Smoke gets in your eyes 2

angry doc had a bit of a deja vu when he read this news article this morning:


Warning labels disgusting, but effective
Alicia Wong

FEAR is a factor when it comes to discouraging smoking in Singapore — in more ways than one.

While lung cancer is the most feared condition here, more Singaporeans feel “extremely fearful” when they look at health warning images on cigarette packs.

Almost 40 per cent here felt that way about graphic labels, much higher than the 26 per cent in Scotland, according to a survey of attitudes and awareness toward smoking in both countries.

In this instance, the images were from Australia, so both sets of respondents, less than a quarter of whom in Singapore were current or ex-smokers, were not familiar with them.

About 40 per cent of the 115 respondents here, adults at outpatient clinics in Alexandra Hospital (AH), also gave a score of 10 for disgust. In comparison, 20 per cent felt no fear and 12 per cent felt no disgust – which was worrying enough for housewife Grace Seah, 34. “It’s unbelievable they don’t see that they’re not immune to the consequences of smoking. But maybe those who felt no fear at all are non-smokers, so they are naturally not concerned,” she told Today.

However, the bottom line was that more than half indicated that these labels, which also carry information on various diseases, were effective in discouraging the habit.

And non-smoker Vincent Loh thinks the results are encouraging. “Every smoker that quits or every smoker-to-be that is deterred because of the images is great. At least there are more who are disgusted than those who are unaffected,” said the 29-year-old engineer.

AH registrar of ophthalmology and visual sciences, Dr Srinivasan Sanjay, said: “Graphic warnings de-glamourise cigarette packs and let people know what they get in return from smoking.”

The link between smoking and glamorous lifestyles, through the tobacco industry’s marketing campaign, is putting half a billion young Asians at risk of diseases associated with nicotine, the World Health Organisation (WHO) said on Friday.

On the eve of the WHO-designated World No Tobacco Day, Asia-Pacific director Shigeru Omi called on policymakers to support a total ban on tobacco advertising, sponsorship and promotion as stipulated in the WHO Framework Convention on Tobacco Control, a global tobacco control agreement.

The WHO added that the tobacco industry’s current focus on young females is a challenge that has to be dealt with urgently.

In Singapore, awareness levels on smoking can be increased, according to the survey, which found that a “strikingly low level” of 37 per cent of Singaporeans knew that smoking causes blindness. So, while 32 per cent feared lung cancer the most, only 17 per cent cited blindness.

The Health Promotion Board :“Is constantly monitoring the evidence on the causal relation between smoking and disease and we regularly revise the health warnings by updating the warnings with other less commonly known diseases like neck cancer and gangrene, to ensure that the warnings remain effective”, chief executive officer Lam Pin Woon told Today.

He promised that HPB’s smoking control programme would highlight “in the coming years, other lesser-known diseases, such as smoking and its impact on vision”.


We've actually discussed this topic two years ago, but since it has made the news again...

It is not surprising that disgusting pictures cause, well, disgust in people who view them. However, angry doc would not hasten to call an anti-tobacco programme that succeeds in disgusting some people sitting at an outpatient clinic 'effective', even if "more than half [those surveyed] indicated that these labels... were effective in discouraging the habit", especially when it is not clear if they themselves were indeed smokers.

With many things in healthcare, it is important to begin with the end in mind, and keep the end in mind.

The aim of an anti-tobacco campaign must be in the end to reduce the mortality and morbidity that is caused by tobacco use. Since there is no way to determine the correlation between the number of people who are disgusted by disgusting pictures and mortality and morbidity statistics, angry doc thinks that the survey was at best a useless piece of information, and at worst a piece of misinformation.

As angry doc has mentioned in his previous post, he believes that better surrogates for the information we want are the smoking prevelance in the population and the statistics for tobacco products inmported and sold in the country.

angry doc wonders why the HPB seems to be more concerned with the amount of fear and disgust their campaign cause than with the number of lives they are saving.

Selfish Reasons

angry doc apologises for not posting as often as he should, but he has been busy trying (but has so far failed) to get himself on a quake-relief mission to China... for entirely selfish reasons, of course; much like these two characters mentioned in a news article today:


Sharon Stone’s bad ‘karma’

Actress Sharon Stone has sparked a storm of criticism in China after suggesting the earthquake that killed at least 68,000 was bad “karma” due to Beijing’s policy on Tibet. Stone, 50, made the remarks at the Cannes Film Festival last week.

“I’m not happy about the way the Chinese are treating the Tibetans because I don’t think anyone should be unkind to anyone else,” Stone said in Cannes. “And then all this earthquake and all this stuff happened, and I thought, is that karma ­– when you’re not nice and bad things happen to you?”

The Beijing Times yesterday quoted Mr Ng See Yuen, founder of the UME Cineplex chain, as saying that from now on, no film featuring Stone would be shown in any UME cinema in Hong Kong or the mainland. UME is one of China’s biggest cinema chains.

Meanwhile, Chinese online activists have criticised Stone for her remarks, using YouTube among other forums to spread their message.

“I want her to say sorry. It’s not for me. It’s for the dead people,” said a young man, who described himself as a Chinese called Adam, on his YouTube video. “I hope this video is useful for people to get together and help each other and make Sharon Stone say sorry.”


angry doc doesn't know if Ms. Stone meant to have herself quoted, or whether it was just a slip of tongue on her part. Either way, there is no way she, or anyone for that matter, can know whether or not the quake was the karmic result of China's actions in Tibet, or her lack of action in what happened in Myanmar or is happening in Darfur. What we do know, however, is that earthquakes occur because of tectonic movements.

Perhaps Ms. Stone sought to make use of the widely known doctrine of karma to bring the issue of Tibet back into the limelight, or perhaps she wanted to believe that karma was at work because it was easier for her to accept that bad things happen to people because of the bad actions of some people, and not because of the rather amoral movements of rocks.

Whichever the case, angry doc believes that Ms. Stone said what she said because she wanted to give meaning to a natural phenomenon in a way that would make her feel better about herself.

In the same vein, 'Adam' has no way of knowing whether those who have died will know or care about what Ms. Stone has said, which makes his demand for an apology 'for the dead people' rather suspect. In fact, if 'Adam' believed that the soul survived in some form after our bodily death, a concept shared by (and indeed a precondition to) the doctrine of karma, how can he be so sure that Ms. Stone was not in fact right and thus did not owe the dead an apology?

angry doc suspects that like Ms. Stone, 'Adam' too is making use of a superstition, in this case to give meaning to his feeling of displeasure at an insensitive remark made at a time of tragedy: the idea that the dead could hear us and be offended by what we say gave him both a justification for his unhappiness, and a 'victim' for him to fight for.

angry doc doesn't think speculation on how karma is applied or the feelings of the dead are helpful to survivors of the earthquake; he would rather try to help by applying some medical science - that is if he is given a chance to. He is keeping his fingers crossed, and you might want to wish him good luck too.

Today we speak in blogosphere...

... next month, the real world.

Fellow Clearthought-blogger Leng Hiong will be speaking at Touche at Tampines Changkat CC Auditorium, Level 4 on 8 June, Sunday from 1pm to 6pm.

angry doc will not be able to attend, but Clearthought-blogger Edgar will be making a video record of the event and hopefuly upload it somewhere so angry doc will be able to experience this historic event.

(Yes, Clearthought is growing in strength. Soon, all your base will belong to us...)

What we don't know about sex

(edited at 11:25 PM)

Unsurprisingly, the call for a safe sex campaign targeted at teenagers has drawn opposition from the public.

Joanna Koh-Hoe believes "that safe(r) sex is not actually safe", and that "the increased rate of teenage sexually-transmitted infections (STIs) and pregnancies is contributed by the teens who have bought into the safe sex message and think that premarital sex is okay so long as they use a condom".

Alphonsus Tan questions the statistics quoted in the news article. He too believes that "[t]he knowledge imparted to youth that condoms are 99 per cent safe, protecting them from pregnancy and sexually- transmitted diseases, will... let them know that they are not so vulnerable. Armed with that knowledge, they would be more willing to engage into sexual activities". "Educating them about condoms only empowers them to do the deed," he concludes.

Bryan Goh wonders if "by encouraging safe sex and the use of contraceptives... are we actually advocating the wrong (read: 'relaxed') idea about sexual activity?".

So what works? Abstinence campaign, or safe-sex campaign? Does a combination work better, or does mixing the two send a 'mixed signal' to teenagers and actually encourage them to have sex?

Well, it depends on what one means by "work", angry doc supposes. Different people and groups have different definitions of what a successful sex education campaign is. Some want teenagers to abstain from sex until they are married, some want teenagers to delay the age when they start having sex, and some just want fewer cases of sexually-transmitted infections and unwanted pregnancies, never mind how many teenagers are having sex.

We can look at studies from other countries, but as far as Singapore itself is concerned, angry doc is not sure we have enough data to answer the question of "what works?".

Surveys on sexual status and activities rely on self-reporting, and can therefore be inaccurate. Statistics on sexually-transmitted infections (and HIV/AIDS) on the other hand are probably more reliable, since these diseases are notifiable.

To be helpful to policy planners, the STIs and HIV/AIDS statistics must be viewed as a function of the number of teenagers in the country, as a function of the percentage of teenagers who are having sex, and as a function of the percentage of teenagers who practise safe sex.

More importantly, to assess the success on any intervention programme or campaign in influencing the sexual behaviour of teenagers, we need to have data for the period before and the period after the intervention. Right now, we can't even be sure if the rise in HIV/AIDS amongst teenagers is occurring in the context of more teenagers having sex but practising safe sex, or fewer teenagers having sex but practising unsafe sex, or merely as a result of the same number of teenagers having the same kind of sex on the background of a population increase!

Unless we have the data, we can never know if a "safe sex" campaign will actually encourage teenagers to have sex, or if "abstinence only" campaigns for Singapore will work.

angry doc would like to suggest that the ministry conduct a study to obtain the baseline data so we can have a frame of reference, except he is worried that asking teenagers whether they are having sex will in itself encourage them to have sex...

Good for what ails you! 2

angry doc must have been sick the day they taught water-medicine in med school...


Beating HFMD: Drink water

THE rising number of reported hand, foot and mouth disease cases shows that stepped-up hygiene standards and checks on the young charges are not enough to arrest the crisis.

One way that can help tackle the problem is to be mindful of children's water intake. I am not advocating just drinking lots of water. Water intake should be more specific, in proportion to the child's body weight. The key
is to drink it in sufficient quantity and regularity.

The rule of thumb is: Drink at least one ounce of water for every two pounds of the child's body weight. The metric equivalent is: 31.42ml of water for every 1kg of the child's weight. In addition, mix 6/100 (0.06) teaspoon of sea salt (do not use table salt) into every 314.2 ml of water.

For thousands of years, doctors have successfully treated their patients with nothing more than plain water and natural salt. Water and natural salt, when combined together, give you everything your body and mind need.

Soong See Choo


angry doc certainly didn't know that "[f]or thousands of years, doctors have successfully treated their patients with nothing more than plain water and natural salt", or that "[w]ater and natural salt, when combined together, give you everything your body and mind need".

Why didn't they just tell me that on the first day of medical school and just let me go on an extended vacation for the remainder of the five years?

Of course, Mr Soong didn't just come up with the figures of 1 ounce per pound per day off the top of his head; if you google around a little you will find where he got his formula and beliefs from.

It's not surprising that a layman like Mr Soong will come across unsubstantiated claims of a miracle cure and believe them. What is surprising and unacceptable to angry doc is the way a national newspaper periodically prints letters from advocates for unproven forms of therapy without fact-checking. The lack of editorial vigour is just irresponsible.

Them 10

(Edited on May 12, 2008)

Nevermind the gays, now it's those pesky teenagers who are spreading AIDS! Just look at the statistics!

(emphasis mine)

Teens, sex and Aids: Time to face up to today's realities
With teen hiv on the rise, is the abstinence-based approach relevant?
Tan Hui Leng

Amid the heady flush of first love, or lust, can two hot-blooded teenagers abstain from sex when even grown-ups yield to temptation?

More importantly, are we willing to live with the risk of giving them the benefit of the doubt when their lives and future could be at stake?

Risk, in this case, is spelt HIV. Just look at the statistics.

According to the Ministry of Health (MOH), human immunodeficiency virus (HIV) infections have been on the rise annually, registering a record high of 422 diagnosed last year. Those in their 20s and 30s make up the biggest proportion of total patient load.

Does that mean they contracted the virus only in their 20s? Do we know when they started having sex?

According to the Durex Global Sex Survey Report, the mean age at which Singaporeans lose their virginity is 18.4 years old. How many teens under 18 are having sex if the average yardstick is 18.4 years?

Well, teens have been registering single digits in annual HIV statistics. It may not look significant, but each year, the numbers creep up quietly. This is in tandem with the rising trend of sexually-transmitted infections among teens — which has also been steadily increasing in recent years.

It was revealed last week that there were nine teenagers diagnosed with HIV last year, all of whom were between 17 and 19 when detected. This is up from one to four cases each year between 2003 and 2006.

With a higher rate of premarital sex, presumably with multiple partners for some, comes a higher risk of sexual infections.

Despite this, the Ministry of Health is not rolling out its full-fledged HIV prevention programmes for teens.

In Parliament recently, Health Minister Khaw Boon Wan explained the sensitivity in broadcasting the ABC (Abstinence, Be faithful and Condom-use) message nationwide: "Many parents will be upset with such a campaign and we will be accused of promoting promiscuity."

"So, the general broadcast has a small 'c'. On the other hand, the ABC campaign targeted at high-risk groups will have an enlarged 'C' as the main theme."

While this is similar to the argument put forward in the Section 377A debate — let us not upset the majority of the population who are conservative, or rather, heterosexual — it does not hold water when the majority of Singaporean parents could possibly be affected.

Whether they like it or not, there is likely a 50 per cent chance their children are having sex even before they turn 18.

That the importance of condom usage is overshadowed by the message of abstinence is disturbing in the light of the recent HIV statistics.

Mr Khaw said that those in "high-risk" groups would be given a stronger message to use condoms. The recurring question is, who are in "high-risk" groups, particularly if we are talking about teenagers who are exploring their sexuality?

To wait until a youth presents a sexually-transmitted infection before counselling on safer sex kicks in is to hide behind a veil of ignorance.

Promoting abstinence and faithfulness is effective in keeping HIV under control, but more focus is needed on efforts to educate sexually-active teens about sexuality and condom use, said volunteer group Action for Aids. How will the authorities get a chance to help teens when premarital sex is emphasised as a moral wrong?

And do the sexuality and parenting programmes we have equip parents adequately to talk to their children about condom use?

Singapore's rapid development in the last 40 years has fast-tracked a generation that may hold different values from those of their parents. Whether one agrees with what teenagers do in their bedrooms is not the issue — and should not detract from the issue, which is: There is a need to implement an effective solution that will not stigmatise. It starts with acknowledging today's realities.



You can see the statistics mentioned in the article here. As mentioned the 20 - 29 and 30 - 39 group together make up 38% of those diagnosed with HIV in 2007.

What the article doesn't tell us, however, is the fact that men aged 40 and above make up 55% of the total, or that Chinese make up 84%.

Teenagers, or rather those aged 19 and below, make up 2.4% of the total. And if you minus off the one case of perinatal transmission, the figure falls to 2.1%.

Even when we take into account an average latency period of 8 to 10 years and include those in the 20 - 29, 'teenage sex' still only accounts for 15% of the total.

Going by statistics, we should be targeting the campaign at 'dirty Chinese old men' and not teenagers - but why let facts and statistics get in the way of a story, or for that matter a public health campaign, right?

In fact, to further lend credibility to her argument, our reporter makes the observation that "[w]ith a higher rate of premarital sex, presumably with multiple partners for some, comes a higher risk of sexual infections", as if extramarital sex with multiple partners did not come with high risks too.

angry doc welcomes a campaign that doesn't dodge the issue that people are having sex with multiple partners without barrier protection - admitting that this is in fact the case and that it is the major cause of HIV transmission in Singapore is probably the first step in solving the problem.

angry doc also sees the point of having a campaign that targets teenagers; even though not all teenagers are the same, we know enough about their mindset and behaviour as a group to know that we must tailor the message in a way that will reach them and engage them in a way that will not look like talking down to them. (However, angry doc feels that past health messages aimed at looking 'cool' and 'hip' to teenagers have always looked rather forced and lame...)

One problem with a targeted campaign, however, is that it can - as exemplified by this article - create a false impression that the group being targeted forms the bulk of the problem. As angry doc has shown above, this is clearly not the case here.

Another problem with a targeted campaign is that it can lead to stigmatisation of a group, especially when the 'grouping' is based on the observation of a correlation, but does not in fact represent causation.

The truth is the boxes that we put people in when we present HIV/AIDS statistic - age, race, marital status, sexual orientation - are not really useful in telling us how or why people caught the infection; they are merely used because they are 'visible' and therefore convenient labels we can use to try to put some semblence of order in all those numbers. These divisions should be used only to help us plan and tailor our educational programmes when trying to reach different segments of our population, but not to give the impression that it is one group or another that is responsible for our HIV/AIDS problem.

Turf War 2

There isn't really a part I to this post, but the title refers to this article in Today which caught angry doc's, well, eye.


Eyeing Lasik surgery?
Risk of some vision loss more than wearing contacts: Experts
Jinny Koh

IN A country with one of the world's highest rates of myopia, would Singaporeans opt for laser eye surgery if they knew that the risk of some vision loss is about 100 times more than that when wearing contact lenses?

This risk was highlighted by Professor Fiona Stapleton, head of the School of Optometry and Vision Science at the University of New South Wales, Australia, at a press briefing for the fifth Asia Cornea and Contact Lens Conference yesterday.

According to her study, six out of 100,000 contact lens wearers suffer some form of vision loss each year, compared to 700 cases per 100,000 refractive surgeries such as Lasik (laser-assisted in situ keratomileusis). However, she noted that 50 out of 100,000 contact lens wearers suffer from contact lens-related corneal infections every year.

Lasik will also leave the patient with a thinner cornea and compromise the quality of vision after surgery, said Dr Koh Liang Hwee, vice-president for the Singapore Optometric Association (SOA), which is the organiser for the conference.

Other possible side effects of Lasik include loss of contrast, poor night vision, as well as seeing haloes or starbursts. Dr Koh said Singaporeans should know the risks involved before undergoing the procedure.

However, consultant eye surgeon Dr Lynn Yeo said that having a thinner cornea after surgery has no ill effects on the patient, unless the cornea becomes too thin, which is unlikely because of the pre-operation screening guidelines Lasik surgeons have to adhere to.

"If the patient's cornea is naturally too thin, we will recommend implantable contact lenses for them if they are found to be suitable," she said.

Dr Yeo added that few Lasik patients have complained of night vision problems after surgery.

"With the customised wavefront-guideline Lasik treatment, the chances of getting these side effects have been minimised," she said.

Alternative help for myopia

An alternative in treating myopia is the use of rigid gas-permeable contact lenses worn at night to reshape the cornea.

Known as orthokeratology (Ortho-K), it has been available in Singapore for 15 years, but only became popular about five years ago, said Mr David Chong, president for the Singapore Optometric Association. About 20,000 Singaporeans have been treated using Ortho-K.

Another way to improve eyesight is through NeuroVision, which uses a series of computerised visual tasks to train the brain to process visual information.

When asked how Ortho-K compares to NeuroVision, Mr Chong said that the latter has not been subjected to a worldwide trial. It is also not a treatment for myopia but a means to enhance one's visual capability, he added.
However, Professor Donald Tan, medical director of the Singapore National Eye Centre, noted that a pilot study at Evergreen Primary School last year showed that children who participated in the NeuroVision programme improved their vision by more than 70 per cent and reduced the progression of myopia by almost 50 per cent.


angry doc doesn't think that there is in fact a turf war between ophthalmologists and optometrists, or amongst ophthalmologists themselves. However, it does look to angry doc like the reporter is trying to paint the picture that there is one, perhaps in the hope of imitating the 'success' a reporter in another newspaper had recently in covering a "turf war" between doctors?

O the competition!

Fear as a Tool 2

HSA, Singapore's Quackbuster, makes the news again today:

Drug firms told to stop running 'educational' adverts
HSA says the campaigns are really thinly veiled ads, which are banned here; some also use scare tactics
By Salma Khalik, Health Correspondent

DRUG companies have been told to stop running 'educational' advertisements because they are anything but educational.

The Health Sciences Authority (HSA), Singapore's medicines regulator, is concerned about the increasingly 'creative' slant drug companies are taking. It told The Straits Times that these educational campaigns were thinly veiled advertisements, which are banned here.

It plans to re-look the issue with the industry. It wants stricter rules to ensure that drug companies do not cross the line, using campaigns to push their products.

Like most countries, Singapore does not allow direct-to-consumer advertisements for prescription drugs. It prefers to let doctors tell patients about medicines.

When the HSA agreed four years ago to allow drug companies to run educational campaigns, the understanding was that they would provide objective and unbiased information about a disease.

This would encompass alternative treatments, including the benefits of diet and exercise.

Instead, some advertisements rely on scare tactics and give little information. Some promote new and innovative products that lack long-term safety data, said HSA deputy director Madam C. Suwarin.

She said some drug companies were also becoming 'too creative', such as paying for coverage in newspapers, magazines and on the radio.

A few years ago, the HSA chided Merck, Sharpe & Dohme (MSD) for its bus stop ads. MSD promptly removed them.

MSD marketing director David Peacock said his company had no intention of breaching the rules and all the campaigns that the company has run since then had complied with the regulations.

He felt that there was a role for educational campaigns, especially when many are unaware that they have a disease.

Dr Kevin Tan, vice-president of the Diabetic Society of Singapore, agreed that a review might be timely. But he also felt that campaigns by drug companies had helped patients and he 'would not like to see this end'.
Educational efforts by the Government were not enough and 'coverage would just not be as intense without the help and drive of pharmaceutical companies', he said.

Dr Beh Suan Tiong, president of the Obstetrics & Gynaecology Society of Singapore, also supported industry education. He said: 'They are important components in any disease management and prevention, be it by public or private organisations. Both have their roles.'

Madam Suwarin said the HSA also thought it good for the industry to help patients. She said: 'We know we need to work with others. We want to be a smart regulator, carrying a small stick, like a conductor building a symphony. Not a big stick to hit them with.'

But it must also make sure that drug companies do not push patients into demanding medicines that they do not need.

She said that the focus on depression in the United States has sent the number of prescriptions for anti-depressants soaring. Such medication is meant only for severe depression, but doctors dole it out freely.

The drugs can have severe side effects, including suicidal thoughts in youth.The HSA does not want to see it happen here.

Well, leaving aside what the poster is trying to sell (which is itself another controversial topic), angry doc does think the advertisement aims to hit the heart more than the head. But as he had mentioned before, angry doc has no objections to using fear as a tool in healthcare.

As for the issue of direct-to-consumer advertising (DTCA), angry doc does not have a firm opinion on it, but just takes the conventional view that it is not something desirable because of the likelihood that drug companies will "push patients into demanding medicines that they do not need".

Many doctors will no doubt agree, because DTCA has indeed be shown to be "associated with increased prescription of advertised products and there is substantial impact on patients’ request for specific drugs and physicians’ confidence in prescribing" while at the same time, "[n]o additional benefits in terms of health outcomes were demonstrated". (Neverthelss, the same doctors will likely claim that they themselves will never succumb to such pressure from their patients.)

To angry doc's mind the underlying issue with DTCA is that medicine is a confidence good. Drug companies will always try their best to increase their sales (and they wouldn't be pushing for DTCA to be legalised if they didn't think it increased their sales, would they?), and patients will probably never have sufficient knowledge to discern advertising hype and scare tactics from reasonable concern and risk-benefit ratios.

At the end of the day, it is up to the doctor to understand the products being sold, and deciding if it is beneficial for the patient he is seeing. The fact that DTCA seems to be affecting our clinical judgement speaks poorly of us as a profession, and is another example of how the market fails when it comes to managing healthcare.

Not that angry doc will let his judgement be affected by DTCA, you understand...

Them 9

Alex Au of Yawning Bread has posted a new article on the increase in HIV/AIDS incidence and the amendments to the Infectious Diseases Act. The article contains much data and information and is well-worth a read.

Mr Au identifies moralisation of HIV/AIDS as one of the underlying problems with our HIV/AIDS programme, and doubts that legislation will make things better. angry doc tends to agree with him.

But whether or not one agrees with Mr Au's observations, one cannot deny that the data he has presented suggest that whatever Singapore has been doing to try to reduce the number of new cases of HIV/AIDS is not really effective, and that at the same time, some countries are in fact experiencing successs in their fight against HIV/AIDS. Perhaps there is a place on Earth where moralisation and/or legislation of HIV/AIDS will work, but so far Singapore doesn't look like that place.

Faced with the latest figures, angry doc feels that we should take a step back ask ourselves why we are failing. We should look critically at whether the programmes we seem to be pursuing currently have in fact been shown to be successful elsewhere in the world, and also look at programmes which have been shown to be successful.

We may want to consider evidence that "[p]rogrammes that exclusively encourage abstinence from sex do not seem to affect the risk of HIV infection in high income countries", and ask ourselves whether we should review the emphasis of our programme.

We may also want to look at the success Brazil has had, which is attributed to "its integrated approach of prevention, respect for human rights and to free of charge universal access to state of the art antiretrovirals", and ask ourselves if there is something we might learn there.

There is a lot more data out there to be looked at, and we should look at all the data and learn from them because HIV, being a virus, obeys the laws of nature and not moral or penal codes, and looking at the data objectively and scientifically may be our best chance of beating the disease.