Midnight Musings

July 4th, 2011

Midnight Musings

Last Thursday I saw Midnight in Paris. I haven’t been to the movies as much as I should and I haven’t seen a Woody Allen film in years.  But this one’s a gem: funny, sweet and wise – just what you need on a mid-summer night.  The film’s protagonist is a thirty-something successful screenwriter (played by Owen Wilson) on vacation in Paris worrying about a novel he is writing about a dealer in memorabilia. In a back-to-the-past-back-to-the-future story line, he meets his heroes from the Paris Jazz Age:  F. Scott Fitzgerald, Gertrude Stein, Salvador Dali (a very funny Adrien Brody), Ernest Hemingway, Pablo Picasso. He falls in love with Picasso’s mistress Adriana (Marion Cotillard), who is also Hemingway’s lover. For Adriana, the 1920s are pretty ho-hum and she longs back to the Belle Epoque, 40 years earlier.

Of course, when you close your eyes, it’s all Woody Allen you see and hear. Never mind, I had a great time and I won’t say much more about the movie since you might still want to see it (you should).

Besides some allusions to concurrent partnerships (involving Hemingway and Picasso no less), why write about the movie on STDPO? Well, of course, thinking about STDs all the time (or STIs for that matter) makes you a bit dull and talking about the latest Woody Allen movie just makes for better conversation during the Holiday barbecue than hidden epidemics in general and the resurgence of syphilis in particular.  

If there is a moral in the film, and I guess there is, it is that whatever the “present” you live in (2011, 1920, 1880), the good old days are always, well, “old”. The present and future always look bleak and grim, but the past has a golden hue. Same in STD prevention: back then we had resources and declining rates of syphilis and gonorrhea. Now we have no money and a syphilis epidemic on our hands. STD clinics are disappearing. HIV rates are stagnating. We are continuously asked to do more with less. Yeah, you can’t always get what you want, especially in economically distressed times with more austerity coming down the pike. But while we have no idea what STD control will look like tomorrow with less money and competing priorities for health reform, we know for certain that it will be a heck of a job to get what we need.

Still, there is only one way forward.  We must learn to live within our means and, yes, do more with less. Of course there is also an opportunity: becoming more efficient, critically look at the effectiveness and cost-effectiveness of programs, even those we care deeply about. We simply can’t afford to keep our pet projects alive if they don’t hold up to renewed scrutiny. We must also find ways to better collaborate and share the products and processes that have been developed and found successful elsewhere. Efficiency means scale; the more people we reach, the smaller the marginal cost per service delivered. Unfortunately, the way federal dollars are disbursed among state and large metropolitan jurisdictions is an impediment to scale-up across jurisdictional lines.

But this is no time to keep (re-)inventing the wheel.  If there is an STD program that has developed a functional product, let’s place grant monies strategically to allow such a clinic to package its products for  use by other programs instead of having each program spend large sums of dollars to develop their own. Florida’s PRISM system comes to mind. For another example, the Internet does not stop at state borders and there is no reason that Internet-based programs, such as online partner-notification cannot be scaled up regionally or nationally. If we decide that there is a place for online testing such as the I Want The Kit or I Know programs, why have multiple programs instead of having the economies of scale of a single large program? We are still way behind the technology curve and it’s time we get ahead of it.

I have made these arguments before in previous blogs and I have also made arguments on how the CDC STD Division could become leaner by integrating a number of programs; I have specifically suggested, the creation of regional STD Centers of Excellence that could serve multiple roles, including training, sentinel surveillance (including GISP), and program research.

Granted, some of these ideas look nice on paper and might not hold up well when discussed and scrutinized. However, the point is that these times require us to become creative and start to think way outside the box. I suggest that STDPO can be the forum for the exchange of such ideas. On that note, I profoundly thank the American STD Association for becoming the site’s main sponsor so that it can fulfill this role.