Harm Reduction Project News Digest March 18, 2007

News & Opinion This Week 1. Gonorrhea Increases 42 percent In 8 Western States In Five Years 2. Who's Afraid Of Gardasil? 3. Free-Speech Case Divides Bush And Religious Right 4. For U.S. Troops at War, Liquor Is Spur to Crime B Upcoming Conferences and Events C Quote D How To Help E About HRP F Subscription Information ----- I. Gonorrhea Increases 42 percent In 8 Western States In Five Years By Jia-Rui Chong Los Angeles Times / March 18, 2007 Gonorrhea cases are rising at an alarming pace across the Western United States, even while declining in the rest of the country, the federal Centers for Disease Control and Prevention reported Thursday. The number of cases in California and seven other Western states, including Utah, increased by 42 percent from 2000 to 2005 compared with a national decline of 10 percent, according to the report. An increase in gonorrhea is typically associated with a rise in other sexually transmitted diseases - most importantly HIV. ''This is one of the most significant increases we've seen in gonorrhea in years,'' said Lori Newman, an epidemiologist at the CDC and one of the report's authors. ''Unless we take action now, we'll be in trouble in the future.'' The outbreak is spreading most intensely in Nevada, where the proportion of new cases per 100,000 people went from 77 in 2000 to 123 in 2005, according to the report. Utah went from 10 new cases per 100,000 people in 2000 to 30 in 2005. Overall, the CDC reported about 360,000 new gonorrhea cases nationwide in 2005. Researchers are uncertain why gonorrhea is increasing in the West at such a dramatic rate, but surmised that it was at least partly related to an increase in risky sexual behaviors driven by methamphetamine use, Newman said. More and better screening for gonorrhea also has contributed to the rise, Newman added. Gonorrhea is a bacterial infection that can lead to severe complications in women, including infertility. The disease can be treated with antibiotics. From 1975 to 1997, cases nationwide dropped by 74 percent, due in part to better screening and education about sexually transmitted diseases. The latest CDC report found that gonorrhea cases dropped by 22 percent in the South, 16 percent in the Northeast and 5 percent in the Midwest. --- 2. Who's Afraid of Gardasil? by KAREN HOUPPERT The Nation / March 26, 2007 Issue The HPV vaccine story has gotten all tangled up. As recently as June 8, 2006, public health advocates, progressives and many parents were celebrating a huge victory: The Food and Drug Administration had approved Merck's new vaccine Gardasil, a shot series that would help protect girls from cervical cancer and genital warts. To their continuing delight, the Centers for Disease Control's immunization committee recommended less than a month later that the shots immediately be given to all females between the ages of 9 and 26. The committee acted on persuasive data indicating that the vaccine, which prevents the sexually transmitted human papillomavirus (HPV), works best before girls are sexually active. Human papillomavirus is the most common sexually transmitted infection in the world, and most women have had it-- 80 percent of US women, by the CDC's estimates. Often it goes away on its own, without its carrier's awareness. But each year hundreds of thousands of women and girls in the United States develop persistent infections from it, more than 10,000 get cervical cancer and 3,700 die from the cancer. Gardasil, given in a series of three shots, protects against four strains of HPV. Two of those strains cause 70 percent of the nation's cervical cancer cases, and two of them cause 90 percent of genital warts. This new vaccine, widely given, has the potential to make cervical cancer almost obsolete here. All good news, right? Apparently not. Today, as thirty-one state legislatures consider mandating the vaccine for middle school girls, skepticism about the wisdom of embarking on this swift and widespread inoculation program has bubbled up from critics who span the political spectrum. These strange bedfellows include Christian conservatives and their abstinence-only ilk, who have long argued that safe sex encourages profligate sex; a slew of Big Pharma critics, who see how Merck (which stands to make $4 billion a year on the vaccine by most estimates) is angling to corner this huge new vaccine market; the growing antivaccine movement, which objects to all such school-entry requirements; the parental-rights folks with a libertarian strain, who bridle at any mandates regarding their children's health; and a smattering of women's health advocates, who worry that the pace of the vaccine's introduction is jeopardizing its ultimate success. What's all the noise about? Some of it is predictable and comes from the usual quarters. Cultural conservatives and abstinence-only hardliners have been trotting out familiar arguments: Safe sex leads to more sex, they insist. Conservative California State Senator George Runner told the Los Angeles Times recently that he objected to this immunization because the disease was a result of lifestyle decisions, as opposed to contagion. He wondered: "Is there a more productive way for us to spend the money that may help someone who's in a health situation that has nothing to do with their personal choices? Where do you want to focus your resources?" Conveniently avoiding any logical extension of his argument to lifestyle decisions like, say, smoking, Runner and his allies insist Americans have to distinguish between the deserving and the undeserving ill. The face of the undeserving ill, according to the moral conservatives, belongs to Illinois State Senator Debbie Halvorson, who, as co-sponsor of a bill to require the vaccine in her state, admitted that she herself had HPV and underwent a hysterectomy because of precancerous cells. Pro-abstinence bloggers and columnists see this as permission to grill her regarding her sexual history: "You would think she'd focus on her behavior that caused her to contract that sexually transmitted disease," Jill Stanek wrote in the online Illinois Review. "Halvorson could discuss the number of sex partners she has had in her lifetime and how each one increased the likelihood of contracting HPV...whether it was her husband who passed HPV on to her after sleeping with other women...[or] if Halvorson contracted HPV through rape, she could discuss ways to avoid rape." Enter, stage left, anticorporate muckrakers and consumer rights activists. These players fret about the role Merck has played in peddling this drug and are wisely skeptical of a pharmaceutical industry with a track record for putting profits before safety. A couple of things set off alarm bells. First, what was the pro-abstinence Republican Governor of Texas, Rick Perry, doing fast-tracking this vaccine by issuing an executive order that would make the shots compulsory for all sixth grade girls? This made everyone sit up and say, hmmm. (His conservative constituents expressed their befuddlement by screaming bloody murder. Perry did his best to mollify them in a linguistic high-wire act that laced the language of abortion foes with reproductive rights rhetoric: "While I understand the concerns expressed by some, I stand firmly on the side of protecting life. The HPV vaccine does not promote sex, it protects women's health.") But that was only the beginning of Perry's problems--and by extension the problems many state politicians were having as they tried to get the vaccine mandated. The press discovered Perry's ties to Merck: Not only did his former chief of staff now work as a lobbyist for Merck but the Governor had accepted $6,000 in campaign contributions from Merck's political action committee. It didn't look good. And it got worse. A nonprofit called Women in Government, comprising female state legislators, has been behind the push to make the vaccine compulsory, educating members about its value and urging them to introduce bills in their respective states requiring the shots--even going so far as to offer sample wording for the legislation on its website. It turns out Merck--whoops!--was a big WIG donor. Fueling everybody's mistrust was Merck's own image problems. As maker of the arthritis drug Vioxx, which may have been responsible for 28,000 deaths before it was withdrawn from the market in September 2004, Merck was, well, suspect. Especially since it stands to make a bundle by charging $360 for each shot series. And it has a motive to corner the market quickly: GlaxoSmithKline is hot on its heels with an HPV vaccine of its own that it hopes to introduce before the end of the year. What's more, if it's lucky Merck stands to double its money. When seeking approval for the vaccine, the company also submitted data on clinical trials for Gardasil and boys. Though the vaccine thus far appears safe for young men, it may be more complicated to prove it effective--and to sell to parents. (After all, the cancer-preventing imperative is more circuitous: Boys aren't the ones being protected from cancer; their future partners are.) In an effort to defuse the controversy, Merck backed off a bit in late February, issuing a statement saying, "We are pleased that Gardasil has been so widely embraced and do not want any misperception about Merck's role to distract from the ultimate goal of fighting cervical cancer, so Merck has re-evaluated its approach at the state level and we will not lobby for school requirements for Gardasil." Enter the antivaccine groups, which had been waiting in the wings for the big break that finally arrived with Merck's public whipping. These groups, an eclectic mix of alternative medicine proponents, conspiracy theorists and libertarians, form a growing contingent of parents who are refusing to vaccinate their children against any diseases. They have assailed the HPV shots and, because their network of skeptics was already in place, were able to serve up outspoken critics on the spot to eager reporters. "Our concern is that this vaccine has not been studied long enough, or in enough children, to start mandating its use," said Barbara Loe Fisher, who heads the National Vaccine Information Center, a self-described organization of "parents of vaccine-injured children." This group, which according to its website pretty much opposes every vaccine mandate for every reason it can muster, strongly objects to this one being a requirement of school entry for sixth graders. "This is particularly egregious because HPV is not a disease communicated in a school setting like other diseases with mandatory vaccines," Fisher says, insisting (nonsensically) that this negates the government's "compelling interest" in curtailing HPV. Those who work in public health were not blindsided by these critiques from the antivaccine organizations--and in fact have been worriedly monitoring the swelling ranks of vaccine opponents for several years now. "Vaccines have raised concerns for similar reasons throughout history," says Greg Zimet, a professor of pediatrics and clinical psychology at Indiana University School of Medicine who served on the Society of Adolescent Medicine's HPV committee. (The society strongly endorses the vaccine and is confident of its efficacy and safety but has not yet formally weighed in on the mandating issue.) When you consider that only a century ago infant mortality in the United States was 20 percent and another 20 percent of kids died before the age of 5, according to a 2005 article in the journal Health Affairs, the critical role that compulsory vaccination plays is clear; the infant mortality rate today is less than 1 percent. "But vaccines are their own worst enemy," Zimet says. "When they work, they reduce the element of risk to almost negligible. Who knows anyone who has ever had diphtheria or polio today? Take the deadly diseases so far out of the equation, and these parents will focus on what the vaccine's side effects may be." Pointing out that as many as 3 percent of US children are no longer being vaccinated against any disease because their parents object (a number that jumps as high as 20 percent in some school communities), Zimet says public health officials and pediatricians worry that the positive effects of what they call "herd immunity" are already being compromised. Because there is a class of people for whom inoculation poses a health risk--those with AIDS or a host of other illnesses, for example--requiring that everyone else be vaccinated can help protect these populations as well. That's how the government justifies mandating immunization. But, like many of the rifts that divide our civic conversations into opposing camps, the vaccine debate pits individual rights against group rights--and some parents are hopping mad. It's here that Fisher's antivaccine group marches in lockstep with antigovernment libertarians. Both insist that making the HPV vaccine compulsory violates their parental rights. "We are not against vaccine availability, just vaccine mandates," says Fisher. While she concedes that every state but two has some kind of opt-out clause for parents who object to the vaccine for health, religious, moral or ethical reasons, she says parents who refuse immunization are harassed. "Your name goes on a state list. You get harassing calls from the CDC for your views on vaccines. Some families get thrown off health insurance plans, thrown out of their pediatricians' offices, thrown out of public schools--or parents are put in a room and grilled by officials about the depth of their religious convictions on this." Finally, the backdrop to all these conversations is one unfurled by women's health advocates, who insist that we set the current action in a historical context. Walking around with the DES-Thalidomide-Dalkon Shield pharmaceutical disasters in the back of their minds, some worry that Merck's profit-driven rush to mandate this drug may prove problematic. "There's merit to questioning industry's motives in this case," says Heather Boonstra, public policy analyst at the Alan Guttmacher Institute, a nonprofit organization focused on sexual health research and analysis. "Because Merck itself has pushed so hard to make the vaccine mandatory, there's a bit of skepticism about industry's motives." Even those who would be expected to be chomping at the bit to promote this vaccine are holding back. "We haven't taken an official position on mandating the vaccine," says Amy Allina, program director for the National Women's Health Network. Though she acknowledges that "the data look excellent so far," she wavers, arguing with herself even as she speaks: "If you mandate the vaccine, this is how you get access for those with barriers to care--and if it's not mandated it's going to be much harder for many girls to get the vaccine. On the other hand, it's early to require this for such a huge population." Almost all the major health organizations (American Academy of Pediatrics, the Society for Adolescent Medicine, the American College of Obstetricians and Gynecologists, the Institute for Vaccine Safety, the CDC, etc.), whatever they think about the aggressive push to require the vaccine immediately, are strongly recommending that girls be inoculated and are confident the vaccine poses no dangers. "This is a remarkably safe vaccine," says Dr. Neal Halsey, a professor in the department of International Health and Pediatrics at Johns Hopkins's Bloomberg School of Public Health, director of the Institute of Vaccine Safety and chair of the vaccine group at the Infectious Diseases Society of America. "There is no evidence of any increased risk of serious adverse events." What worries him are logistics. "I think it's premature to require this for school entry, because we don't have good systems in place to make sure we can deliver this to all girls," he says. "We need to make sure the supply can be maintained, and we need to make sure we have good mechanisms in place to get this shot to all those who need it." According to Halsey, we do a great job of getting babies and little kids immunized in this country because well-baby visits insure regular contact with doctors and because the government has a system in place to make sure all young children--even those without insurance--can get the required shots free. "But we are doing a terrible job delivering vaccines to adolescents, due to a lack of infrastructure at the CDC and state health departments," he says. He worries that rushing school immunization requirements for the HPV vaccine will just overwhelm an already stretched system. "We're pushing too early, too fast." This troubles him: "It is a very valuable, very useful vaccine--our first for cancer--so let's do it right." One of the biggest obstacles to the vaccine, even strong advocates acknowledge, is the swiftness with which it is being mandated. There hasn't been enough time to educate parents properly, and that has led Americans to react with all the nuttiness that any whiff of teen sexuality evokes--despite the assiduous effort of promoters to frame it as a "cancer vaccine," downplaying the issue of sexual transmission and never, ever emphasizing the vaccine's role in reducing genital warts. "When you educate parents, research shows, the numbers who say they are likely to give the vaccine to their kids shoot up," says Deborah Arrindell, vice president of health policy at the American Social Health Association. She cites a 2004 study published in the Journal of Lower Genital Tract Disease: Among 575 parents, only 55 percent thought the vaccine was a good idea before they read a one-page educational fact sheet about HPV. Seventy-three percent of them favored the vaccine after learning more about it. "If we had just a little more time, we would have a lot less controversy." Even so, Arrindell still thinks it is vital to mandate the shots. That's because leaving the shots voluntary means some girls will get them, but a lot won't. And those who won't get the shots are those who can't afford them. Mandating the vaccine makes it much more likely that insurers will cover the costs, that Medicaid will pay and that federally funded vaccine programs will quickly offer free vaccines for uninsured children. All the experts agree on one thing: Any serious effort to address cervical cancer and genital warts has to target these populations. After all, these are the communities hardest hit. According to the Guttmacher Institute, African-American and Latina women are 1.5 times more likely to develop the cancer and are more likely to die of the disease as well. The explanation for this discrepancy is easy: More than half of those who develop cervical cancer in this country haven't had a pap smear in the previous three years, and these are disproportionately low-income and women of color who lack access to healthcare, Guttmacher reports. "Unfortunately, there is a lot of distrust of the health community and their history of clinical trials among African-Americans," says Arrindell. For example, the Washington Afro-American, a local paper in DC and Baltimore, came out firmly against the vaccine in an editorial invoking the Tuskegee experiment and other efforts to restrict the reproductive rights of blacks, proclaiming that the government should "stop trying to shove it down our throats." Running with the piece was a cartoon featuring a young girl cowering from a huge syringe wielded by Uncle Sam in a Merck lab coat. "I'm really concerned that this controversy over the vaccine is causing the African-American community to shy away from a vaccine that can save women's lives," says Arrindell. She says there are valuable lessons here. "Middle school may be the last public health gate we all walk through together, before kids begin dropping out of schools or get a crummy job without health insurance, or enter the workforce in general with its fragmented healthcare system." "We should not get lost in the controversy over this," insists Arrindell, who would rather see a debate over the best ways of making this vaccine affordable and accessible--both to American girls and to those in developing countries who may never get the regular pap smears they need for early detection of cervical cancer. "This is the best public health news we've had for women in fifty years. It's huge. It's exciting. It's wonderful." She delivers a succinct epilogue: "It's a good thing." --- 3. Free-Speech Case Divides Bush and Religious Right By LINDA GREENHOUSE NY Times WASHINGTON, March 17 — A Supreme Court case about the free-speech rights of high school students, to be argued on Monday, has opened an unexpected fissure between the Bush administration and its usual allies on the religious right. As a result, an appeal that asks the justices to decide whether school officials can squelch or punish student advocacy of illegal drugs has taken on an added dimension as a window on an active front in the culture wars, one that has escaped the notice of most people outside the fray. And as the stakes have grown higher, a case that once looked like an easy victory for the government side may prove to be a much closer call. On the surface, Joseph Frederick’s dispute with his principal, Deborah Morse, at the Juneau-Douglas High School in Alaska five years ago appeared to have little if anything to do with religion — or perhaps with much of anything beyond a bored senior’s attitude and a harried administrator’s impatience. As the Olympic torch was carried through the streets of Juneau on its way to the 2002 winter games in Salt Lake City, students were allowed to leave the school grounds to watch. The school band and cheerleaders performed. With television cameras focused on the scene, Mr. Frederick and some friends unfurled a 14-foot-long banner with the inscription: “Bong Hits 4 Jesus.” Mr. Frederick later testified that he designed the banner, using a slogan he had seen on a snowboard, “to be meaningless and funny, in order to get on television.” Ms. Morse found no humor but plenty of meaning in the sign, recognizing “bong hits” as a slang reference to using marijuana. She demanded that he take the banner down. When he refused, she tore it down, ordered him to her office, and gave him a 10-day suspension. Mr. Fredericks’s ensuing lawsuit and the free-speech court battle that resulted, in which he has prevailed so far, is one that, classically, pits official authority against student dissent. It is the first Supreme Court case to do so directly since the court upheld the right of students to wear black arm bands to school to protest the war in Vietnam, declaring in Tinker v. Des Moines School District that “it can hardly be argued that either students or teachers shed their constitutional rights to freedom of speech or expression at the schoolhouse gate.” The court followed that 1969 decision with two others during the 1980s that upheld the authority of school officials to ban vulgar or offensive student speech and to control the content of school newspapers. Clearly there is some tension in the court’s student-speech doctrine; what message to extract from the trio of decisions is the basic analytical question in the new case, Morse v. Frederick, No. 06-278. What is most striking is how the two sides line up. The Bush administration entered the case on the side of the principal and the Juneau School Board, which are both represented by Kenneth W. Starr, the former solicitor general and independent counsel. His law firm, Kirkland & Ellis, is handling the appeal without a fee. Mr. Starr and Edwin S. Kneedler, a deputy solicitor general who will present the government’s view, will share argument time on Monday. The National School Board Association, two school principals’ groups, and several antidrug organizations also filed briefs on the school board’s side. While it is hardly surprising to find the American Civil Liberties Union and the National Coalition Against Censorship on Mr. Frederick’s side, it is the array of briefs from organizations that litigate and speak on behalf of the religious right that has lifted Morse v. Frederick out of the realm of the ordinary. The groups include the American Center for Law and Justice, founded by the Rev. Pat Robertson; the Christian Legal Society; the Alliance Defense Fund, an organization based in Arizona that describes its mission as “defending the right to hear and speak the Truth”; the Rutherford Institute, which has participated in many religion cases before the court; and Liberty Legal Institute, a nonprofit law firm “dedicated to the preservation of First Amendment rights and religious freedom.” The institute, based in Plano, Tex., told the justices in its brief that it was “gravely concerned that the religious freedom of students in public schools will be damaged” if the court rules for the school board. Lawyers on Mr. Frederick’s side offer a straightforward explanation for the strange-bedfellows aspect of the case. “The status of being a dissident unites dissidents on either side,” said Prof. Douglas Laycock of the University of Michigan Law School, an authority on constitutional issues involving religion who worked on Liberty Legal Institute’s brief. In an interview, Professor Laycock said that religiously observant students often find the atmosphere in public school to be unwelcoming and “feel themselves a dissident and excluded minority.” As the Jehovah’s Witnesses did in the last century, these students are turning to the courts. The briefs from the conservative religious organizations depict the school environment as an ideological battleground. The Christian Legal Society asserts that its law school chapters “have endured a relentless assault by law schools intolerant of their unpopular perspective on the morality of homosexual conduct or the relevance of religious belief.” The American Center for Law and Justice brief, filed by its chief counsel, Jay Alan Sekulow, warns that public schools “face a constant temptation to impose a suffocating blanket of political correctness upon the educational atmosphere.” What galvanized most of the groups on Mr. Frederick’s side was the breadth of the arguments made on the other side. The solicitor general’s brief asserts that under the Supreme Court’s precedents, student speech “may be banned if it is inconsistent with a school’s basic educational mission.” The Juneau School Board’s mission includes opposing illegal drug use, the administration’s brief continues, citing as evidence a 1994 federal law, the Safe and Drug-Free Schools and Communities Act, which requires that schools, as a condition of receiving federal money, must “convey a clear and consistent message” that using illegal drugs is “wrong and harmful.” Mr. Starr’s main brief asserts that the court’s trilogy of cases “stands for the proposition that students have limited free speech rights balanced against the school district’s right to carry out its educational mission and to maintain discipline.” The brief argues that even if Ms. Morse applied that precept incorrectly to the facts of this case, she is entitled to immunity from suit because she could have reasonably believed that the law was on her side. The religious groups were particularly alarmed by what they saw as the implication that school boards could define their “educational mission” as they wished and could suppress countervailing speech accordingly. “Holy moly, look at this! To get drugs we can eliminate free speech in schools?” is how Robert A. Destro, a law professor at Catholic University, described his reaction to the briefs for the school board when the Liberty Legal Institute asked him to consider participating on the Mr. Frederick’s behalf. He quickly signed on. Having worked closely with Republican administrations for years, Mr. Destro said he was hard pressed to understand the administration’s position. “My guess is they just hadn’t thought it through,” he said in an interview. “To the people who put them in office, they are making an incoherent statement.” The solicitor general’s office does not comment publicly on its cases. But Mr. Starr, by contrast, was happy to talk about the case and the alignment against him of many of his old allies. “It’s reassuring to have lots of friends of liberty running around,” he said in a cheerful tone, adding: “I welcome this outpouring because it will help the court see that it shouldn’t go too far either way.” --- 4. For U.S. Troops at War, Liquor Is Spur to Crime By PAUL von ZIELBAUER - March 13, 2007 / NY Times In May 2004, Specialist Justin J. Lillis got drunk on what he called “hajji juice,” a clear Iraqi moonshine smuggled onto an Army base in Balad, Iraq, by civilian contractors, and began taking potshots with his M-16 service rifle. “He shot up some contractor’s rental car,” said Phil Cave, a lawyer for Specialist Lillis, 24. “He hopped in a Humvee, drove around and shot up some more things. He shot into a housing area” and at soldiers guarding the base entrance. Six months later, at an Army base near Baghdad, after a night of drinking an illegal stash of whiskey and gin, Specialist Chris Rolan of the Third Brigade, Third Infantry Division, pulled his 9mm service pistol on another soldier and shot him dead. And in March 2006, in perhaps the most gruesome crime committed by American troops in Iraq, a group of 101st Airborne Division soldiers stationed in Mahmudiya raped a 14-year-old Iraqi girl and killed her and her family after drinking several cans of locally made whiskey supplied by Iraqi Army soldiers, military prosecutors said. Alcohol, strictly forbidden by the American military in Iraq and Afghanistan, is involved in a growing number of crimes committed by troops deployed to those countries. Alcohol- and drug-related charges were involved in more than a third of all Army criminal prosecutions of soldiers in the two war zones — 240 of the 665 cases resulting in convictions, according to records obtained by The New York Times through a Freedom of Information Act request. Seventy-three of those 240 cases involve some of the most serious crimes committed, including murder, rape, armed robbery and assault. Sex crimes accounted for 12 of the convictions. The 240 cases involved a roughly equal number of drug and alcohol offenses, although alcohol-related crimes have increased each year since 2004. Despite the military’s ban on all alcoholic beverages — and strict Islamic prohibitions against drinking and drug use — liquor is cheap and ever easier to find for soldiers looking to self-medicate the effects of combat stress, depression or the frustrations of extended deployments, said military defense lawyers, commanders and doctors who treat soldiers’ emotional problems. “It’s clear that we’ve got a lot of significant alcohol problems that are pervasive across the military,” said Dr. Thomas R. Kosten, a psychiatrist at the Veterans Affairs Medical Center in Houston. He traces their drinking and drug use to the stress of working in a war zone. “The treatment that they take for it is the same treatment that they took after Vietnam,” Dr. Kosten said. “They turn to alcohol and drugs.” The use of alcohol and drugs in war zones appears to reflect a broader trend toward heavier and more frequent drinking among all military personnel, but especially in the Army and Marine Corps, the two services doing most of the fighting, Pentagon officials and military health experts said. A Pentagon health study released in January, for instance, found that the rate of binge drinking in the Army shot up by 30 percent from 2002 to 2005, and “may signal an increasing pattern of heavy alcohol use in the Army.” While average rates of alcohol consumption in the Navy and Air Force have steadily declined since 1980, the year the military’s health survey began, they have significantly increased in the Army and Marine Corps and exceed civilian rates, the Pentagon study showed. For the first time since 1985, more than a quarter of all Army members surveyed said they regularly drink heavily, defined as having five or more drinks at one sitting. The rate of illicit drug use also increased among military members in 2005, to an estimated 5 percent, nearly double the rate measured in 1998, a trend that the study called “cause for concern.” The study also found other health problems in the military, from the growing popularity of chewing tobacco to a 20 percent increase during the past decade in service members who are considered overweight. Lynn Pahland, a director in the Pentagon’s Health Affairs office, said the rising rates of heavy drinking and illegal drug use among active-duty military personnel are particularly troubling inside the Defense Department. “It is very serious,” Ms. Pahland said in an interview. “It is a huge concern.” In the military, seeking help for psychological problems, including alcohol and drug abuse, is considered a taboo, especially among officers competing for promotions. Several officers interviewed for this article said the Pentagon was not doing enough to reduce that stigma. Though the Pentagon has spent millions of dollars on several initiatives to reverse the trend, including a new Web site that deglamorizes drinking, financing to combat alcohol abuse has fallen over time, a Pentagon spokesman said. Spending on programs to reduce alcohol abuse, smoking and obesity dropped to $7.74 million in the current fiscal year from $12.6 million in fiscal year 2005 — a 39 percent decline. Some military doctors and other mental health experts said the Army’s greater use of so-called moral waivers, which allow recruits with criminal records to enlist, may also be a factor in the increased drug and alcohol use. Getting liquor or drugs in Iraq is not difficult. One of the most common ways to smuggle in brand name gin or clear rum is in bottles of mouthwash sent from friends back home, soldiers said. Blue or yellow food coloring makes the liquid look medicinal. Some Army medics have been known to fill intravenous fluid bags with vodka, Army officers said. In Iraq, liquor of a distinctly more dubious quality can be purchased from Iraqi Army soldiers or civilian contractors working on American bases, and Iraqi soldiers have sold locally produced prescription drugs to American troops for a tidy profit. Commanders have not always regarded drinking as a problem. The Army “was a culture in the 1970s that encouraged drinking,” said a retired Army colonel. “You’d go out drinking together and you’d find your buddy hugging the toilet at the officer’s club and think nothing of it.” Command tolerance for such behavior began changing in the 1980s, and by the 1990s, “if you had more than a couple drinks at the club, people started looking at you strange,” the retired colonel said. But at a time when the military is fighting two major ground wars, the often serious consequences of heavy drinking has emerged with increasing clarity as more troops return from Iraq and Afghanistan with post-traumatic stress disorder, depression and other mental health problems, military officials and mental health experts said. “I think the real story here is in the suicide and stress, and the drinking is just a symptom of it,” said Charles P. O’Brien, a psychiatrist at the University of Pennsylvania School of Medicine who served as a Navy doctor during the Vietnam War. There is a high incidence of post-traumatic stress disorder among Iraq veterans, he said, adding that “there’s been a lot of suicide in the active-duty servicemen.” More than 90 percent of sex crimes prosecuted by the military involve alcohol abuse, defense lawyers and military doctors said. Roughly half of the marines charged with crimes in Iraq exhibit clear signs of post-traumatic stress disorder, a Marine defense lawyer said. “They turn to alcohol and drugs for an escape,” he said. The health study released in January was produced for the Pentagon by RTI International, a nonprofit research organization. Robert M. Bray, the group’s project director, first agreed to be interviewed for this article but later declined after a Defense Department spokesman said he was not available to comment. In the past two years, though, top military officials have begun talking publicly about the danger that excessive drinking among the troops. In 2005, the Army’s deputy chief of staff at the time, Lt. Gen. Franklin L. Hagenbeck, wrote in an editorial in a magazine for Army leaders that the rising rate of heavy drinking and drug use “seriously impacts mission readiness.” General Hagenbeck, now the superintendent of the United States Military Academy at West Point, said more than half of soldiers discharged for misconduct had also been disciplined for drug or alcohol use within the previous year. “When one soldier has an alcohol or other drug incident, it impacts the whole unit,” General Hagenbeck wrote. That kind of ripple effect has played out repeatedly in Iraq, military defense lawyers said, as soldiers who drink or use drugs commit crimes and hinder their unit’s combat and support missions. Specialist Lillis, for example, was given a bad conduct discharge and sentenced to 10 years in prison as punishment for his drunken shooting spree; he is in a military prison in Fort Leavenworth, Kan. A military judge sentenced Specialist Rolan, who testified that he drank to relieve depression in Iraq, to 33 years in prison for killing a fellow soldier. Two of the soldiers charged in the Mahmudiya case pleaded guilty to murder, and a former Army private described as the ringleader, Steven D. Green, is awaiting trial for rape and murder in a federal district court. Last year, the Pentagon spent $2 million to initiate its “That Guy” campaign, (www.thatguy.com), which recommends that service members “reject binge drinking because it detracts from the things they care about: family, friends, dating, sex, money and reputation.” The Pentagon is poised to launch another Web-based antidrinking campaign this summer. Capt. Robert DeMartino, a doctor with the United States Health Service who is coordinating the project, said the hope is that service members returning from Afghanistan and Iraq will use the site to find help coping with post-deployment problems, including alcohol dependency. Andrew Lehren contributed reporting. --- B Upcoming Conferences and Events 18th International Conference on the Reduction of Drug Related Harm – "Harm Reduction: Coming of Age" May 13, 2007 - May 17, 2007 Location: GROMADA Conference Centre, Warsaw, Poland Contact: +48 22 640 82 71, [email protected] More Info: http://www.harmreduction2007.org --- C Quote But if you're asking my opinion, I would argue that a social justice approach should be central to medicine and utilized to be central to public health. This could be very simple: the well should take care of the sick. - Paul Farmer --- D How To Help The Harm Reduction Project is able to provide services through the support of individuals such as yourself. Please help us make a difference and pledge your support today! --- E About HRP The Harm Reduction Project works for the enhancement of services available to marginalized populations. 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