Sustainability or sustainable assistance?

Over the past few years, there have been a number of international initiatives aiming to prevent, control or provide curative treatment for diseases disproportionally affecting the world's poor countries. The Global Fund to Fight AIDS, Tuberculosis and Malaria is probably the most ambitious: the Fund is a financial institution that is meant to bankroll programs that are led by local experts, implemented by local health care professionals, and target local health priorities related to the 'big three' epidemics.

A recent paper in PLoS Medicine in a sense applauds the Global Fund for its acknowledgement of the challenges of implementing such projects in resource-poor countries. It is not enough, to make such projects work, to merely supply resources such as medicines. Someone, possessing the relevant knowledge and skills, has to administer the medicines. Someone has to stockpile and control the distribution of medicines. Someone has to monitor the progress of the afflicted. And these people have to be paid for their time and effort. This is where other funding agencies jump ship. Financially supporting the purchase of medicines for the poor is sexy; paying for the basic preconditions of health services, such as the wages of poor doctors, nurses, pharmacists or counselors is not so appealing. Often funding agencies regard wages as something that should fall under the responsibility of the local health care system, even when it is clear that the local health care system is not capable of paying a living wage, training a sufficient number of new doctors or nurses, or stopping the health workers they do train from migrating to Australia, Canada or the USA.

As the authors of the article indicate, new global health initiatives need to be realistic about the notion of sustainability. The usual concept of sustainability assumes that beneficiary countries will gradually -- sooner rather than later -- replace international financial support with domestic resources. Resource-poor countries will not be able to seriously tackle diseases killing millions of their citizens unless there are vast improvements in local health care infrastructure, but the latter will require international funding (including funding of wages) for a very, very long time. The authors call for what they call 'sustainable assistance': reliable international support that supports developing world health systems over decades. To use current political rhetoric, trying to seriously fight AIDS, TB or malaria in a couple of years on the cheap amounts to 'cutting and running' or 'leaving before the job is done'.

For a few dollars more: compensating the poor in international research

Takafira Mduluza has written a piece entitled Beyond ethics: biomed research and the poor on the always interesting Sci Dev website. I am not convinced that his views go 'beyond ethics', but reflecting a bit deeper on the implications of what Dr. Mdulza is saying -- particularly about compensation for participation in research -- is a worthwhile exercise. Let me explain.

Mdulza argues that the lack of fair compensation for research participants is the biggest problem facing clinical trials in the developing world. Compensation could be given to either individuals or communities or both (depending on the nature of the trial), and should take some appropriate form, such as financial donations to local institutes or organisations, or take the form of cash, goods, food or housing benefits for individual participants. Local ethics committees should act as brokers, negotiating fair and appropriate compensations. If a research organization is doing a malaria vaccine study, and the community agrees to participate, a fair compensation could be (for example) the distribution of free bednets to everyone in the community.

Mdulza is probably talking about research in low-income countries conducted by institutions or companies from the more affluent northern parts of the globe. When such institutions or companies come into town, rent upmarket apartments and office spaces, have their researchers drive around SUVs around, equipped with laptops and cellphones, it is hardly surprising that locals regard them as, well, rich. And that they think these expat researcher are in a position to offer generous forms of compensation to research subjects -- which they often are not. Many funding agencies --particularly in the US -- do not permit much latitude when it comes to offering compensation to research participants. Their budgets only permit a bare minimum required for the successful conduct of research: maybe enough to cover busfare, and maybe whatever an hour of their time is worth in dollars, but little more than that. Many researchers working with impoverished communities would like to offer more -- a new school, a water pump system, basic medicines -- because they can see the local needs. (Meeting some of these needs could easily have a greater impact on community health than the research itself.) International researchers working with poor populations often find themselves caught in middle: they are not part of a humanitarian or charity organization, but they cannot easily ignore the plight of their research participants either. They are, after all, supposed to be promoting health.

If research agencies are not permitted by their funders to address obvious and immediate needs of poor communities, but only to focus narrowly to what furthers the conduct of research, perhaps the whole idea of international health research has to be rethought. Starting with the funders, but working up the funding food chain, to where the deeper pockets are: governments of more affluent countries and multinational pharmaceutical corporations. The question is whether they want to embed international health research in a wider political and economic movement to actually improve the health of populations in the world's poorest countries. If the status quo on 'research compensation' is anything to go by, the answer is no.

Circumcision and HIV: If it can make it there, it can make it anywhere

I know that this blog has discussed male circumcision and HIV prevention before. But now that the World Health Organization has endorsed the use of male circumcision to reduce risk of HIV transmission, the issue has really gone global. News items are everywhere. And Americans can no longer think it is something that just Africans, living in high HIV prevalence countries, have to contend with. No, the debate has arrived, like many a new immigrant to these shores, in New York.

The Department of Health and Mental Hygiene in New York City is planning a promotion campaign for male circumcision among populations deemed to be at risk for acquiring HIV. The Department has started asking some community groups and gay rights organizations to discuss circumcision with their members. Health and Hospitals Corporation, a company that operates city hospitals and clinics, is being asked to perform the procedure at no charge for men without health insurance. As usual, New York is being avant guard, since the Centers for Disease Control and Prevention have not formulated national guidelines yet. The Department of Health and Mental Hygiene is so proactive that it seems to have even caught New York City Mayor Michael Bloomberg off-guard.

There are a lot of unknowns and issues raised by the use of male circumcision as HIV prevention strategy in a place like New York. One is that the African studies were about the reduction of HIV risk among circumcised men in hetrosexual relations. The high-risk groups in the US are mostly injection-drug users and men who have sex with men, and the studies say little to nothing about that. New York City's Health Commissioner, Thomas Frieden, claims that if a man's risk from penetrative anal sex with an HIV positive man is about the same as the risk from sex with an HIV positive woman, then the African studies should mean that gay men who are circumcised are at lower risk for HIV acquisition too. Of course, that is not how science works. You are supposed to run a study with the population in question. But apparently the city that doesn't sleep doesn't have time for that.

The comments (85 and counting) about this possible new initiative in one of the New York Times' articles are well worth reading. Besides interesting insights -- such as the possibility that uncircumcised men in the gay community could become stigmatized analogously to injection drug users -- you have the whole gamut: conspiracy theories, non sequiturs, accusations of distorting scientific facts, libertarians in favor of adult circumcision, human rights activists against infant circumcision as 'genital mutilation', as well as those who are absolutely convinced that the retention of a foreskin is a condition sine qua non of sexual joy.

New York City is apparently poised to undertake a massive social and epidemiological experiment; the rest of us will just have to watch and wonder.