America sure does love its national commemorative months (PDF), especially health-related ones. Take April, for example. Right now we are celebrating, or at least acknowledging, Youth Sports Safety Month, National Poetry Month, Confederate History Month (Southern states only), and Sexually Transmitted Infection Awareness Month.
Happy Sexually Transmitted Infections Awareness Month, dear! Though Hallmark has not yet signed in with a series of cards and e-grams, other commercial enterprises surely have. Trojan, the condom maker, which has 69% of the $600 million-a-year U.S. condom market, is working with a venerable organization, the American Sexual Health Association (ASHA), to spread the grand good news about condoms and STIs by funding the website factsaboutcondoms.com/.
ASHA is celebrating its centennial anniversary this year, having been founded in Buffalo back when the “s” stood for “social” and the “h” for “hygiene” as a movement to de-taboo the world of venereal diseases. The society gathered momentum quickly as a source of frank information for soldiers in World War I. In those early days, ASHA members also helped scatter prostitutes away from army bases to keep our boys healthy.
Despite the efforts of ASHA and others, however, condoms and sexual health and all that stuff remained relatively hidden from polite society until HIV first began to kill scores of people in the early 1980s. With identification of the cause, the treatment, and the routes of transmission, discussions about prevention focused at the highfalutin end on vaccines and at the lower side, on the humble condom.
Condoms, for the first time in their 3,000-plus year history, suddenly became a hot property. Annual sales globally are expected to reach $5.4 billion dollars by 2018. Fair trade people have entered the fray as well, seeking rubber extraction that is decent to the workers and a condom product that is easier on the environment. Even Bill Gates has gotten into the act by setting up a competition for people to develop a condom that improves the pleasure or either partner (preferably both); late last year, he gave out $100,000 to each of 11 winners (out of 812 entrants) in the condom V2.0 sweepstakes.
This is great, right? Tackling a complex public health problem by joining commerce (Trojan), good people with deep pockets (Gates), and a nonprofit society that has been doing its work with praise and without since Woodrow Wilson was president. A perfect example of the public-private partnership, where eviscerated government services are rescued by rich guys and by commercial interests with aligned goals—in this case more condoms equals less STI, less unwanted pregnancies, and better sales for Trojan. A win-win-win proposition all around.
What’s awry here is the simple fact that public health activities cannot and must not proceed as public-private partnerships.
Not really. First of course, many eviscerated government services are not taken up by business. Rat control, anyone? Perhaps Orkin might want a piece of it? What better to way to assure public health than to maintain a fleet of well-trained vermin exterminators to keep disease from spreading. But this is just the sort of program that disappears when city budgets shrink, as municipal tax bases shrivel from anti-tax fervor.
Worse though than the never-resurrected programs is this: sometimes—usually slowly—the venerable nonprofit is replaced bit-by-bit by the big business. Take ASHA, for example. (Please note that I know nothing about its finances and so am speaking from a suspicious, world-weary, good nose for bullshit stance but without real information—ah, the joys of writing.) Trojan seems to be giving ASHA some bucks to make pro-condom videos that include a feature on visiting a Trojan condom factory. Um, not exactly a public service, though admittedly fun to watch. And one can’t help but note that ASHA seems extra-aware of diseases like herpes and human papilloma virus (HPV), which are widespread and incurable, that can be treated (herpes) or prevented (HPV) by a product line that might—might—be profitable to the companies that support the organization.
Let me extend my paranoid tractate a bit more. In reading about ASHA, its current location is hard to overlook—Research Triangle, North Carolina. This is a wonderful place, full of scientific progress for sure, but also the one-time home of Burroughs Wellcome (inventor of the antivirals that treat herpes) and other companies that see diseases as market opportunities. Which in the topsy-turvy reality of the modern world, surely they are—the U.S. remains the center of innovation exactly because the profit motive continues to seduce so many so profoundly.
What’s awry here is the simple fact that public health activities cannot and must not proceed as public-private partnerships. When this occurs, messages are slowly effaced and priorities re-set: the 65 million people in the U.S. with an “incurable STI” (those with herpes and HPV, presumably) are not the medical or moral equivalent of the 1 million in the U.S. with HIV or the 24,000 women each year who become infertile because of untreated chlamydia infection. Yet as commerce and not public health drives the message, we’re all in it together, all patients, all victims, all in need of a pill or a shot or something with a reasonable co-pay. Diseases are reduced to bullet-points on the latest memo.
The point of government, however feeble and evasive it may be, is to stand apart from the immediate and the expedient, and to set priorities that look beyond the next quarter’s bottom line. Democracy after all is for people, not diseases and conditions—unlike us, they are not all created equal.
When profit potential and not human health set goals, we are at serious risk of fixing the wrong mess.