Sunday, October 25, 2009

I pay thy poverty, and not thy will

In Romeo and Juliet, there is the scene where Romeo goes to an Apothecary to obtain a poison. Juliet is presumed dead; Romeo wishes to go to the Capulet's family tomb, take the poison and join her in a deadly embrace. The Apothecary hesitates: distribution of such poisons is against local law. The two have the following exchange:

ROMEO: Art thou so bare and full of wretchedness, and fear'st to die? Famine is in thy cheeks, need and oppression starveth in thine eyes, contempt and beggary hangs upon thy back. The world is not thy friend nor the world's law. The world affords no law to make thee rich; then be not poor, but break it, and take this.

APOTHECARY: My poverty, but not my will, consents.

ROMEO: I pay thy poverty, and not thy will.

I was reminded of this exchange while reading a blog post on the Washington Post website, entitled 'In Praise of Human Organ Sales.' The author, Gary S. Becker (a Nobel prize-winning economist) argues that allowing people to buy and sell their organs would help solve the problem of shortages in organs for transplant, while countering possible objections to this idea. Neither the proposition nor the objection are particularly new; people working in bioethics have made this proposal before and objected to it before. The novelty lies in how quickly and brutally Becker states his case. His response to issues of social justice is succinct:

Another set of critics fears that the organ supply would be likely to come mainly from the poor, who would be induced to sell their organs to the rich. It is hard to see any reasons to complain if organs of poor persons were sold with their permission after they died, and the proceeds went as bequests to their parents or children. The complaints would be louder if, for example, mainly poor persons sold one of their kidneys for live kidney transplants, but why would poor donors be better off if this option were taken away from them?

It is true, the poor who sell their organs, either when they are alive or posthumously, would get their cut -- like the Apothecary. The rich would get their organs, and the middlemen, well, they would get richer. The poor would be mined -- with their agreement, of course -- for organs, without this sacrifice of body parts being likely to improve their lot very much. They would not be in a position, for instance, to buy organs for themselves if they needed them. For their part, the rich would have no (economic) motivation to put up their own organs for sale. Hard to see any reasons to complain here? Depends where you are looking. Romeo was unbalanced, and desperate, but at least he was honest: I pay thy poverty, and not thy will.

Thanks to Steve Levingston at Washington Post, who sent me the link to Becker's piece, and thereby informed me about the Post's excellent Book World blog.

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Tuesday, October 20, 2009

HIV treatment: the good news and the bad

First, the good news: more people worldwide living with HIV/AIDS are receiving treatment than ever before. Over the last 5 years, there seems to have been a 10-fold increase, and now some four million people are taking antiretroviral drugs. Traditionally, UNAIDS 'epidemic updates' on treatment access in Africa made for depressing reading, with only tiny percentages of HIV-positive persons within African countries being treated. For the vast majority of Africans, HIV/AIDS remained what it was in the beginning, a death sentence, even if had obtained the status of a chronic disease in far-off (and better-off) countries. Now there are three million Africans taking AIDS drugs. This impressive achievement has taken more than a decade of advocacy, negotiations with pharmaceutical companies, creation of cheaper generic drugs, lobbying, program development, investments in local capacity ... blood, sweat and tears, in other words.

The bad news. The numbers of persons 'on treatment' cannot be trusted altogether. The statistics are developed by governments in a vested interest in stating the highest possible estimates. To do otherwise might show incompetence in the use of (mainly external) funding. The numbers also tend to reflect the number of those who were placed on treatment, and not those who later stopped treatment for one reason on another.

But even if the numbers were more trustworthy, there are other concerns. AIDS treatment and care is lifelong. To keep these millions of persons on treatment in the future requires a vast and ongoing investment. The World Health Organization is considering revising its treatment guidelines on account of studies that indicate earlier initiation of treatment increases life-expectancy. More HIV-positive persons will fall into the category of those in need of treatment, and meeting this new demand will add to the already soaring costs. In addition, some of those currently on first-line treatment will develop drug resistance and need to switch to (more expensive) second-line drugs. And last but not at all least, millions of persons continue to be infected by HIV, meaning that the 'treatment pool' will grow larger and larger in the coming years.

The old questions keep coming back: is this magnitude of spending on HIV/AIDS treatment ethically justified? Is it justified when there are other diseases and conditions, causing greater numbers of deaths, but which do not attract nearly the same level of political and financial support? Why not devote greater attention to HIV prevention research or prevention strategies that may help reduce the rate of new infections?

This is becoming a dramatic example of 'hell being paved by good intentions.' Back a few years ago, we had the unacceptable situation of Africans routinely dying of untreated AIDS, while North Americans and Europeans accessed antiretrovirals and went on with their lives. It was a striking case of global health inequality, and no one with any sense of solidarity could fail to be moved by it. But in the process of trying to improve the situation, something else, vaguely Frankensteinian, has emerged. Billions of dollars will need to be spent to keep the (growing) millions of HIV-infected on treatment. This might not be sustainable, and all the spending might not be proportional or fair, but it would also be unwise to stop financing global AIDS treatment programs now that they have been started. Halting treatment would not only spell death for those living with HIV/AIDS, it could also mean creation of new drug-resistant strains of HIV, making prevention efforts more difficult than ever.

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