Wednesday, June 10, 2009

Targeting Sickness Versus Promoting Health

Questions of whether HIV has or hasn’t been exceptionalised and whether this is a good or a bad thing are often raised. Discussion sometimes involves the issue of horizontal health care, which deals with the overall health of a population as opposed to vertical health, which deals with particular diseases, such as polio, intestinal parasites or HIV.

I am of the opinion that HIV has been exceptionalised and that this is a bad thing. I also believe that health care should aim to be more horizontal. Vertical approaches to individual diseases have sometimes been successful, at least up to a point, but they leave out too many vital areas of health. There is little to be gained by protecting a whole population from a handful of diseases when so many of them will be wiped out by diseases that have been ignored.

Indeed, many people do die from easy to prevent and easy to treat illnesses, such as acute respiratory infections and diarrhoea. The biggest threats to health, especially among infants and children, are things like water and sanitation, poor living conditions and nutrition. These are important for adults, too, as are basic health and medical services.

Big eradication campaigns tend to ignore the most basic health needs of populations. They concentrate on a single or a small number of diseases, they tend not to develop broader health infrastructures or deal with determinants of health and they cost a lot. Often, money could be better spent on ensuring the determinants of healthy populations, but it tends not to be.

The World Health Organisation (WHO) is presently promoting a vaccine that prevents diarrhoea that is caused by the rotavirus, estimated to kill half a million children a year. It is recommended that this vaccine be included in national immunisation programmes. Rotavirus is often fatal to children in developing countries because of lack of access to clean water, sanitation and basic medical care.

However, the WHO recommends a comprehensive strategy that includes improving water and sanitation and providing some of the healthcare products that are required to deal with diarrhoeal diseases. A comprehensive strategy is crucial. There are many water borne diseases and many diseases that are caused by poor sanitation and lack of hygiene.

But this is just a recommendation from WHO. When it comes to funding programmes like this, pharmaceutical companies are always interested in having huge quantities of their products purchased for ‘aid’ projects. The problem is that you don’t cure diseases by providing countries with huge quantities of pharmaceutical products. Who will meet the logistical costs, the healthcare costs and the costs of improving water and sanitation in developing countries?

Rich institutions like the Bill and Melinda Gates Foundation have shown a lot of interest in financing projects in developing countries but much of this money tends to be spent on the development of products, things that can be sold, especially branded products that cost relatively little to produce and create a high level of dependency. For example, antiretroviral therapy for those infected with HIV, genetically modified organisms for farmers, etc. Whether this foundation or other donors would be interested in financing projects that don’t promise to make a lot of money is an open question.

Similar arguments apply to the approach that many countries take to HIV prevention. Most money that has been spent on HIV has gone towards treating and caring for those who are already infected. In Kenya, less than 25% of HIV spending has gone towards prevention and much of that goes into counselling and testing and prevention of mother to child transmission (PMTCT).

These all deserve funding, of course, it is absolutely necessary to test and treat people and to prevent mother to child transmission. But in the meantime, hundreds of thousands of children come of age every year and become sexually active. Many of them will be infected with HIV before they receive proper sex education (if they ever receive it) or go for a test or are exposed to any kind of HIV prevention activity.

It’s extraordinary that negligible amounts of prevention money go into targeting commercial sex workers, men who have sex with men and intravenous drug users, people who are at particularly high risk. But even others, who are also at risk, are unlikely to receive any more than some sort of behaviour change communication (BCC). BCC may well be wonderful, there are certainly some wild claims about how wonderful, but the fact is that HIV is still spreading. It is spreading in places where it has long been spreading and it is spreading in new places.

The problem with our approach to preventing HIV is not that the disease is exceptionalised or horizontal, the problem is that it is not working. We have known for a long time that, although people’s sexual behaviour may be somewhat influenced by BCC, it is not influenced a great deal. And the claims about changes in behaviour are not translating into lower HIV transmission. HIV prevalence in Kenya and many other developing countries has been fluctuating for many years. Rates in many places are now lower than they once were. But in other places, rates are higher.

Prevention of HIV (and diarrhoeal diseases, acute respiratory infections and any other diseases) requires us to look at people’s health, not their diseases. We need to know what healthy people are like, what their circumstances are, how to ensure that they will stay healthy, what could help them avoid health risks and risks of any other kind. That means looking at their economic circumstances, housing, nutrition, employment, education, access to information, equality and any other areas that may be relevant.

Most children will grow up and will have sexual experiences, sooner or later. Rather than wagging fingers at them and telling them to wait till they are older and possibly telling them how to reduce risks, we need to address the circumstances that make risk harder to avoid. They need more information about sex, contraception, risk, sexuality, etc. Issues of gender inequality in school, in the workplace and in society as a whole, also need to be addressed. Prevention programmes also need to include people who are HIV positive, whether they are on treatment or not.

We seem to be going the wrong way with HIV prevention. There are many things we could be doing and are not doing yet. The HIV agenda seems to be set by commercial and political interests and this can only continue to do harm. Healthy people do not make money for healthcare, nor do they make careers for politicians. But being healthy is a right and this should be acknowledged and addressed by countries and institutions that are pouring money into developing countries. We need to change direction with HIV prevention if we want to reduce transmission and eventually eradicate the disease altogether.


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