Innocent Mistake or Academic Fraud

     In the paper "Condom Promotion for AIDS Prevention in the Developing World: Is it Working?" by Norman Hearst, MD, MPH1 and Sanny Chen, MHS1,2, the authors use footnotes fraudulently in an attemp to prove their points.  This paper is available from the pro-abstinence Medical Institute for Sexual Health, in a pdf called "Evidence Monograph."

     First, a little background.  Human Rights Watch has this report which is pretty useful.  Basically, in 1987, Uganda began what it calls the ABC program for fighting HIV/AIDS, then ravaging the country.  This included, but was not limited to, education of primary and secondary school children about HIV/AIDS, condoms, and the value of being abstinent before marriage and faithful after marriage.  Uganda is often considered a success story, which, it turns out, is part of the problem.

     For Christian leaders, like President GW Bush, want to credit abstinence and faithfulness, and others want to credit condoms.  Apparently, some groups are getting rich off condom distribution.  Others want condoms stopped, because it violates their ethical or religious sentiments.

     Let's look at this one paragraph of the "Condom Promotion" paper by Hearst and Chen.

Condoms were not central to the initial (ie, pre-donor) response to the AIDS epidemic in Uganda. Messages focused on delaying sexual debut, abstinence, being faithful to a single partner (called "zero grazing"), and condoms, roughly in that order.41,48 Large- scale condom social marketing did not begin until the arrival of the foreign donors in the mid-1990s.54 In fact, as late as 1995, only 6% of Ugandan women and 16% of Ugandan men had ever used a condom, with consistent use being much lower.48 Although Ugandans now use more condoms, particularly with casual partners, these recent condom use rates cannot be credited for what happened earlier.51

     Powerful facts, if they happened to be true.  Let's look at the footnotes cited.

• 41: Joint United Nations Programme on HIV/AIDS (UNAIDS). Thailand Epidemiological Fact Sheets on HIV/AIDS and Sexually Transmitted Infections (2002 Update). Geneva: UNAIDS; 2002. Link (pdf)
• 48: Kilmarx PH, Palanuvej T, Limpakarnjanarat K, Chitvarakorn A, St. Louis ME, Mastro TD. Seroprevalence of HIV among female sex workers in Bangkok: evidence of ongoing infection risk after the "100% condom program" was implemented. Journal Acquired Immune Deficiency Syndrome 1999; 21(4):313-316. Link(abstract)
• 51: Stoneburner R, Carballo M, Bernstein R, Saidel T. Simulation of HIV incidence dynamics in the Rakai population-based cohort, Uganda. AIDS 1998; 12(2):226-228. Link(pay subscribers only)
• 54: Deloitte Touche Tohmatsu. Commercial market strategies, Uganda report; 2001 Link(pdf)

     First, link 51 isn't an article, it is a letter, and as such didn't meet the same scrutiny requirements of other material.  Second, link 54 has a chart (PDF page 11, numberered page 7) which says "socially marketed condoms" were trivial in amount before 1991, but this doesn't mention that "socially marketed" condoms are a special type of sale, defined by the UN as "For example, social marketing programs offer condoms for sale at lower prices and at many non-traditional outlets, like markets, hotels and bars." Socially marketed condoms make up what % of total condom sales?  No information is presented.  Link 51 also says "The decline in incidence and prevalence [of HIV/AIDS] are complex and not yet completely understood. This is especially true regarding the earlier years (i.e., there is little HIV-related Demographic and Health Surveys (DHS) data prior to 1995)."  Link 41 and 48 don't mention Uganda at all, so we are left wondering "where do Hearst and Chen get the idea that only 16% of Ugandans have ever tried a condom?"  Well, in the paper HIV incidence and sexually transmitted disease prevalence associated with condom use: a population study in Rakai, Uganda they do provide that number, limiting it only to one, rural province in Uganda.

     I believe the explicit STD, sexual health and HIV/AIDS education provided to primary and secondary school children, now being removed by President Museveni, probably had the largest impact.  That education stressed A, B and C, but now C is being removed from the picture by a christian revivalist movement.

     Whatever the truth turns out to be, nothing in Hearst and Chen's paragraph above is supported by the footnotes provided, although one (link 54) does provide some indirect evidence.

     This reminds me too much of Dr. Page, Bush's choice for Secretary of Education, and the way Houston School District numbers were rigged to make them far better than they really were (by throwing kids out of school who weren't testing better).  A complete lack of suspiciion of voices on their own side.

---

CORRECTION: The Evidence Monograph containing this paper also contains a paper by Dr. Green of the Presidential Advisory Council on HIV/AIDS.  I didn't notice the pdf contained two papers, and originally, mistakenly, connected Dr. Green with the fraudulent footnotes.