Thursday, December 10, 2009

The One Trick Pony That Can't Defy Gravity

When debates become polarized there can be a danger that neither side can accurately characterize the view of their opponent. Thus, Gregg Gonsalves of the International Treatment Preparedness Coalition characterizes a particular view as the 'Aids backlash' and lumps together a number of views that may not even be held by any particular person or group. He characterizes the backlash thus:

The belief that "the fight against AIDS has misdirected our energies towards broader goals in health and development; the provision of antiretroviral therapy is a folly, it's too expensive and isn't worth the money to continue its expansion; efforts against AIDS are destroying health systems and promoting unnecessary deaths from other simpler-to-treat diseases and conditions such as childhood diarrhea".

Personally I think there is probably not enough money put into the fight against Aids and that much of that money is not being used very well. In particular, I think too little of the money is being spent on prevention and almost all of that is not being used very well. True, it took some time for the international community to face the threat that Aids presented but when they did face it, they came up with a level of funding that has never been matched by campaigns against other diseases or disease groups (such as sexually transmitted infections, water borne diseases, etc).

I don't think the provision of antiretroviral therapy (ART) is a folly and I don't think people who hold the sort of sceptical view I've expressed in the last paragraph necessarily do either. The fact that there are many more people becoming infected than there are being put on ART is not an argument to reduce ART programmes, rather, it is an argument for finding out why HIV prevention is being ignored and rectifying this situation urgently. There is little point in spending nothing on people until they become infected with an incurable illness if something could be done to prevent them from becoming infected.

But also, there is little point in treating people for HIV and leaving them to die of something else. There are many preventable and treatable diseases that are killing people, including people who are HIV positive. I think that this is, in part, because of poor health facilities and services and an acute shortage of personnel. But also, there is a lack of funding that goes back several decades.

I am in complete agreement with Gonsalves when he points out that poor health services are not a result of the Aids pandemic. This is clearly true in Kenya and many other developing countries, where poor health services date back to the early 1980s, when Aids existed but hadn't been identified and certainly hadn't even begun to wreak the havoc that came later. Aids didn't help these ailing health services and certainly decimated the health workforce, as well as the workforce as a whole. But in short, Aids was just another nail in the coffin for public services in general, not just health.

I sympathize with Gonsalves to some extent, but when is money going to be spent on HIV prevention programmes that work, as opposed to programmes that promote purely political (including religious and pseudo-religious) ends? When is money going to be spent on the things that concern the most people, the many diseases and social problems that most people face? I needn't list the diseases or even the problems, Gonsalves would be more aware of them than most.

Some of the people that Gonsalves may gloss over as the 'Aids backlash' wonder how HIV positive people will benefit from a one trick pony health programme that can give them ART but nothing much else, perhaps not even the food they need to be able to take the antiretroviral drugs. They wonder why HIV positive people with certain diseases are more worthy of treatment than those who are dying of the very same easily preventable and treatable diseases. They wonder why those who are at risk of becoming infected with HIV are not entitled to very much, but if they become infected, they may receive a great deal.

But, more importantly, I think: what kind of HIV programmes can be implemented successfully in countries that have inadequate health services, along with poor standards of education, hardly any social services, very little infrastructure, lack of political leadership, governance, legal systems and levels of equality that would be required for these very expensive programmes to work? Even one trick ponies can't work without any solid foundation, as the Aids one trick pony amply demonstrates.



Claire said...

Yes, surely the disproportionalte amount spent on HIV might be in part *because* it is a prevantable disease. Once we get into the argument that treatment is the best way to deal with HIV, funding this becomes much less important than treatments to reduce other diseases of high mortality, both on grounds of reducing disease burden, and also because treating most infectious diseases has a hughe impact on onward transmission (not as clearly true in the case of HIV).

Simon said...

Hi Claire, thanks for your comment. I think the disproportionate amount spent on HIV is because it has been hi-jacked by political and commercial interests, whereas preventing it is seen as disease prevention in general, not very important, really.

Health appears to be seen as a matter of diseases to be treated and perhaps controlled but is not seen as having anything to do with healthy people, just unhealthy people.

The argument that treatment is the best way to deal with HIV is unsupported by evidence. Treatment is clearly part of prevention but it is not and can never be the whole of prevention.

Even if every HIV positive person was on treatment, an unlikely feat, there would probably continue to be new cases of HIV, for various reasons, especially considering the millions of people who are HIV negative but are married to someone who is HIV positive.

But I don't see us ever achieving 100% testing in the near future, let alone 100% treatment coverage!