Saturday, April 17, 2010

Health Aid: Supporting People or Supporting Indicators?

While news that maternal mortality has been decreasing since 1980 has been welcomed by many, others point out that a significant contributor to maternal mortality is HIV. A lot of attention and resources go towards mother to child transmission of HIV (MTCT), but very little go towards the health and survival of the mothers. Concentration on the single indicator of numbers of infants infected by their mothers, also called vertical transmission, seems to have left the health of HIV positive mothers out of the picture.

Of course, it is madness to ignore the HIV status of the mother, for many reasons. For a start, mothers are people too, not just 'cases' or carriers of disease. They, like their children, husbands and other family members, are entitled to health and to treatment when their health is compromised. And it would be madness too to ignore any other diseases, in mothers and children or anyone else. But health funding is mad. Hence the selection of a few headline grabbing indicators.

HIV positive mothers can go on to transmit HIV to their infants at a later stage, through various routes, or to their partners. They are at risk of dying from Aids related illnesses or of suffering from serious and prolonged illnesses. These will also have an impact on the health of their children and other family members. Even the MTCT prevention treatment (PMTCT) can lead to drug resistance in mothers. In developing countries this can seriously affect the chances of the mother being successfully treated or cut the length of time that the treatment remains effective.

It seems extraordinary that health funders still take this piecemeal approach to disease reduction, even when it directly affects their chosen indicator(s). Unsurprisingly, the report was funded by the Gates Foundation. They particularly favour somewhat rarefied approaches to health issues, selecting the bits that they are interested in and leaving the rest. For example, the foundation is interested in finding a vaccine for cholera but not so interested in clean water and sanitation, which could reduce incidence of numerous water related health issues. (They give small amounts of money to water and sanitation projects but nothing like the amount going to vaccines and the like.)

A particularly worrying aspect of approaching MTCT in this piecemeal fashion is that as many as half of infant infections may result from mothers who were infected while they were pregnant or whose positive status was not detected while they were pregnant (perhaps because they were in the 'window' period, where they had not yet seroconverted). This occurred in a PMTCT programme in Malawi, considered to be one of the best. Another survey found that such missed maternal HIV infections resulted in a high percentage of infants being born HIV positive. Ironically, the paper also concludes that recently increased child mortality rates in KwaZulu-Natal could be caused, in part, by increased maternal mortality.

It has been suggested that this may be a potentially useful role for pre-exposure prophylaxis (PrEP). PrEP involves putting HIV negative people on antiretroviral drugs, usually where they are thought to be at particular risk of infection. Of course, some of these women may not have been infected through sexual intercourse. It is not even clear from the article whether the mothers of infants subsequently found to be HIV positive were also re-tested or were just assumed to be positive because their infants were. Apparently, an unusually high percentage of women who were not found to be HIV positive before delivery were later found to have HIV positive infants.

Concentrating on one disease or on that disease in one demographic, or even looking at absence of sickness as the only criterion for health, is not going to ensure the health of whole populations. The dominant approach to HIV and the almost universal adherence to the behavioural paradigm (the view that the disease is predominantly sexually transmitted) is wrong for many reasons that have been made clear, in particular, by our lack of success in significantly slowing the pace of transmission. It's time to look at HIV as being part of health as a whole, as being related to the totality of conditions in which people live and work.

If we continue to fail to ensure good health services, education, nutrition levels, food security, infrastructure and numerous other conditions, all diseases, including HIV, will continue to spread. This will reduce people's quality of life and life expectancy. Self serving reports that show how well some favoured indicator is doing should be seen for what they are. Billions of people still suffer from and die from preventable and treatable diseases every year. That's nothing to celebrate.

(For further discussion of PrEP, see my other blog,


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