Day: July 24, 2012

An AIDS-Free Generation? HIV Is Not A Fad

The International AIDS Society conference began Sunday in DC, the first time the conference has been held in the United States since 1990 because of the now-lifted travel ban on HIV+ people coming to the U.S. That means that 25,000 activists, researchers and clinicians have converged on DC and what seems like a fanciful goal – an AIDS-free generation. Given that donor foreign assistance budgets are increasingly constrained around the world, what gives advocates such hope that a renewed push against AIDS will be successful? For a disease that lacks a cure, does an AIDS-free generation means an “end” to AIDS?

I’ll elaborate below, but let me preface this post by saying that the turn to treatment over the past decade has been a tremendously amazing representation of global collective action and moral generosity. However, the
storm clouds of the economic downturn and some portents in pharmaceuticals markets have me worried that these gains could be upended by spendthrift donors and new development fads. (On another note, this is the second IAS conference running where my paper was rejected. What does a scholar have to do to get on the agenda? Seriously. Harder than APSA.)

Seizing upon recent studies that suggest that antiretroviral treatment can help prevent the transmission of HIV (one study found a 96% reduction in transmission risk),  activists are encouraging a scaling up of treatment as prevention. What this means programmatically is a little unclear, though advocates have identified the goal of putting 15 million people on treatment by 2015. Today, July 24th, activists will be doing their part to put this front and center on the agenda of the policy community through a major protest action.

The Good News

Lazarus Effect: Before and After ARVs

If funding were not constrained, that might be doable. UNAIDS estimates that more than 8 million people are now on treatment in low and middle income countries, up from just 400,000 in 2003. 6.2 million of them are in Africa which has experienced an incredible scale-up of therapy such 56% of those estimated to be sick enough to need treatment now have access to it.

(These estimates may be somewhat problematic as the proportion of people “lost to follow-up” can be shockingly high a year or two after people are put on the treatment rolls, perhaps as much as 70% in some projects but certainly not that high for all).

UNAIDS also announced that last year the world community spent $16.8 billion on AIDS in low and middle income countries and that half (!) of that money is coming from affected countries themselves. South Africa, the country with the largest number of HIV positive people, has assumed 80% of the costs of treating its citizens since Jacob Zuma took office and reversed the denialism that had previously undermined the country’s AIDS policy under Thabo Mbeki. 

And, in other good news, CHAI, the Clinton Health Access Initiative, released a study that found that average cost of treating a patient in low and middle-income countries for a year has fallen to $200. This isn’t just about driving drug prices down (which has happened thanks to CHAI even for newer, second-line ARVs) but it’s also due to efficiencies in supply chain management of getting the drugs to the clinics and in task-shifting so that trained local health care workers can carry out some essential duties.

The U.S. Contribution
As Tom Hart of the ONE campaign reminded us, the United States has led the way:

Thanks largely to support from Americans of all stripes – Democrats, Republicans, religious leaders, college students, public health officials and the business community – 8 million HIV-positive people around the world now have access to life-saving treatment.

The United States is the largest international donor to global AIDS efforts, and for this, the American people should be proud. George W. Bush, whatever his flaws as president (and there were many), deserves enormous credit. Indeed, the former president is spending his energies these days taking on other global health challenges like cervical cancer.

Take a look at the data for last year. In 2011, if you look at al international donor disbursements, the United States contributed an astounding 59.2% in 2011. With that money, PEPFAR says it is supporting 4.5 million on treatment and is poised to support 6 million on treatment by the end of 2013. 

(Note: When the USG says support, it does not mean that PEPFAR supports 100% of the treatment costs. Activist Brooke Baker suggested it was actually about 50%. 
Looking at this PEPFAR study, it really varies by country. For example, in middle income countries, PEPFAR only paid $139 of the $1017 in per patient treatment costs. For first-line therapies, the estimated average PEPFAR contribution was $305 of the $708 in annual treatment costs.)
The Not So Good News
The not so good news is that there were still an estimated 2.5 million infections last year. And, though that is down by 20% since 2001 and there are lots of countries where the rate of new infections has fallen even faster, the prevention agenda has to be much more front and center.

And, notably, donor funding for HIV/AIDS remained flat at 2008 levels. If this goal of 15 million by 2015 is to be met, an additional $2-3bn in resources would be needed per year to reach $22bn by 2015. This also comes at a time when the United States may be facing a huge budget fight over sequestration that could lead to across the board cuts for major programs. Obama’s proposed 2013 PEPFAR budget was already 3% lower than the previous year, the House and Senate topped it up a little bit. If the politics play out wrong, AIDS funding and treatment goals could suffer.

Moreover, the economic crisis in Europe has already had some effect on European donations for global AIDS efforts, particularly in Germany and the Netherlands which have seen their contributions slump since 2009. Countries like Italy have never really given much. Outside of Europe, Japan is another rich country that has been miserly on AIDS (though maybe given Fukushima we can cut them a little slack).

AIDS-Free Generation
So, what’s all this talk about an AIDS-free generation? Basically, I think activists are excited to think that with a combination of early treatment, other prevention strategies like male circumcision and universal mother to child therapy, that the next generation will be AIDS-free.

Secretary Clinton affirmed these ideas in a speech on Monday where she promised an additional $150 mn for targeted interventions alone these lines. She said:

It is a time when, first of all, virtually no child anywhere will be born with the virus. Secondly, as children and teenagers become adults, they will be at significantly lower risk of ever becoming infected than they would be today no matter where they are living. And third, if someone does acquire HIV, they will have access to treatment that helps prevent them from developing AIDS and passing the virus on to others.

I think what the USG and other donors are hoping is that with rising efficiencies in service delivery and increasing middle income country assumption of the costs of treatment that you can get more for less. However, even with improved efficiencies in the supply chain, I fear that drug prices (at least for first line older drugs) don’t have that much more to fall. Without some infusion of new money, you don’t get much more for little or no new money. You may get less than you want with less than you need.

Should We Spend More Money on AIDS? Yes.
Last night, the World Bank hosted a vigorous debate that had UNAIDS’ Michel Sidibe and Columbia’s Jeff Sachs in support of more funding for AIDS and CGD’s Mead Over and Roger England taking the opposing position.

Over’s position was basically similar to the one Bjorn Lomborg has adopted on climate change, that there are lots of other problems that are equally deserving of attention and where money would go further in saving lives. Now, I know Over has a nuanced position about the need to focus on prevention (which I’m all for), but I fear that economists are a little tone deaf to both the politics and the nature of the disease itself. It’s not as if there is a pot of $25 bn for a bunch of different health interventions and we can choose which ones make most sense.

People mobilized on AIDS because millions were dying, overflowing hospitals and treatments existed that could keep them alive. Other diseases don’t have as capable political boosters. And many other health issues like malaria and TB, even primary health, have ridden AIDS’ coattails.

Moreover, as Laurie Garrett noted on twitter, for communicable pandemic diseases, you do need specialized funds. You can’t partially address this challenge and then let the situation revert to larger and larger numbers of new infections.

And for those 8 million people on treatment (or however many it actually is), we have made a commitment to treat them for the remainder of their lives. If donors and governments renege on such a promise, that is a death sentence and morally unconscionable. However, just treating the people who have it now and doing nothing for those who need it or little more on prevention is not sustainable.

While all of the rhetoric about treatment as prevention is compelling, there are some huge logistical and financial challenges. Putting people on treatment early offers immense promise to break transmission but my understanding is that you have to catch it early when people still have high viral load levels and have a higher risk of passing on the virus to their partners.  The current approach basically forces people to wait until people they already have had the virus for a while and are sick enough to meet certain thresholds. If you only have a limited amount of money, you would want to get the healthier HIV+ people on treatment early for prevention purposes, but morality dictates that you treat those who are really sick. I don’t have answer other than more money for that.

All of this does mean that going forward we have to think strategically about how best to achieve the desired ends given that we have millions on treatment and too many millions of new infections. I still have yet to see what the realistic plan is to break the back of AIDS in a generation, but that’s where we have to go.

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R2P and the “Double-Standard Problem”

Jean-Baptiste Jeangène Vilmer (writing at the Fair Observer) argues that there’s no double-standard problem because the Libyan intervention did not establish or reflect a generalized responsibility to protect.

The R2P is a slogan that has some media efficacy but a rather dubious legal existence. That does not prevent the majority of observers asserting that it was the basis of Resolution 1973, authorizing intervention in Libya. That is not true either. The Resolution reiterated the internal responsibility “of the Libyan authorities to protect the Libyan population”, but nowhere did it speak of an external responsibility of the international community to intervene. This does not imply that the concept did not play a role in the motivations of certain permanent members, only that it is not considered as a consensual “norm” worthy of being explicitly mentioned. 

The military intervention in Libya did not represent an implementation of a purportedly universal “responsibility to protect”, but an ad hoc consensus among powerful states. Moreover, it was motivated by both humanitarian reasons and national interests, as British Prime Minister David Cameron explained in his March 18 speeches evoking the security risk for Europe, posed by terrorist threats and potential migration pressure. It is also a question of moral image and political gain. Nicolas Sarkozy used the intervention to consolidate his presidential calibre and keep the failures of French diplomacy in Tunisia and Egypt out of the limelight.

I definitely agree that the intervention was an ad-hoc arrangement where a combination of principles, interests, and opportunities facilitated intervention, but I’ll leave the rest to international-law scholars.

Check it out.

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“Have foresight and it’s real”: Carly Rae Jepsen And The Problem of Asymmetric Information

The logic of inappropriateness

Below, Scott Weiner argues that Carly Rae Jepsen’s song “Call Me Maybe” is an illustration of the dynamics of standard game-theory models, specifically the prisoner’s dilemma and stag hunt. Weiner assumes that Jepsen is a rational actor, that both Jepsen and her beau are better off being together than being apart or with different partners, and that Jepsen is rationally choosing to communicate her availability to facilitate their coming together. I share these assumptions, but as I demonstrate Weiner misses the key points of the song. If, as Weiner suggests, both Carly and the boy are better off together than apart, then why signal that “this is crazy”? And why is the song called “Call Me Maybe” instead of “Call Me Right Now So We Can Be Together”?

The answer is that Carly is trying to communicate that, despite her forward approach to the boy, she is nevertheless suitable for him. Sometimes, disclosing more information hurts rational actors, and for Carly to disclose that she is interested in the boy after having just met him could signal to the boy that she is an undesirable partner—not just because of old-fashioned notions (“she’s not wife material“) but also because an aggressive partner of either sex might not be interested in a long-term relationship (Hall and Oates, 1982).

So we are left with a puzzle. If Jepsen is rational and can assume her potential partner is as well, why pursue a strategy that both stresses her availability (“call me!”) while highlighting her ambiguity (“maybe?”) and stressing that the situation is causing her to behave in an unusual way (“and this is crazy”)? The answer lies in the fact that dating is a game played under asymmetric information, which changes the dynamics of the interaction in ways Weiner does not appreciate. I provide an informal treatment below.

Assume there’s some distribution of types of potential dating partners in the world, “worthy” and “tragic.” (We assume that the dating game is multiple-shot; as is well understood, one-shot romantic games have dramatically different properties.) The preference of each player, worthy or tragic, is to find a worthy partner and to avoid ending up with a tragic partner. Worthy partners would rather be alone than with a tragic partner; tragic partners would rather be with a tragic partner than alone.However, although every player knows his or her type (that is, whether they are themselves tragic or worthy), they can’t know with certainty whether other players are. Consequently, players who advertise themselves as worthy may be lying, and there’s no way to tell in advance.

How, then, for worthy partners to advertise themselves as being worthy? As Schelling and others would point out, there has to be some sort of credible signal. This, however, is likely to be reticence, since tragic partners are made much better off by being with anyone than by being with the right partner. Consequently, the dating scene is likely to be made up of tragic partners pretending to be worthy ending up with each other. (Game theory is often realistic that way.) This is a perverse equilibrium: The only players left on the scene are the ones who shouldn’t be dating anyone, because all the worthy partners know that trying too hard puts off other worthy partners.

Let’s assume, however, that Carly and her boy are both worthy. If Carly comes off too strong, then the boy may assume that she is tragic. So she instead engages in signaling by saying that she’s not normally this way, that the situation is highly unusual, and that she’s putting off all the other boys who are interested in her to talk to the boy–all signals that she is interested but not tragic.

Unfortunately for Carly, the ploy is unlikely to work if the boy is a worthy partner. While Weiner does not provide an independent assessment of how likely Carly and her object of attraction are to end up together, his analysis suggest that they will be happy together because they are better off together. Alas, my analysis suggests instead that all such posturing will be dismissed as merely cheap talk.

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Call Me, Maybe: Cooperation and Coercion in the Music of Carly Rae Jepsen

This is a guest post by Scott Weiner, a PhD student in Political Science at George Washington University.

One of this summer’s most popular hit singles is “Call Me Maybe” by pop artist Carly Rae Jepsen. In the song, Carly attempts to score a date with an attractive male by giving him her number and asking him to call her in order to set up the outing. This strategy is eventually successful, and while the male “took his time with the call,” Carly “takes no time with the fall.” This outcome is puzzling given that existing accounts of the scenario might predict a sub-optimal outcome given Carly’s strategy. Why does Carly Rae Jepsen give the boy her number despite her own realization that “this is crazy?” Why does Carly Rae Jepsen tell the boy, ambiguously, “call me, maybe” when her preferences are not at all ambiguous given that she very much wants him to call her? How can scholars understand the successful outcome of this strategy?

Existing literature understands the basic scenario presented in “Call Me, Maybe” as a prisoner’s dilemma. In the prisoner’s dilemma, two rational actors who cannot communicate with each other are given a choice of cooperation with each other or defection, with a system of rewards and penalties for each:

In the basic prisoner’s dilemma, the optimal strategy is to defect since the cooperation of the other actor cannot be guaranteed. Each actor’s payoff will be better by defecting regardless of the choice of the other player. Since Player A cannot guarantee the cooperation of Player B she will choose the best course of action for herself regardless of B’s choice.

For the purposes of this model, we can assume Carly Rae Jepsen is a rational actor. She begins the song with the words “I threw a wish in a well / don’t ask me I’ll never tell.” This indicates a clear set of preferences. The fact that she will not reveal her wish under any circumstances indicates that these preferences are constant throughout the game. Carly also sets up a ranked order of preferences, noting “I’d trade my soul for a wish / pennies and dimes for a kiss.” This monetization of kisses indicates her ranking is in fact quite sophisticated.

However, assuming the boy is a rational actor as well (which Carly does) the prisoner’s dilemma would predict that her optimal strategy is to defect. Since she cannot guarantee the boy will call her, the prisoner’s dilemma predicts she should not give him her number, and that her actions are, in fact “crazy.” What accounts for not only Carly’s actions, but also the success of her strategy? To answer this question, we must look beyond the constraints of the prisoners dilemma. Other models may in fact lend more explanatory leverage on the issue.

I. A Shadow of the Future

One of the most important rules at play in a classic prisoner’s dilemma is that it is a one-shot game. However, if the game is played over and over with the same actor, this is known as an “iterated prisoner’s dilemma.” In this case, since the game is repeated, each actor will have to live with the consequences of his actions after the first round is over. This added condition is called the “shadow of the future.” When a shadow of the future is present perpetually (i.e. the game does not have a set end point), the optimal strategy ceases to be one of defection and instead becomes a “tit-for-tat” strategy, in which the actors try to mirror each other’s actions (see Axelrod’s “The Evolution of Strategies in the Iterated Prisoner’s Dilemma“)

Carly opens the game by giving the boy her number, which is cooperation. Since if they were to date the game would repeat without a definite end-point, Carly calculates that it is in the boy’s rational interest to call her. Until the point that either Carly or the boy defect from the game, cooperation is the optimal strategy according to the model.

However, the reality is not quite so simple. Rationally, Carly should signal every intent to cooperate to the boy in order to maintain her credibility. Yet she deliberately tells him “Hey, I just met you / and this is crazy.” What explains this puzzling signal?

II. Signaling Intentions In The Stag Hunt

Carly’s predicament could also be explained via a model known as the stag hunt. Originally developed by Jean-Jacques Rousseau, the stag hunt involves two players who get a small payoff from hunting two rabbits separately but a large payoff from hunting one large stag together. Hunting stag requires a different weapon than hunting rabbit, however, and the weapon choice of the other player is unknown.

In a sense, Carly and the boy in question are in a sort of stag hunt. We assume for the purposes of the game that both Carly and the boy would prefer to go on a date over not going on a date (“Before you came into my life / I missed you so bad”). However, they also do not want their time wasted by trying to score a date with someone who is uninterested in going out with them. We can model the payoff structure of the game as follows: 

As the matrix reveals, there are two equilibria in the game, but one has a higher payoff than the other. When such a payoff structure exists, actors will try to communicate their intention to cooperate (ie, go on a date) in order to try to induce cooperation from the other party. Communication is a highly theorized area of international relations, which involves signaling capability, resolve, and credibility. How can we understand Carly’s communication in this regard?

Carly’s statement “Hey, I just met you / and this is crazy” is an attempt to communicate both intentions and resolve. In particular, both statements are intended to highlight the costly signals Carly is giving of her intentions. Were Carly not interested in the boy, giving him her number after having just met him, an admittedly “crazy” action, would incur significant costs. By doing so regardless, Carly is communicating that she is in fact interested in having him call her. Her willingness to challenge social norms is an attempt to communicate resolve, especially given communication difficulties implicit in the situation at hand (“It’s hard to look right / at you baby”). That is, she is in fact interested in the boy and does in fact want the boy to call. Carly supports this signaling regime by noting that “all the other boys / try and chase me” a statement that she is committed to exclusive cooperation with the boy at hand.

The addition of the word “maybe” at the end of her signal is a tactic designed to highlight the choice which the boy now has to make between calling and not calling. Schelling would categorize “maybe” as as a “trip-wire,” in which one actor sets up an automated series of events which the other actor will trigger with a certain action. Since the first actor, Carly, has already chosen a risky course of action and the decision is out of her hands, it falls to the boy to pursue a strategy with the lowest risk for himself. This also turns out to be the one with the biggest payoff for Carly as well. As it happens, the boy does eventually call, and both Carly and the boy achieve their Pareto-efficient equilibrium.

In conclusion, Carly’s strategy is actually a rational one given the payoff structure she faces in the given situation. While such an explanation cannot explain her decision in the music video to wash a car in 5-inch heels, it can explain her actions as the outcome of a rational strategy. Further research should examine the generalizability of the argument by accounting for critical cases such as “Payphone (explicit)” by Maroon 5 (ft. Wiz Khalifa) and “Wide Awake” by Katy Perry. Ultimately, such inquiry serves to provide scholars with a deeper understanding of the complex world of interpersonal relations as relayed through pop songs.

UPDATE: Duck contributor PM provides an an alternate model of Carly Rae Jepsen’s song.

Ed. note: as a bonus, here’s the Star Wars version of the song:

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Morning Linkage


Globalization of Law:

Economic Armageddon, Round II:

Education:

  • Chris Lehmann at Practical Theory: “there are a lot of powerful folks right now who are advocating for a pedagogy that they do not want for their own children. Some of these powerful people are running networks of schools that have a pedagogical approach that is directly counter to the educational approach they pay for for their own children. Moreover, these same powerful people tend to get upset when asked about the disconnect, saying that that question is off limits.”
  • On a similar note, Daniel Luzer argues that online education shouldn’t be thought of as a straight substitute for the in-class experience.

Nerd Stuff:
Middle East:
  • Everyone’s talking, including Obama, about Syrian chemical-weapons threats. Also lack of CIA assets in Syria — but remember, stories like these are ways of publicly airing fights within the national-security bureaucracy.

Asia:

Strategery:

Climate:

  • David Schuler reminds us what the trends on Chinese carbon emission look like, and argues that the US and Europe basically outsourced pollution to the PRC.
Rugged Individualism:
  • Jon Scalzi’s post on being a “self-made man” is making the rounds, and for good reason. 

Sally Ride:

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