Is America Sicker or Overmedicated? The Public's Abandoment by the Health Sector—Zhandra Ferreira-Cesar

The Issue-

It is true that many drugs help people live longer and better lives. However, others may hurt patients in ways they do not know about. Everyday people place their full trust and lives in the hands of doctors, public health practitioners and pharmaceutical companies who advertise their mission to be an increase in the quality of life and the eradication of diseases. However, what happens when those same professionals whom the public trusts to educate and create the safest medications are also the same individuals who regularly treat the creation of drugs as a billion dollar industry that can be manipulated to enhance profits regardless of what this means for the population? Pharmaceutical and supplement manufacturers have to increase sales and profits, as all businesses must, and they do so in part by developing drugs to treat disease and also by convincing people they need medications to prevent disease or lessen the perceived risk of future illness. Is America sicker or just overmedicated? While the number of people with disease is not growing, the number of adult Americans taking medication is increasing. According to J. Douglas Bremner, MD 50% of Americans take prescriptions drugs and 81% take at least one pill everyday [3]. This problem can be attributed to the increase in the number of advertisements used by the pharmaceutical companies who have moved from the area of sick people, to individuals who look well but may have some genetic marker that makes them more susceptible to disease [9]. Thus the era of disease prevention starts in the medical world. At the end of the day, however, rather than increasing awareness about the key diseases affecting the public, public health practitioners have lost control of the efforts and joined in a billion dollar industry dedicated to treating people who are not sick.

Healthcare or business-

Throughout history people have regarded medical professionals as compassionate, selfless, devoted individuals who dedicate their lives to saving others. This image however has been tarnished with the latest movement to get new pills off the shelves and into the mouth of the American public. This frenzy began when government deregulation and an earnest attempt to help HIV/AIDS patients get easier access to crucial life extending drugs collided. A need for faster approval of drugs to serve patients coupled with an understaffed FDA dealt the leading hand to the pharmaceutical companies [3]. In order to speed drug patenting, the FDA had to develop a system that would provide it with the necessary funds to operate. In a response to this need, Congress passed a law mandating that pharmaceutical companies pay a fee every time a drug patent is requested in an attempt to offset the bureaucratic cost of the FDA [8]. However, this fee implementation did not obtain the necessary funds, and thus the funding for surveillance and research of approved drugs was drastically diminished. This initial budget cut initiated the snowballing effect of a hungry industry to make money and forget the focus of its initial humanitarian purpose—the well being of individuals [3].

Another interesting event came as a result of the change in law: the limits and boundaries between pharmaceutical companies, the FDA, and doctors became increasingly vague. In some cases, individuals that worked for the FDA acquired jobs with drug companies; therefore making their relationships with the FDA a major priority for the success of their careers [3]. These same FDA officials who approve a drug are also in charge of monitoring it after it enters the market, which means that these people have no incentives to admit an error and say that the drugs that they previously categorized as safe are now unsafe, even if it means that those patients making use of these drugs may be at risk [2]. Finally, it is noteworthy to mention that the FDA gets most of its input from a panel of doctors who are experts in their fields [8]. However, it is not accurate to say that these doctors are unbiased when analyzing the data presented to them since most of these doctors receive payment as consultants, or are given research grants and support for travel to conferences from drug companies [1]. All these incentives deter physicians from fully acknowledging all side effects of the drugs being presented for approval, thus increasing the chances that they will be patented and reach the public to cause harm and leave behind catastrophic death rates, like the arthritis medication Vioxx did by increasing the incidence of heart disease [3]. The cooperation between the FDA, drug companies, and doctors therefore, actually presents itself as a conflict of interest that completely disregards the initial job of the healthcare system, which is to care for, treat and educate individuals about pertinent health issues [4].

Take for example, USA Today reported on October 16th, 2004 in the article “Cholesterol Guidelines Become a Morality Play” that nine of the doctors that sat on the committee for the production of cholesterol guidelines were also making money from the companies that developed drugs to lower cholesterol, which were urging Americans to take these drugs via the media [3]. This exemplifies the heavy influence that drug companies have upon physicians, which leads to the conclusion that not even family physicians have the power to control the treatment for their patients. Ultimately, the drug companies have the power to dictate which drugs are being consumed and which diseases will emerge by means of carefully framing and delivering their desired message through the media. This is mainly because only so much information reaches physicians, and the information that does reach doctors is carefully selected and presented as the ultimate truth in the medical world [12]. Dr. Curt D. Furberg, a former head of clinical trials at the National Heart, Lung and Blood Institute describes the way in which information reaches physicians as published on the Los Angeles Times on December 22nd, 2004, “The National Institutes of Health: Public Servant or Private Marketer?” saying, “The company reps tell the doctors,’ you should follow these guidelines’ implying that you’re not a good doctor if you don’t follow these guidelines” [9].

One point that should be made on behalf of the doctors, however, is that these physicians do not have the time to be reading every journal and study that is released. Thus, it is only natural that they place their trust in the drug companies who claim to have the same interests as they do [6]. This is clearly not true as pharmaceutical companies often ignore obvious signs that a drug is failing in order to make extra earning regardless of how many individuals are being affected.

The media and pharmaceutical companies-

People have inherent trust in medical professionals due to the social acceptance and glorification that has been established over time. Surveys conducted of the general population show that Americans trust pharmaceutical companies to advertise the adequate and proper information regarding the side effects of drugs and their advantages [2]. However, is the purpose of drug advertisement really to increase awareness and educate the mass public about the positive and negative effects of new drugs or is their main purpose to make profits?

The first clue that the pharmaceutical market has turned its back on the sick population is displayed in the creation and expansion of a new market that is composed of healthy individuals as the target for preventive medicine, which has become a multibillion-dollar business. In order to promote this market shift, pharmaceutical companies have initiated educational programs, which they claim are meant to identify those individuals who are at risk of developing the targeted conditions. Some examples of these are hypertension, heart disease, and osteoporosis [11]. These programs are usually put on by making large donations to the organizations that research and support the various diseases, and in return these organizations “spread the word” about these newly invented drugs that promise to prevent undiagnosed and underdeveloped diseases [2]. This increases awareness and the number of screenings and with that also the number of individuals who can potentially take the medication. This is fine for individuals who have not been diagnosed with high blood pressure or for those at the early stages of cancer; however, these campaigns are not created to be completely altruistic and educational. Most of these campaigns are directly linked to the pharmaceutical companies’ media campaigns, whose only intentions are to convince the average American that they need a pill to prevent any possible disease [8].

Another factor that has increased the use of prescription drugs in America took place in 1997 when the FDA lifted the ban on direct consumer advertising. In addition, the law that requires every possible side effect to be listed was also removed [3]. The effect of this change is displayed strongly on the various television advertisements that target the emotional state of viewers rather than identifying the problem and effect of the drugs being advertised. This change in legislation allowed drug companies to attack Americans with a mass amount of media and news telling Americans to go and “ask [their] doctor for a specific drug [8]. In fact, America is the only country where you can turn on the TV, open the newspaper or a magazine and be told to go ask your doctor for a specific drug and brand [6]. However, what is more alarming is that doctors will prescribe medications to their patients if they ask for them even if they do not entirely need it. Dr. Marcia Angell author of “The Truth about Drug Companies” says that studies show that 54% of the time physicians will prescribe a brand of medication if the patient asks for it [3].

The prime example of this medical fraud that has let America down and destroyed the public’s trust involves ADHD medications. The creation of ADHD as a disease is one example of a series of conditions that has given the pharmaceutical companies an open door into the market of healthy people to promote long-term drug consumption [2]. The media has emphasized ADHD as a serious behavioral disorder that must be controlled with medication. However, it has failed to inform the public that in fact there is very little known about ADHD aside from the very broad hyperactive behavior, which many argue is just a characteristic of childhood [10]. Therefore, rather than informing the public of the serious side effects of ADHD medications, which some doctors have compared to the effects of cocaine, the drug companies, physicians, and public health practitioners have increased the use of ADHD medication by 369% in the past three years [9]. In the case of ADHD medication, rather than increasing awareness of the disease and promoting various modes of treatment, health professionals have increased drug use among American youth [12]. Rather than improving their quality of life, the use of ADHD medications has added a new dimension to their lives, which includes increased social isolation and cognitive toxicity [1]. Cognitive toxicity refers to the power of drugs to superficially create focus and increase simple analysis, while inhibiting more complex cognitive behavior and function [10]. Side effects such as these and the rapid increase of youth drug use are clear evidence that the alternative model of advertising and marketing, in the case of drug treatment awareness has failed, and rather than aiding American society it has opened the doors to a lucrative industry that is more interested in making money than helping the public [4].

The drug deregulations and the obvious favoring that occurs on behalf of the drug companies by removing the educational component of advertising campaigns leaves people wondering if in fact the well being of society is the priority of the FDA. It is obvious however that what lies at the top of the priority list for the FDA includes the protection of profit for pharmaceutical companies.

Modern medicine and American society:

Culture has a lot to do with the effectiveness of the various advertising attempts made by the business sector. In essence, the media cannot succeed if they do not know the beliefs and customs of the target population. However, what is even more complicated is that these beliefs and sentiments are often established by the media themselves and just accepted and adopted by society [8]. This leads one to the conclusion: that in order to increase awareness and establish a desired pattern of behavior, the media is the right means by which to do this [3]. It is clear that health practitioners have already discovered this, and as a result of this also discovered the tremendous opportunity to make money at the expense of people’s trust and health.

Health practitioners constantly express their regard and concern for the health of Americans; however, if these are genuine then the question persists—why is America still sick? There is no doubt that America has a prescription drug problem. The United States spends twice as much money on drugs and intakes twice as many drugs than other countries and yet still continues to have worse health than other industrialized countries [5].

It is no accident that throughout time America has become obsessed with health and the infinite number of pills available to cure so-called diseases. The purpose here is not to discredit all medications, or to say that drugs do not ever successfully treat diseases. However, the fact of the matter is that the health field has lost perspective of their mission and become greedy. John Abramson, M.D. author of Overdosed America: The broken Promise of American Medicine explains that America is pouring money into expensive drugs and outrageous medical devices, and in the process has left behind the best type of preventive treatment, which includes diet modification and exercise [3]. In order to refocus and alter the current beliefs of society, there needs to be a massive media movement that will push America away from the medication frenzy that has driven this society to the overconsumption and long-term addiction to the various drugs created by the industry that claims to have the public’s interest in mind.

Implications for the public health field-

Public health practitioners have as their focus and goal to improve the physical, mental and social health of Americans. As a result of this, they have joined with the various groups on the medical field to increase awareness and health screenings across America. However, this cooperation with medical sectors such as pharmaceutical companies has proclaimed this mission of awareness and goals of better health and opportunities as a failure.

Detox for an Overmedicated America-

Health professionals have throughout time been given the responsibility of taking care of the welfare of the public. This trust has been given without any hesitation and with the full confidence that these well-intentioned and trained individuals possess the ability, moral and ethical obligation to improve the overall health of the public. However, it is clear that they have failed to reach their publicized goal of educating and increasing awareness of the most common diseases attacking the American public and the prescription drugs available for use. Instead they have created a multibillion-dollar industry that survives and flourishes rapidly at the expense of the American people’s trust and health. It is clear that the health professionals’ attempt at increasing awareness and educating the public regarding the various health threats attacking them have been a complete failure that has resulted in an overmedicated America that finds relief and comfort in the hands of pharmaceutical companies. Therefore, the means by which the field initiated intervention to increase awareness and education need to be reevaluated and reinvented so that the goal of helping the public can be refocused and accomplished. The reinvention of the initial efforts to increase awareness on medical screening and the threats common diseases pose upon people must include the cooperation of government agencies, the education department, health professionals and the media.

The initial step that needs to be taken in order to achieve the initial goal of increasing awareness and education regarding disease prevention involves the government of the United States of America. This government was founded with the idea that it is “a government by the people for the people.” This statement, however, does not seem to be supported any longer as government organizations such as the FDA, seem to love the profit being generated by direct-to-consumer advertising so much that they have made it even easier for the drug companies to advertise their products by not requiring that all side effects be listed during commercials and by being able to run direct ads through the television and printed news scripts [5]. Therefore, it is time that the FDA rearranges its priorities and puts the welfare of people at the top rather than pharmaceutical profits. It is crucial that limits are set for these companies and that rather than advertising a brand by invoking overall positive emotions, their true effects and ability to help individuals is advertised [12]. The introduction of a new set of advertising guidelines put forth by the FDA for pharmaceutical companies will then reverse the standing effect of simply selling drugs for profit to a more focused idea that involves helping the public understand the proper use of prescription drugs and their side effects and other potential risks.

The next step to the successful intervention on the use of prescription drugs and their potential side effects involves the full cooperation of health professionals at all levels. The problem of overmedicating in America is due to the notion that a pill can solve every symptom of discomfort. This erroneous belief needs to be fixed at its root and this can only be accomplished by encouraging all health professionals to start taking the time with their patients to explain alternative preventive methods, such as an increase in exercise and a change in diet, in order to prevent a large majority of these diseases such as hypertension and diabetes that are affecting the American public at alarming rates [4]. In addition, physicians need to be reminded that their number one priority is the well being of people and that as public servants they must first and foremost fulfill this duty. If these physicians do no fulfill their duty they are in fact violating their medical oath and ought to be reminded of their priority. However, it would be illogical to place the responsibility of changing existing social trends entirely on physicians. Therefore, public health practitioners must also reassess the techniques being used to alter existing destructive behaviors and societal beliefs. In order to accomplish a successful intervention, it is crucial that they work in cooperation with physicians and social workers in order to introduce this new way of thinking into mainstream America and to assure that it is accepted and implemented at all societal levels. Once health professionals at all levels have reached a consensus on the best and most efficient way to educate and implement alternatives methods of preventive medicine, they can then take a step forward in an attempt to reverse the negative effects that a media-drug-driven America have had on its members.

Once the missions of the FDA, health professionals and pharmaceutical companies have been reevaluated and focused, an effective intervention should work to target and teach educators the importance of a balanced diet and exercise. In addition, teachers should be asked to join the team and provided with the necessary and proper diagnostic and observational tools that can help them to accurately distinguish a child that is in fact suffering from a behavioral disorder from one that is just simply acting according to their age. Such important and convenient tools can drastically reduce the number of misdiagnosed ADHD cases, a disorder that has claimed millions of children as slaves of Ritalin [1]. This addition to the education department has the ability to reset the American standards of medical treatment and therefore raise a generation that is not drug dependent and that amidst this fast progressing society is able to find health by means of the traditional treatment of a healthy lifestyle, awareness, education and alternative methods of preventive medicine. Even though a new method of treatment and means of implementation can be designed and deemed appropriate and ethical, in the 21st century whatever intervention designed will not be successful if the most powerful form of introduction and acceptance of new ideas in this society is not brought aboard to cooperate and make this issue the utmost important matter affecting the nation currently

The problem of overmedicating in America already exists and abolishing this already accepted way of thinking is one of the hardest goals to accomplish. Regardless of how well teachers and doctors are trained to teach and advertise the importance of understanding the use of prescription drugs and alternative methods of preventive medicine, the bottom line is that America is a society of consumers that relies on the media to be told what is ok to do, what it is that one needs, and the various things one should purchase. It is because of this that the number one factor that could help save America from overdosing is ironically the same instrument that brought it to the alarming high consumption of drugs at which it stands today. In order to reverse the beliefs of this industrialized society in addition to the full cooperation of government, medical professionals and educators, the ultimate intervention to limit the use of unnecessary drugs in America and the development of preventable diseases can only be successful if the media places this issue at the top of its agenda. They, in addition, must award the time, framing and present it with a degree of urgency that deserves to be spoken about daily until the American public realizes that a change in lifestyle and their current medical treatment options need to be changed. Furthermore, the prioritization of this issue by the media should also teach Americans to seek other options other than the easy way out and attempt to treat their various symptoms at the root rather than superficially with the use of pharmaceutical medications.

After educating the different levels of professionals regarding the changes that must be made in order to bring the alarming use of drugs in America to a halt, an advertising plan needs to be created in order to change the awareness, knowledge, and attitude of consumers towards a specific change being discussed. These changes take place all throughout the buying, a decision-making pattern that results in a change of behavior and standard beliefs. The first step in this intervention would involve the introduction of awareness. Past interventions have shown that the simple introduction of the importance of exercise and a balanced diet is not successful due to their lack of understanding of the average American lifestyle, which is fast paced and constantly being bombarded by economic hardships. Therefore, it is imperative that this campaign works to show first the alarming effects of overmedicating and the detrimental effects it can have on any one person. Once the negative aspects and acknowledgement of the problem is introduced the intervention moves into the next stage of consideration. In order for consideration to occur a solution to this alarming problem must be introduced with careful consideration of the various social and environmental factors that are affecting Americans today. It is at this point that the intervention seeks to make a connection with the consumer. Highlighting the costs of the various unnecessary medications being consumed and the money that pharmaceutical companies are wasting on advertising rather than investing on research are truly affecting the American society and the world can help make this connection. This approach on the economic effect is sure to receive attention especially due to the economic hardships that America is confronting today. It is at this point that alternative “cheaper” methods of preventive medicine can be introduced and the name of health professionals advertised as large pools of information at the disposal of the public.

The third stage of this intervention involves reaffirmation. At this stage of the advertising campaign the public reassesses the product or idea being introduced and attempts to find a place for it in their lives thus determining how convenient and appropriate it is for them. It is at this point that the importance of paying a visit to their physician is important and that a change in lifestyle that is characterized by an increase in exercise and a balanced diet can be stressed. However, the stress placed on these changes should be made in a different manner than in the past. They should be marketed with alternatives methods such as the addition of easy enjoyable exercises that can be done at home or outside or even ones that can be integrated during the workday. In an effort to obtain and retain a large audience these changes that need to be made must be attached with the idea that consumers will be saving money when opting for this option rather than spending thousands of dollars on unnecessary medications. This approach will certainly catch the attention of consumers during this time of recession.

The last couple of stages of this intervention all happen quite quickly as action tends to take place once the behavior is introduced enough times into the life of the individuals targeted. This is then reinforced by the constant repetition of the issue and its recommended solutions by the media who use the trusted physicians and other health care professionals in order to submit the desired behavior as a social standard and therefore into mainstream culture [12].

In conclusion the intervention used in order to assess the overmedicating problem in America needs to start with the cooperation from all levels of the health sector in this country. Once this cooperation has been reached, an advertising campaign displaying the negative effects of overmedicating and the various affordable solutions available to avoid future spending due to unnecessary problems can be used to grab the attention of an America that is overwhelmingly concerned with the ongoing recession.

References:

1-Are Children being given too many Drugs? Norwich Evening News 24, August 2006.

2-Bergin, Sue 2005. Stoning Young America: Over Prescribing Harmful Stimulants as a Treatment for Children with ADHD. Brigham Young University.

3-Bremner, Douglas J. 2006. Why do Americans take so many Prescription Drugs? Prescription drugs Review.

4-Healy, Melissa 2007. The Push to label many drugs isn’t well studied in children Revise standards, critics say. Los Angeles Times, Health.

5- Jensen, Peter S. MD; Kettle, Lori BS; R, Margeret T. MS; Sloan, Michael T. BA; Dulcan, Mina K. MD; Hoven, Cristina Dr PH; Bird, Hector. MD; Bauermeister, Jose J. PhD; Payne, Jennifer D, 1999. Are Stimulants Overprescribed? Treatment of ADHD in Four U.S. Communities. Child and Adolescent Psychiatry.

6-National Center for Health Statistics and Centers for Disease Control and Prevention. Health, United States, 2007. Department of Health and Human Services.

7-Null, Gary, PhD; Dean, Carolyn MD, ND; and Feldman, Martin, MD. 2006. Overmedication Seniors. LE Magazine.

8-Overmedicating of America. CBS News, Health. 2000.

9-Rados, Carol. 2004. Truth in Advertising: Rx Drug Ads Come of Age. FDA Consumer Magazine.

10-Rowland, Rhonda 2001. Ritalin Debate: Are we Over-medicating? CNN Health, CNN Medical Unit.

11-Salaman, Maureen Kennedy 2006. The Medicating of America. National Health Federation News.

12- Sighn, Llina, 2004. Doing their jobs: mothering with Ritalin in a culture of mother-blame. Faculty of Social and Political Sciences, Center for Family Research, University of Cambridge, Cambridge, UK.

13-Standish, Maude, 2008. Too many drugs? American Academy of Pediatrics News. Vol. 29 No. 9, p. 28.

14-Too many Drugs “Not Child Tested.” BBC News, Health. 2006.

Increases in Tobacco Taxes Fail to Deliver Public Health and Instead Offer Public Risks - Bing Chen

Tobacco use is a leading cause of preventable death and disease in the United States. As of 2007, 19.8% of Americans adults (43.4 million) smoked regularly, causing 443,000 premature deaths per year and a total economic burden of $193 billion dollars per year(1). Comprehensive prevention and control programs can thus save the United States millions of lives and billions of dollars every year. A potential solution has emerged in the past decade, gaining popularity and momentum across all national regions: increase taxes on tobacco. At first, the logic appears simple: raise the price of cigarettes and other tobacco products, and people in every income bracket will have to cut back on tobacco purchases, effectively curbing use. What many politicians and researchers fail to consider, however, is the economic, social, and psychological implications of taxing a condemned product such as tobacco. Raising taxes on tobacco products will only lead to government dependence on tobacco sales and companies for revenue, while this single-factor approach to tobacco control holds no long-term prevention of actual smoking and usage. Worst of all, an increased tobacco tax is easy to evade and will encourage the growth of dangerous black markets and bootleggers.

Recent History of Tobacco Tax Increases

Since 2002, 44 states have passed more than 80 separate tax increases on tobacco products. Support has been strong and bipartisan, with 36 of the state tax increases signed into law by a Republican governor and 34 by a Democratic governor. The average size of the tax increases was 54 cents per pack(2). In 2007, 11 states enacted tobacco tax increases, and current bills to further raise taxes on tobacco products are active in 22 states(3). As of January 1, 2008, the median state excise tax on a pack of cigarettes is $1.00, with Missouri with the lowest tax ($0.17) and New Jersey with the highest tax ($2.57) per pack(4).

Many states look to these increased taxes as a way to generate much-need revenue for state healthcare programs. In Massachusetts, if the state manages to raise its cigarette tax by $1.00 per pack, it can generate a projected $175 million dollars per year. With the state government in need of an estimated $869 million for the next year in order to maintain the State Children's Health Insurance Program (SCHIP), politicians are quick to jump on any form of additional state revenue(3).

Raising Taxes on Tobacco Products Causes Government Dependence

While tobacco taxes would generate lucrative revenues for state governments, dependence on those revenues can cross into questionable moral territory. The paradox: can the government expect to employ effective and comprehensive anti-smoking and tobacco prevention campaigns while simultaneously banking on the large cash flow rolled in by the tobacco product market? Answer: no.

The state of New York raised its cigarette excise tax by $1.50 earlier in 2008 and though the Health Commissioner and Governor both boasted of expected significant decreases in smoking, the government has already made room in the state budget for the projected $265 million per year raked in by tobacco sales(5). The truth, however, is that even though supporters of higher excise taxes like to frame tobacco sales as a public health issue, studies have shown no connection between increased prices and decreased smoking(6). Cigarette and tobacco taxes are simply a government cash cow, a way to generate easy revenue without regard to the social responsibility needed to tackle a problem so multi-faceted and diverse as tobacco addiction. What politicians fail to inform the public is that, when they raise excise taxes, the government makes more money from cigarette sales than any corporation actually involved in the tobacco industry. In Massachusetts, government officials and supporters alike have failed to acknowledge that in order to reach the revenue goals for the State Children's Health Insurance Program (SCHIP), they actually need more people to smoke(7). Not just a few new smokers, either; Massachusetts will need 9 million new smokers in the next 5 years to maintain SCHIP and 22.4 million new smokers for the following 5 years(8).

The government cannot allow itself to depend on cigarette consumption to fund essential healthcare programs and services. Even if tobacco purchases decrease slightly in the short-run after the tax increase, the inherent incentive for governments not to enact effective anti-smoking and tobacco prevention programs that will reduce cigarette consumption in the future poses a far greater risk and danger to public health(9). Furthermore, the state governments would perpetuate the illusion that buying cigarettes would technically help fund healthcare programs, thereby giving tobacco companies and the smoking image a valuable positive platform. The general population needs to keep an accurate perspective on the proposed tax increases. Government officials have framed the bill to look like a public health intervention, but the true frame of tobacco sales is economics. Tobacco generates large monetary funds, and state governments want a larger piece of the addiction pie. They simply refuse to admit that they eat out of the same one as tobacco companies.

Raising Tobacco Prices Will Not Affect Actual Usage

Tobacco addiction cannot be defined by simple nicotine addiction or the exact price of cigarette and tobacco products. The act and continuation of smoking hinges on a variety of interactive factors, including past history with tobacco, current socio-economic status, the surrounding social environment, and personal values and perceptions. Changing one factor, the price of cigarette products, but failing to consider the socio-psychological attachments of smoking cannot produce any long-term effect against tobacco usage.

Advocates of the tax hikes rely on the Health Belief Model, which assumes that an individual makes the decision for a behavior change solely on the perceived costs or benefits of the action. They believe as long as they increase the "Perceived Costs of Smoking" by raising the price, people will naturally stop purchasing tobacco products. These advocates do not understand that traditional public health intervention models, like the Health Belief Model, lack the dynamic adaptability needed to affect a large population of diverse people. Americans fall prey to a widespread range of unhealthy behavioral habits, and even habits as destructive as tobacco abuse have continued to skyrocket in the past few decades(1). The lesson learned is that people rarely act rationally or individually, and people especially do not make health decisions, such as whether to abuse tobacco products, inside a vacuum. A single-factor approach in a public health intervention is not enough to control a problem as complex as tobacco addiction; a successful intervention must either tackle multiple actors affecting usage, such as psychosocial reasons for addiction or positive reinforcement for usage from the surrounding environment, or provide the social support system necessary for people to stop smoking.

Taxes on bad habits are popular with governments because of the thick revenue stream, but these taxes are also incredibly regressive. People in the lower-income brackets simply spend a greater percentage of their income on tobacco, even when they cannot afford it, because they use tobacco as a coping device for general life stress and pressure(10). In fact, increases in tobacco taxes affect the lower income spectrum much more than the middle and higher income end, thereby placing the burden of the cost and government revenues on the shoulders of young adults and minorities. Half of current smokers come from homes that earn less than 200% of the federal poverty line, and 43% of smokers are aged 24 to 44(8).

These are people who likely strain their finances by purchasing tobacco products even without the increased excise taxes; raising the price on cigarettes will not deter them now, either. Lower income and younger smokers do not start or continue to use tobacco products based on monetary cost. In an actual case study done in Taiwan to evaluate the effects of increased tobacco taxes, the conclusions even stated the many obstacles that would inhibit a successful intervention. The researchers suggested that middle and higher income level smokers, who can monetarily afford to smoke, do not base tobacco use solely on price. They can switch from a premium or higher brand of cigarette to a lower premium brand to cut costs, while still maintaining the addictive habit(11). Unless the government addresses the real reasons why people abuse tobacco, no intervention will find success or long-term stability.

Increased Tobacco Tax Easy to Evade

In addition to the arguments brought up in the previous section about the little effect that increased taxes would play on actual tobacco usage, another extension that tax advocates try to ignore is the case of consumer evasion. Not only can people switch from more expensive brands to cheaper cigarettes, but also people can ship cigarettes from states that have lower excise tax rates, such as California or Idaho(12). Higher domestic tobacco prices can also drive people to ship tobacco from overseas, thus evading the higher costs without cutting down on tobacco usage. As long as the government fails to curb the actual demand for tobacco, there will always exist a market to cater a supply to that demand, whether that market is the American tobacco industry, overseas corporations, or black markets and bootleggers.

Black markets specialize in the illegal sales of government-related or prohibited products. These markets are usually underground and run by organized crime syndicates in large urban areas. When the state of New York raised taxes on tobacco products, the backlash directly caused an invigorated supply for bootlegged cigarettes, which crime syndicates used to fund international terrorist organizations. Crime syndicates shipped cigarettes and tobacco from other states with lower excise taxes or shipped products in bulk from overseas manufacturers where labor and material was far cheaper than the United States. Just one van of cigarettes could produce a profit of $10,000(10).

Many lower income and young smokers live in cramped urban areas, where their environment and socio-economic status play a significant role in lifestyle behaviors and decisions. Even though raised taxes would make cigarettes and other forms of tobacco more expensive, the black market and bootleggers provide the same supply at a lower price, thus canceling any deterring effect of the health intervention. Critically, the health intervention would actually backfire, because the tobacco products supplied by crime syndicates may contain even more harmful or unknown substances. Similarly, any illegal activity undermines state and federal authority and safety, which in turn undermine the health of the general population. By driving people to turn to illegal products, the government also risks alienating smokers and weakening the effect of other anti-tobacco campaigns. Black markets act as a crucial confounder to the increased tax proposal, because they steal possible revenue from the government by illegally selling tobacco products at a lower price but they still contribute to the health risks and disease outcomes of tobacco abuse.

Conclusions

The United States could save millions of lives and billions of dollars per year as long as the government employs effective and comprehensive tobacco prevention campaigns. Increased tax proposals on tobacco products, however, fall neither under effective nor under comprehensive. Despite the recent popularity of excise tax increases, research studies and previous examples have shown the risks and dangers associated with such a narrow-minded design. Even though states, such as Massachusetts, hope to fund healthcare programs with tobacco revenue, such dependence on the tobacco industry can only lead to moral paradoxes in the future. Increased taxes should be framed as an economic issue rather than a public health intervention. The burden of the cost lands on the shoulders of lower income and young adult smokers, whose addiction to tobacco extends past simple price numbers and who cannot be expected to quit tobacco abuse from such a single-factor and individualistic solution. Worst of all, these higher prices for products are easy to evade, especially with the presence of illegally run black markets and bootleggers, which actually threaten social stability and further weaken the public's safety.

An Alternative Approach: Using Economics for Public Health Benefit

Despite the significant shortcomings in raising taxes on tobacco products as an attempt to curb tobacco use, more regulated and relevant taxation can produce fruitful and advantageous results when combined with effective anti-smoking campaigns. Instead of depending on tobacco revenue to fund statewide health programs, increasing tobacco taxes by a slight amount and then using the revenue generated to solely fund anti-tobacco campaigns can prevent usage and abuse, as well as allow the government to present a united front on the dangers of tobacco products. Well-funded and well-designed tobacco campaigns could target the real reasons why people use tobacco products, and these public health interventions would actually affect and decrease the number of smokers in the United States, which simply raising tobacco prices have proven otherwise. Lastly, a controlled and small increase in taxes, merely enough to fund anti-smoking campaigns and treatment for quitting, would deter consumer evasion and weaken the need for black markets and illegal sales of tobacco products.

Recent History of Anti-Tobacco Campaigns

In 1997, the United States government won a settlement worth $13 billion against the Tobacco Industry for fraudulent and misleading advertisements about the health effects of smoking. The settlement went toward creating and financing the Public Education Fund from 1998 to 2003, which in turn financed all of the major anti-tobacco campaigns in the United States for those five years(13). Unfortunately, the obvious conflict of interest that occurred from tobacco companies attempting to fund anti-tobacco campaigns preceded a long line of ineffectual anti-smoking ads. Alarmingly, studies have shown that Tobacco Industry-led anti-smoking campaigns gave youth a more favorable view toward cigarettes -- the opposite of what a public intervention should achieve(13).

In 2000, Florida launched an anti-smoking pilot program called the Truth campaign aimed at the prevention of youth usage. The Truth campaign used edgy television, radio, and print advertisements featuring youth-led activism against tobacco companies. It focused on empowering teens to combat the Tobacco Industry and was the only such national campaign not directed by the tobacco companies themselves. Even though within two short years the Truth campaign had managed to cut youth smoking in Florida by nearly a third, loss of funding -- no doubt due to the Tobacco Industry's reluctance to continue such an effective anti-smoking campaign -- forced its discontinuation(14).

Currently, Florida is experimenting with a myriad of different anti-smoking campaigns, each carefully tailored to appeal and affect a specific demographic. "I care" is a promising campaign aimed at adults, particularly parents. The campaign uses somber television ads to depict how tobacco often aggravates child neglect and cripples familial relationships. These new campaigns have caused a significant spike in smokers seeking help to quit from state stop-smoking hotline numbers. The various anti-smoking campaigns cost a combined $17 million per year, which the state takes from a recent $58 million settlement against the tobacco companies(15). Unfortunately, there remains insufficient evidence to determine how long these campaigns can be sustained without further funding.

Transforming the Economic Frame into a Public Health intervention

Raising taxes on tobacco products should still be framed as an economic issue, but governments can and should use those economic sensibilities to fund actual public health interventions. Instead of relying on the taxes as a simple cash cow to finance unrelated state programs, the revenue should solely be used for anti-tobacco campaigns or treatment services for tobacco abuse and addiction. That would erase the moral dilemma of state governments employing effective campaigns while they simultaneously bank on large revenues generated from tobacco sales. Instead, state governments can have a united front on fighting the spread of tobacco products: revenue from increased tobacco taxes fund tobacco prevention and treatment programs, and the resulting decreases in smoking and tobacco purchases would directly correlate with decreased needed expenditures for anti-smoking campaigns. Similarly, the United States spends $193 billion per year on health-related smoking costs(1), so effective campaigns that actually curb tobacco usage would allow governments to cut down on those costs and allocate those resources to other healthcare areas.

Many of the major anti-tobacco campaigns of the past decade were designed and funded by tobacco companies. Thus, much of the anti-smoking movement depended on the assistance from the very source that perpetuated and provided the products. Tobacco still remains a cause of leading preventable death and disease will likely remain that way unless effective campaigns are launched large-scale across the country for a consistent period of time. Regrettably, the few anti-smoking campaigns that actually achieve significant success lack the monetary resources to continue and expand(14). Therefore, revenue from tobacco taxes would act as an integral sponsor to enable the implementation and execution of actual public health interventions. Success of the tobacco tax would thus not be defined by decreases in tobacco purchases but rather defined as a way to fund existing and new anti-tobacco campaigns.

Worthy Anti-smoking Campaigns in Need of Funding

Whereas simply increasing the price on a tobacco product does not produce significant decreases in actual tobacco usage(6), effective anti-smoking marketing campaigns can produce noteworthy results in preventing and treating tobacco addiction. Mass media anti-smoking campaigns in particular have shown the best success in reducing cigarette consumption and in helping people quit smoking(16). The Truth campaign exemplifies how aggressively attacking the Tobacco Industry to challenge social norms and perceptions may appear controversial but ultimately achieves the most effectiveness. The campaign only ran for two years, however, due to limited funding and pressure from tobacco companies. Within those two years, the Truth campaign managed to cull high school usage of cigarettes from 28% to less than 23%, a drop of more than 1 million smokers(14). Other current media-based anti-tobacco campaigns, such as the "I Care" campaign aimed toward parents, have caused a skyrocketing number of adult smokers in Florida to call quit-smoking hotlines for help(15).15 Mass Media anti-tobacco campaigns have shown great promise for success in health promotion, but they require sustained funding or else these campaigns will simply stagnate in the developmental or initial stages or, such as the fate of the Truth campaign, fade away into extinction.

Carefully regulated tobacco tax increases can provide the sustained funding needed. Anti-tobacco campaigns will no longer have to rely on the tobacco companies for financing, and the Tobacco Industry can stop designing anti-smoking campaigns that do more harm than good. If the successes in reducing tobacco usage on the state level are extrapolated to the national level, the United States should see a significant decrease in tobacco addiction and reliance and hopefully usher in a new era of anti-tobacco campaigning and prevention.

Modest Increases in Tobacco Taxes Will Off-set Consumer Evasion

As long as the sole purpose of increased tobacco taxation is to fund anti-tobacco campaigns, the increases in tax should be minimal. Part of the 1997 settlement from the Tobacco Industry required the tobacco companies to donate $300 million per year for the Public Education Fund to fight and prevent tobacco addiction. The $300 million per year sum was enough to fund major, albeit ineffectual, national anti-tobacco campaigns; financing for the Truth campaign also came out of the Public Education Fund. In order to raise $300 million per year from tobacco taxes on the national level, that would only cost a penny and half per pack of cigarettes(14). Compared to the $1.00 and $1.50 increases in tobacco taxes from states such as Massachusetts and New York(3), respectively, a modest $0.05 to $0.10 increase in tobacco taxes should deter people from seeking suppliers outside of the country or from black markets. Many states try to enforce high taxes on tobacco because the governments plan to use the generated revenue on expensive public programs; Massachusetts' State Children's Health Insurance Program cost an estimated $869 million per year to maintain(3), compared to statewide anti-tobacco campaigns that cost in the ballpark of only $17 million per year(14). The lower expenditures needed means lower taxes. Thus, tightly regulated tax increases solves the problem of consumer evasion and side-steps the many disadvantages of illegal sales, such as undermining government authority and the increased cost of law enforcement and terrorist funding.

Conclusions

While increased tobacco taxation by itself is too limited in scope to reduce tobacco use, moderated taxation can provide the necessary funds to implement effective anti-tobacco campaigns without relying on the Tobacco Industry for financing. Funneling the revenue generated from tobacco sales into prevention and treatment campaigns also successfully allows governments to stand united against the adversities of tobacco abuse. As long as tobacco taxes are kept strictly for the use of anti-tobacco campaigns, only a minimal increase in taxation would be required, thus preventing consumer evasion and the growth of black markets.

REFERENCES

1. "U.S. Won't Meet 2010 No-Smoking Goals," U.S. News, 13 November 2008 .

2. "State Cigarette Tax Increases Since January 1, 2002," Campaign for Tobacco Free Kids, 2008.

3. Kevin Sack, "States Look to Tobacco Tax for Budget Holes," New York Times, 21 April 2008 .

4. "State Excise Tax Rates on Cigarettes," Tax Administration, 1 January 2008 .

5. "State Cigarette Tax Increase of $1.25 Protects Public Health," Department of Health Press Release, 11 April 2008 .

6. Brian Phillips, "West Virginia Eyeing Cigarette Tax Increase," Tax Foundation Blog, 7 December 2006 .

7. "The New Tax Policy: Max the Tax on Lower Income Individuals; Recruit New Smokers to Pay for Government Health Program," Reynolds American Inc., 16 July 2008

8. http://www.heritage.org/Research/HealthCare/wm1548.cfm>.

9. Mike Siegel, "Health Groups' Knee-Jerk Support for Cigarette Taxes Starting to Backfire: Re-Thinking of Cigarette Taxation as a Tobacco Control Strategy is Needed," Tobacco News Analysis, 26 November 2005 .

10. Radley Balko, "Hike in Cigarette Tax Opens Door to Other Vices," Chicago Sun-Times, 7 April 2006 .

11. Jie-Min Lee, "Effect of a large increase in cigarette tax on cigarette consumption: an empirical analysis of cross-sectional survey data," The Royal Institute of Public Health, Elsevier Ltd., 7 July 2008.

12. James Sinks, "Cigarette Tax? Oregon Voters Will Get Final Say Nov. 6," Wescom News Service, 17 October 2007 .

13. Kim Krisberg, "Anti-smoking campaign lowers youth smoking rates with ‘truth’: Funding threatened," April 2005 <>.

14. Kim Krisberg, " Successful 'Truth' Anti-Smoking Campaign in Funding Jeopardy: New Commission Works to Save Campaign," 3 May 2004 .

15. Lisa Greene, " Florida unwraps mild anti-smoking campaign," St. Petersburg Times, 25 May 2008 .

16. Michael Siegel, " Mass Media Antismoking Campaigns: A Powerful Tool for Health Promotion", Annals of Internal Medicine, 15 July 1998 .

The ABCs of HIV Intervention- Bridget Kelleher

Introduction

UNAIDS/WHO estimates that since 1981, 25 million people have died as a result of the HIV/AIDS epidemic (1). Needless to say, it has been a priority for the public health community to develop an effective intervention program to control this virus. Many organizations have developed various approaches to the problem, ranging from education programs to policy changes. One interesting program is called the ABC approach.

ABC was first developed in the early 1980s in Uganda under President Yoweri Museveni (2). After recognizing and acknowledging the potential danger of the disease, the national government implemented a program that encouraged people to ("A") abstain from sexual activity, to ("B") be faithful and maintain monogamous relationships, and to use ("C") condoms if people were not abstaining from sex. This program, which later became known as the ABCs of HIV/AIDS intervention, was successful in significantly lowering the prevalence of HIV/AIDS in Uganda (2). In 2004, citing the achievement in Uganda, President Bush incorporated the ABC approach into his own global AIDS action plan. He stated that the method was successful and a “practical, balanced and moral message” (3).

The U.S. surgeon general and most experts agree that the best way to prevent the spread of HIV/AIDS is through a comprehensive program that is rooted in evidence-based data (15), and the ABC approach meets those requirements. However, despite its public health stamp of approval, the method has major flaws.

Rational Choice

ABC wrongly supposes that individuals “strive to make the most rational choice possible” (14). What does it mean to ‘be rational’ in the first place? To be a rational human being means that a person weighs the options presented to him to make a decision that he feels is best suited for him at the time. Humans who follow rational thinking will apply logic and rules to a situation to develop a course of action.

It does not follow, though, that rational action necessarily means good action. For example, if a man who is married feels that his wife is mean to him and doesn’t engage in wifely activities (however he defines them), then for him it might be a rational choice to find a women who will treat him well and fulfill his needs, since his current wife is not living up to her end of their marriage contract. Stepping out on his wife is not a morally good choice, nor is it a nice one, but it could be considered a rational choice.

Applying rational choice to health means to compare the ‘positive’ and ‘negative’ health outcomes of particular courses of action. An action with the most positive outcome would be the rational choice. The ABC method is centered on the belief in an individual’s rational choice. The Health Belief Model (HBM), a type of public health intervention model, plays a large role in ABC. HBM is a cost-benefit model based on people’s rational behavior in which perceived susceptibility of a disease (in this case HIV/AIDS) is weighed against the likelihood of actually developing the negative outcome in question. “Other factors such as SES, age, and race come into play in mediating whether an individual is able to act on 'cues to action' in exercising sound health care choices” (9).

The idea of a rational mentality that supposedly dictates choice is flawed. Dan Ariely writes in his book, Predictably Irrational, that humans have a deep belief in their ability to make rational decisions for themselves; however, this belief doesn’t automatically translate into perfectly rational thinking. Ariely argues quite the opposite, stating that humans are in fact often irrational; moreover, we are predictably irrational (i.e. “our irrationality happens the same way, again and again”) and thus that there are a number of situations in which we predictably diverge from rational thinking (12).

The assumption that humans are rational beings is a supposition many public health interventions make. The ABC method is no exception. This strategy honestly believes that people will view the threat of AIDS as so great that they will be able to rationally think about the risk from having sex, calm their rampant hormones, and delay first sex. It also honestly believes the converse of that situation—that people who are having sex will not only use a condom every time, but will also use a condom every time correctly. It is not to say that individuals are incapable of weighing the risks of a decision; however, it is easier (and more fun even if for a moment) to throw caution to the wind and engage in the risky behavior than to calculate your personal risk.

Another problem with rational choice theory is that it assumes that intent translates into behavior. From a rational point of view, if an action will yield the best results for a person, it is assumed that he will do the action. For some people this may be true, yet this is not the case for all. A good example of failing to act despite the intention is seen in teenage Abstinence Pledges. An Abstinence Pledge is a pledge to God, family and self to abstain from sexual activity until a person marries. Unfortunately, as one eight year study published in 2005 found, this intention didn’t result in the intended action as “61 percent of the consistent pledgers and 79 percent of the inconsistent pledgers reported having intercourse before marrying or prior to 2002 interviews” (13). This example is one of many where people may have the right intention, but end up failing in the follow through.

Individual-level

A second issue with the ABC program is that it is targeted at the individual level. The logic makes at least prima facie sense: sex happens at the individual level, so if you want to curtail HIV, which is transmitted through sex, then you should have a program at the individual level. Putting programs at the individual level, however, can foster the assumption that choices happen in a vacuum. The idea that people make choices in a vacuum is two-fold: first, that every action takes place as isolated cases, separate from past actions, and second, that every decision is made independent of an individual’s social systems and general beliefs. It is preposterous to think that a person’s past actions, family, friends, and culture don’t play a role in his choices. As John Donne wrote: “No man is an island entire of itself, every man is a piece of the continent, a part of the main” (6). No individual is separate from the world with which he lives. The community and the people within the community are all being influenced and influencing each other.

Making the decision to abstain from sex, to be faithful to your partner, or to use condoms consistently isn’t a decision devoid of outside influences. From government officials to religious leaders to your neighbors down the street everyone is talking about their views on sex. The extent to which an individual internalizes others' opinions varies, but it is an important factor that has to be acknowledged in any successful intervention program.

Public health officials like to think that putting an approach at the individual level places control of health decisions in the hands of the individual, but that assumes that individuals have control over their lives. Setting the ABC strategy at the individual level is supposed to empower individuals, giving them control over their sexual behaviors. Although nice in theory, this idea falls apart in practice. Most women in non-Western countries do not have the power to refuse sex or negotiate safe-sex practices (5). Due to cultural standards women are subjugated to their male partner’s wants and will, and if he doesn’t want to abstain from sex, if he doesn’t want to be faithful to her, and if he doesn’t want to use a condom, then the women is powerless to protect herself. Beatrice Were, a Ugandan woman, said, “the approach places a huge burden on a woman to abstain and, when she's married, to be faithful. Personally, I did all of that, but I still got infected” (5).

Were’s quote touches upon another flaw in ABC. It is a “segmented approach that targets different messages to different groups of people” instead of allowing the possibility that “the same people may need different messages at different stages of life” (4). How does a married woman who wants to become pregnant simultaneously protect herself from infection when her husband in unfaithful? How does ABC plan to assist young girls, who delay first sex, when they decide to become sexually active? These are valid questions pertaining to sexual risk reduction that ABC has yet to answer.

Framing

The ABC method efforts “defining a situation” (11) represent a comfortable view of an unpleasant disease. According to Erving Goffman, frames allow individuals or groups of individuals “to locate, perceive, identify, and label” events (11). As a result, individuals are able to deduce meaning, compile experiences, and direct actions. Framing, in the social behavioral sense, is a social construction of a phenomenon. Typically those with power, such as mass media or specific social movements, can influence how a person perceives meanings attached to rhetoric.

ABC frames sexuality to only apply to heterosexuals. The three risk groups for contracting HIV/AIDS according to UNAIDS are sexually active heterosexuals, men who have sex with men (MSM), and injecting drug users (1). Yet ABC does not discuss or include the last two groups in its program. While MSM are still transmitting the virus through sexual intercourse, it is doubtful that President Bush and like-minded supporters had this particular population in mind when adopting ABC for PREPFAR in 2004. In fact, “in virtually all regions outside sub-Saharan Africa, HIV disproportionately affects injecting drug users, men who have sex with men, and sex workers” (1).

The fact that the ABC approach simply ignores the case of MSM is an example of the public health community favoring the status quo and overlooking the marginalized. As Michael Siegel writes in Marketing Public Health:

Practitioners have respected the value heterosexuals place on long-term relationships, commitment, love, and marriage by acknowledging that heterosexuals do not need to use condoms to prevent AIDS after entering into a faithful marriage or monogamous relationship (8).

Yes, the ABC approach can be applied to self-identified homosexuals, who are free to be open about their sexuality, and not hold their relationships in a different light than heterosexual couples. Homosexuals are just as able to weigh the risk of HIV and choose a type of action (either A, B, and/or C) as heterosexuals are. However, ABC does not take into account MSMs. The MSM label is not just a politically correct term to make people feel less uncomfortable talking about homosexuality, but it is a category to encompass those who engage in homosexual activities but who do not label themselves as “gay.” MSM make up a significant proportion of HIV/AIDS infections and therefore, as a matter of public good, should not be overlooked or excluded in prevention programs.

Furthermore, the ABC method frames the idea that HIV/AIDS is transmitted through sex more than any other mode of transmission. The ABC strategy was designed to lower the risk of contracting HIV through sexual relations. Although sexual transmission of the virus is still a leading problem, it is not the only mode of transmission. Injected drug use is still categorized by UNAIDS as a high-risk behavior strongly associated with the transmission of HIV. It is this particular behavior that threatens the success of any HIV/AIDS intervention because not only will people who use illicit drugs share needles with other users, thus potentially transferring the virus to others, but they will also have unprotected sex while high. ABC has no way of dealing with this problem since it assumes that people will be in a clear mindset when making decisions pertaining to sex.

Conclusion

ABC was successful in Uganda not just because “Abstain, Be faithful, and Condomize” was a novel idea, but because the government was able to tailor the program to their community’s needs and to mobilize community leaders, citizens, and the media to create a new social norm. However, without those extra factors working in conjunction with the message, ABC alone is insufficient. It lacks an acknowledgement of people’s culture, irrationality, and group influence. ABC poorly defined the situation and was not an approach realistically capable of being applied to all groups.

The U.S. Surgeon General, Dr. Satcher, in his Call to Action to Promote Sexual Health and Responsible Sexual Behavior defined sexual health as including the “freedom from sexual abuse and discrimination and the ability of individuals to integrate their sexuality into their lives, derive pleasure from it, and to reproduce if they so choose” (16). By ignoring the reality of two groups at risk for HIV/AIDS, MSM and intravenous drug users, the ABC strategy not only does not contribute to basic sexual health as Dr. Satcher defines it, but it also fails to address other risk factors associated with HIV/AIDS.

A Fresh Look at The ABCs of HIV Intervention

ABC was successful in Uganda during the 1990s not just because “Abstain, Be faithful, and Condomize” was an effective message, but also because the government was able to tailor the program to their community’s needs and to mobilize community leaders, citizens, and the media to create a new social norm. However, without those extra factors working in conjunction with the message, ABC alone is insufficient. It lacks an explicit acknowledgement of the influence of people’s culture, of their ‘predictable irrationality’, and of the strong effect social norms can have on individual behavior. Without these additions, ABC becomes a slogan, not a program, and cannot realistically be capable of being applied effectively to all groups.

This is not to say that the entire message of ABC needs to be discarded. The approach has many merits, one of them being its comprehensive view of sexual choices. However, ABC can be improved by incorporating explicitly a heuristic framework based on the social sciences.

Predictably Irrational

Sexual arousal is a low impulse-control state. When people are sexually aroused, they have even less impulse control than they expected to have (12). This is why safe-sex programs that depend on condom use are less successful than anyone, even the participants, expects.

It is common knowledge that women in general are more cautious about sexual encounters than men. After all, women have much more to lose from a casual sexual encounter; they’re the ones that have the baby. It would seem that an intervention that makes women the gatekeepers would be more effective. However, there is a complication: women hate conflict. In fact, they may be willing to trade almost anything, even their health, for the love and security of a male. Louann Brizendine writes in The Female Brain that the circuitry in a women’s brain prevents her from initially expressing emotions of fear, anger, and aggression. Her circuitry opts instead to force her to process and avoid conflict and anger (17). By interrupting the anger response, the female is able to protect herself and her children from “an extreme response from a trigger-tempered male” (17). Even if the male doesn’t respond with violence, the threat and fear that he would leave her is enough to make a woman bite her tongue. Thus, an intervention that makes women the gatekeepers must also provide them with resources to deal with conflict and their fear of it.

Imagine an advertising campaign that utilizes a modified ABC. Particularly because each intervention must be targeted to a specific group and a specific community, the first step would be to go into the field, find women who are successfully managing this conflict, study what they do, and decide how to present these techniques to other women. The ad should portray a woman using these field-tested techniques and words to convey interest in her partner and her respect for him, thus avoiding undo conflict, while protecting herself from disease. A follow-up ad could show groups of women revealing that they had successfully used these techniques, both reinforcing the behaviors and giving women additional confidence.

Community-Level

The traditional ABC approach also did not explicitly emphasize the important role cultural and societal norms play in modifying and shaping human behavior. No individual is separate from the world in which he lives, devoid of his culture and community beliefs. Individuals, to a certain extent, will follow the rules dictated by the norms of their society. This idea is formalized in social expectations theory, which states that people act en masse based on the social norms of a group (10). Therefore, by combining the message of ABC with social expectations theory, and targeting self-identified hetero- and homosexual individuals, it should be possible to design a more effective ABC-style intervention.

Laws, agenda pushing from social movements, and even endorsements from well-known and respected local figures, do affect human behavior. Therefore, one possible intervention would rely on research conducted in each community to learn who is the leading authority figure, or is otherwise highly influential, within different age groups. Depending on the age group and the community, the person could be a government official, a leading businessman, the local minister, a well-respected doctor – anyone who could not only act as a cultural broker between public health clinicians and the community, but who also commanded sufficient community respect and personal influence to modify or improve what people in the community did and expected, to more closely align that with the ABC message.

Framing

Another big problem with the ABC approach was that it framed the issue of HIV as mainly being transmitted through heterosexual sex. This clearly isn’t the only group at risk for HIV/AIDS. Men who have sex with men (MSM), prostitutes, and drug users also need to be included in any well-rounded HIV intervention.

In the Western world we talk about safe-sex practices with ardent fervor, but what about safe-drug practices? How often do we openly discuss safer ways to do drugs? (The answer is hardly ever.) The topics of illicit drug use and deviant sexual practices are still very taboo even in the “developed” world.

One way to break social taboos is by practicing agenda setting—if you can get your issue on the media’s agenda long enough, people will start to accept your message. Perhaps if “developed” countries put the topics of risk reduction and safe-drug practices in relation to HIV prevention on the agenda, it would not only reduce the incidence of HIV/AIDS in their own areas, but also possibly make other countries start to feel more comfortable talking about the taboo topics surrounding AIDS. Heterosexual acts are not the only vehicles for the transmission of HIV/AIDS. Reframing intervention programs to explicitly include MSM, prostitutes, and drug users may be more effective.

Conclusion

It is easier to critique a faulty intervention than to develop its replacement. The intervention strategies presented in this paper are based on theories that have been proven to be successful in social science and mass communication. It is reasonable to propose that public health programs based on these theories would be equally effective. HIV/AIDS is not a simple disease, and its method of transmission is complex as well, so any intervention program targeting it cannot be simple, either. The best HIV intervention program would appear to be one that utilized a heuristic framework based on the social sciences. Unfortunately, even the best of interventions may not able to eliminate HIV, since at least some people in a community will engage in risky behavior, and that will probably always be the case. However, the hope is that by implementing an evidence-based program founded on a well-developed ecological model, HIV will become rare, if not completely eliminated.

REFERENCES

1. UNAIDS. UNAIDS 2008 Report on the global AIDS epidemic. Geneva, Switzerland: UNAIDS, 2008.
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5. The Center for Public Integrity. Bush’s AIDS Initiative: Too Little Choice, Too Much Ideology. Washington D.C.: The Center for Public Integrity. http://projects.publicintegrity.org/aids/report.aspx?aid=800
6. Donne, J. No Man is an Island. New York, NY: Villard, 1970.
7. Rosenstock, I. (1974). Historical Origins of the Health Belief Model. Health Education Monographs. Vol. 2, No. 4.
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9. Smith, M. “Fear,” “Forgetfulness”—or Patient Blaming?Senator Joe Biden and Some of the Real Reasons Women at Risk May Not Get Annual Mammograms. SB 721 2006 Class blog.
10. De Fleur, M.L. Theories of Mass Communication. New York, NY: David McKay Company, Inc, 1970.
11. Goffman, E. Frame Analysis: An Essay on the Organization of Experience. Cambridge, MA: Harvard University Press, 1974.
12. Ariely, D. Predictably Irrational. New York, NY: HarperCollins, 2008.
13. Connolly, C. “Teen Pledges Barely Cut STD Rates, Study Says” The Washington Post. 19 March 2005.
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15. Surgeon General. The Surgeon General's Call to Action to Promote Sexual Health and Responsible Sexual Behavior. Washington, D.C.: Surgeon General.
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