Kelly's long public health rant.

Why doesn't our behavior follow the rules of rational thinking?

I admit that I disagree with David Brooks on occasion. I appreciate his insights into the meritocracy of today's college students and his sarcastic look at his own social class. But I don't think that I've ever said, "He has it right." However, reading his Sunday editorial was amazing. This article concerns the problems associated with the spread of HIV. As he said:

"We have tried economic development, but that too is necessary but insufficient. The most aggressive spreaders of the disease are relatively well off. They are miners who have sex with prostitutes and bring the disease home to their wives. They are teachers who trade grades for sex. They are sugar daddies who have sex with 14-year-old girls in exchange for cellphone time." [I'm guessing MTN and Vodacom pre-paid]

.....

I think that everyone in my study abroad program struggled with the question of effective policy implementation and behavioral changes. For their independent study project (ISP), most people conducted surveys and found that youth had a strong knowledge of HIV and how to contract/prevent HIV, but none of this translates into action. Certainly, behavior is more complicated than a rational decision. Knowing that I should not bite my nails does not mean that I have never bitten my nails.

On a more somber note, entering HIV infection and premature death into the equation is not the first consideration. Living for the present is as equally important as the future, perhaps even more so. To buy the tight Levis or the Forschini shirts or Truworths jewelry required for social status, teenage girls seek a sugar daddy. For many, it's a mutally beneficient relationship. Pride, for these girls, come from their perception by their peers, not unlike that of a typical suburban American middle school.

It's not a coincidence that the areas with highest HIV rates are those with lowest employment. Nor is it a coincidence that the breakdown of what were once deeply embedded cultural traditions and pride in one's history as a Xhosa or Tswana or Sotho has occured. One does not see a future beyond what one has. Similarly for prostitutes, when one gets more money to not use a condom, money that is needed to live, HIV infection and an AIDS-related death in 15-20 years seems too far off. One needs food for tomorrow. But these are facts that everyone involved in public health and HIV/AIDS work in sub-Saharan Africa knows.

Satistically, it seems like the easy choice to suggest that people be tested for HIV. Those who are tested practice safer sex practices for up to two years longer than those who are simply told the dangers of unsafe sex practices. The World Health Organization lists clear benefits to HIV testing: one can plan for the future, know whether to increase protective measures, and also enter upon a regiment to receive treatment if necessary. Yet people are, by and large, not being tested in droves, although this number has increased with the increased availability of antiretroviral drugs (ARVs).

Which is why I'm not sure that David Brooks was right in his assessment of the situation. He correctly says that "The AIDS crisis is about the sanctity of life. It's about people who have come to so undervalue their own life that ruinous behavior seems unimportant and death is accepted fatalistically. " However, he goes on to say that:

"It's about these and a dozen other things - trust, fear, weakness, traditions, temptation - none of which can be fully addressed by externals. They can be addressed only by the language of ought, by fixing behavior into some relevant set of transcendent ideals and faiths. "

Brooks and I would agree that a personal, moral compass is needed. I think that Brooks is referring to the transcendent ideals of the church. However, I would take it to mean something more. There are unmet needs at work. Listening to the stories in the HIV Wellness clinic made me realize that the decision to be tested rested on two components: hope and pride. That what is effective policy are the efforts to increase self-esteem in the individual by increasing one's pride in one's self, one's culture, one's faith (as it may be), and one's nation.

An HIV prevention plan is a plan that instills pride in one's self so that one's life is worth living (and ensure that one does not become infected with the virus). I don't care if it's religious or cultural or what. To increase the standards of living and the overal economic prosperity of the poorest further confirms that one's life has value and promotes more constructive behavior. The antiretroviral regiment for those who qualify coupled with an aggressive campaign against secondary infections (availability of flucanozole, INZ, etc, for treatment and prophylatic purposes) provides hope after one has been infected.

By doing so, one retains hope that one's life is not only worth saving, but can be saved.