Sunday, October 9, 2011

Redefining 'Health' to Maximise Economic Viability

A paper by Egilman, Bird, Mora and Druar puts into perspective some of the most salient barriers to progress in reducing HIV transmission, especially in countries where rates are highest. The very title of the paper alludes to the social and environmental 'determinants of health', something that the most discussed and best financed 'solutions' to the HIV pandemic generally ignore. As a result, global health aid can be rendered ineffective, even damaging, to healthcare in general and to narrower HIV prevention efforts.

The authors are particularly critical of disease-specific interventions or 'vertical approaches' to healthcare. Many of these, upon singling out a particular disease, such HIV, TB or malaria, proceed to expend copious quantities of money and other resources on these, to the exclusion of any attempt at addressing the reasons why these diseases are spreading.

The money is generally spent on drugs and other commodities, items that require people to be infected with the disease in question before being of any use. Anything that reduces the underlying health risks that people face, such as water, sanitation and hygiene, nutrition and food security, literacy, empowerment, poverty, etc, is ignored.

It's not a new discovery that drugs are a necessary, but by no means sufficient means of eradicating a disease. No disease has ever been eradicated by drugs alone and it seems unlikely that one ever will. Technical solutions, such as mass roll-out of drug therapies (antiretroviral treatment, Pre-exposure Prophylaxis, microbicides, male circumcision, vaccinations, and the like), are expensive. But if there is little or no health infrastructure, each vertical program needs to create its own infrastructure. This is inefficient and can contribute to what could be called the 'Bill Gates effect': everyone gets a pill but no one gets clean water with which to swallow it.

A far better way of characterizing health, which would have given rise to a more 'horizontal' approach, was that enshrined in the Alma Ata Declaration on Primary Health Care of 1978. This defines health as "a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity", involving "the action of many other social and economic sectors in addition to the health sector."

The date of the Alma Ata Declaration is particularly poignant because HIV, which had probably been spreading for decades, was only identified a few years later. Luckily, it was identified in a rich country, as it might have remained unnoticed for many more years if it had only infected people in developing countries.

Also poignant is the fact that the Declaration's definition of health was quite contrary to what became the dominant health paradigm, vertical programming. With vertical programming, disease is the measure of health; if you don't have a disease, you don't receive any of the benefits of health programs. Indeed, if you don't have the right disease, your health or lack of it is of no relevance.

The paper discusses the Gates Foundation approach to HIV and a handful of other headline grabbing diseases. This approach excludes any consideration of the conditions people live in, which allow these diseases to infect and affect so many. It also notes the shocking fact that two thirds of the Foundation's HIV/AIDS funding goes to vaccine research, which is labeled "preventative".

Even if a vaccine were developed and were made available to countries where HIV prevalence is highest, it is unlikely to prevent HIV transmission to any great extent. First, HIV prevention programs need to be able to identify who is most at risk of being infected. Currently, the majority of people infected in countries like Uganda, Kenya and Tanzania are those who would be thought least likely to be infected, those who don't engage in 'high risk' sexual behavior.

The paper discusses many vital issues in public health and development but I'll finish this posting with the authors' observation that "a usually unmeasured negative consequence of aid is the increase in nosocomial (hospital acquired) infections that can accompany immunization programs", and contaminated injections in general. In 2000, it was found that nearly 40% of injections were given with reused equipment and "caused an estimated 21 million HBV infections, two million HCV infections and 260,000 HIV infections, accounting for 32%, 40%, and 5% [of all transmission].”

Vertical programs generally don't measure such phenomena as infections, injuries and even deaths. The authors cite an apposite case of traditional birth attendants in Mexico being issued with one needle a month to administer depo provera, the hormonal contraceptive whose injectible version is common in African and some other developing countries, but strangely uncommon in wealthy countries.

HIV, like all diseases, is not independent of the conditions in which people live and spend much of their lives. That is precisely why health is "a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity".

How cruelly ironic it is that what could have been the most important and well timed decision about health ever made was replaced with a decision to view health as a commercial opportunity. As a result, big money only goes into that which allows the big players, the global pharmaceutical and healthcare industry, big philanthropy and NGOs, academia and international health institutions, to continue to grow and prosper.


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