(New York) - Watching the Presidential candidates debate, the question I'd like to ask is "how many times per page would you make your Surgeon General refer to you in her speeches?" Two weeks ago former Surgeon General Richard Carmona told a Congressional panel that he was ordered to mention President Bush three times on every page of his speeches. I figure any candidate who pledges two or fewer references would be a positive step towards putting US health policy back on track.
And as the Surgeon General made clear, we can certainly use better policies when it comes to our failed response to fight AIDS.
In the US, despite half a million deaths and 1.5 million HIV infections over 26 years, there is still no strategic national plan to eliminate HIV/AIDS domestically. Although we are spending $16 billion per year, the money goes to an ad-hoc array of national, state and local programs with no consistent monitoring, benchmarks or review. This lack of coordination results in inconsistent access to prevention and treatment programs. For example, federal AIDS Drug Assistance Program (ADAP) funding and eligibility guidelines differ by states, so that the program that is the safety net for low income persons ineligible for any other coverage may or may not be available depending on where you live. And as of March of this year there were 571 people on waiting lists for drugs in 4 states. In 2006, 4 people died while on the South Carolina waiting list.
There is no national plan to address the crisis in the African-American community, which accounts for one half of all new HIV infections, even though blacks are only 12 percent of the US population. Latinos have the second highest AIDS case rate in the nation and Latino adolescents have 3.5 times the case rate of adolescent whites. Yet, current US AIDS efforts regularly ignore the issues which make these groups vulnerable and affect their access to health care, such as housing, education and employment, and focus instead on simplistic strategies like "National HIV testing day" (June 27th).
Surgeon General Carmona testified that as "the nations doctor" he wanted to address sex education, and that scientific studies suggest that the most effective approach to sex education includes a discussion of contraceptives. Yet Dr Carmona stated that he was blocked from doing so by those who "wanted to preach abstinence only". This is not merely a scientific debate - the US spends well over $150 million annually for abstinence-only sex education programs in public schools and since President Bush took office the US has spent more than $2 billion worldwide.
Similarly, despite overwhelming evidence of their efficacy in reducing HIV transmission, federal policy prohibits funding of needle exchange programs. Like abstinence-only, the ban on funding of needle exchange programs has been a triumph of ideology over evidence. At the July 10th hearing, former Surgeon General David Satcher said that while the Clinton administration had discouraged him from issuing a report showing that needle-exchange programs were effective, he had released it anyway.
In Dr Satcher's report, he wrote: "After reviewing all of the research to date, the senior scientists of the Department and I have unanimously agreed that there is conclusive scientific evidence that syringe exchange programs . . . are an effective public health intervention that reduces the transmission of HIV and does not encourage the use of illegal drugs." However, under President Bush, the Office of National Drug Control Policy (ONDCP) has continued to misconstrue evidence in support of needle exchange as an effective strategy for HIV prevention. A recent interview with an ONDCP policy analyst entitled "What's Wrong with Needle Exchange Programs?" claimed that research about the programs' effectiveness in lowering HIV infection had been inconclusive, and that their effect on continued drug use is unknown.
For the fourth year in a row, the President's budget has proposed cutting funding for the Centers for Disease Control and Prevention (CDC). Adjusted for inflation, CDC spending on domestic HIV prevention in 2006 was the lowest since 1993. Not coincidentally the number of new HIV infections in the US is unchanged since 1990. And evidence of politics trumping public health science does not stop at the Office of the Surgeon General. The Department of Health and Human Services (HHS) has increasingly put the Atlanta-based CDC under greater restrictions and scrutiny from political appointees. Staff requests for overseas travel are required to be vetted by political appointees in Washington. A recent internal CDC memo leaked to the Atlanta Journal Constitution complained that such approvals were causing roughly half of CDC overseas posts to be unfilled. And HHS has also routinely gone around CDC to push its ideological agenda. For example, the department funds a website, www.4parents.gov, targeting adolescents which highlights contraceptive failure rates and gives such helpful tips as this: "Find non-sexual ways to show you care (give a card or a nice comment)."
Under President Bush, the CDC has capitulated to pressures from Washington to censor information about the effectiveness of condoms and to restrict funding to community AIDS organizations not preaching abstinence. At a national conference on sexually transmitted diseases sponsored by the CDC last year, officials bowed to pressure from Congressman Mark Souder and added two pro-abstinence speakers to a panel and removed a scientist whose presentation had been accepted via peer review. The title of the panel - proposed by public health scientists - was changed from "Are Abstinence-Only-Until-Marriage Programs a Threat to Public Health?" to "Public health strategies of Abstinence Programs for Youth".
Surgeon General Carmona was testifying to the House Oversight and Government Reform Committee as part of an effort by Congressman Henry Waxman to examine ways to strengthen the authority and autonomy of the Office of the Surgeon General. It is essential for the credibility of that office, and for the entire Department of Health and Human Services that such reforms take place. For the health of our nation, we should be confident in America's doctor being able to speak openly and honestly.