Power Law, Sex Workers, and HIV/AIDS

After 12 agonizing days our project is back on track! Unfortunately, I'm going to delay telling the back story of our lay-off yet again. Hopefully the suspense is building - I hope we don't disappoint when the time comes!

In the meantime, our project has developed a clear direction - employing a FrontlineSMS system
around the Bhoruka Charitable Trust’s HIV prevention programs. BCT is part of a larger network of organizations working in a comprehensive HIV program. They implement the preventative side of the equation- including outreach, education, referrals for testing. BCT focuses almost entirely on high risk populations- mainly sex workers. But why sex workers? What about everyone else?

I spent one of my off days powering through Malcolm Gladwell's Outliers - a very interesting study that attempts to explain extraordinary people. Gladwell is a great writer for a number of reasons- including his gift for turning complex streams of information into a narrative. His writings also get the user to question closely held assumptions and do something we often don't stop to do - think. Since Gladwell got me thinking, I'd like to attempt to do the same for you - explaining the pilot use of our project (including the question of “Why sex workers”) in the context of one of his writings - a New Yorker article from 2006 called "Million Dollar Murray" (accessible here)

I’d recommend reading the article, but I’ll try to summarize as best I can. Gladwell believes that we have a tendency view problems ranging from homelessness to HIV as “normally” distributed. He explains what he means by this using the LAPD’s issues with racism and violence following the Rodney King riots:

In the language of statisticians, it was thought that L.A.P.D.'s troubles had a "normal" distribution— that if you graphed them the result would look like a bell curve, with a small number of officers at one end of the curve, a small number at the other end, and the bulk of the problem situated in the middle. The bell-curve assumption has become so much a part of our mental architecture that we tend to use it to organize experience automatically.

In fact, the opposite is often true. Problems like violence at LAPD can be said to follow something called the “Power Law”. The problem is not in the middle, but rather at the extreme. Gladwell claims that a small population accounts for the majority of the costs associated with homelessness (the namesake of the article is an individual from Reno named Murray who racked up over a million dollars in hospital expenses over 10 years!). The optimal solution changes the minute you begin to envision problems as following a power law distribution. In the case of homelessness it became rounding up the chronically homeless population (read: the long tail) and offering them a free apartment and intense case management.

Now try to envision HIV/AIDS as following a power law distribution. What if you focused on the population that accounted for a large proportion of the infection’s spread? Turns out that some visionaries in Thailand did just that (read more here). While other countries were spending vast resources on Anti-Retroviral Drugs (ARV’s), Thailand invested its funding in prevention programs- including interventions with the country’s sex worker population. Describing the “100% Condom Program”:

This program aimed to enforce consistent condom use in all commercial sex establishments. Condoms were distributed free to brothels and massage parlours, and sex workers and their clients were required to use them. Brothels that failed to comply could be closed. Without this program, it is estimated that Thailand’s national HIV prevalence would be ten times higher than it currently is.

Sounds pretty familiar right? Thailand has been able to reduce its number of new HIV infections from 143,000 in 1991 to 19,000 in 2003. The same cannot be said of countries in Sub-Saharan Africa that did not pursue this approach.

For some this may still feel wrong. Power law solutions often don’t. One doctor here expressed his frustration with the response of NGO’s here. He believed that everyone should be tested for HIV, not just high-risk populations. There is also a moral hazard here - why not just shut down the brothels all-together? why should we spend tens of thousands of dollars housing a few select homeless people?As Gladwell puts it: “Power-law problems leave us with an unpleasant choice. We can be true to our principles or we can fix the problem. We cannot do both.“ It’s worth noting that Thailand combined their targeted interventions with a massive public information campaign and other initiatives.

After meeting with sex workers here and listening to their diligence surrounding condom use and HIV/AIDS it’s hard to deny that important progress is being made. Our hope is that a FrontlineSMS system can build on the success of this and other programs. Who knows what lessons we may learn.

- Dan