Hands-on health care monitoring, Mozambique style

Somehow it is hard to imagine this happening outside Africa. Mozambique's Health Minister, Ivo Garrido, has started to make a habit of dropping in on local health clinics during the night shift, apparently to see how things are going. And to pitch in. Last Tuesday, he performed minor surgery on a taxi fare collector who was admitted with a throat laceration. After that, he headed over to the ICU, the maternity and the pediatric wards to field complaints and offer guidance. Yes, have no fear, Dr. Garrido is a licenced surgeon.

Mozambique's clinics can use the help. The HIV/AIDS epidemic has hit the country hard, and the health care sector has been severely affected. As Garrido has stated himself, some 6000 health care workers are predicted to die from AIDS by 2010, undermining the government's plan to aggressively expand delivery of antiretroviral treatment, and weakening primary care services as a whole. That's not counting the numbers of doctors, nurses and laboratory technicians moving to greener pastures in South Africa, Portugal and the United Kingdom.

In this perspective, Garrido's nocturnal journeys are nothing strange; it is simply what medical ethics demands in dire circumstances.

The politics of pandemics

Researchers at the University of Toronto have recently raised interesting issues about political implications of effective pandemic disease control. In federalist states, like the United States and Canada, there is a decentralization of political power to regional governments. Part of what regional governments are empowered to do is make health care system decisions, including the management of health-related patient information . The devolution of powers may have its virtues in other contexts, but in cases of deadly epidemics like SARS, the structure of federalism may hinder rapid and coordinated public health responses.

So one question is: how much are we willing to let the threat of global pandemics (like bird flu, perched on the horizon) shape longstanding political arrangements that we may value? The threat of terrorism has already made inroads on civil liberties, and now emergent diseases may have us making still more difficult political tradeoffs.

Drug donation: is charity a good thing?

Everyone probably in the better-off nations has drugs in their medicine cabinet which will eventually end up in the garbage. This seems an incredible waste, considering that people in developing countries often have little to no access to medicines, even the most common ones for sour throats and headaches. It would be better, one might think, if surplus drugs could be donated to low-income countries in greater need of them. An organization in the United Kingdom has stepped up to the plate, and has also helped reveal the complicated ethics of drug donation.

As its website states, International Health Partners (IHP) is a non-profit, charitable organization dedicated to providing donated medical aid to communities in the developing world, and acts as a bridge between drug, vaccine and medical suppliers in the developed world and organizations and individuals in low-income countries, especially (but not exclusively) in times of humanitarian crisis. Founded last November, IHP has been successful in sending millions of dollars worth of medications to Pakistan, Angola, the Democratic Republic of Congo, Afghanistan, Cambodia, the Philippines and Romania. Undoubtedly, some good has been done. But critics have argued that some of the major benefactors are pharmaceutical companies, who donate merely to enhance their corporate image while strategically dumping surplus drugs (close to their expiration date) they did not want in ways that can upset their competitors. There are quality control issues. There are issues about dosage for particular populations. And donating drugs may not be very charitable after all if the beneficiaries do not have a health infrastructure that can deliver the medications in a safe, effective and equitable way: medications cannot be simply dropped by helicopter. They are only as good as the doctors who prescribe them, the pharmacists who stock them and the refrigerators they may be stored in.

This may be the crux of the matter. The entire framework of donation seems to assume that there are magic bullet solutions to health problems in low-income countries: just throw some drugs at them. While access to medicine is critically important, drug donation schemes don’t get at the root of health inequities between rich and poor nations, and it is hard to see how they contribute to local capacity-building in the production of medical resources, rather than leaving low-income countries in a relationship of literal drug dependency.

The ICASA conference in Nigeria: emerging themes

Last week, the 14th International Conference on AIDS and Sexually Transmitted Infections in Africa (ICASA) took place in Abuja, Nigeria. Despite the disproportionately high burden of these diseases on the African continent, ICASA typically gathers modest media coverage. A recent and tragic plane crash in southern Nigeria quickly overshadowed the event in the international press. All the more reason to briefly profile two hot themes emerging from this year’s conference: abstinence as HIV prevention strategy and access to second-line AIDS drugs.

Abstinence is obviously a politically heated topic, considering that the ‘just say no’ approach is predictably favored by the Bush Administration, a major funder of HIV prevention programs in Africa, while the actual effectiveness of abstinence promotion is deeply questioned by the scientific community. It is no small irony that Winnie Madizikela-Mandela should appear at the ICASA conference as a vocal proponent of abstinence, given her personal struggles with abstinence when her husband Nelson was languishing on Robben Island, and her issues with old-fashioned fidelity after his release from prison in 1990. Perhaps in this sense she functions as a living symbol of the conflict between the allure of purity and the reality of human desire, though I doubt that she (or her followers) see things quite this way.

Access to first-line AIDS drugs in Africa is very limited – according to recent WHO figures, less than 10% of AIDS patients in need of anti-retrovirals in Africa are now on treatment. So it is deeply worrying to learn that a percentage of whatever ‘lucky few’ manage to gain access to first-line drugs will need to switch to more expensive second-line regimes, which pharmaceutical companies are not marketing in Africa (because poor people are poor consumers) and for which no generic equivalents are being produced. According to a presentation at ICASA by Doctors without Borders, standard first-line therapy currently costs $194 per year, while second-line treatment costs approximately 8 times as much ($1661).

It is discouraging to realize that new efforts to lower prices for second-line AIDS drugs will have to be launched when the vast majority of AIDS sufferers in Africa still cannot get the first-line treatments, and while AIDS patients in developed nations virtually have universal access to treatment -- first-line, second-line and beyond. There is no way around it: the abiding problems surrounding access to AIDS treatment are unlikely to be overcome without narrowing global inequalities.

Domesticating Global AIDS

If one counts from the first report from the Centers for Disease Control in June 1981, the AIDS epidemic is entering into its 25th year. There is little cause for celebration. A few short decades ago, many epidemiologists believed that they were winning the war on infectious diseases. The emergence and persistence of AIDS – as well as the recurrence of other serious infectious diseases such as tuberculosis, malaria and measles -- has shown how wrong they were and how vulnerable we are. The most recent report released by UNAIDS hardly paints a rosy picture:

-- Number of people living with HIV in 2005: approximately 40.3 million
-- Number of people newly infected with HIV in 2005: approximately 4.9 million
-- Number of AIDS deaths in 2005: approximately 3.1 million

It is also clear from the report that some of us are far more vulnerable than others. Impoverished developing world countries marked by oppression, civil conflict, corruption, famine or overpopulation provide ecological niches for infectious agents like HIV. Of the 40.3 million living with HIV in 2005, 25.8 million live in sub-Saharan Africa, which also accounts for 2.4 million AIDS deaths in 2005.

Against this background, a sounding board article (‘Applying Public Health Methods to the HIV Epidemic’) in the New England Journal of Medicine published on this World AIDS Day makes for disturbing reading. In it, the authors advocate the use of standard disease control methods against HIV/AIDS, including routine HIV testing and partner notification. For those unfamiliar with these terms, routine (or ‘opt out’) HIV testing means the integration of HIV testing into hospital practice, like testing for hypertension; the patient is told he/she will be tested for HIV unless he/she refuses. Partner notification means that when a patient tests positive for HIV, the sexual partner of the patient will also be told the test result. These measures, according to the authors, were not taken earlier in the epidemic when there was no treatment and no legal protections against discrimination. But now that the latter exist, the time to bring in these methods is now: the time of ‘AIDS exceptionalism’ is over.

The arguments for routine testing and partner notification are not what is most disturbing about the article. It is rather that on World AIDS Day, the New England Journal of Medicine sees fit to publish a prominent opinion paper on public health approaches to HIV/AIDS that is entirely focused on the epidemic within America’s borders, when the its share of global deaths due to HIV/AIDS stands at 0.5%. Are practices like routine testing and partner notification to be recommended for the countries with the highest burden of disease, where access to treatment is currently dismal and legal protections against discrimination virtually non-existent? In such settings, should concerns about confidentiality and stigmatization be trumped by public health methods aiming at the most efficient control of disease? How should the balance between individual lives and population-level disease control be struck? These are crucial questions in the struggle against global AIDS, but they cannot be answered by an opinion paper that is apparently only really meant for domestic consumption.