Saturday, February 16, 2008

Unhealthy health policies

Do we believe that good health policies can reduce mortality and morbidity at a population level? The answer is yes: scientific research, meetings, consultations, reports and all the other magical ingredients that go into health policy formation are driven by the idea that if our policies are well-constructed and implemented, they will have a beneficial effect on public health. The whole process assumes that policies can have real and widespread effects. Conversely, it seems to follow that if the process of health policy formation goes awry, and we end up with wonky policies, needless death and disease can be produced in substantial numbers. Normally, the production of human death and suffering on an industrial scale raises strong ethical objections. Especially when guns are involved, we have strong words to describe this sort of thing: massacre, slaughter, carnage, genocide. Oddly, when errant health policies produce similar 'end points', in similar numbers, the ethical (and legal) responses are quite different. Ministers of health do not normally get hauled off to The Hague. And there really are some unhealthy health policies: there is an interesting book of case studies describing a selected few of them.

I was led to these thoughts by a recent case in South Africa of a physician who was suspended for giving HIV-positive pregant women a more effective drug combination to prevent them from transmitting the virus to their infants. You read that sentence correctly. A doctor in KwaZulu Natal, Dr. Colin Pfaff, gave dual therapy (nevirapine and AZT) to HIV positive mothers, rather than the 'nevirapine only' regime that is currently government health policy. But the government policy is behind the times. Dual therapy has already been recommended by the World Health Organization for a year, and has been shown elsewhere in South Africa to reduce the chance of mother-to-child HIV transmission down to 8%, while monotherapy with nevirapine has only reduced chances of transmission down to 22% in KwaZulu-Natal. The Southern African HIV Clinicians Society have condemned the decision to threaten Dr. Pfaff with discipinary action, and petitions have been written. It is a strange world when a physician is threatened with punishment for providing a superior standard of care, and when doing so cost the local health department nothing, because the AZT had been donated by a British NGO.

There has been pressure for sometime for the South Africa health ministry to alter their mother-to-child HIV transmission policy (last revised in 2001) to keep up with scientific advances and international recommendations, but its responses have been ambiguous, hesitant and sometimes openly hostile. This is part of a larger and deeply entrenched pattern in the country. From the beginning of the epidemic in South Africa, president Thabo Mbeki made no secret of his embrace with 'HIV dissidents' -- who believe that HIV does not cause AIDS or that HIV does not exist at all -- or his suspicion that drugs like AZT are harmful and promoted in Africa only to make money for corporations. By appointing health ministers sympathetic to his views, Mbeki has guaranteed that national responses to the epidemic will be marked by foot-dragging and denial. For almost ten years now, health minister Manto Tshabalala-Msimang has been responsible for a kind of 'Alice in Wonderland' approach to health policy leadership, carefully cherry-picking whatever scientific research seems to support her own beliefs about HIV in Africa, sidelining the rest, while touting the benefits of herbal concoctions and aligning herself with quacks. She was, for example, very quick to abandon provision of nevirapine when some studies indicated its use led to drug resistance among HIV positive mothers. Now, when it comes to providing dual therapy, Minister Tshabalala-Msimang wants to stick with nevirapine. Or she did, until the story with Dr. Pfaff hit the newspapers.

In South Africa, the struggle against HIV/AIDS is especially hard, because it partly a struggle against a government whose commitment has never been more than lukewarm. True, in the beginning of the HIV epidemic in the United States, there was strong government reluctance to engage in the control of a 'gay disease.' But that changed after a few years. In South Africa, that kind of obstructionism in high places endures, with deadly effect. In the future, perhaps it will be possible to estimate how many people in South Africa became infected by HIV or died of HIV-related causes due to the country's delinquent style of HIV policy-making. Will anyone be held responsible? Very unlikely.

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