Brasileiro vence concurso do The Lancet

O médico Enrique Falceto de Barros, recém formado na Universidade Federal do Rio Grande do Sul venceu com mais cinco concorrentes o prêmio Young Voices In Research for Health do The Lancet e do Global Forum for Health Reseaarch. Para ler a monografia de Enrique, clique aqui.

Winners of the 2008 essay competition, Young Voices in Research for Health The Lancet, together with the Geneva-based Global Forum for Health Research, is pleased to announce the winners of the 2008 essay competition, Young Voices in Research for Health. The theme of this year’s contest was research for climate change and health. Essayists were asked to devise research questions on the topic as it applies to vulnerable populations around the world. Almost 300 entries were submitted, from 66 countries. A shortlist of 42 was chosen by a team of judges from the Global Forum and The Lancet. Six winners were selected from the shortlist. The six winners, whose essays are posted here, are Enrique Falceto de Barros (Brazil), Philippa Bird (UK), Lester Sam Geroy (Philippines), Rhona Mijumbi (Uganda), Marame Ndour (Senegal), and Charles Salmen (USA).

Boanerges de Souza Massa: história finalizada

Boanerges formou-se em medicina na USP em 1965 (ano a confirmar). Durante muito tempo foi uma figura mítica na Faculdade, pouco se falava dele, a maioria das vezes como se fosse ou um louco irresponsável ou um agente policial disfarçado. (assim ouvi mais de uma vez nos anos 70) Nunca foi alçado à condição de "herói da resistência". Alguns lembravam dele por uma cirurgia realizada em ambiente clandestino em um militante da Ação Libertadora Nacional (ALN) que fora baleado. Eduardo Manzano e Heloisa L. Manzano, médicos que moram em Porto Nacional e, se formaram com ele, afirmam que o viram no início dos anos 70 e, mantinham a descrição de Boanerges em seu livro "Memórias de um casal de médicos nas barrancas do Tocantins" como a de um sujeito estranho. (expressão a confirmar, transcrita pela memória do blogueiro)

Nessa semana, duas publicações, uma transcrita no Correio Braziliense de um livro que não foi publicado de autoria do próprio Exército nos anos 80 e, a outra o livro Sem Vestígios de Taís Morais trazem informação nova. Boanerges de Souza Massa era militante do Movimento de Libertação Popular (MOLIPO), uma dissidência da ALN esteve em Cuba, montou um foco guerrilheiro no oeste baiano e, foi preso em Goiás em 1971.Após sessão de tortura foi conduzido à Bahia para reconhecer o local e, na volta foi executado em um sítio em Formosa, Goiás.

O secretário dos direitos humanos, Paulo de Tarso Vannuchi, ex-militante da ALN, ex-aluno da FMUSP poderia conduzir o reconhecimento póstumo de Boanerges, como mais um daqueles da Casa de Arnaldo que tombaram nos anos de chumbo.

P.S recomendo o livro Sem Vestígios onde descreve as "memórias" de Carioca, um agente da repressão política. Há momentos horríveis como a descrição da morte de David Capistrano. Porém, a autora poderia ter revisado melhor algumas passagens onde derrapa em gongorismos e redundâncias. Mas, o pior foi a nota de rodapé, que inimigos de José Dirceu utilizaram fora de contexto, com a interpretação de que o ex-presidente do PT e ex-chefe da Casa Civil teria sido agente duplo (uma mera suposição do Carioca, sem base fática).

BMJ: uma vez mais a emigração de profissionais de saúde da África.

Globalisation spurs migration of healthcare workers from poor nations; John Zarocostas Globalisation has made it easier for rich nations to "pull in" skilled migrants such as healthcare workers from poor nations, says a report from the International Organization for Migration, which promotes humane and orderly migration. Such migrants include a large number from sub-Saharan Africa, the region with the greatest shortage of healthcare personnel, and the trend is unlikely to abate, the report says. "Their [rich countries’] ability to offer higher pay, better working conditions and greater opportunities in safer environments will continue to pull foreign health workers until supply exceeds demand," says the report. It says that the search for employment is at the heart of most migration and concludes that pressures "are set to increase." There are "more than 200 million international migrants in the world today, two and a half times the number in 1965," it says, and most countries are now simultaneously countries of origin, transit, and destination. Nearly a quarter of foreign trained doctors in countries of the Organisation for Economic Co-operation and Development were trained in sub-Saharan Africa, and the report suggests a series of possible policy options to limit the negative effects of emigration on the countries of origin. Countries of destination should continue to develop guidelines for recruiting skilled professionals from poor nations, the report recommends, but it emphasises that self imposed restraints on recruitment by public sector employers "have not been effective in limiting the migration." It says that "exhorting private-sector employers to recruit ethically" is also likely to prove equally ineffective. "These [guidelines] can serve as a benchmark against which civil society organisations and the nationals and governments of destination and origin countries can evaluate the practice of destination countries." Anita Davies, a public health specialist at the International Organization for Migration, said that the World Health Organization has taken the lead by preparing a global code of recruitment of health workers, in consultation with other relevant agencies and stakeholders. A draft has been sent out for comment and will be presented to WHO’s governing board for consideration in January. If agreed, it will be sent to the annual World Health Assembly for adoption. The report says that policy innovations can help to mitigate some of the risks to poorer nations of diminished service access and availability. These schemes include flexible, multi-use, multi-annual work permits that may allow poor nations of origin to manage flows more effectively and thus avoid critical shortfalls in the provision of health care. Such schemes may include fixed term contracts to train or work for a period in a rich nation and may also include commitments to upgrade their own healthcare system with the support of a destination country. The report estimates that Lesotho and Namibia have lost more than 30% of their physicians to emigration and that this percentage rises to more than 50% in Malawi, Tanzania, and Zambia and to 75% in Mozambique. Every year 1000 doctors emigrate from South Africa, says the report, and an estimated 30% to 50% of all South African medical school graduates emigrate to the United Kingdom or the United States annually. Doctors from South Africa make up just under 10% of all foreign trained doctors in Australia and 7% in the UK, it says However, it points out that South Africa is also the destination for skilled health workers from other parts of Africa, including Botswana, the Democratic Republic of Congo, Ghana, Nigeria, and Zimbabwe. South Africa has the highest ratio of doctors to population on the continent, at 56.3 per 100 000 people, whereas in the Democratic Republic of Congo the figure is only 6.2 per 100 000. The report says that South Africa has tried to deal with staff shortages in the public health sector by hiring Iranian and Cuban health personnel to work in rural areas. Meanwhile, a joint working paper by the OECD and WHO on international health mobility in Canada concludes that foreign trained doctors accounted for more than 22% of Canada’s total in 2005-6. Among rich OECD nations, New Zealand had the highest proportion of foreign trained doctors, with 36%, it says. The joint study also found that in 2005 about 15% of newly registered doctors in Canada were trained in countries from the WHO list of countries with critical shortages of health personnel. The corresponding figure for the UK was 46% and that for the US was 39%. But the report also shows that in 2006 about 8000 Canadian trained doctors were practising in the US. It says that differences in income and availability of positions were often among the reasons cited for emigrating

Circuncisão e prevenção da aids: vale a pena ler texto do NEJM

Circumcision — A Surgical Strategy for HIV Prevention in Africa. Ingrid T. Katz, M.D., M.H.S., and Alexi A. Wright, M.D. In a radical departure from earlier strategies, public health officials are now arguing that circumcision of men should be a key weapon in the fight against infection with the human immunodeficiency virus (HIV) in Africa. Recent studies have shown that circumcision reduces infection rates by 50 to 60% among heterosexual African men. Experts estimate that more than 3 million lives could be saved in sub-Saharan Africa alone if the procedure becomes widely used. But skeptics argue that efforts to "scale-up" circumcision programs on the continent that has the fewest physicians per capita may draw funds away from other necessary public health programs, ultimately threatening already tenuous health care systems. How circumcision prevents HIV transmission is not completely understood, but scientists believe that the foreskin acts as a reservoir for HIV-containing secretions, increasing the contact time between the virus and target cells lining the foreskin's inner mucosa. Early evidence of circumcision's protective effect dates back to the late 1980s. Researchers working in Africa and Asia noticed that HIV-prevalence rates differed dramatically among neighboring regions and were often lowest in areas where circumcision was practiced. More than 40 observational studies followed, but most researchers remained skeptical about the results. Then, in 2002, Bertran Auvert, professor of public health at the University of Versailles, launched one of the first randomized, controlled trials of circumcision in Orange Farm, South Africa, a community with a low rate of circumcision and a high prevalence of HIV infection. After the 12-month interim analysis, the data and safety monitoring board decided to stop the trial. The data were clear: circumcision reduced the rate of HIV infection among heterosexual men by 60%. Since then, two other randomized, controlled clinical trials in Kenya and Uganda have confirmed the results from South Africa. Both were stopped early because of overwhelmingly positive results. The research teams thought it was unethical to require men in the control group to wait 24 months before undergoing circumcision. A few men had already obtained off-protocol circumcisions, but since the study results were released, the demand has skyrocketed. "We have three operating rooms running every day," said Ronald Gray, lead author on the Ugandan study and professor at the Johns Hopkins Bloomberg School of Public Health. "We have done about 1000 surgeries in 3 months — after completing all of the surgeries for trial participants." Researchers have also found that circumcision provides increased protection against the human papillomavirus, herpes simplex virus, syphilis, and chancroid. But the most compelling evidence is still for HIV prevention, argues Roger Shapiro, a researcher at Harvard School of Public Health who is helping to implement a pilot program to offer infant circumcision in Botswana: "Circumcision isn't a new scientific breakthrough, but it works. It is the only proven medical intervention that can complement condom use and improve protection. If we had this level of data for a vaccine or a microbicide, you can bet there would be a massive push for immediate scale-up." Key distinctions between penile surgery and less-invasive methods of HIV prevention, however, may hinder momentum. For one thing, some African officials remain wary of circumcision because of concerns about cost and safety. Currently, physicians are performing most circumcisions, but many countries are hoping to decrease costs by training a cadre of lower-level health care workers (such as medical or clinical officers and nurses) to fill the provider gap that many countries face. Adequate training is essential, however, since complication rates ranged from 1.7 to 3.6% among HIV-negative men in the trials (as compared with rates of 0.2 to 2.0% associated with infant circumcision in the United States). Most complications were minor — pain or bleeding — but higher complication rates have been reported outside trial settings. One recent report indicated that severe complications developed in 18% of men, and 6% had permanent adverse sequelae including mutilation of the glans, excessive scarring, and erectile dysfunction. Inadequate sterilization procedures and surgical instruments were probably important factors in the higher rates, but Daniel Halperin, senior research scientist at Harvard School of Public Health, argues that high complication rates primarily reflect a problem with training, not with the procedure itself: "Circumcision can be performed safely, with relatively few complications, anywhere in the world, if clinicians are trained properly." Policymakers are also struggling with complex cultural barriers in societies where circumcision is not part of mainstream practice. In countries such as South Africa, for example, most men are not circumcised, but certain subpopulations, including the Xhosa ethnic group, practice circumcision of boys as a rite of passage into manhood. Many South Africans frown on the practice, and after several young Xhosa boys died from circumcision-related complications, then-President Thabo Mbeki signed a bill banning (with some religious and medical exceptions) circumcision in boys under 16 years of age. Some fear that the deaths associated with traditional circumcision have prevented expansion of the program in South Africa, but others argue that offering clean, safe medical circumcision to these communities could be lifesaving. Many public health researchers fear that there are deeper reasons for some African governments' skepticism. Some speculate that Africa's colonialist history has left these leaders with lingering suspicions about possible oppression, which have long taken the form of "deep denial regarding HIV treatment and prevention in certain regions of Africa," according to Francois Venter, clinical director of HIV management and reproductive health at the University of the Witwatersrand in South Africa. Others reference the dark history of surgical interventions deployed in the name of public health, citing the Indian sterilization camps of the 1970s. All agree that implementation of circumcision on a national level will require in-country champions and strong political will to succeed. "Currently all of the funding is coming from Western nations," says Venter, "and this makes people suspicious." To counterbalance perceptions of Western intrusion, the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) is working with local governments and public health partners to create an acceptable and sustainable model for implementing circumcision programs. "Countries are going to have to scale-up according to their own goals," said Catherine Hankins, chief scientific adviser to the Joint United Nations Program on HIV/AIDS (UNAIDS). "We are not setting any international agendas." UNAIDS, the World Health Organization (WHO), and their partners have set up a Web site (www.malecircumcision.org) to allow interested countries to trade information directly. Most people involved in scaling up adult male circumcision recognize that the surgery is a costly endeavor and a socially complex intervention that may compromise other public health priorities. Venter argues, "In South Africa, we have many other competing health issues, including maternal and child health and tuberculosis, which still need much more support." Nevertheless, he remains a proponent of circumcision as a means for getting young men into the health care system to help protect them against HIV and educate them about safe sex practices. Major international funders, including the Bill and Melinda Gates Foundation and PEPFAR, agree that ramped-up circumcision efforts must be funded as add-on services to guarantee that they will not detract from other programs. Although PEPFAR has granted $26 million for circumcision programs in 13 African countries — Botswana, Kenya, Rwanda, Zambia, South Africa, Lesotho, Malawi, Mozambique, Tanzania, Uganda, Namibia, Ethiopia, and Swaziland — implementation has been highly variable. In order to optimize HIV-prevention measures, officials from WHO and UNAIDS are advising that countries offer a minimum package of services in addition to circumcision, including HIV testing, screening for sexually transmitted infections, promotion of condom use, and counseling on safer sex. Such a comprehensive approach is meant to address concerns that circumcised men may adopt riskier behavior because they feel protected after undergoing the procedure. Despite these concerns, Gray and others have shown that there are no differences between the sexual behaviors of circumcised men and those of uncircumcised men — reassuring news, since many researchers and policymakers see circumcision programs as an opportunity to engage young men and women in HIV prevention. Robert Bailey, lead author on the Kenya study and professor of epidemiology at University of Illinois at Chicago, has noticed more participation of sexual partners in voluntary HIV counseling and testing since circumcision programs started. Reaching women through other prevention methods is important because there is no direct evidence to date that circumcision reduces the risk of transmission from men to women. In a small substudy, Ugandan researchers circumcised HIV-positive men and then followed their HIV-negative female partners to see whether their risk of infection was reduced. Data presented earlier this year did not demonstrate a benefit — a failure the researchers attributed to a sample size too small to allow differences to reach statistical significance. Indirect evidence from modeling, however, suggests that women will ultimately benefit from circumcision programs that reduce the HIV prevalence among men. Although circumcision has increasing support from researchers, donors, and politicians, its status as a non–behavior-based intervention may ultimately be its biggest obstacle. Neil Martinson, deputy director of the Perinatal HIV Research Institute at the University of the Witwatersrand in South Africa, summarizes this concern: "People are used to policies that target behaviors, but circumcision is a surgical intervention — it's cold, hard steel — and that doesn't always go down well." Ultimately, as programs move forward, the scale-up of circumcision will require strong political backing, adequate funding, and leaders to champion the cause to ensure that it is a safe, low-cost option available throughout Africa.

Demitir Jack Bauer, acabar com a tortura

Futuro Presidente dos EUA, Barack Obama: demissão sumária de Jack Bauer.

Secretário dos Direitos Humanos, Paulo de Tarso Vanucchi: menos bravatas em auditórios com ar condicionado e caça aos Jack Bauers tupiniquins.

Who is Jack Bauer? Dr Homer Drae Venters MD (publicado no The Lancet) A patient of mine, Kofi, once asked me, “Who is Jack Bauer?” I felt a little queasy because the patient, question, and answer all shared a common element, torture. I first met Kofi when I was a resident, only 1 year into my training in assessing survivors of torture who were seeking asylum at the Bronx Human Rights Clinic, New York, USA. The application of these people can be strengthened by medical examination of the physical and mental sequelae of torture. Before fleeing his country, Kofi endured several brutal detentions, as part of government persecution of his ethnic group. During his assessment at the Bronx Human Rights Clinic, Kofi described in detail the beatings, stabbings, and various humiliations that his government had perpetrated on him. Kofi then underwent a laborious 3-h physical examination, cataloguing every scar and musculoskeletal and neurological finding. The final part of this examination was to assess Kofi's psyche for the inevitable consequences of his experiences. Several months later, Kofi's asylum application was granted; we have continued to see each other for his primary-care needs. So what of Jack Bauer? Kofi has taken a deep interest in the politics of his adopted country, and has watched every US presidential debate so far. During one debate, a scenario was put to all the candidates, that can be summed up as the torture dilemma: terrorists have struck on US soil; the authorities have detained suspects, and have reason to think that some may possess knowledge of another imminent attack. The presidential candidates were asked whether to torture or not to torture. Only one candidate, Senator John McCain of Arizona, unequivocally responded in the negative; the others advocated various forms of so-called enhanced interrogation: a phrase which gives torture a more palatable label, and perpetuates the false impression that torture enhances interrogation. The most popular and memorable response came from Representative Tom Tancredo of Colorado, who responded: “I'm looking for Jack Bauer at that time, let me tell you”. Jack Bauer is the immensely popular character from the Fox TV show 24, who regularly relies on his own version of enhanced interrogation. Jack Bauer makes torture popular. Somewhere in the fog of war, terror, and politics, we have become accustomed to the idea of torture. Recent polling shows that American acceptance of torture is increasing, from 36% in 2006 to 44% in 2008.Additionally, more than half of Americans support torture in some situations, and an equal number support the practice of so-called rendition to other countries for the purpose of torture.During prime-time television, this approval of torture is generated and reflected by Jack Bauer, roughing up prisoners in a weekly struggle to protect the country. As I chatted with Kofi about how we arrived at this acceptance of torture in the USA, he said, “You have no idea what you would do to your neighbour if you thought he would harm your family.” Kofi went on to explain that acceptance of torture can arise from a heightened level of fear, that overcomes good judgment and gives way to inhumanity. For him, tribal fears and animosities paved the way for his persecution. For Americans, Kofi observed, a toxic fear of terror has allowed torture to emerge as an accepted practice. A central argument against torture is exemplified by Senator John McCain's belief that torture is inherently un-American. Senator McCain believes that to torture is to debase our national identity. George Washington, as a general in the American War for Independence, observed British troops executing surrendered American prisoners, and banned any retaliation in kind, stating: “Treat them with humanity, and let them have no reason to complain of our copying the brutal example of the British Army in their treatment of our unfortunate brethren”.4 In torturing, even out of fear for our survival, we lose our virtue and identity as a nation. Virtually every US president since George Washington has endorsed his rebuttal of torture as un-American, as has President-elect Senator Barack Obama. If we cannot torture because of who we are, the damning question then becomes: who have we become if we accept torture? The use of torture undoubtedly has consequences for the external identity of a nation as well. Referring to revelations of torture by US forces in Iraq, historian Alfred McCoy writes that it has “subtly subverted American rhetoric about democracy and has damaged the nation's moral leadership in the Middle East”.5 The use of torture by US forces was not new;6 but the photographs from Abu Ghraib in Iraq forced people to ask if systematic use of torture was consistent with the ideals of democracy and freedom. A second critique of torture is that it simply does not work. Torture apologists often appeal to a desire to get tough, and the reported need to increase the amount of information extracted from so-called high-value detainees. Without widespread understanding of the ineffectiveness of torture, the debate often devolves into duel by anecdotes. But analysis of interrogations has shown torture to be ineffective. One of the most successful US interrogators during World War 2, Marine Corps Major Sherwood Moran, eschewed torture as counterproductive. During interrogations of Japanese prisoners, Moran observed that brutality “played right into the hands of those who were determined not to give away anything of military importance”. By contrast, Moran's success was based on the approach to “forget, as it were, the ‘enemy’ stuff, and the ‘prisoner’ stuff. I tell them to forget it, telling them I am talking as a human being to a human being”.7 After World War 2, the US Military Intelligence Field manual was updated to state that the USA “prohibits the use of coercive techniques because they produce low quality intelligence. The use of force is a poor technique as it yields unreliable results, may damage subsequent collection efforts, and can induce the source to say whatever he thinks the interrogator wants to hear”. A 2006 report by the National Defense Intelligence College reviewed all available evidence on interrogation techniques and concluded “…studies of the role of assault in promoting attitude change and in eliciting [false] confessions revealed that it was ineffective. Belief changes and compliance were more likely when physical abuse was minimal or absent…although pain is commonly assumed to facilitate compliance, there is no available scientific or systematic research to suggest that coercion can, will, or has provided accurate useful information from otherwise uncooperative sources”. In his book, Torture and the Ticking Bomb, Robert Brecher further deconstructs the usefulness of torture, particularly in the type of scenario presented in the debate watched by Kofi. Brecher concludes that in matters of extreme urgency or importance, a nation would be ill-served to turn to the least reliable method of interrogation. These two arguments against torture, though compelling, still fall flat when I think of Kofi. Each of these criticisms addresses a larger context: our national identity and our national security. However, the most abhorrent aspect of torture is what Kofi and other survivors of torture often reveal to their physicians. That one human being picked up a knife and cut into another. Or suspended them from the ceiling while they were beaten. Or raped them. Or burned them. Long after his scars healed and he adjusted to the aches in his joints, Kofi has continued to struggle with mental anguish from being tortured. We are tempted by the glamour and raw charisma that we project onto Jack Bauer, the illusion of protection, and the lure of vigilante justice. But the raw truth of torture is that whatever the original motive, the torturer and the tortured are transformed into a perpetrator and a victim of violence. The torturer visits inhumanity on his victim, but also on himself and the surrounding community. Athar Yawar notes the relation between the use of torture and the inexorable decay of social fabric, as cruelty and inhumanity becomes pervasive and normative.

In an analysis of state tyranny, Riadh Abed similarly observes that the dehumanisation of the individual torturer and the acceptance of his acts “leads to the erosion of accepted social norms of behavior and the normalization of violence”. As physicians, we have a responsibility to oppose torture. We treat many patients who describe torture, and many more who have experienced it, but cannot bring themselves to disclose it. If Kofi is correct that irrational, overwhelming fear can lead to inhumanity, we should stoke the fires of reason. Three areas for intervention exist for us as physicians. First, we can educate ourselves (as students, residents, and attending physicians) about torture as a public-health issue, its prevalence in our patient populations, and how it affects our ability to deliver care. In recognising torture as a form of violence affecting many of our patients, we can develop standards of screening, medical education, and patient information that facilitate good medicine. When physicians become more knowledgeable about the effects and prevalence of torture, we can begin to detect and, when necessary, treat the adverse effects of torture among our patients. Second, we should strengthen ties with human-rights organisations, lending the credibility and resources of our profession to this endeavour. Just as physicians eventually became integral to campaigns against child abuse and intimate-partner violence, we should now join the international effort against torture. In their landmark report, Medicine Betrayed, the British Medical Association stated that physicians who are aware of torture “have a positive obligation to make those activities known”.

Finally, we should proceed in the least partisan manner possible. The political nature of torture is inescapable. But we will need to cast this discussion in terms of violence, public health, and our ability to deliver medical care to our patients. By bearing witness to the brutality visited on Kofi and others, we may be able to care for our patients better, while helping to eliminate public acceptance of torture.

Sensacionalismo e ciência: mamografias e circuncisão

Shah Ebrahim é editor do International Journal of Epidemiology e, um arguto observador da cena mundial. Abaixo, um texto instigante exigindo mais ação e menos sensacionalismo ou de como o culto às celebridades nos desvia de questões da maior importância, como a prevenção da aids.

Media hype: good or bad for patients and the health care system?Shah Ebrahim E-mail: shah.ebrahim@lshtm.ac.uk Kylie Minogue develops breast cancer and the associated publicity might well be expected to increase young women's demand for breast screening. Kelaher and colleagues1 demonstrate the expected increase in breast imaging (about 20%) in the months following publicity. Interestingly, the biopsy rate did not change in younger women and declined in older women. The odds of surgical procedures following biopsy also fell markedly. These findings led the investigators to propose that the media furore affected doctors as well as patients, leading to a retraction of usual evidence-based practice in the months after the publicity. Is this a good or a bad thing? Celebrity disease is something that can be used to good public effect—notably Ronald Regan's Alzheimer's disease diagnosis contributed to moving dementia syndromes from Cinderella status to high National Institutes of Health funding opportunities in the United States. But what about preventing breast cancer given rising incidence rates (http://info.cancerresearchuk.org/cancerstats/types/breast/incidence/). Kylie Minogue was young but was at risk due to nulliparity—a powerful risk factor, first recognized in the 1920s by Janet Lane-Clayton.2 The Million Women study has demonstrated the importance of number of children and breast feeding, among other risk factors,3 prompting Valerie Beral, its director, to urge greater research on prolactin, a hormone that increases in late pregnancy and regulates lactation, at a recent UK National Cancer Research Institute conference. While there are plenty of ‘orphan’ or neglected diseases craving publicity, AIDS is not one of them. The theme of this issue is human immunodeficiency virus—do we still need upper case to denote its importance? Usually associations of social inequalities and disease are negative—it is the poor that suffer. In an analysis of the Tanzanian HIV/AIDS indicator survey, higher standard of living was associated with increased odds of HIV infection, whereas there was no evidence of association with education.4 Higher occupational status was associated with HIV in women but unemployed men were at greater risk than working men. These findings indicate that simplistic notions of HIV risk among rich and poor need to be more nuanced in appreciating what is clearly a complex social matrix of risk. Perhaps the greatest success in the last year has been the randomized trial evidence, building on a decade of observational epidemiology, demonstrating the reduction in risk of infection due to male circumcision. Many doubted the original observational evidence, so it is particularly gratifying to see how large robust clinical trials have been implemented and pooled to provide strong, compelling evidence of benefit in terms of relative risk reductions as big as a halving of risk.5 On a recent visit to South Africa, in a particularly high prevalence location, I asked about how this new evidence was going to change policies, practices and research directions locally. ‘Not at all’ was the reply. The prospect of persuading young men to have circumcisions is not everyone's favourite challenge, but it does seem important that preventive surgical initiatives are evaluated and that private sector circumcisions are safely performed, for example. Londish and Murray's6 paper in this issue follows in the steps of previous attempts to model the effects of male circumcision using a wider range of covariates than in previous models. They conclude that targeting of interventions to younger men with risky sexual behaviours is the most effective strategy. In an accompanying commentary, Gray and colleagues7 question whether models will persuade reluctant health service providers and funders to invest in services. They note that several obvious conclusions derive from commonsense: the impact of circumcision is clearly going to be greatest in high HIV incidence but low circumcision prevalence places; circumcising men who are HIV positive is unlikely to be helpful and may increase transmission of infection to sexual partners; opting for infant circumcision, rather than adolescent and adult surgery, will delay any impact by 20 or more years. HIV modelling also gets some criticism in Elizabeth Pisani's remarkably entertaining and insightful book, The Wisdom of Whores,8 reviewed in this issue by John Cleland from the London School of Hygiene and Tropical Medicine9. Pisani was a student of demography at the School and went on to build a successful career in HIV modelling having been a journalist formerly. The story she tells is of misdirection of research effort and resources as individuals and institutions attempt to get their share of the action. I took this with me for holiday reading and was not disappointed. I recommend you read Cleland's review, get a copy of the book and read it too—whether you are in the HIV field or not.