

Dignity, equality, and application of sound public health findings: “Moods, fads, and fashions.”

Andrew Sullivan’s “Familiar Feeling” — and a Qualified Defense of Obama

May 14th, 2009 No comments

Well, we’re not even four months into the Obama Administration and already the LGBT community is frustrated at the pace of developments. And, really, who can blame us, after the betrayals of the Clinton Administration and the hostility of his successor who-must-not-be-named? Here’s Andrew Sullivan, in a sobering and angry piece on the Atlantic website (“The Fierce Urgency of Whenever”):

“I have a sickeningly familiar feeling in my stomach, and the feeling deepens with every interaction with the Obama team on these issues. They want them to go away. They want us to go away.

“Here we are, in the summer of 2009, with gay servicemembers still being fired for the fact of their orientation. Here we are, with marriage rights spreading through the country and world and a president who cannot bring himself even to acknowledge these breakthroughs in civil rights, and having no plan in any distant future to do anything about it at a federal level. Here I am, facing a looming deadline to be forced to leave my American husband for good, and relocate abroad because the HIV travel and immigration ban remains in force and I have slowly run out of options (unlike most non-Americans with HIV who have no options at all).

“And what is Obama doing about any of these things? What is he even intending at some point to do about these things? So far as I can read the administration, the answer is: nada. We’re firing Arab linguists? So sorry. We won’t recognize in any way a tiny minority of legally married couples in several states because they’re, ugh, gay? We had no idea. There’s a ban on HIV-positive tourists and immigrants? Really? Thanks for letting us know.”

Steve Sanders over at Sexual Orientation and the Law Blog expands on the point, noting that some of the things Obama’s promised to do might be accomplished without legislative action; arguably, he already has the executive authority to stop the discharges under the completely indefensible “don’t ask, don’t tell” policy.

These points are fair, and we’re right to be concerned about both the pace of change and, perhaps as important, the weakening or outright disappearance of rhetorical commitment on central issues, such as federal civil unions; the Employment Non-Discrimination Act; and the repeal of  DADT. But the story isn’t this simple.

Sullivan himself is of two minds on this, as are many of us. He prefaces the eviscerating remarks quoted above with the following:

“[I]t’s tedious to whine and jump up and down and complain when a wand isn’t waved and everything is made right by the first candidate who really seemed to get it, who was even able to address black church congregations about homophobia. And obviously patience is necessary; and legislative work takes time; and there are real challenges on so many fronts….No one expects a president to be grappling with all this early on, or, God help us, actually leading on civil rights. That’s our job, not his.”

So, where are we and how concerned should we be?

Let me start with Sullivan’s “familiar feeling.” I’m less concerned than he is (of course, I’m not about to get kicked out of the country, either), principally because Clinton and Obama are so different, tempermentally. Clinton, for all of his obvious intelligence, was in many ways an incautious, borderline reckless, man: “I’ll just issue an order allowing gays into the military. What could be hard about that?” Obama’s endlessly analyzed personality is that of the careful incrementalist, who listens to all parties, decides on a course of action (and sometimes reconsiders his position, as with yesterday’s about-face on the release of prisoner abuse photos), and then works patiently and tirelessly for consensus. Anyone who could herd the divas on the Harvard Law Review has some accomplishment to commend his approach.

So what looks the same from one perspective — the lack of progress on gays in the military — may be quite different in underlying significance. We don’t know what Obama is doing (or thinking) behind the scenes, but I’m willing to bet it’s…something.

Not exactly reassuring, is it? I don’t have any way of verifying my suspicion on this issue, and I might be totally off. (I really hope not. DADT is just nuts; made even more so now that same-sex couples can marry or civilly unite. That legal act is now a ground for discharge under the policy. My next post will be of a conversation I had with the unceremoniously brilliant Alex Nicholson, the founder of an organization dedicated to repealing the policy, Service Members United.)

But there is movement. Let’s put this into context. For approximately forever, the only traction gay issues had at the federal level had been as a wedge issue — against us. I’m talking about DADT and the Defense of Marriage Act, not to mention the Federal Marriage Amendment (which never had a chance of passage but was conveniently unsheathed whenever an election loomed), and of course the epidemiologically and ethically indefensible ban on HIV-positive immigrants.

Now we have a gay-inclusive hate crimes bill set to pass and be enacted into law, likely quite soon. (I don’t agree that this is entirely symbolic; but even if it were, symbols matter). “Sources” tell me that there is a place on the legislative agenda this year for the Employment Non-Discrimination Act. (Whether it will be trans-inclusive is less certain, but vital: Who most needs this protection? Not me.) ENDA has been around since, if I’m remembering correctly, the Truman Administration. Neither Sullivan nor Sanders discusses this issue, on which progress looks quite likely.

Meanwhile, lifting of the HIV ban is moving along — albeit at the glacial pace of the federal regulatory process. Again, Sullivan (first quoting):

“’The Department of Health and Human Services has submitted for OMB review a notice of proposed rule-making to implement this change.’

“Translation: we’re doing the bare minimum to make us look no worse than Bush, but we have no real interest in this and are letting the bureaucracy handle it, and we guarantee nothing.”

I think that’s too critical. HHS Secretary Sebelius acted within one week of her confirmation to get this long-overdue repeal moving through the process. As this site reports, the bureaucrats are following standard procedure here, needed to put into practical effect the legislative repeal (changing the law meant that HIV was no longer required to be on the list of excludable diseases; now it must be removed).

Imagine it’s the end of 2009: The hate crimes bill is law, so is ENDA, and the HIV repeal is lifted (in time for Sullivan, I sincerely hope; but as he points out, there are many others for whom the ban leaves fewer, or no, options). DADT continues to be assaulted, relentlessly, from many perspectives, but is still in place. Civil unions, flowering all over the country, lie beneath still-frozen soil in D.C.

Would we regard this record as one of success? Let’s see if we get there, first. And let’s continue the relentless advocacy that is finally, I believe and dare to hope, beginning to push on the hinge of history.

Equality Forum: Picking up an Important Piece on Health Services

May 4th, 2009 No comments

On the day after Equality Forum’s week-long stampede finished trampling me, I’m able to stagger back to my computer and pick up a piece from last Saturday’s collaborative programming that I didn’t want to leave behind. (Tomorrow I hope to be able to post on the National Equality Rally that took place on Sunday.)

One of the panels I stopped in on, Health Care Reform: What Does it Mean for the LGBT Community?, ended up ranging over a wide swath of issues concerning the community. This wasn’t surprising, because the panel was conducted by the Mazzoni Center, an organization that delivers a staggering array of health-related services to the community; mostly for free. In addition to primary care, the Center: does anonymous HIV testing (and services for those infected with the virus); offers mental health counseling; provides a smoking cessation program as well as an array of support  groups; and has a number of education outreach programs, importantly including “The Collective.” This is a collaborative effort that does culturally targeted HIV prevention and services for gay and non-gay identified men who have sex with men (MSM, in the accepted public health acronym). This approach is generally recognized as the only one with a decent chance of working in communities that, for historical reasons, harbor a deep distrust of public health.

In short, the Mazzoni Center stands at the intersection of private health care and public health, recognizing that the prevention and education efforts at the center of the public health mission can reduce the need for chronic and acute medical care that consumes much of the health care time and dollar. So it was natural that the conversation was similarly expansive.

Listen to Nurit L. Shein, Executive Director, speaking of the need for coverage of services that are specific to the transgender community: “This is an issue that the LGBT community needs to coalesce around.” Is it reasonable to believe that whatever health care reform is on the table at the federal level will address this issue? Not unless advocates, like the Mazzoni Center and those they serve, get in touch with their officials, show up at public hearings, and agitate. Thus far, the LGBT response has been, too often, to let the “T” kind of dangle from the end of the alphabet string.

Mazzoni’s vital work, though, is often frustrated by the failures of public and private health elsewhere. Robert Winn, the Center’s Medical Director, somewhat surprised me by stating that he’d lost track of how many times patients had come to him after being informed by their former primary care providers that they didn’t want to care for gay people. (I  just checked my iPhone’s calendar; yes, it’s 2009.) Of course, this is a strictly illegal position in Philadelphia, but most people don’t sue: they just find another doctor. But until those with a public health, population-based approach combine with the AMA to drive these homophobic views out of existence, private prejudice will continue to negatively influence the medical and mental health outcomes of the community.

It’s well known that sexual, racial, and other minorities have much worse health outcomes than the majority. Every day, Mazzoni’s dedicated workers try to push a very large boulder up a very steep hill.

Equality Forum Day 1: From VIP Kickoff to the Margins

April 27th, 2009 2 comments

Imagine this life: You’re not safe at school. The very sight of you makes people uncomfortable, sometimes angry. Your family disowns you, but no one else will adopt  you or take you in for foster care. Without mooring, and unsure of your own identity, you turn to drugs and alcohol, perhaps landing in jail. You can’t find a “legit” job, so sex work becomes your “best” option. You contract HIV, or Hepatitis, but have no access to health care to pay for your treatment. Low-level bureacrats decide whether to honor your chosen gender on identity documents, making routine transactions an occasion for recurring humiliation.

This nightmare is reality for many transgendered people. Even the “mainstream” gay and lesbian community has only recently begun to wake up and recognize these realities. The National Transgender Panel – significantly, the first substantive program of this year’s Equality  Forum – was an energizing, often moving conversation about the legal, social, and political obstacles that block the full citizenship and dignity of the transgender community. Indeed, the story told  above was pieced together from the comments made by both panelists and audience members, whose input the panelists constantly sought — and received in effective abundance.

The panelists, themselves all members of the community, spoke authoritatively about legal issues (Benjamin Jerner); the national political landscape (Kathy Padilla) and the hugely complex public health challenges faced by this community (Ben Singer).

Perhaps because of my own interest in public health and the legal issues relating to it, I  found Singer’s presentation particularly compelling. He’s a smart activist who understands the need for data-driven results; as he puts it, if you’re not on the public health radar (and you get there by showing a problem affecting a population), you don’t exist. But the issues facing the transgender community are more than a “blip” on any morally defensible radar; they amount to an on-going emergency. A few of the sobering examples confronting this community will have to suffice here: (1) Violence against them is epidemic, and the situation becomes graver as the categories of oppression pile up. Thus, transgendered women of color are at the greatest risk. (2) HIV/AIDS are at levels otherwise associated with sub-Saharan Africa. (3)The community faces high levels of medical uninsurance, a problem connected to joblessness and homelessness, themselves endemic.

Against this backdrop,  many of the issues of formal equality that many of us (including your humble blogger) most often concern ourselves with seem less vital. Really, do you think people facing the kinds of issues I’ve just mentioned have marriage equality on their plate? Again, Singer:  “We talk more about these grand legal issues and not these other ones.”

But “these other” issues were thoroughly chewed over — by the audience. In a wonderfully  generous move, Singer invited the audience to answer a question about the kinds of problems routinely faced by transgendered youth. The answers should pain any person with a halfway developed sense of empathy. One young woman was thrown out of her home and not adoptable. A young man ended up abusing drugs and doing time in prison. Several regarded every day of school as a kind of torture. Of course, any kid growing up gay — or different in any way, really — can share painful experiences. But these really did seem different in kind, not  just degree.

“Every spark of friendship and love will die without a home.”

Yet not all transgendered people are in the desperate situation Singer describes, and, for some at least, it would be very helpful if the state were to grant them basic legal rights, including the recognition of their marriage. Jerner discussed a case with which I’m familiar, in which the Kansas Supreme Court idiotically declared null a long-term marriage between an opposite-sex couple (where the wife had been born a male), thereby disinheriting the surviving spouse in favor of an evil offspring. Although I have a quibble with his reading of the case,1 his point about the need for legal remedy is sound.

The panel ran over time. The audience was large; about 100, I’d guess, many of them young, bright activists.  They didn’t seem to want it to end, and that’s not surprising. There was a great deal to be said. Afterwards, I had a chance to speak to Singer, Padilla, and moderator Joelle Ruby Ryan, a warm and gentle giantess who ran an open and generous forum. Singer and Padilla are very interested in the untold story of transgender activism (newsflash: Stonewall wasn’t the first time members of the GLBT community rose up in protest). Padilla showed me some of her materials, and I’m sure I’m only one of many encouraging her to turn these into a book, or at least a long article. In the meantime, I’m hoping to do a follow-up blog on this issue of the history of transgender resistance — with help from Singer and Padilla,  who are enthused, knowledgeable, and in possession of all kinds stuff that’s by turns really cool and very moving.

I couldn’t have asked for a better blogging assignment to get me excited about the rest of the week.


Before this amazing panel, Equality Forum kicked off, as always, with the VIP Party in City Hall. This year’s event was staged, aptly, in the grand Conversation Hall. Probably a couple of hundred folks were VI enough to have garnered invitations, and most of the people I spoke to were impressive leaders of various organizations, or were directly involved with Equality Forum.

Dwight Evans, the Pa. State Representative who received a distinguished service award for his legislative efforts on behalf of the LGBT community, is a gregarious man with an expansive view of equality and opportunity. His charter school has been around for more than a decade, and he’s been a consistent advocate for GLBT rights in Harrisburg, where  the political winds don’t reliably blow in a favorable direction. I enjoyed a brief conversation with him, in which he showed himself to be a member of a rare and beautiful species: the pol without affect. His view of equality? “You don’t have to convince me.” His acceptance speech spoke to the need to “get past typical barriers and walls,” and concluded, quite sensibly (yet somehow movingly) with: “Thanks. And let’s move on.”

Also effective was Mayor Michael Nutter, the poor guy stuck with a job that no reasonable person would have taken had he known of the economic collapse to visit the city within nanoseconds of his inauguration. On radio, he comes across as bright and logical, but a bit stiff. In person, he’s witty and relaxed – but just as compelling. The short: He’s on our side. And Equality Forum founder and Executive Director Malcolm Lazin, to whom I must give props for giving me this “forum” to blog about the event, closed the proceedings with an inspiring call to take part in this Sunday’s Equality Rally and March, linking these events to a courageous march here in Philadelphia forty years ago led by gay pioneers Frank Kameny and the late Barbara Gittings. Very effective — now let’s hope the event is the success it needs to be.

Well, it’s late and I’m almost blogged out. But here’s a light moment from the Kickoff Party. Having just speared an unwilling olive after a too-epic struggle at the hors d’oeuvres table, I was standing near it (catching my breath), when a jovial fellow spun around and bumped into me. He was so apologetic that I didn’t have the heart to tell him he’d sent my only olive spinning out of my hand and through the air. I was reminded of the Seinfeld “Junior Mint” episode, and only hoped that the escaped refreshment hadn’t had a similarly calamitous result. Alas, I believe (but do not know for sure) that it landed in a scoop of perfect, high hair — unknown to the “victim.” If so, I’d like it back. No questions will be asked.

  1. He says the court declared that transgendered people couldn’t marry anyone — I think that reading is possible but not compelled. The case is In re Estate of Gardiner,42 P.3d 120 (Kan. 2002).

Medical-Legal Partnerships

April 24th, 2009 No comments

We just finished hosting a symposium on what may seem, to some, the unlikeliest collaboration of all: doctors and lawyers. Indeed, any doctor whose child informs her that she’s thinking of going to law school is likely to respond with the rending of garments, and a prospective disownment of said offspring — to take effect once the bar exam has been passed.

But that’s only because most think of doctors and lawyers as poised eternally on opposite sides of a medical malpractice suit. Law schools, though, have lately changed their orientation away from teaching students about litigation as the sole tool of problem-solving. Instead, we’re placing emphasis on law as problem-solving, with litigation the nuclear option to be deployed when diplomacy, negotiation and other less drastic measures have been exhausted. This sea change has opened us up to collaborative efforts, among them the medical-legal partnership.

In the mid-1900’s, Boston physician Barry Zuckerman had the insight that many of the patients he was seeing repeatedly had unmet legal needs. Unless those were addressed, the medical problems wouldn’t go away. For example, a child who keeps showing up at the emergency room with an acute asthma attack may be living in substandard housing. If those housing conditions are addressed — a legal issue — the asthma problem will disappear or at least be made less serious.

From this seed, more than 80 medical-legal partnerships have now germinated. Some are housed within hospitals themselves; others work through law school clinics; still others are free-standing, or connected to a legal aid organization. What they share is an understanding that the legal and medical professions have the common goal of helping achieve a healthy population, where both legal and medical needs are met so that patients (and now clients) can begin to achieve potential that had been blocked.

Perhaps these collaborations can form the foundation of better relations between these two often-warring professions.

Sex Crimes

April 11th, 2009 No comments

In Canada, a man is convicted of murder when two of the women with whom he had sexual relations later died of AIDS-related cancers. His crime was in knowing his HIV status, and then purposely withholding it while having sex. Does the punishment fit the crime? Not according to this commentator, one Sky Gilbert:

“I say that criminalizing HIV-positive men who fail to disclose to female sex partners only serves to disempower women…What happened to our bodies, our choice? Women are not —  under the law or otherwise — passive, mute playthings.

“Safer sex is about the liberating notion  that all people…are responsible to protect themselves by insisting on safer sex or to assume the risk that they may become HIV positive if they don’t.

“Aziga’s so-called victims could have chosen to insist on the use of condoms.”(emphasis added)

This analysis is naive and dangerous, and requires only a few sentences to demolish. But Gilbert makes other points in his essay that need to be taken more seriously. Let’s start with what’s wrong.

Gilbert falls prey to the fallacy of equating the political goal of gender equality with the reality, which is of course quite different. Many women have little or no choice in whether their male sex partners use condoms. How, I wonder, does Gilbert know that these women “could have chosen to insist” on the use of condoms? Was he there? Sexual power and dynamics are complex; if they weren’t the prevalence of HIV/AIDS would be much lower. Indeed, UNAIDS has identified the empowerment of women as one of the primary means of combatting this scourge. But that empowerment is a long way off for many of the world’s women. These women no more consented to sex with an HIV-infected person than a person living in a high-crime area “consents” to being killed by foregoing a bullet-proof vest while stepping out into the public sphere.

Nonetheless, this case is a cause for concern. First, were these women murdered? Under the Model Penal Code, murder requires the intent to kill or “extreme indifference” to human life.  It’s the second of these that might be argued here, but it’s a stretch. Sex is complicated, and often those infected with HIV are in denial about the likelihood they’ll infect someone else. (In this case, though, the defendant apparently convinced his victims that there was no need to use condoms; this hardly helped his defense.) Manslaughter would seem the more appropriate crime, because this requires “recklessness”: knowledge of a risk and conscious disregard of it. It’s easy to see how Aziga could fit this definition.

Gilbert ignores all of this, and makes the astonishing claim that the defendant’s actions shouldn’t be criminalized at all; for him, this is a public health issue. Well, it is. But sometimes public health embraces criminal as well as civil coercion. There is a risk, as he notes, that criminalizing the transmission will hinder prevention efforts, but I think that risk is minimal. Given the universal availability of treatment for HIV (in Canada, anyway), would people really choose not to be tested because of the remote chance they’d be prosecuted if they found out their serostatus and then had sex without telling their partners?

In fact, testing provides a good opportunity for education and intervention. Moreover, those who are receiving anti-retroviral treatment are much, much less able to transmit HIV to their partners, thereby reducing the likelihood of another Aziga case.

Does that mean that prosecutors should seek to punish every similar case? Probably not. These facts may have been outrageous, but it may also have been that undercurrents of racism had as much to do with the decision to punish Aziga, a Ugandan, as did the simple dictates of justice.

Comments like those issued by Sky Gilbert hardly shed light on a difficult topic.

Categories: HIV/AIDS, public health, race Tags: , , , , , , , ,

DC About to Provide a Preview of Congressional Marriage Equality Debate?

April 10th, 2009 No comments

Even as Vermont was breaking through the Governor’s veto to enact a marriage equality law on Tuesday, the District of Columbia’s Council was voting unanimously (12-zip) to recognize same-sex marriages from other states. This was a preliminary vote; the Real Deal happens in early May. Then what?

The Home Rule Act of 1973 gave the District some long-overdue autonomy, but Congress couldn’t resist retaining a veto for itself: As set forth on the DC Council’s website, “Congress reviews all legislation passed by the Council before it can become law….” This could make for an interesting summer.

Note, first, that this isn’t the marriage equality bill: The council  members support equality, but are sticking a tentative toe into the whirlpool of Congressional politics. If this gets through, expect a full equality bill on its heels. So, what might happen to this trial balloon?

The easiest approach would be to, er, punt. This outcome seems to me likely. Here’s what one Congressman had to say in 2007 about approving DC’s  needle-exchange program: “You know, I came here to be a member of the United States Congress. I didn’t come here to be a member of the D.C. City Council.” Inasmuch as the Dems control everything in Congress right now, all but the most blood-red state Republicans might sit this one out, deferring to home rule and avoiding the merits of the debate.

Or they might take the advice of right-wing pundits like Michael Goldfarb and use the opportunity to make their (blue dog?) Democratic colleagues squirm. But will they squirm? It seems that either  side can use, as convenience dictates, arguments about home rule and about federalism (although, strictly speaking, this isn’t federalism as DC’s status has always been unique — and, more to the point, it’s not even a state).

But moderates in Congress might not find it necessary to avoid the merits. If marriage equality itself is directly up for discussion,we’ll get a good sense of where lawmakers stand, and likely a first read on the likelihood that the Defense of Marriage Act might be repealed sometime soon.