Harm Reduction Project News Digest May 21, 2007

News & Opinion This Week 1. About 13M Injection Drug Users Worldwide Need Access To HIV Prevention, Treatment Services, UNAIDS Says 2. Wretched of the Earth 3. HPV Vaccine Also Guards Against Vulval and Vaginal Cancer (Attention, this study, like many others done on the vaccine, was industry funded) 4. [U.S. Largest HMO] Kaiser Agrees To Reforms In Settlement Of Homeless Dumping Case 5. [Hillary] Clinton Is Quiet On Her Past Role With Wal-Mart [As Board Member] B Upcoming Conferences and Events C Quote D How To Help E About HRP F Subscription Information ----- I. About 13M Injection Drug Users Worldwide Need Access To HIV Prevention, Treatment Services, UNAIDS Says 18 May 2007 - AP/International Herald Tribune About 13 million injection drug users worldwide are in need of HIV/AIDS prevention and treatment services in order to control the spread of the disease, UNAIDS said on Monday in a statement released at the 18th Conference on the Reduction of Drug Related Harm in Warsaw, Poland, the AP/International Herald Tribune reports. Prasada Rao, UNAIDS Asia Pacific regional director, on Sunday said that injection drug use is estimated to account for about one-third of new HIV cases outside sub-Saharan Africa, but only 8% of IDUs worldwide have access to HIV prevention services (AP/International Herald Tribune, 5/14). According to UNAIDS, injection drug use is a major mode of HIV transmission in Southeast Asia, Central Asia and Eastern Europe. In addition, drug use is emerging as a new source of HIV transmission in Kenya, Nigeria, South Africa and Tanzania, UNAIDS said. According to Rao, about "10% of all new HIV infections worldwide are attributable to injection drug use. If you exclude Africa, that figure rises to 30%." In addition, access to antiretroviral therapy is "unacceptably low" among IDUs because of a "lack of information, exclusion and widespread stigma and discrimination," according to UNAIDS. To be effective, HIV prevention program need to reach about 80% of IDUs, UNAIDS said. In addition, programs targeted at IDUs should provide users with access to clean needles and drug-substitution programs, according to AFP/Yahoo! News. "The allocation of financial resources must be used in more strategic and innovative ways to deliver more effective prevention programs to people most at risk of HIV infection," Rao said (AFP/Yahoo! News, 5/14). He added that in countries where injection drug use is fueling the spread of HIV, "focused harm reduction programs which reach people who inject drugs must be built into the national AIDS plans" (AP/International Herald Tribune, 5/14). You can view the entire Kaiser Daily Health Policy Report, search the archives, or sign up for email delivery at http://www.kaisernetwork.org/dailyreports/healthpolicy. --- 2. Wretched of the Earth By Nicholas D. Kristof - The New York Review Of Books - Volume 54, Number 9 · May 31, 2007 Poor People by William T. Vollmann / Ecco, 450 pp., $29.95 Understanding Poverty edited by Abhijit Vinayak Banerjee, Roland Bénabou, and Dilip Mookherjee Oxford University Press, 443 pp., $35.00 (paper) No interview haunts me more than a conversation with a Cambodian peasant, Nhem Yen, in 1996. She was forty years old, though she looked much older, and was living with her family in a clearing in the Cambodian jungle. The area was notorious for malaria, but the family members were ambitious and industrious and figured that it was worth the risk to make more money by cutting wood for sale. Nhem Yen's eldest daughter, who was twenty-four and pregnant with her second child, promptly caught malaria. There was no money to get med-ical treatment (effective drugs would have cost less than $10), and so she died a day after giving birth. That left Nhem Yen looking after five children of her own and two grandchildren. The family had one mosquito net that could accommodate about three people. Such nets are quite effective against malaria, but they cost $5—and Nhem Yen could not afford to buy any more. So every night, she agonized over which of the children to put under the net and which to leave out. "It's very hard to choose," Nhem Yen told me. "But we have no money to buy another mosquito net. We have no choice." That is the real face of poverty: it is not so much the pain of hunger or the humiliation of rags, but the impossible choices you face. If you can only afford school fees for some of your children, which do you send? If you must choose between medical treatment for Dad, the breadwinner, or for Daughter, the A student, which is it? Do you use your savings to provide a good dowry so Eldest Daughter can get a decent husband, or do you settle for the drunkard who will beat her and instead invest the savings in a food cart that may help provide an income to send the younger ones to school? One measure of the ubiquity of these tradeoffs is that today, as every day, 30,000 children will die of hunger, disease, and other consequences of poverty, according to UNICEF. In many cases, those will be daughters, because parents (particularly in South Asia) don't have the resources to keep all their children alive, so they put a finger on the scales on the side of their sons. In India alone, among children aged one to five, girls are 50 percent more likely to die than boys—meaning that 130,000 Indian girls are mortally discriminated against each year. Poverty both in the US and around the world remains a central fact of twenty-first-century life; a majority of the world lives on less than $2 a day, one common measure of who is poor. Yet we manage, pretty successfully, to ignore it and insulate ourselves even from poverty in our own country. When it pops out from behind the screen after an episode like the Watts riots of 1965 or the New Orleans hurricane of 2005, then we express horror and indignation and vow change, and finally shrug and move on. Meanwhile, the world's five hundred wealthiest people have the same income as the world's poorest 416 million. These days, however, something interesting is stirring in the world of poverty. People like Bill and Melinda Gates and Warren Buffett have made it almost as prestigious for philanthropists to underwrite vaccinations as to underwrite the ballet. Bono and Angelina Jolie have made Africa almost sexy. And several Democratic presidential candidates have real expertise and interest in the issue, particularly domestically: Barack Obama worked as a grassroots antipoverty organizer in Chicago; Hillary Rodham Clinton has long labored on child poverty; and John Edwards has spent the last few years assiduously studying poverty and speaking out about it. On the Republican side, Sam Brownback is also very serious about poverty and related issues, including prison conditions and recidivism. So we now have a wealth of interest in poverty. A fruit of that, or perhaps a beneficiary of it, is William Vollmann's new work, bluntly titled Poor People. Vollmann is a terrific reporter and writer who won a National Book Award in 2005 for his novel Europe Central. He also comes across as an exceptionally nice guy, not only handing out money to people right and left but also allowing homeless people to squat next to his house in California. He gets a little testy when they use the area as a public toilet, but he still earnestly takes his daughter with him to chat with the homeless and has her shake their hands to show respect. Then he takes her inside to scrub that hand. Vollmann's book is difficult to describe. It's not a systematic examination of poverty, and it's certainly not a treatise on how to respond to poverty —he barely discusses possible solutions. Mostly, it's a pointillist description of poor people he has encountered and interviewed extensively in Thailand, Russia, China, and elsewhere. Vollmann asks them questions like "do you consider yourself poor?" Or "why are poor people poor?" Or "are men and women equally poor?" Or "why are you poor?" Or "why are some people rich and some poor?" The problem is that the answers often aren't very interesting, persuasive, or authoritative. It's useful to ask poor people about poverty, but after wading through three hundred pages of their equally impoverished answers, unleavened by some larger context or theme, I think Vollmann would have been better off spending some of his time asking such questions of a panel of Ivy League professors. (Granted, I'm being unfair in asking for a book that Vollmann apparently didn't want to write.) Vollmann has written something that is perhaps closer to travel literature than poverty literature. His book is a bit like one of Paul Theroux's— but a compassionate, warm Theroux— with its finely drawn characters who are interesting in themselves but whose comments don't suggest some larger truth. The first person Vollmann sketches is a Thai woman named Sunee, a drunkard and probably a former "entertainer" in Japan. She has a daughter to whom Vollmann sometimes gives money (which Sunee periodically confiscates). Sunee rings true to me, as do all the other figures in the book. But the interview with her doesn't illuminate the challenge of poverty or suggest how to resolve it. The most moving evocations of poverty have been fictional: Zola's Germinal, or Steinbeck's Grapes of Wrath. Those novels have heroic characters, and you want to reach into your pocket and solve their problems by handing them a pile of cash. But in the real world, many tales of poverty are less moving and more nuanced, with a dash of self-destructiveness thrown in. It may not be entirely Sunee's fault that she is a drunkard, but it does make you less likely to react sympathetically when you read of her decline. In that sense, Vollmann's work is a useful reminder that poverty is often a shortage of more than cash. The optimistic efforts of the antipoverty campaigns of the 1960s and of many foreign aid programs didn't work out as well as hoped partly because they ended up treating poverty essentially as a redistribution issue—and it's far more than that. The best nonfiction book on American poverty I have ever read is Jason DeParle's brilliant American Dream: Three Women, Ten Kids, and a Nation's Drive to End Welfare.[1] It's a close-up look at three poor women and the impact of the effort to end welfare "as we know it." It's far too rich and complex a work to offer simple solutions, but in the end it suggests that there are real benefits to pushing some families out of welfare into work—but that those benefits are modest and still leave little hope of resolving the challenges of poverty. Still, DeParle (a colleague at The New York Times) does examine at the end of his book some programs to combat poverty and suggests that in the 1990s we began to learn what works and what doesn't in alleviating its worst forms in the United States. There is, I think, a liberal squeamishness about confronting the reality that one important element that sustains poverty is culture: a self-destructive pathology that arises from poverty and then entraps the poor in it for generation after generation. The culture varies with the society, and it is different for Dalits (or Untouchables) in India and for villagers in Congo and for the homeless in the US. Often, though, this culture involves elements of hopelessness, substance abuse, underinvestment in education, self-fulfilling expectations of failure, and squandered resources. Less vivid but more insightful in depicting poverty is a recent scholarly article in The Journal of Economic Perspectives. Abhijit V. Banerjee and Esther Duflo have written a fascinating—and troubling—examination called "The Economic Lives of the Poor," based on surveys of people living on less than $2 a day in thirteen countries.[2] The surveys found the respondents to be undernourished, with 55 percent of poor adults in Udaipur, India, suffering from anemia (which also limits their ability to work and earn money). The poor also invest negligible sums in education (about 2 percent of their income), even though more investment in schooling might offer their children a way out of the cycle. Yet it's much too simple to conclude that their lack of spending on adequate food and education is solely because they don't have the money. Part of it is the way they spend money—7 percent of their spending went for sugar. As the authors write: A common image of the extremely poor is that they do not get to make many real choices....Yet among the non-food items that the poor spend significant amounts of money on, alcohol and tobacco show up prominently. The extremely poor in rural areas spent 4.1 percent of their budget on tobacco and alcohol in Papua New Guinea, 5.0 percent in Udaipur, India; 6.0 percent in Indonesia and 8.1 percent in Mexico.... Perhaps more surprisingly, it is apparent that spending on festivals is an important part of the budget for many extremely poor households. In Udaipur, over the course of the previous year, more than 99 percent of the extremely poor households spent money on a wedding, a funeral, or a religious festival. The median household spent 10 percent of its annual budget on festivals. In South Africa, 90 percent of the households living under $1 per day spent money on festivals. In Pakistan, Indonesia, and Cote d'Ivoire, more than 50 percent did likewise. Festivals are one way for the poorest and most degraded families to gain dignity for a day. But the best single investment to gain long-term dignity is education, and that's the way to break the cycle. As the authors of this article note, one reason for the underinvestment in education is that illiterate parents can't judge what investments in education will pay off. The pattern of misallocation of resources is confirmed by what I've seen in poor countries. It's routine to visit a family with a severely malnourished child (with consequences for the child's cognition if it survives), and find out that the family has some meager savings—but Dad is off drinking them up at a nearby bar. And this is dispiriting for a man to admit, but it's typically that way: abundant research shows that in poor families, women invest money in food, children, and small businesses—and men squander funds on cigarettes, alcohol, video halls, and prostitution. We should be clear: one smart way to fight poverty is to empower women (by educating girls, by giving daughters legal rights to inheritance, by promoting banking institutions that give women control over the accounts). Once mothers control family spending rather than fathers, family resources are invested more productively, and some families can rise out of poverty very quickly. This makes the fight for gender equality in the developing world not only a moral imperative but also an economic one. Aid groups recognize this and are adjusting their strategies. For example, Helene Gayle, the new head of CARE, is making empowerment of women—including microfinance—a major strategy because of its implications for fighting poverty.[3] Whether in the US or abroad, I always find grassroots antipoverty workers much more useful than "experts" in Washington. At the local level you see all the frustrations and complexities of overcoming pathologies of misplaced priorities, drugs, alcohol, broken families, violence, and vast webs of self-destructive behavior —including simply acquiescence. One of the great canards of modern life is that the poor are particularly grasping, always demanding entitlements. In fact, one of the problems in combating poverty is the opposite: the poor are far too willing to acquiesce. Vollmann writes that one of the characteristics of poverty is its invisibility —and he's right, because by and large the poor have been conditioned to retreat to the margins. When I was covering the aftermath of Hurricane Katrina in 2005, I spent my days in shelters with poor people who had lost everything while spending my nights with the family of a well-to-do doctor whose lovely home had been barely damaged (because it was well built and in a neighborhood located above the flood line). That's always the pattern. In a Bangladeshi cyclone, the hovels of the poor are swept away so that poor families lose their children and everything they ever owned—while the wealthy sit tight in concrete homes on higher land. In the Kobe earthquake in Japan in 1995, it was the poor who were crushed to death when their old houses collapsed; one rich family I visited at the epicenter had suffered little harm other than the destruction of its wine collection. Even when middle-class or wealthy families were displaced in, say, New Orleans, they mostly figured out how to get what they needed. For a start, they demanded it. Loudly. Insistently. But the people stuck in the shelters, black and white, were typically not only poorer but also less demanding, less assertive, less skilled in negotiating their way through the system. Poor families in the shelters were neglected precisely because they were suffering so patiently. After that experience, I caught myself thinking that the problem is not that the poor riot, but that they don't riot enough. The complexities of poverty have major implications for health care reform. A leader in emphasizing this is Dr. Irwin Redlener, president of the Children's Health Fund, a passionate advocate for medical care for the poor, who also was my guide in New Orleans. I had thought that the obstacle for poor people—and the reason they die as a result of deficient health care —was that they couldn't afford it. But that's only one factor. What we've seen over and over is that even if there is a free clinic, the poor family may depend on a single mother who doesn't have a car or driver's license and so can't get there. Or she can't afford the gas. Or her car doesn't have insurance. Or she doesn't understand how serious the symptoms are. Or she is working at a low-level job where she can't just ask for time off to take a child to the clinic. Or she doesn't speak English. Or she's illegal and is worried that INS agents may look at the clinic's records. Or she's got three other small children and can't leave two at home while she takes her sick child on a series of bus rides to the clinic. Or...the possibilities are endless. The point is that making medical care accessible to the poor requires much more than making it free. Poverty is connected, of course, to race. But in recent years we've learned that it's not exactly race, because blacks from the West Indies and newly arrived immigrants from Africa have often thrived in the US while traditional African-American descendants of slaves are more likely to be stuck in the whirlpool of poverty. There is, I think, a parallel with the minority of Japan, the burakumin, sometimes called the Untouchables of Japan. The burakumin are not a racial minority but an occupational one: they are the descendants of those who worked with leather, with dead bodies, or with dead animals. But they were no less shunned and discriminated against than American blacks, and when I lived in Japan I sometimes heard Japanese friends tell me that the burakumin "are not real Japanese." A few decades ago, burakumin were rarely invited into ordinary people's homes, they could never work in restaurants, they had little hope of marrying a non-burakumin, and they were almost universally ostracized. Even today, parents sometimes hire private detective agencies to research the backgrounds of their children's fiancés to make sure that burakumin blood does not creep into the family. The upshot was that burakumin felt excluded from the Japanese social compact, and they fell disproportionately into alcohol, drugs, divorce, and crime. The yakuza, Japan's criminal network, is overwhelmingly composed of burakumin and another ostracized minority, ethnic Koreans. It's hard to avoid the conclusion that when a society excludes a group and treats it as second-class citizens, then the result can be not only poverty as such but also self-destructive cycles of culture and behavior that make escape from poverty all the more difficult. Yet the story of global poverty is, in spite of what most people think, in some ways a surprisingly successful one. We focus on those who are still poor, but in the last quarter-century far more people have been pulled out of poverty than ever before in the history of the world. Largely that's because of the economic success of Asia, and it should give pause to critics of globalization. In fact, it's precisely because of globalization that hundreds of millions of Chinese, Indians, Indonesians, and Malaysians are moving into the middle class. Another new book on the subject, Understanding Poverty, a collection of essays by scholars, has both the depth and the data that Vollmann's book lacks. It's the kind of book that you can put down, but it's a serious examination of where we stand and what we need to do. An excellent opening chapter by the three editors—Abhijit Banerjee, Roland Bénabou, and Dilip Mookherjee—notes that in the period from the early 1980s to 2001, poverty rates fell by almost half: approximately 400 million people crossed the $1 threshold during this time [$1 a day is often used as a measure of extreme poverty; $2 a day is also often used]. This amounts to a fairly dramatic reduction in poverty. There is thus no basis for views, often expressed by protesters against globalization and privatization, that these trends have coincided with a rise in global poverty. Most of the poverty reduction happened in Asia, and particularly in China, which has experienced growing integration into the world economy and a rise in market forces. It's also worth noting that the part of the world that has most withstood the forces of globalization (or simply been ignored) is Africa, where the number of poor people doubled. The common perception of rising global inequality is true in a sense— but this is largely because entire nations have prospered while others have not; it is not because of rising inequality within poor countries. The gap between the world's wealthiest and poorest people is overwhelmingly accounted for by inequities from one country to another. In contrast, most nations appear to have reduced inequality within their borders (although this is not true of the US). The decline of poverty is not some gimmick or statistical ploy. Anybody who has traveled regularly in Asia has seen it. My wife, Sheryl WuDunn, is Chinese-American, and when we first visited her ancestral village in 1987, it was dirt poor and consisted mostly of illiterate peasants with fantastically crooked teeth (China then apparently had one orthodontist in the entire country). Now it has a paved road, the children go to school and aspire to college, the adults have cell phones and television sets, and people are starting to look plump. And the children's teeth are straight. The same transformation is evident across China, and in South Korea, Indonesia, Thailand, and elsewhere. It is now taking place in Vietnam, Cambodia, India, Bangladesh, and Pakistan. Africa has been left out, but even Africa has some countries with exceptionally strong economic performance, like Botswana, Rwanda, Mozambique, and Mauritius. After the fall of communism, there was a period when the former Soviet Union and Eastern Europe were spiraling down into penury. A few countries, like Moldova, Belarus, and Turkmenistan, are still wretched. But Russia, in large part thanks to its mineral resources, is booming. So are other parts of the former empire like Georgia, Armenia, and especially the Baltic Republics. Estonia is one of the most dynamic countries in Europe. Even in the US, for all the despair about poverty, the mid- and late-1990s saw remarkable drops in poverty rates. (The progress stopped in 2000.) So we should approach poverty with real hope. The last fifty years have shown that these problems have solutions—and that's why it's a bit frustrating that Vollmann is strictly a tour guide of the slums, without pointing more directly to the policies that will help. There's no magic bullet, but health interventions have been very successful. The US spent $32 million to fight smallpox over ten years, achieving eradication in 1977. Now we save that sum every two and a half months in reduced spending on vaccines and health care. Total savings have been $17 billion, plus 45 million lives around the world, and as an investment that $32 million has yielded a return of 45 percent per year. That's why we need similar campaigns against other diseases, including malaria, elephantiasis, and of course AIDS. Education has also proved an excellent investment, and we now know that the most cost-effective way to keep children in school isn't to ban child labor, to pass laws requiring school attendance, or even to build schools. Rather, it's to bribe parents with cash grants for keeping kids in school. Understanding Poverty cites improvements in school attendance rates of 20 percentage points by such programs. A large-scale Indonesian program to spread primary education in the 1970s is estimated to have paid returns equivalent to 10 percent per year. Likewise, microfinance was justly recognized as an outstanding antipoverty tool by the award of the Nobel Peace Prize to Grameen Bank in Bangladesh and its founder, Muhammad Yunus. Partly that's because microfinance often targets women, raising their status within societies and giving them more control over the family spending. In the US as well, we have a clearer sense of what policies work. Large-scale income distribution programs, such as welfare and public housing, weren't very successful, and that fed a cynicism and resignation about anti-poverty efforts. But in more recent years we've learned that in the US education is a critical path out of poverty. Early childhood education and intense schooling and tutoring make all the difference. Job training helps. After-school programs help. The earned-income tax credit raises incomes of poor families. These approaches aren't easy or cheap, but they work—and these costs of empowering poor people are cheaper than the alternative of incarcerating them in large numbers. The upshot is that we now have a much richer understanding of poverty than we did at the time of the launch of the War on Poverty, and a much better hope of success if we try again. We know that it's not just about more equitable distribution of assets, but that there are also crucial cultural issues to be addressed. We also have a better understanding of the tactics and policies that work, both in the US and in poor countries abroad. The remaining question is whether we have the will. Perhaps books like Vollmann's may at least remind us of the poor, removing them for a moment from invisibility, and help replace our current resignation with policies that would make a considerable difference. We are not going to eradicate poverty in our lifetimes, but we could make a much bigger dent in it—and that's important if you're one of the poor. As Albert Camus said in 1948: "Perhaps we cannot prevent this world from being a world in which children are tortured. But we can reduce the number of tortured children." In the meantime, today another 30,000 children will die of the consequences of poverty. And as dusk falls in Africa and Asia, aching parents will struggle to decide which of their children to put under the mosquito net and which to expose to malaria. Notes [1] Viking, 2004; reviewed in these pages by Christopher Jencks, December 15, 2005. [2] See The Journal of Economic Perspectives, Vol. 21, No. 1 (Winter 2007). The article can be found at http:// econ-www.mit.edu/faculty/download_ pdf.php?id=1346. [3] For a discussion of how women's empowerment and microfinance programs are being used to address public health issues in rural African villages, see Helen Epstein and Julia Kim, "AIDS and the Power of Women," The New York Review, February 15, 2007. --- 3. HPV Vaccine Also Guards Against Vulval And Vaginal Cancer By Crystal Phend, Staff Writer, MedPage Today Reviewed by Zalman S. Agus, MD; Emeritus Professor at the University of Pennsylvania School of Medicine. May 17, 2007 (Caution, this study, like many others done on the vaccine, was industry funded) Young women given the vaccine had 71% fewer high-grade vulval and vaginal lesions associated with HPV types 16 and 18 than those not vaccinated, regardless of exposure, reported Jorma Paavonen, M.D., of University Central Hospital here, and colleagues in the May 19 issue of The Lancet. The industry-funded report adds to mounting evidence on the efficacy of the vaccine in preventing cancers. Other groups reported in the May 10 issue of the New England Journal of Medicine that the vaccine was nearly 100% effective against cervical cancer-causing HPV types 16 and 18 at three years and also reduced the risk of throat cancer. Dr. Paavonen and colleagues reported three-year follow-up of three randomized clinical trials. The studies included 18,174 women ages 16 to 26 from 24 countries across four continents. These women were randomized to receive either placebo or the quadrivalent vaccine against HPV genotypes 6, 11, 16, and 18 at baseline and two and six months later. Placebo consisted of the aluminum hydroxyphosphate sulfate adjuvant used in the vaccine. Participants also underwent repeated anogenital examination over two years. Biopsy and HPV type-specific DNA testing were done on any suspect lesions. After a mean of three years of follow-up, the findings for high-grade vulval intraepithelial neoplasia (VIN2-3) and vaginal intraepithelial neoplasia (VaIN2-3) were: * 100% efficacy against lesions associated with HPV16 or HPV18 among susceptible women not previously exposed, the per-protocol population (no cases versus 15 in placebo group). * 71% efficacy against lesions associated with HPV16 or HPV18 in the intention-to-treat population, including women who were previously exposed to HPV (nine versus 31 cases). * 49% efficacy against lesions regardless of causal HPV type or exposure in the intention-to-treat population (27 versus 53 cases). Five trials and two adolescent studies assessed safety, typically assessed with report card-style surveillance for 14 days after each vaccine or placebo injection. Overall, only 0.1% of participants discontinued due to adverse events, and 0.06% reported a serious systemic adverse event judged to be vaccine related. The most common vaccine-related adverse reactions were fever (10.3% versus 8.6% placebo), nausea (4.2% versus 4.1%), dizziness (2.8% versus 2.6%), injection-site pain (83.9% versus 75.4%), swelling (25.4% versus 15.8%), erythema (24.6% versus 18.4%), and pruritus (3.1% versus 2.8%). The 71% efficacy rate was the best estimation "of the potential public-health benefit of an effective HPV vaccine," the investigators wrote. However, while the trials included "a broad representation of women from developed and developing countries," they under-represented women who had had more than two sexual partners, those with a history of abnormal pap tests, and those with genital warts. "From this perspective, this low-risk population of enrolled women might not be fully comparable to the general population," Dr. Paavonen and colleagues wrote. Nonetheless, the results are encouraging because vulval cancer has been on the rise in younger women, almost always in association with HPV, the researchers said. In the analysis, 64% of cases of high-grade vulval intraepithelial neoplasia in the placebo group were due to HPV16. "This trend is worrying because these cancers are not amenable to a screening program," they added. For both vulval and vaginal cancers, precursors are often missed and treatment typically consists of mutilating surgery, they said, so prevention offers real benefit to women. "However, the real benefits to individuals and society will need to be weighed against the costs in a formal economic assessment of the vaccine," the investigators concluded. The study was funded in its entirety by Merck, maker of Gardasil. Dr. Paavonen reported receiving research grants from Merck through his hospital to conduct a clinical trial of this vaccine. He has also received consulting and lecture fees from Merck and served on Merck's paid advisory boards. Other researchers also reported financial links with Merck and a variety of other companies, including Commonwealth Serum Laboratories, GlaxoSmithKline, Sanofi Pasteur, Digene, Frosst, and Roche Diagnostics. Several researchers are employees of Merck and hold stock or stock options in the company. --- 4. [U.S. Largest HMO] Kaiser Agrees To Reforms In Settlement Of Homeless Dumping Case By ANDREW GLAZER, Associated Press - May 15, 2007 Los Angeles More than a year after an elderly Kaiser hospital patient was found wandering crime-ridden Skid Row in a hospital gown and slippers, the nation's largest HMO agreed in a settlement with the city to reforms aimed at ending the dumping of homeless patients on local streets. Kaiser Permanente will create new protocols for discharging homeless patients in its chain of hospitals, train staff and allow retired U.S. District Court Judge Lourdes G. Baird, a former U.S. attorney, to monitor its progress, officials said Tuesday. Carol Ann Reyes, 64, was discharged from Kaiser's Bellflower hospital in March 2006 and dropped off by a taxi outside the Union Rescue Mission. She wandered around, apparently confused, for several minutes until mission staff took her in. City Attorney Rocky Delgadillo filed criminal charges in November and said he wanted to send a message to hospitals nationwide engaged in patient dumping. Los Angeles authorities are investigating allegations that a dozen area hospitals have dumped more than 50 homeless patients downtown. Kaiser faced criminal false imprisonment charges and civil claims related to the mistreatment of Reyes. As part of the settlement, Kaiser will pay $5,000 in civil penalties, $50,000 in investigative costs to the city attorney's office and contribute $500,000 to a charitable foundation benefiting local homeless programs. Kaiser previously denied any wrongdoing. Kaiser spokeswoman Diana Bonta said in November that hospital staff had called a taxi to take Reyes to Skid Row, but called ahead to the mission to let staff know she was on her way. Dr. Benjamin Chu, president of Kaiser Permanente's Southern California region, said Tuesday the release of Reyes was a breakdown in existing hospital protocol and an aberration. "I don't think the policies and procedures were wrong," he said. "They just weren't as tight as we'd like them to be." The settlement, he said, was "an example of what can happen when people of good will sit down together." Mark Rosenbaum, legal director of the American Civil Liberties Union Foundation of Southern California, said the lawsuit and settlement called attention to a rarely addressed nationwide problem. "What happened to Ms. Reyes was disgraceful and this agreement will help bring dignity back to the treatment of homeless people in this city's hospitals," he said. --- 5. Clinton Is Quiet On Her Past Role With Wal-Mart By Michael Barbaro - May 20, 2007 -NY Times In 1986, Sam Walton, the founder of Wal-Mart, had a problem. He was under growing pressure from shareholders — and his wife, Helen — to appoint a woman to the company’s 15-member board of directors. So Mr. Walton turned to a young lawyer who just happened to be married to the governor of Arkansas, where Wal-Mart is based: Hillary Rodham Clinton. Mrs. Clinton’s six-year tenure as a director of Wal-Mart, the nation’s largest company, remains a little known chapter in her closely scrutinized career. And it is little known for a reason. Mrs. Clinton rarely, if ever, discusses it, leaving her board membership out of her speeches and off her campaign Web site.According to fellow board members and company executives, who have rarely discussed her role in Wal-Mart, Mrs. Clinton used her position to champion personal causes, like the need for more women in management and a comprehensive environmental program, despite being Wal-Mart’s only female director, the youngest and arguably the least experienced in business. On other topics, like Wal-Mart’s vehement anti-unionism, she was largely silent, they said. Her experience on the Wal-Mart board, from 1986 to 1992, gave her an unusual tutorial in the ways of American business — a credential that could serve as an antidote to Republican efforts to portray her as an enemy of free markets and an advocate for big government.But that education came via a company that the Democratic Party — and its major ally, organized labor — has turned into a political punching bag, accusing it of offering unaffordable health insurance and mistreating its workers. So rather than tout her board membership, Mrs. Clinton is now running from it, even returning a $5,000 campaign donation from the giant discount chain in 2005, citing “serious differences” with its practices. But disentangling herself from the company is harder than it may seem. Despite her criticism, Mrs. Clinton maintains close ties to the Wal-Mart executives through the Democratic Party and the tightly knit Arkansas business community. Her husband, former President Bill Clinton, speaks frequently to Wal-Mart’s current chief executive, H. Lee Scott Jr., about issues like health care and even hosted Mr. Scott at the Clinton’s home in New York in July for a private dinner. And several months ago, Mrs. Clinton helped broker a secret meeting between a top Wal-Mart executive and former Democratic operative, Leslie Dach, and leaders of the retailer’s longtime adversary at the United Food and Commercial Workers union, according to several people briefed on the matter, who spoke on condition of anonymity because they were not authorized to do so publicly. The goal of the meeting was to tamp down the rancor between the company and the union, which has set up a group, WakeUpWalmart.com, that has harshly criticized the chain and leaked embarrassing internal documents to the news media, though little progress has been made. Mrs. Clinton declined to be interviewed for this article. In a statement, her spokesman said, “Wal-Mart is now one of the country’s largest employers, and Mrs. Clinton still believes it is important to try to influence the decisions they make because they can affect so many people.” In Mrs. Clinton’s complex relationship with Wal-Mart , there are echoes of the familiar themes that have defined much of her career: the trailblazing women, unafraid of challenging the men around her; the idealist pushing for complicated, at times expensive reforms; and the political pragmatist, willing to accept policies she did not agree with to achieve her ends. “Did Hillary like all of Wal-Mart practices? No,” said Garry Mauro, a longtime friend and political supporter of the Clintons who sat on the Wal-Mart Environmental Advisory Board with Mrs. Clinton in the late 1980s and worked with her on George McGovern’s campaign for president. “But,” Mr. Mauro added, “was Wal-Mart a better company, with better practices, because Hillary was on the board? Yes.” Mrs. Clinton was not Mr. Walton’s first choice. That honor belonged to a female executive at Nordstrom, the upscale department store. But Nordstrom opposed the idea of its employees sitting on a competitor’s board, so Wal-Mart turned instead to the 39-year-old Mrs. Clinton. They offered her about $15,000 a year for her time, generally four meetings a year. She was a logical candidate: the wife of the governor, a Wal-Mart shareholder — with stock worth nearly $100,000 at one point — and a highly regarded lawyer at the Rose Law Firm, which had represented Wal-Mart in several cases. But if her circumstances made her a natural choice for the board, her often liberal beliefs did not and she struggled to change the rigid, conservative culture at Wal-Mart, achieving modest results. Early in her tenure, she pressed for information about the number of women in Wal-Mart’s management, worrying aloud that the company’s hiring practices might be discriminatory. The data she received would have been troubling: by 1985, there was not a single woman among the company’s top 42 officers, according to “In Sam We Trust,” the 1998 book about Wal-Mart by Bob Ortega. John E. Tate, who served as a director with Mrs. Clinton from 1988 to 1992, recalled that by the third board meeting Mrs. Clinton had announced “that you can expect me to push on issues for women. You know that. I have a reputation of trying to improve the status of women generally, and I will do it here.” Mr. Walton appeared relieved to have a woman on the board to deflect criticism, telling shareholders during the annual meeting in 1987 that “we have a strong willed young lady on the board who has already told the board it should do more to ensure the advancement of women.” Still, the board’s discussions did not translate into significant progress. By the late 1990s, after Mrs. Clinton had left the board, Wal-Mart had added a second female director, but the number of women in senior management remained paltry, according to company records. (Today, 23 percent of Wal-Mart’s top 300 corporate officers are women, but the company is fighting a lawsuit claiming sex discrimination by 1.6 million current and former female employees.) Mrs. Clinton had greater success on environmental issues. At her request, Mr. Walton set up an environmental advisory group, which sent a series of recommendations to the company’s board. When it came time to pick members, Mrs. Clinton, who led the advisory board, reached out to at least two colleagues from the 1972 McGovern presidential campaign — Mr. Mauro and Roy Spence, who headed an advertising firm in Texas that did extensive work for Wal-Mart. Under her watch, the advisory group drew up elaborate plans. Consumers would bring in used motor oil and batteries for recycling. Suppliers would reduce the size of their packaging. And Wal-Mart would build stores with energy-saving features. Wal-Mart executives put much of the program into place. In 1993, for example, they opened an experimental “eco-store” in Kansas, with dozens of skylights and wooden beams from forests that were not clear cut. One executive derided it as “Hillary’s store” because it was more expensive to build than the average Wal-Mart, but several of its features, like the skylights that cut energy bills by the need for artificial lighting, were widely copied across the industry. “We were on the leading edge of something that is being mandated now,” said Bill Fields, the head of merchandise at Wal-Mart in the early 1990s who worked closely with Mrs. Clinton on the environmental project. For Wal-Mart, the largest employer in Arkansas, Mrs. Clinton’s presence had obvious advantages: on matters big and small, the company had the ear of the governor’s wife. For Mrs. Clinton, being a director at Wal-Mart gave her access to several of the state’s most powerful business executives. In the early 1980s, for example, Mr. Waltonhad been instrumental in building support for a corporate tax program, pushed by Mrs. Clinton, that financed a major education reform plan in Arkansas, a signal achievement of her husband’s governorship. Though she was passionate about issues like gender and sustainability, Mrs. Clinton largely sat on the sidelines when it came to Wal-Mart and unions, according to board members. Since its founding in 1962, Wal-Mart has aggressively fought unionization efforts at its stores and warehouses, employing hard-nosed tactics — like firing union supporters and allegedly spying on employees — that have become the subject of legal complaints against the company. A special team at Wal-Mart handled those activities, but Mr. Walton was vocal in his opposition to unions. Indeed, he appointed the lawyer who oversaw the company’s union monitoring, Mr. Tate, to the board, where he served with Mrs. Clinton. During their meetings and private conversations, Mrs. Clinton never voiced objections to Wal-Mart’s stance on unions, according to Mr. Tate and John A. Cooper, another board member. “She was not an outspoken person on labor, because I think she was smart enough to know that if she favored labor, she was the only one,” Mr. Tate said. “It would only lesson her own position on the board if she took that position.” Mr. Tate, a prominent management lawyer who helped stop union drives at many major companies, said he worked closely with Mr. Walton to convince workers that a union would be bad for the company, personally telling employees when he visited stores that “the only people who need unions are those who do not work hard.” A spokesman for Mrs. Clinton said, “Wal-Mart workers should be able to unionize and bargain collectively.” --- B Upcoming Conferences and Events The 2007 International Drug Policy Reform Conference December 5-8, 2007 Working Toward a New Bottom Line December 5-8, 2007 ~ Astor Crowne Plaza ~ New Orleans, LA ~ The Drug Policy Alliance's International Drug Policy Reform Conference is the world’s principal gathering of people who believe the war on drugs is doing more harm than good. No better opportunity exists to learn about drug policy and to strategize and mobilize for reform. For more information, please click here. --- C Quote Prison continues, on those who are entrusted to it, a work begun elsewhere, which the whole of society pursues on each individual through innumerable mechanisms of discipline. Michel Foucault --- 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! PLEASE CLICK HERE TO DONATE or call 801-355-0234 ext 1# for more information. --- E About HRP The Harm Reduction Project works for the enhancement of services available to marginalized populations. HARM REDUCTION PROJECT | SALT LAKE CITY | TEL (801) 355.0234 FAX (801) 355.0291 | 235 West 100 South, Salt Lake City, Utah 84101 HARM REDUCTION PROJECT | DENVER | TEL (303) 572.7800 FAX (303) 572.7800 | 775 Lipan Street, Denver, Colorado 80204 www.harmredux.org