tinypliny - 12/31/08 11:07
oops. ^not intending to pour it down the drain in bulk!

tinypliny - 12/31/08 11:05
@(e:zzzzoooobbbbaa)rrr: Be bothered. BE REALLY BOTHERED! ;)

@(e:drew): I am not sure which post that was... I am a sucker for skeletal accessories. (pun totally intended!)

@(e:libertad): I am glad you liked it. :) Though now seeing yours and (e:mike)'s comments, I am somewhat freaked out that I am being psychoanalysed and judged this minute by my groceries!!! And yes, it is the evil works. I got it because it has hydrochloric acid in it and I wanted to scrub the rust off of my bathtub. Its been annoying me for a while now. Bleach isn't doing much for it so I figured it was some limey hard-water deposit + rust. HCl does a good job of melting any Ca-Chloride or Ferrous Oxide complexes. I know it is toxic but I am intending to pour it down the drain in bulk. It actually melts away any rust and if pipes are old and rusted along the way, there is a chance that it might eat through them. It does not harm intact steel/copper. Maybe if the pipes are rusted, they need to be replaced?

@(e:mike): You are welcome! :) I share your guilty pleasure as well. Mostly, I don't have a grocery list and I try and look at people's carts to see if I might have missed something. Hehehe.. Sometimes I buy new things because people ahead of me have those things in their carts! It sounds crazy but a lot of times I remember stuff that I have forgotten to buy or try new things that I never would have otherwise.

@(e:metalpeter): LOL. What did you say about bones and milk in that post?? Now, I am curious! Fat-free milk has all the other components - proteins, carbohydrate sugars, minerals (Calcium etc.) and added Vitamin D. They just take out the fat and reserve it for other purposes such as cheese making, processed foods etc. Yes, I know. Real baking is such fat-ridden orgy. I guess that's why I think I can never be a good baker. I don't generally use milk in my cooking. There are one or two Indian speciality dishes that call for whole milk but I never make them because they also require copious amount of sugar - something I never have.

The furry creature is a hamster.

Yeah, you make an interesting point. We struggle with that very question of precise dietary assessment in all the measurement techniques we use in nutritional epidemiology.

metalpeter - 12/27/08 15:03
(e:drew) I don't really like re looking at that picture my self (with the paper), HA.

(e:tinypliny) I do have one question that I don't get, if you have no fat that what is in the milk?, HA. Don't forget if you use it to cook you have to somehow make up for the fact that there isn't any fat even with 2%. My other question is what was that furry creature? That video led me to see some ad for a think a gum that took me to other Booby videos.

On a side note looking at what people buy when at a store like Wegmans can kinda tell something about them or there eating habits, but you don't know if they are buying for them selves and if so for how long of a time so you kinda have to guess.

mike - 12/27/08 13:29
i love looking in people's grocery carts. It does explain so much about them! tahnks for the insight into your life!

libertad - 12/27/08 12:45
I love looking at other people's groceries. You can tell so much about a person by what they are buying. Thanks for letting us be grocery voyeurs. I have to ask. Is that toilet bowl cleaner non-toxic or is it the one called "the works" which is super toxic?

drew - 12/27/08 12:13
Great post. Was that milk glass based on an infamous (e:metalpeter) post? (No, I am not going to look up the permalink. Sorry Peter, don't need to see that again)

zobar - 12/27/08 11:20
I'm vaguely bothered by the smiling gut flora.

How long does it take you to write & illustrate these?

- Z

libertad - 12/26/08 22:47
Oh I miss Calvin and Hobbes. The snowmen are the best! Some of them are so morbid too, like snowmen who have hung themselves.

james - 12/17/08 12:14
Thank you for putting all the work into this Tiny. It is a very interesting read.

tinypliny - 12/16/08 22:37
And just because all this is so absorbing, you might find this paper by the moral-king of PEPFAR (who was later involved in consorting with prostitutes) pretty interesting: :::link:::

More interesting are 7 almost paper-length machine-gun fires against the moral-king's paper from a team of researchers that reads like a whos-who of current HIV research coming from not only all ivy-league elite schools here, but also from distinguished departments and schools across the world. :::link:::

And of course, the moral-king's response that leaves you wondering what kind of weirdo had been put in charge of applying the $15 billion aid. And the obvious question as to what kind of politician chooses such a damaged individual as the head of such an enormous fund management.

tinypliny - 12/16/08 22:16
I agree COMPLETELY about core lab science not making sense to the general population. I also agree about the education measures. But I think that science is not some isolated thing that scientists do in labs. Science and research also involves understanding how best to implement what we have learnt in our laboratories in the most effective and painless way in populations. People are not going to listen when I tell them to wear a condom because a million epidemiological studies have shown it to be effective. People are definitely going to be listening when a patient with an ulcer tells them how he has not be wearing a condom. Science is not a remote process. Its personal and its anecdotal when its applied to populations. Community and peer involvement in interventions are priceless in public health. Education is all fine but NOTHING beats peer-related personal anecdotal evidence applied to public health on an individual basis.

Yes, I do bicker about the efficacy of the program because of the attached clauses. I agree that its really generous to invest this amount of money in altruistic pursuits. I agree that it takes a great deal of compassion to do this. I agree that we should be viewing Bush in a sympathetic light. But at the same time, I do not appreciate squandering the scientific merits of such an altruistic donation to accomodate politically-driven and culturally inappropriate clique-pandering clauses that damage the impact of such a huge financial committment.

tinypliny - 12/16/08 22:13
The study you linked is really interesting from an epidemiological point of view. Let's look at the results of this study carefully. Just so we are on an even footing, I am going to only dissect the pubmed-accessible abstract here. (Let me know if you want to discuss the whole paper.)

From the study:
"Reported condom use was low, with the proportions of men and women who reported frequent condom use with all non-spousal partners being 21-25%, for men and 11-24% for women."

--> Note how the condom usage reported by women during the interview start from 11% (nearly half that for self-reports from men). Why is that? Aren't the women able to convince their "non-spousal partners" to wear a condom? What does this indicate? Why would men in the same population say that they wore a condom relatively more times than what women claim? How many of these men were homosexual? Were these findings stratified by sexuality?


From the study:
"A higher level of condom use by city was not associated with lower aggregate level of HIV infection."

Brilliant. TWO hedge words in one sentence. First hedge word "by city" - not the ideal "by individual". Second hedge word "lower aggregate level" - not the ideal just "HIV infection in an individual". While a hedge-free statement: "A higher level of condom use in individuals was not significantly associated with consequent HIV infection." implies just that, the way the authors phrased it implies that the usage of condoms by a city as a whole is not associated with the level of HIV infection in the population of that city as a whole. This is a classic ecological fallacy in epidemiological studies. More on the mechanics of an ecological fallacy at this :::link::: So this statement doesn't really mean anything. At this point I was looking for a reason why this study actually got published in AIDS - a journal with relatively good readership in HIV research circles. Read on further.


From the study:
"The proportions of men reporting genital pain or discharge during the past 12 months were significantly lower among those reporting frequent condom use in all sites except Yaoundé: in Cotonou, adjusted odds ratio (OR) = 0.28, 95% confidence interval (CI) = 0.09-0.94; in Kisumu, adjusted OR = 0.34, 95% CI = 0.14-0.83; and in Ndola, adjusted OR = 0.33, 95% CI = 0.12-0.90." - (1)

Check. At an individual level, genital pain/discharge (obvious symptoms of most STDS) were lower with lower condom use in all but one study centre.

"The same association was found for reported genital ulcers in two sites only: in Cotonou, adjusted OR = 0.14, 95% CI = 0.02-1.02; and in Kisumu, adjusted OR = 0.18, 95% CI = 0.04-0.75." - (2)

Check. Genital ulcers are a symptom of more advanced STDS. So this finding makes sense. The study subjects are not coming from a hospital-based setting where you would expect to find people with more advanced disease. It is coming from a population-based sampling frame. Thus you would expect to find more low-level "tolerated" symptoms (pain/discharge) in a population. Had they had more advanced disease (manifested by ulcers and sores), they would have reported to heathcare and be in a hospital - and thus not be in this study. Naturally, they found a low association between advanced disease and condom use. The real population-wide association would only be clear, had they included equal proportions of study-subjects representing the full range of severity of the disease (mild to advanced) - which would have meant, recruiting from the hospitals as well - which they didn't do.

From the study:
"There were few statistically significant associations between condom use and biological indicators of HIV infection or other STDs in any of the cities."

OH REALLY? Did they just forget what they said in finding (1) and finding (2)???? Come on! And what other "biological indicators" (apart from pain/discharge/ulcers) did they examine? Why didn't they include them in the results??

From the study:
"Similar levels of condom use were found in all four populations, and aggregate levels of condom use by city could not discriminate between cities with high and low level of HIV infection."

Again, the use of hedge words to construct ecologically fallacious conclusions. WHY in the world did they interview each person in this study if they wanted to clump conclusions of a whole city together and compare it against an aggregate of all HIV tests together? The reasoning eludes me.

From the study:
"It seems that rates of condom use may not have been high enough to have a strong impact on HIV/STD levels in the four cities."

Finally, a sane concluding statement. YES. and agreed. YOU NEED PROGRAMS TO INCREASE CONDOM USE!

From the study:
"At an individual level, only a male history of reported STD symptoms was found to be consistently associated with lower rates of reported condom use."

YES. The lower the reported condom use, more were the reported STD symptoms. The women did not have this association because, as noted in the results of the study the women who reported condom usage in their partners varied from 11% to 24%. When compared to the male proportions -> 21% to 25%, the range in the women is pretty wide. I am guessing that this would dilute measures of association between your exposure and your outcomes.

If you are not convinced, take a careful look at the 39 odd studies that have cited this study: :::link:::

tinypliny - 12/16/08 22:09
First, to answer (e:Joshua) :) (and I think I will have to do this in three parts!!) Here goes...

Excellent arguments, and here is a small counter-argument. :)

You say that my arguments assume an element of Western social thought. On the contrary, I was arguing against western social thought in the implementation of any anti-HIV program. I did bring up gender inequality as one of the driving forces of the epidemic, but I never said that trying to erase this inequality using western methods was an effective way to combat HIV because (and pardon my "Un-American" "Non-feminist" "Chauvinistic" view here) it does not work that way in societies within the "developing" world. Western approaches to gender inequality are completely off the target in countries like India.

I think I would not be off the mark if I said that the Indian experience with HIV is a lot closer to the African experience than say, a US or a European experience. I am not just talking out of my experience being involved in AIDS related healthcare in India (yeah, for those interested, this is how I have known quite a few genuine hookers on a personal basis and respect them) From 1984 or so, if you look at the primary research journals for AIDS, most of the study populations have been from Africa and other "developing" countries. A search for HIV research on African populations in pubmed bears this out. :::link::: There have been nearly 1500+ reviews and 16,000+ peer/non-peer reviewed research articles from that continent. Nearly 4000 of these articles have research elements incorporating behavioural research. :::link:::

I don't think any epidemiologist (who usually help in drafting federal research grant funding for epidemic diseases such as HIV) would have been happy or quiet if the program had proposed funding for interventions that were not culturally applicable to another continent. In fact, the PEPFAR, because of its massive budget has been scrutinized to hell - so much so that a complete book exists on the findings (including references used as a basis to the initial funding initiative -> :::link::: ) . These are the conclusions of the relatively bias-free impact finding mission. :::link:::
I admit I have not read this book, (Maybe a good read, when you finish your Obama book. We could have a book club. ;) ). However, the results of this impact finding mission are clearly visible in the sensible 2008 ammendments to the PEPFAR. What I did read was this report on the program evaluation, as a whole for 3 similar programs including PEPFAR. :::link:::

So, no I wasn't using non-representative studies to make my argument. Like you so nicely put, I was trying to say:
"Use the science, but apply it in a way that will be most effective to Africa." So the Bush program did everything right - except for one major Bushoid western social(ly-conservative) agenda that was tacked on to the program without evidence or research that imbalanced all the rest of the researched program implementation - the anti-prostitution pledge and the assumption that the western religion-influenced abstinence guilting tactics would work just as well in Africa as they (apparently) "work" here. And you know what? I think it was essential for the program funding to have passed here. The clearly insular administrators who controlled the implementation of the PEPFAR bill when it was brought to vote initially, would NEVER have agreed to a $15 billion charity if it were not for this insane oh-my-god we-got-to-push our-righteous-morality-on-a-whole-continent clause in the bill. So yes, this pledge served its purpose and the bill got approved and implemented. But that single clause and the whole abstinence-faith charade that went with it was not "applying the science so it might be most effective in Africa". It was not science at all. It was politically driven moral-religious agenda. AND forget Africa, its not even effective here!

metalpeter - 12/16/08 20:46
I will admit that I don't know much about this. But from one documentary I saw (Henry Rollins) a small part of it was about this guy who was HIV positive who went to a clinc to get meds for his HIV and now he tells other people, I guess in South Africa there is a stigma about being HIV positive. I think that is a factor that needs to be addressed. People who are positive or who maybe need to be able to talk to others and spreed the word this might also help prevent some cases and help make things better. On a side note it is nice to see Bush trying to Help Africa, but I don't think it was his Idea, I think he was just the money guy, or he thought well people want to make it so AIDS Medication is Cheap over there, I better make sure it given out on a moral basis. I can't say if what he did made things better or worse. But it would be nice if he would have cared about the poor people in this country. Onto the shoe thing since that is what started it all. The media guy should have thrown a Camera instead. I can understand hating Bush. But you are still a member of the press, the least you can do is ask a tough question like "hey asshole who invited you, you allready fucked up the Iraq, why are you coming back to pour salt in our wounds". Throwing a shoe isn't the way to go, even though it couldn't really hurt anyone.

heidi - 12/16/08 19:41
I'm not at all a researcher in this area but I do occasionally read stuff in it. In Uganda, pre-Bush, they were seeing a DROP in HIV rates, but during the Bush years their thoughtful Abstinence, Be Faithful, Condoms prevention program is no longer supported, in fact, the emphasis in Bush's program * 55% of the money * is/was on giving $ to pharmaceutical companies to spread anti-viral drugs around "developing" countries, with only 20 percent of the appropriation going to prevention, and major chunks of that prevention funding went to faith-based orgs with no assurance that they were giving accurate information.

• quote*

Incorporated in that law were requirements that at least one-third of all HIV prevention funds be reserved for abstinence-until-marriage programs; that nongovernmental organizations adopt a position opposing prostitution and sex trafficking in exchange for PEPFAR funding; and that faith-based organizations be given priority in receiving funding, without regard to their willingness to provide truthful information about the effectiveness of condom use in preventing HIV, if they provide any information about condoms at all.

• end quote*
  :::link:::

It was a chance to spread the anti-abortion and anti-prostitution/sexworker ideologies rather than any common sense HIV prevention - Bush gets the glory you're heaping on him, but for what??? He hasn't DONE $15bn of help. The Ugandan program wasn't a Western-led one, it was Uganda's invention. Your claim that condoms are just a Western idea that's being pushed on ignorant Africans is just not accurate and its really condescending.

Success in Uganda

• quote*

Measuring sexual behavior change. Among public health experts, it is by now generally agreed that during the critical time period between the late 1980s and mid-1990s, positive changes in A, B and C behaviors occurred and that all of these changes played a role in reducing HIV rates. Uganda's HIV prevalence steadily increased until about 1991, when it peaked at about 15% (30% among pregnant women in urban areas). It then turned sharply downward through the mid-1990s and reached 5% (14% for pregnant urban women) by 2001.

The findings of an analysis released by The Alan Guttmacher Institute in November 2003, A, B and C in Uganda: The Roles of Abstinence, Monogamy and Condom Use in HIV Decline, are consistent with the current consensus. Between 1988 and 1995, the time period during which HIV prevalence was declining, key changes in behavior occurred.

• Fewer Ugandans were having sex at young ages. The proportion of young men who had ever had sex decreased substantially and the median age at which young women began having sex rose from 15.9 in 1988 to 16.3 in 1995. Importantly, however, among those people who were having sex, overall levels of sexual activity did not decline.

• Levels of monogamy increased. Sexually active men and women of all ages, particularly the unmarried, were less likely to have more than one sexual partner in a 12-month period in 1995 than in 1989. Other research has found that the proportion of men reporting three or more sexual partners also fell during the period.

• Condom use rose steeply among unmarried sexually active men and women. Among unmarried women who had had sex in the last four weeks, the proportion who used condoms at last intercourse rose from 1% in 1989 to 14% in 1995; among unmarried men, condom use rose from 2% to 22%.

• end quote*

:::link:::

For more history on Bush's HIV agenda:
:::link:::

libertad - 12/16/08 19:30
That is so interesting Tiny! I'm glad that you posted it as a journal rather than a comment.

joshua - 12/16/08 18:42
Thanks for posting in response to me. When you say "when you donate $15B to a cause, etc. etc." I tend to agree... and that goes for anything the government spends money on.

My problem with your argument is that, while certainly scientific minded, it assumes an element of Western social thought that I don't think is appropriate, or in some cases, is potentially inapplicable. For example, you've brought up gender inequality and the need for needles/condoms. That, in my estimation, is the application of a modern Western solution for a problem rooted in medieval thinking and poverty (which I think you have 100% right, incidentally) in Africa. I don't quarrel with any of the suggestions you've brought about regarding what the studies show, but I don't believe that such studies, most if not all of which have been completed in modern industrialized countries, reflect the reality of the situation in Africa.

In other words, I don't think using these studies as a reference to fix the problem as it is in Africa is entirely appropriate. Use the science, but apply it in a way that will be most effective to Africa. For example - here is an abstract of a study in Africa :::link::: which found that higher usage of condoms didn't affect HIV infection rates. This is why we can't waltz into the continent and expect results similar to what is found in studies outside of Africa.

You're right in mentioning the complexities of the social aspect - perhaps more education will help people to understand the dangers of their own health and how to help themselves. But we have to remember, this is a place where by and large the world of science that you live in doesn't even exist. How do explain microbiology and how it affects the human body to people that aren't even close to being sophisticated enough to understand the information? Personally, I think the education aspect will be the key. Condoms, etc. are fine but without some illumination those people won't give two shits about what the scientists say.

Finally - while you may bicker with how the program has worked, the fact still remains that no organization, politician or private individual (even Bill Gates and his foundation - my cousin's wife is working on his malaria project) has done as much for the cause as President Bush - for that matter, it isn't even close. NGOs and scientists are always going to bicker about how the program is implemented. And it has and will continue to save lives, and he should be given credit for it. At this point, the question is what else can be done and how should it best be accomplished, taking into consideration the environment and what will be most effective in that environment.

heidi - 12/16/08 13:13
omg! I have to see this!!!! It looks hysterical! (Have I ever mentioned that Kung Fu Hustle and Drunken Master or any Jackie Chan movie rank among my favs?)