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A crop-duster sprays a field with pesticides. Various counties in North Carolina are deploying similar strategies to control mosquito swarms. Depositphotos

Tornadoes may not bring sharks, but as North Carolinians are now discovering, hurricanes can bring giant insects. In the wake of Hurricane Florence, more than two dozen counties have been inundated with massive mosquitoes, creating what for many amounts to a nightmare scenario.

The scene was like “a bad science fiction movie,” according to Robert Phillips, a resident of the centrally located Cumberland county. ” I told my wife, ‘Gosh, look at the size of this thing.’ I told her that I guess I’m going to have to use a shotgun on these things if they get any bigger,” Phillips told The Fayetteville Observer.

But now North Carolina is fighting back against the invaders. Governor Roy Cooper dedicated $4 million in relief funds to combat the outbreak on Friday, and as of Monday morning anti-mosquito trucks were already rolling the streets of Cumberland, spraying the air with insecticide, The Fayetteville Observer reported. Health experts have labeled these particular insects as more of a nuisance than a threat, but are still encouraging people to wear long sleeves and mosquito repellant, as a small fraction of the bugs could carry diseases such as the West Nile virus.

Even among scientists who study mosquitoes for a living, Psorophora ciliata has a fearsome reputation. In addition to being one of the largest species in North America, the gallinipper, as it’s commonly called, also has an especially painful bite. It seems to know it too, with scientific literature recognizing its “legendary aggressiveness.” North Carolinians, understandably disturbed, have taken to social media to practice some amateur entomology.

Although they look like a subtropical nightmare, gallinippers actually live all over the eastern half of the U.S., their habitat stretching from Texas to New Hampshire. Females lay their eggs wherever they can find damp dirt, and the eggs lie in wait for a flood or heavy rain. Hurricane Florence provided both when it dumped dozens of inches of precipitation on North Carolina last month, triggering a hatching frenzy. After getting rehydrated, gallinippers reach adulthood in less than a week—bringing North Carolina to its current state.

Governor Roy Cooper moved quickly to combat the swarms, announcing that $4 million in relief funds were available to help more than half of the state’s counties control their booming mosquito populations on Friday. The first wave of counter-measures has already begun. Insecticide-spraying trucks started patrolling the streets of Cumberland County before 8 a.m. on Monday and will resume after the work day ends, The Fayetteville Observer reports. An aerial assault will follow in the upcoming weeks, with planes blanketing the affected areas. Individuals can also join the fight with items called “dunks,” small disks that release a mosquito-larva killing bacteria when dropped into pools of water such as birdbaths or small ponds.

Texas counties took similar actions last fall after mosquitoes erupted from the ground in the aftermath of Tropical Storm Harvey, using U.S. Air Force reserve cargo planes to spray a nearly Rhode-Island sized area around Houston. This unusually strong response came because hurricanes hit the two states with a one-two entomological punch. First, the rains soaked the buried eggs and raised dormant species like the gallinippers. These insects activate only during times of flooding and rarely carry disease. But then, since most mosquitoes need open water such as ditches to lay their eggs, standing pools left by receding floodwaters increased the likelihood that other species would be able to breed too.

“Because of the flood there’s going to be more water. There are going to be more mosquitoes, and so we have to do the best we can,” the director of mosquito and vector control for Texas’s Harris County Public Health, Mustapha Debboun, told The Scientist at the time.

While aerial sprays and bacterial bombs represent cutting-edge anti-mosquito weapons, the U.S. has been targetting the winged scourge for more than half a century with decidedly low-tech methods. After The Great Depression, New Deal-era programs put more than 200,000 people to work digging ditches to literally drain the swamps of the south. Public health historians estimate that by 1945, workers had dug enough ditches to reach around the globe and then some, drying well over half a million acres of land (one acre can hatch one million mosquito eggs).

The Office of Malaria Control in War Areas, initially founded in Atlanta to stop soldiers from getting mosquito-borne malaria on southern army bases, delivered the final blow in the 1940s when it coordinated a mass spraying of nearly five million southern homes over the course of two years. The organization, which we know today as the Centers for Disease Control and Prevention (CDC), declared the country malaria free in 1949.

North Carolina won’t require such a wide-scale intervention, however. Upcoming chilly temperatures should kill whatever gallinippers survive the sprayings, experts expect. And there’s another silver lining. Psorophora ciliata enjoys snacking on the mosquito larvae of other species, so much so that some entomologists have suggested intentionally cultivating them to keep other, more dangerous populations down. The notion of releasing big mosquitoes to eat the small mosquitoes hasn’t yet caught on, perhaps in fear of the sci-fi chain of unintended consequences it could unleash (now how are we going to get rid of the mutant swallows??), but North Carolinians are well-positioned to enjoy its benefits nonetheless.

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The Sopranos And Friends Are Hbo Max’S Secret Weapon Against Netflix


Netflix has seemingly cornered the market on streaming original shows. With major titles like Stranger Things, The Witcher, Orange Is the New Black, Grace and Frankie, Big Mouth, and plenty more, it has some popular series but also a massive library of other original titles. As time goes on, though, the streamer is seeing its back catalog of older shows dwindle.

Check out: The best original streaming shows on every major platform

That may very well account for its increasingly low standing with subscribers. Amid a dip in subscribers, Netflix now also faces the reality that it has the lowest “value satisfaction” of all the major streamers, according to a recent poll by Whip Media. That means people no longer think Netflix is really worth the price of admission compared to the competition.

We obviously can’t put all the blame on the loss of many beloved titles from its back catalog, but it can’t have helped. Netflix was once one of the only streaming destinations online. As such, it licensed tons of shows and movies from almost everyone. But as companies like WarnerMedia (now Warner Bros. Discovery), NBCUniversal, Disney, and Paramount launched their own subscription services, they naturally became more protective of their prized libraries.

HBO Max has been catching up to Netflix in the streaming wars.

Among them, one of the major standouts has been HBO Max. Mixed in with original series like The Flight Attendant, Hacks, Raised By Wolves, Station Eleven, and Minx, the Warner Bros. Discovery subsidiary also offers access to titles from HBO, Warner Bros., the Cartoon Network, the CW, New Line Cinema, and many more. HBO Max ranked first for “value satisfaction” in that same poll that saw Netflix losing public confidence, and we think it owes that to its extensive back catalog of shows.


Max, formerly HBO Max, is your home for HBO titles, Warner Bros-made movies and TV shows, the DC Comics superheroes, and more. It’s also the home for new and original movies and shows available nowhere else.

See price at Max

Discovering classics, revisiting favorites


One of my favorite streaming “discoveries” of the last year was The Sopranos. (Yes, as an entertainment writer, it was a huge gap in my viewing history, but there are only so many hours in the day and far more TV shows than that.)

I certainly wasn’t alone. Since the start of the COVID-19 pandemic, the classic HBO series has enjoyed a huge resurgence, especially among new, young viewers. It remains a smart, gripping, and even timely show more than two decades on, and it’s a prototypical example of prestige TV, paving the way for some of the best shows of the last few years.

Young viewers have discovered The Sopranos en masse in the last couple of years.

That’s the beauty of HBO Max. I have easy access to The Sopranos and other HBO classics, plus newer titles like Sex and the City, Six Feet Under, The Wire, Girls, Game of Thrones, and plenty more. If I missed them the first time around, I can go back — either alone or as part of the cultural zeitgeist — and get caught up. Those classics can be discovered anew by a fresh audience at any time, divorced from the constant stream (pun intended) of new content.

See also: The best shows on HBO Max

A similar and maybe even stronger case can be made for revisiting favorites. Warner Bros. Discovery broke the internet in 2023 when its NBC classic Friends was removed from Netflix, only to later make its way to the company’s own nascent streamer HBO Max. NBCUniversal similarly made headlines when it reclaimed its fan-favorite sitcom The Office, now hosted exclusively on Peacock.

What’s more comforting than ending the day with old episodes of Frasier or The Golden Girls?

Rewatches mean big money in streaming. What’s more comforting than ending the day with old episodes of Frasier, The Golden Girls, Law & Order, or Batman: The Animated Series? In 2023, a bizarrely specific subreddit even bemoaned the removal of Futurama from Netflix not just because its members loved the show, but rather because they needed to have it playing to comfortably go to sleep. I’m personally gearing up to rewatch HBO’s stunningly good The Leftovers — once I finish The Sopranos.

HBO Max has made major headway in the streaming wars


Over the years, Netflix’s prices have continued to rise, even as its own third-party back-catalog titles have disappeared. Hence the diminishing perception of its value.

The cheaper HBO Max, on the other hand, has been a value contender from day one. The back catalog of already popular titles is surely no small part of that. It includes a healthy balance of movies and TV shows, and among those is a treasure trove of older titles to supplement the Max originals. But HBO Max isn’t alone in this: Hulu, Disney Plus, Peacock, and Paramount Plus also draw from the libraries of their corporate overlords to compete with Netflix’s considerable head start.

The Coalition Declares War On Gears Of War 4 Quitters With More Punitive Measures

The Coalition declares war on Gears of War 4 quitters with more punitive measures




The Coalition recently rolled out Gears of War 4’s Title Update 3, deploying massive game changes aimed at improving the overall gaming experience. This update brings two new maps and many spectator mode improvements as well as a series of punitive measures to prevent early quitting in the Core and Competitive modes of GoW4.

The new quitting penalties mean that The Coalition finally heard fan uproar and decided to do something about it. GoW 4 players have long requested harsher penalties for rage quitters and the news that The Coalition will finally take the necessary measures to do so have made many fans happy.

I am very excited to see how this new TU will change the game. Extremely pumped for all the quitters to slowly but surely start leaving this game for good 🙂 […] Thank you to TC for listening to the fans requests and taking Gears 4 in a better direction. Can’t wait for future updates with further quit penalties, weapon tuning, hopefully some more swarm/locust characters, and pre-game lobbies. Gonna be an awesome year for Gears fans! Let’s Go!!!

New Gears of War 4 quitting penalties

TC has deployed the first wave of quitting penalties with Title Update 3. More specifically, here’s how the company is planning to punish GoW4 rage quitters:

Players leaving a Core/Competitive game early will be suspended from matchmaking

To avoid unfair penalties due to power shortages, players can rejoin a Core/Competitive match within 5 minutes of quitting

Rejoining and completing a match will remove the matchmaking suspension time

Matchmaking suspension time is displayed and visible including to your Squad Leader. If there is a suspended user in your Squad, you won’t be able to matchmake until their suspension has completed.

TC will implement more punitive measures against early quitters in the coming months as well. Hopefully, this will heavily discourage dishonest gaming behavior and reduce player frustration.

We’re continuing to work on lobbies for Core and Competitive in addition to more punitive measures for quitting and investigating tuning improvements. We can’t wait to deliver all this and more throughout 2023.

GoW 4 quit penalties: Is this really the solution?

So far, we haven’t answered an important question: What is the root-cause for GoW4 early quitting? Many gamers suggest that it’s the matchmaking system’s fault. For example, if a Bronze level player enters a match against a diamond level player, naturally they would want to leave the game.

Many fear that quit penalties will only increase player frustration and they’ll soon just quit the game in reponse. In other words, players suggest that TC should address the game’s imbalances rather than focusing on punishing gamers.

The fact that there are penalties isn’t the most frustrating part. The most frustrating thing is that TC is using the penalties as a means to avoid them having to actually figure out the issues that cause people to leave.

Other players believe that TC will only implement mild punitive measures in order to avoid dividing an already small community.

All in all, early quitting in GoW 4 is a multi-layered issue that TC cannot address with a single solution. The changes the company has implemented and will continue to implement in the future allow it to assess the overall quality of matches. TC can then analyze the data they’ve collected and use it to add further changes.

And this exactly what the company will be focusing on in 2023:

We have further quit penalty and balanced match features in the works – including Core/Competitive pre-game lobbies – coming in future Title Updates to further improve the online experience.

What’s your stance on early quitting in GoW4? Do you think the game’s new punitive measures will help?


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The Case Against Rolling Release Linux Distros

Also see: The 9 Best Linux Distros

Over the past year, I’ve spent more time than ever using rolling release Linux distributions. My experiences have been positive and negative, depending on the distribution and system updates applied.

Having tried a number of different rolling release distros, I’ll be speaking frankly in this article about a solid case against rolling release distributions. But before you jump to any conclusions, it’s worth reading the entire piece to better understand where I’m going with this.

I know for a fact that newer feels better, especially with regard to software. Updates usually come with new features, bug fixes, and even performance improvements! There are some reasonable benefits to updating one’s software on a regular basis, and lucky for us, Linux packaging repositories make this practically automatic. But what happens when the updates come in too quickly, and perhaps are untested?

For example, while most distribution specific repos offer well tested software updates, sometimes the user repos can end up pushing software that might need a little more time in the debugging department. Whether it’s a rolling release or a fixed release, the software offered by your distribution is generally considered to be safe and stable.

Unfortunately there are occasions with desktop environments or kernel related updates where bugs do crop up. On two of my rolling release PCs, a kernel update completely froze out my network cards – wired networking even, nothing uncommon at all. This network card issue affected two completely separate systems because of a kernel bug.

Clearly, I was free to roll back to a working kernel, which was easy enough for me as an experienced user. For a newer user, well, it would have left many feeling pretty disenfranchised.

With a fixed release distribution, this isn’t even an issue. You could burn a CD of Ubuntu’s latest 14.10 release running kernel 3.16, while still using Ubuntu 14.04 with kernel 3.13 and try out the newest release. When you discover that on the live image, networking is a bust – it’s no big deal. Thankfully, you were merely testing things out on a CD and can simply remove it, file a bug report and go on with your day.

I’ll be the first to admit I tend to be a big fan of the dedicated home directory. By the same token, there is something to be said for a clean installation of an operating system vs upgrading an existing one. All the cruft and other unused data can be easily removed by treating yourself to a clean installation of your Linux installation.

Considering the upgrade tool for your fixed release distro is bound to fail eventually, you’re eventually going to end up doing a clean installation. Rolling distributions will have to wait until things become so messed up that rolling back packages or config file editing isn’t going to fix the problem at hand. Point being, nothing runs better than a fresh Linux installation – not even a 5 year old rolling release install.

I accept that I will end up with grief for making this statement, but without question, if you want stability, you want a fixed release distribution of Linux. Rolling releases can be more convenient, but they also open up doors to challenges that might not otherwise be introduced. Taking the time to allow others to test out updates made to desktop environments and kernel updates are something I believe many Linux users overlook.

Granted, distributions such as Arch do a very good job at making sure any “surprises” are mentioned ahead of time in their awesome mailing list. But let’s be honest, unless you’re a super-geek, you’re not going to read a mailing list very frequently. Unless you’re working in IT or you have the discipline to think about it, odds are you’re just as forgetful as I am when it comes to this sort of thing. Stability through self-research before updating is a skill in itself and one that most of us lack.

With a fixed release of Linux, on the other hand, you’re free to be pretty forgetful. Forgot to update for two weeks? No big deal, just install the updates and get on with your day. Even though there are occasions where a bug “could” be introduced, it’s rarely going to break something critical at the desktop or kernel level.

Amd Barcelona Arrives, The Processor War Heats Up

AMD Barcelona arrives, the processor war heats up

This moment was a long time coming. We’ve heard about the Barcelona line of processors from AMD for some time now, but the release date kept getting pushed further and further back due to unnamed “complications.” In a world where dual core has become the norm, AMD is pushing the envelope by providing us with four cores of processing. The new quad-core Barcelona Opteron processors are supposed to be faster, more efficient, and more powerful than anything that AMD has offered in a consumer-level desktop.

As you may already know, Intel released their version of the quad core processor back in November 2006, placing AMD nearly a full generation behind its primary competitor. Talk to any AMD representative, however, and they’ll tell you that they’re actually ahead of the game, not behind it. This is because the Intel quad-core processor really just pulls two dual core processors and melds them into a single package. By contrast, the AMD solution is that of a “native” quad-core design. They say that this design will outdo Intel not only in terms of performance, but also power efficiency.

John Fruehe, worldwide business development manager for AMD’s server and workstation division, said that “the fact that it has four cores is probably the most boring part.” He goes on to describe such features like the “new 2MB level 3 cache that all four cores can share, [and] each core continues to have its own independent level 2 cache, so that you get better performance.” This is all a part of the three-stage cache architecture. The L1, L2, and L3 cache are 64KB, 512KB, and 2MB respectively with the first two caches being core-specific. AMD feels that this design “is better suited for the coming age of virtualization.”

In many ways, Barcelona is not a wholly new architecture as much as it is an improvement over current designs. AMD took what they already had and made it better, rather than creating something completely new altogether. It will be interesting to see actual systems in action, comparing AMD’s quad-core solution against those offered by Intel, the company that still outsells AMD by a fairly significant margin.

In fact, on the same day that AMD finally announced the availability of the Barcelona microprocessors (today), Intel decided to rain on their parade by issuing a statement telling the world that Intel processors are selling better than ever and are doing much better than expected. Normally, this wouldn’t be a cause for alarm for AMD, but given that Intel wasn’t scheduled to make an earnings announcement until October 16th, it is clear that today’s statement was pure strategy. In it, Intel exclaims that demand for its products was “brisker than originally thought” and the margins would be higher than expected.

And the processor war continues. I’ve seen a lot more AMD-powered computers than I have in the past, so just based on my personal experience, I’d say that AMD is slowly taking away some market share from the giant Intel. Where do you stand? Are you an AMD aficionado, an Intel loyalist, or do you just grab whatever’s best at the time?

Doing The Math Behind The World’s Biggest War On Aids

Doing the Math Behind the World’s Biggest War on AIDS BU researchers help shape South Africa’s response to HIV

It was the third blow that spun Busisiwe Sithole’s aching grief into dread. First, her six-month-old son died while Sithole was carrying him on her back. Then doctors told her that her infant had been infected with HIV. Then Sithole learned of her own test results.

“When I found out I was positive,” she says, “it was not an easy thing. I was scared. When I would go to sleep at night, I would see myself dead in my coffin. I would see my older child crying. I was preparing my obituary. Then I talked to a counselor about treatment, and she said, ‘You are not going to die.’”

Seven years later, a healthy-looking Sithole works as a data clerk in Johannesburg’s Helen Joseph Hospital, collecting information for the Health Economics and Epidemiology Research Office (HE2RO), a collaboration of Boston University public health experts and researchers from the University of the Witwatersrand. Just downstairs from her office is the Themba Lethu Clinic, where people come for testing, care, and treatment for HIV and the diseases that go with it. There is, it seems, no end to the patients. In South Africa, one in 10 people is infected with HIV, and HIV/AIDS plays a role in 31 percent of deaths. HIV is the country’s most pressing health problem, and Themba Lethu is its largest HIV/AIDS clinic. With as many as 20,000 patients expected to pass through the doors in 2012, it may be the biggest clinic of its kind in the world.

Sithole says many people she talks to are surprised to learn that she has been HIV-positive for so long, yet shows no signs of ill health. “Just last week a colleague came to me, because she had a family member who didn’t want to take the antiretrovirals because there are stories about them. I told them it’s better to get tested. It’s better to know. Because you can live with it. You can control it. Because I know, I also know that AIDS will not kill me. I know that I am going to see my grandchildren.”

Ian Sanne, a South African infectious disease specialist and a codirector of HE2RO, witnesses the life-restoring powers of antiretrovirals every day. “It’s like a miracle,” he says. “It’s really remarkable what can be done with the drugs.”

It’s also remarkable, Sanne knows, what can be accomplished with data. For the past eight years, he and his colleagues at HE2RO, including Sydney Rosen, a School of Public Health research associate professor of international health, and Matthew Fox (SPH’02,’07), an SPH assistant professor of epidemiology, both at BU’s Center for Global Health & Development (CGHD) and HE2RO codirectors, have been collecting data, running it through algorithms that produce more data, then delivering it to the National Department of Health. HE2RO’s information, empirical evidence of the effectiveness and cost of new and better ways to combat HIV/AIDS, is in some ways as instrumental among South African health policy makers as the new pharmaceuticals are for AIDS patients like Sithole. Decision makers in both the National Department of Health and the Department of Treasury have used the data to frame an HIV program that treats almost two million people.

“There was a significant debate between the Treasury and the Department of Health about how much money should be made available,” says Sanne. “HE2RO, using real data, was able to solve the debate and create a budget with significantly escalating funding over the next five to six years. We managed to persuade the politicians to increase the amount of funding over time to cover three and a half million people.”

Working in a warren of offices in Helen Joseph Hospital, HE2RO’s researchers have embarked on more than 20 studies, most of which focus on better treatment of HIV and tuberculosis. The group’s work, which has mainly been funded by the U.S. Agency for International Development (USAID), has been influential, not only on the design of national health care policy, but also on the international funders of AIDS treatment programs.

“Health economics really drives everything we do, from health effectiveness to costing studies to the new national health policy that the South African government is rolling out,” says John Kuehnle, a health officer at USAID South Africa and contract manager for HE2RO. “BU and HE2RO have been at the front of this movement to use health economics to drive policy. It’s something that USAID and PEPFAR are very thankful for.” PEPFAR (U.S. President’s Emergency Plan for AIDS Relief ) is a government initiative to help save the lives of those with HIV/AIDS worldwide.

“There are a lot of groups that work on research on the HIV epidemic, and typically they approach the problem from the perspective of epidemiology,” says Fox. “Some come from the perspective of economics, or from social science. We combine all of those. By bringing all of that together, we can look at not just what is the best approach for a patient or for a clinic, but we can model the implications for the country. We can find the best strategies and approaches to use on a national scale.”

Despite the vastness of HIV infection in South Africa, the country’s first meaningful treatment programs got off to a painfully late start. Thabo Mbeki, president from 1999 to 2008, publicly questioned the link between HIV and AIDS, and his denial of medical realities delayed the introduction of antiretroviral drugs. Harvard researchers have blamed Mbeki’s failure to act for the deaths of 35,000 babies, as well as for shortening the lives of 330,000 people.

The years of denial were years of frustration for HIV researchers, including Rosen, who began traveling to South Africa in 1999 to examine the implications of HIV/AIDS among workers in the private sector and who lived in Johannesburg from 2003 to 2007. That project introduced her to Sanne, who in 2001 founded a not-for-profit called Right to Care. Since 2004, Right to Care has been funded primarily by PEPFAR, which has spent more than $3.2 billion on programs to prevent and treat AIDS and tuberculosis in South Africa. Right to Care, which has long worked closely with HE2RO, currently provides technical support to 170 treatment sites in five of the nine South African provinces and cofunds treatment for HIV, TB, and cervical cancer for about 150,000 people.

As a base for their joint research on the economics and epidemiology of HIV treatment, Rosen and Sanne founded HE2RO at the University of the Witwatersrand in 2004.

Coming out of HIV denialism

Change in South Africa’s approach to HIV came under Mbeki’s successor, Jacob Zuma, when the National Department of Health considered, in late 2009, adopting treatment guidelines then newly recommended by the World Health Organization (WHO). Those included the sweeping measure of treating HIV-positive people when their CD4 count—a measure of the immune system’s strength—is 350 or below, instead of the 200 count that had been the treatment threshold previously.

“When we came out of HIV denialism, we had a very controlled HIV treatment program,” says Sanne. “We needed to scale it. We also needed a switch in treatment regimens, because we learned that the treatment we had been using was quite toxic and needed a lot of monitoring. We learned that there were better treatment regimens for drug resistance.”

In the new government’s National Department of Health, the deputy director general for strategic programs, Yogan Pillay, had learned the same things. And he was eager to learn more.

“Government officials like myself don’t always know the right questions to ask,” says Pillay, who oversees the department’s programs for HIV, AIDS, and TB. “Often, researchers will lead the process by suggesting which questions need to be answered. Is there, for example, resistance building up in patients? If there is, what drugs do they need to switch to? If clinicians are switching regimens, what is the practice implication, and what are the cost implications? Those things have implications from the individual patient to a systemic level with respect to the ordering of drugs.”

For answers, Pillay was introduced in 2009 to Johannesburg-based HE2RO team member Gesine Meyer-Rath, an SPH research assistant professor at the CGHD. Pillay knew that with Right to Care’s health database of 17,000 patients treated at Helen Joseph Hospital, HE2RO had access to one of the biggest treatment cohorts in the country, which meant that it also had the ability to generate authoritative statistics and stable models.

“HE2RO can tell us what’s happening to patients who started treatment in 2004,” says Pillay. “They can predict what is likely to happen to patients in the long term, and what we need to do to prevent patients from moving from first-line treatment to second-line drugs. We need to keep them on first-line drugs as long as possible, because the difference in cost between first-line and second-line drugs is five- or sixfold.”

Cost data are especially important to the government, because unlike countries that depend more heavily on international donor support, South Africa pays for 85 percent of its national HIV program itself, using domestic tax revenues. Meyer-Rath, a health economist and infectious disease modeler who creates the complex mathematical algorithms at the heart of HE2RO’s policy analyses, recalls one of several studies requested by Pillay’s department.

“We were asked to look at the cost of introducing new guidelines for HIV treatment,” she says. “They wanted to pull in more HIV-infected people, raising eligibility for both adults and children, and there wasn’t data out there on what that would mean in terms of the number of eligible patients and the resulting cost. One of the questions we were asked is, what would be the cost implications of starting all children much earlier than was previously the case. There were studies that showed if you wait until children qualify for HIV treatment under the old WHO guidelines, their immune systems are so run down that you lose half of them. But the cost of pediatric HIV treatment hadn’t been analyzed before. So we had to do our own data collection, going into clinics and going through a sample of patient files.”

The problem, says Rosen, is that that kind of data collection is much harder than it sounds.

“In many places in Africa—and probably some in the United States—medical records and data systems are not well-developed,” she says. “Files get lost, and a patient will show up at a clinic and another file is opened with a new number, and there is no way of knowing that those files are for the same person. There is an endless series of those kinds of challenges. It’s very labor-intensive to develop a data set that just says how much something costs.”

“We look at every resource that has been used by a patient,” says Meyer-Rath. “We count every pill, every visit, and we look at the outcomes. In the end we can say that after X years of treatment, the cost of treating kids is this much, and the outcomes are this. We take all the data and we put it all in a gigantic mathematical model and run it for a couple of years and see what changes. Then we go back, collect more data to fill in the gaps, and start the process anew.”

Over the years, the data collected has helped to save many lives, and the job has yielded at least one major revelation: “You can collect all the epidemiological evidence you want,” says Meyer-Rath. “You can study the feasibility and all the other things, but if you don’t talk about cost and cost-effectiveness, you will not get an intervention off the ground. It’s not the first question. The first thing is to prove that it works, but it is almost always the second question.”

With the newborn study, the answer to that second question showed that treating infants sooner rather than later would save 80 percent of the costs of inpatient care—an average of 11 days during the first year of life. It turned out to be a good answer, says Meyer-Rath, because it resulted in a price tag that the government was “happy to pay.”

Life-sparing push

In another study, HE2RO looked at the feasibility of using nurses to manage treatment for AIDS patients, a task that had traditionally been performed by doctors.

“One of the big challenges in this country is that we don’t have enough doctors, but we do have nurses,” says Pillay. “But there is a lot of resistance to the idea of using nurses to initiate patients on antiretrovirals, both from doctors and nurses. We needed to know first, is it a good idea from a clinical point of view, can it be done, and third, what are the cost implications? HE2RO helped us in all three areas.”

In the last three years the South African government has doubled the budget for HIV treatment. It has tested 12 million people in a single year, is treating 1.7 million, and is budgeting to treat a total of 3.5 million people in the coming years. The life-sparing push started, says Meyer-Rath, with the willingness of the South African government to change its HIV policy and to act based on evidence, including that from HE2RO’s calculations.

“The thing about HE2RO,” says Pillay, “is they are a group of academics. They’re very rigorous and they are independent of us, so the integrity of the results is not questioned. They strike a good balance between being academic and rigorous and being part of the real world.”

“South Africa now has the largest antiretroviral program for treating AIDS in the world,” says Francois Venter, former president of the Southern African HIV Clinicians Society and an HIV researcher at the University of the Witwatersrand. “For a long time, we didn’t know how to get to that point. HE2RO was instrumental in doing a lot of the costing work, a lot of operational work, and a lot of intellectual work. They were the ones who said, ‘These are the choices you have, and this is what it’s going to cost.’ So for the first time, rather than being a gut-feel program, we have become an evidence-based program. HE2RO can take a lot of credit for that.”

For Fox, Rosen, and other CGHD academics who have split their lives between Boston and Johannesburg, the influence of HE2RO is the fulfillment of an important part of their mission, as well as a validation of the value of multidisciplinary, policy-relevant research. But the biggest fulfillment will come when the tools, team, and skills they have built can deliver the evidence needed for policy decisions even after BU goes home.

“The initial collaboration between Boston University and HE2RO was formative,” says Lawrence Long, a South African health economist and a HE2RO deputy division head. “Over time the role has been to provide expert technical assistance to the local group and to build local capacity. They have done that.”

“It’s not realistic to assume that we can work here indefinitely,” says Rosen. “The funding environment is against that, and countries should have their own capacity to do this work. It’s very important to South Africanize our team. We don’t want to be an American organization in South Africa. We want to be a South African organization that is thriving in collaboration with Boston University.”

Read about HE2RO’s research into better ways to fight TB here.

A version of this article appeared in the summer 2012 issue of Bostonia.

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