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A Modern Bugbear, HIV Transmission, The Economist, April 10th 2008

Using the law to contain infections may do more harm than good.

AT FIRST blush the bigwigs at the Health Protection Agency, which monitors diseases, could have told a rosier story. On March 28th they reported that sexual-health clinics diagnosed 8% fewer HIV infections last year than in 2006. But Britain's epidemic is not fading, they insisted. New infections among gay men and straight people are close to all-time highs; falling infections among heterosexuals who caught the virus in Africa account for almost all of the decline (see chart).

There are more ominous trends than these. Britons' understanding of the risks has gradually worsened over the past decade or so. In January a poll by Ipsos MORI found that more than two out of five Londoners do not know that sex between men carries a chance of transmitting HIV. Lately, says Yusef Azad of the National AIDS Trust, a charity, the proportion of gay men having unprotected sex who give blood for a syphilis test but refuse to do so for a HIV test has gone up.

Is this complacency or dread? Mr Azad worries that some gay men may shirk free HIV checks because they fear a positive result could incriminate them in future. Since 2001, 13 people in Britain have been convicted of reckless grievous bodily harm (reckless injury in Scotland) for spreading HIV to their partners. Because recklessness involves taking a known risk, eschewing knowledge of the danger probably averts a court case.

Doctors and campaigning groups such as the National AIDS Trust say that the legal system creates muddled disincentives for public health. One man without a biochemical diagnosis of his status has been convicted after he ignored advice from a clinician and his South African wife that he should get one. But because a court in Liverpool also found him guilty of bigamy and fraud, with all the charges bundled together, his case provides an iffy precedent, if one at all.

The World Health Organisation has branded British police tactics "objectionable" and bemoaned the courts' feeble understanding of virology. Until 2006 prosecutors bedazzled defendants into pleading guilty by waving lab reports of the genetic similarities between the virus in their blood and in their accuser's. Yet such data cannot rule out other possibilities, for example that the accuser really infected the accused or a third party infected both. Sarah Porter, one "AIDS assassin", as the tabloid press often brands those found guilty, may have been wrongly convicted, reckons Matthew Weait, a law lecturer who has written a book on the criminalisation of HIV transmission.

Chaos might be expected given that the law employed in such cases was written before doctors fully grasped that germs caused contagious diseases. It is also why the Crown Prosecution Service recently provided formal guidance. A policy statement published on March 14th makes clear that genetic data will always form part but never the entirety of case evidence. Moot points remain, such as whether someone who does not tell a partner about having HIV and transmits the virus when a condom splits is reckless.

Using the law to punish reckless disease-transmission runs the danger of doing more harm than good. Tellingly, HIV is the only bug ever to have prompted a criminal conviction in England and Wales. And the sentences so far meted out have been more than twice as long as those for the violent whacking and clobbering involved in other grievous-bodily-harm crimes. Yet living with HIV in Britain is less dangerous than living with hepatitis C, another sexually transmitted virus. 

 

www.economist.com/world/britain/displaystory.cfm?story_id=11024358

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Flu Economy -The Business Side of the Health Equation

Flu Economy Takes Unexpected Turn

The Illness's Unusual Course This Year Has Mixed Results For Health-Care Companies,

By THEO FRANCIS and ELLEN BYRON, WSJ, April 3, 2008 

The surprising course of the latest flu season -- one of the most unpredictable in years -- has been a headache for companies from tissue makers to hospital owners.

In recent seasons, the flu has generally hit hard in December and peaked in February before petering out in March. But this year it followed a different pattern, getting off to a tamer start than usual and then roaring back in late February with the strongest surge in years. One reason: Vaccine planners failed to accurately predict the strains of the virus that would emerge this winter, making the flu shots most people got less effective than usual. 

This has created a scramble at companies that count on Americans to sniffle and sneeze. Kimberly-Clark Corp., maker of Kleenex, blamed the cold-and-flu season's initial weakness for a 12% reduction in facial-tissue shipments in the quarter ended Dec. 31, compared with a year earlier.

In January, Walgreen Co. CEO Jeffrey Rein told a shareholder gathering that December marked the first time in his 25-year career at the company that cough- and cold-medicine sales fell during the month. If attendees of the meeting needed to cough, he joked, they should leave the room and "go to a movie theater or on a bus" to spread their germs. "We're really hoping for a very strong flu season," Mr. Rein told the crowd, according to a transcript of his presentation.

Procter & Gamble Co. said on a conference call in January that quarterly sales of its Vicks cold medicine had been weak. "Unfortunately, people have not been getting sick at a rate that we would all like yet," P&G CEO A.G. Lafley said on the call, with a chuckle.

Of course, each year, influenza, with its chills, aches and fever, takes a serious toll, killing about 36,000 Americans and hospitalizing more than 200,000; one government study pegs lost earnings at $16.3 billion a year. For most people, the flu season means having to get through a couple of days of fever, achiness and coughing. Americans bought $4.1 billion worth of cold, flu and allergy remedies last year, according to market-research firm Mintel International.

However, the flu economy encompasses more than just the makers and sellers of cold medicines. Even car insurers can get a financial boost when more drivers get the flu, because at least some stay off the roads. . .

The surge in flu cases that began in February probably saved HandClens, a fledgling hand sanitizer made by Woodward Laboratories Inc., of Aliso Viejo, Calif. It won a big order from Costco Wholesale Corp. last year only to see crowds of healthy shoppers ignore the product in January. "We were absolutely in panic mode," says CEO Kenneth Gerenraich. "We were borrowing from our credit line to pay the bills and keep ourselves afloat."

As the flu flourished in February, so did sales. "Now we're paying our bills, and the checks are flowing in," Mr. Gerenraich says. "Business is good."

Hospitals also rode the roller coaster of this flu season. Sicker patients often bring higher reimbursement from insurers or the government, and the flu can cause pneumonia and other complications. "You have a strong flu season, and the ancillary business is very profitable," David Dill, chief financial officer of LifePoint Hospitals Inc., explained to investors at a conference in January. If an elderly flu sufferer in intensive care needs a tracheotomy, "that turns into higher acuity business for us," he said. "Or, on the pediatric side, young kids coming into the hospital, that's a nice margin for us, as well."

LifePoint, a publicly traded chain based in Brentwood, Tenn., with 49 hospitals in 18 states, reported a 4.2% drop in year-over-year admissions in the fourth quarter of last year, which analysts and the company said was in large part because of the lack of flu cases. A LifePoint spokeswoman said admissions rose as flu cases soared in February and again in late March. . .

A confluence of factors seem to have contributed to this year's flu season. The strains of flu that have predominated in the U.S. in recent years are known as H1N1. Health officials predicted last year that that trend would continue, so pharmaceutical companies pumped out vaccines to target those strains. But H3N2 strains proved more prevalent this year. To make matters worse, H3N2 is a particularly nasty variety of the flu. . .

To read the entire article, go to http://online.wsj.com/article_print/SB120719135290885495.html.

Write to Theo Francis at theo.francis@wsj.com1 and Ellen Byron at ellen.byron@wsj.com2


Past Issue:                                         (current issue)     (previous issue)

It is extremely difficult to bring efficiency to a charity.

Muhammad Yunus Subprime Lender By EMILY PARKER, WSJ, March 1, 2008 Queens, N.Y.

In a Jackson Heights shop for colorful saris and glittering bracelets, several women have gathered to meet with their banker. They laugh and chat in Bengali. Sultana, a 39-year-old woman wearing a headscarf, hands him $128 in cash. She is making her first repayment of the $3,000, six-month loan she'll use to help with her husband's candy store.

Welcome to Grameen America, Muhammad Yunus's brand-new microfinance venture. Mr. Yunus, along with his Bangladesh-originated Grameen Bank, won the 2006 Nobel Peace Prize for battling poverty by lending out small sums of money to the poor. The loans are mainly for income-generating activities -- from making baskets to raising chickens. Since its establishment in 1983, Grameen has given out billions of dollars in loans, helping to pull families out of poverty and inspiring similar operations all over the world.

Mr. Yunus has now brought Grameen to this borough of New York City. Since taking off in January, Grameen America has lent out a total of $145,000, with interest rates at around 15% on the declining loan balance. The money will be used for everything from taxi registrations to sewing machines. I meet Josefina from the Dominican Republic, who has borrowed money to buy women's accessories to sell.

Grameen works a little differently from your average American financial institution. The Grameen banker comes to the borrowers, either in their homes or businesses. Women borrowers take priority. There is no need for collateral, credit-history checks, legalities or complicated paperwork. Just credit, plain and simple. . .

Mr. Yunus, who cheerfully refers to his business as "sub sub sub subprime," seems unfazed by the U.S. subprime mortgage collapse and the various tightenings of credit that followed in its wake. "If subprime cases are risky, Grameen cases are extremely risky," he says. "Because not only are we poorest, [borrowers] don't have collateral, they don't have guarantees, they don't have lawyers, nothing. How risky can you get? Still, our money comes back." Grameen has claimed that over 98% of their debts are repaid.

I mention that Mr. Yunus's way of doing business seems like an "old-fashioned" notion of credit, which a few centuries back was apparently closer to the Latin credere (to believe or trust). To have "credit" in a community, for example, meant that you could be trusted to pay back your debts.

"I use to say this in my speeches, in the early days," he responds. "I said: look at the world, how funny it is. They took the word credit which means trust, and built a whole edifice of credit institutions, refined, very sophisticated, entirely based on distrust." At Grameen, he says, "we went back to the original meaning of credit."

Mr. Yunus would argue that in making credit more easily accessible, he is helping guarantee a fundamental human right. "There are certain items that are listed as human rights: right to food, right to shelter, right to work, right to health . . . but who are going to implement those human rights?"

Some might say that government is responsible. But "that doesn't mean that government has to bring a platter full of food every morning to feed you, that's not what the government could do. Government could not bring health care to every single citizen or work opportunity for every single citizen."

Out of all the rights that he listed, Mr. Yunus says he would put credit as No. 1. "If you agree that each case of receiving microcredit is a creation of self-employment, then my argument is self-employment creates income," he explains. "Income is the thing which brings food. Income is the thing which creates the possibility of shelter, home. And income is the best medicine."

The collapse of the American subprime market has not shaken Mr. Yunus's confidence in credit. Rather, he blames the problem on sloppy business techniques. "They have the collateral, they have the lawyers, they have the entire legal system behind them . . . But they still could not protect themselves. What does it say?" he asks. One, "it says you didn't know how to do business . . . No. 2 . . . you got extra greedy. You overstepped your territory." . . .

Why is Grameen's debt-repayment rate so high? "Self-interest," is one reason. "For the first time, she has been given this opportunity to make money, make an income. Now she has a choice: she can pay back the loan so that she can continue with this door open and she can move on step by step. Or she says, enough is enough, I'm not going to pay back, I'm going to enjoy the money I got. What happens? The door gets closed."

Grameen, crazy as it may sound, "assumes that every borrower is honest." But it does have ways to help ensure repayment. Each borrower joins a group of people from similar social and economic conditions, and the group approves the loan request of each member. In this way, the group assumes "moral responsibility" for the loan.

Mr. Yunus's use of the female pronoun is not accidental. He says Grameen Bank's borrowers are 97% women, the result of a very deliberate policy. It all started when Mr. Yunus complained that Bangladesh's banks weren't lending to women at all. "I was trying to show in how many different ways conventional banking went wrong. So when I began I wanted to make sure that I do not face the same complaint against me. So I wanted to have 50% of my borrowers as women." . . .

After Grameen got to their desired level, 50% women borrowers, "we started noticing that money going to the family through women brought so much more benefit to the family than the same amount of money going to the family through men . . . So at one point we said, forget about 50-50. Let's focus on women because it changes the family faster." . . .

Mr. Yunus's determination paid off. Grameen, in quiet ways, is helping to empower women. "Every single of those seven-and-a-half million borrowers," he says, has a "personal bank account, and they are accumulating quite a significant amount for themselves." This "immediately establishes ownership because she is the only one who can withdraw money. This is her protected territory." . . .

In his new book, "Creating a World Without Poverty," Mr. Yunus does just that. He defines social business as "cause-driven" rather than profit-driven. And yet, it is not a charity: Its owners are entitled to recoup their investments, and the social business must recover its full costs, or more, even as it concentrates on creating products or services that provide a social good. It does this by charging a fee for its products and services. (One example: a business that manufactures and sells low-priced, nutritious food products to underfed children. Grameen America is also a social business.)

Mr. Yunus freely acknowledges that the free market has done a great deal for the poor. "I didn't say that what is there is wrong. I said the structure was not complete. One piece was missing. We couldn't express within the business world all the things we want to do for others."

He argues that in today's world, people whose main ambition is to help those in need tend to be pushed into philanthropy, which isn't always the most efficient way to bring about change. In philanthropy, he says, the "dollar has only one life, you can use it once . . . social business dollar has endless life, it recycles. And you build institutions." He continues, "when it's an institution you bring creativity into it. You bring innovations into it. You bring continuity into it."

Mr. Yunus argues that it's extremely difficult to bring efficiency to charity. But "the moment you bring in a business model, immediately you become concerned about the cost, about the revenue, the sustainability, the surplus generation, how to bring more efficiency, how to bring new technology, how to redesign, each year you review the whole thing . . . charity doesn't have that package.". . .

Mr. Yunus likes to tell a story of going into a village and meeting one of his borrowers, whose daughter has risen to become a doctor. "You look at the mother, that illiterate woman who borrowed money to raise chickens, to buy a cow to send the daughter to school, and now she's a doctor. And I get the question in my mind: the mother could have been a doctor too," he says.

"The whole thing is about making those opportunities available, so that they can change their lives."

To read the entire article, go to http://online.wsj.com/article_print/SB120432950873204335.html.

Ms. Parker is an assistant editorial features editor at The Wall Street Journal.

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