Friday, January 30, 2009

Global health inequality gets personal

There are many ways global health inequalities can be expressed. The usual one is statistics, expressed in graphs, comparing countries using some health indicator or other. Haiti and Canada on child mortality. Sweden versus Senegal on life expectancy. You can see the Powerpoint presentation in your mind's eye. And you might also anticipate that, despite the massive human suffering that lies behind these statistics, you would probably be bored watching it.

I have a personal anecdote about global health inequality, acquired the hard way. On my trip to the Democratic Republic of Congo last week, I felt an unusual bump under my neck on Day 2. I thought, well, it is probably just a swollen gland, some temporary reaction. After all, just being in Kinshasa -- with the dirt, the car exhaust, some of the food, the humidity -- probably compromises your immune system no matter what. Maybe it is the start of a cold from the air-conditioning. So I continued with my bioethics activities.

Except the lump started getting bigger. I started developing two competing amateur self-diagnoses: some sort of a glandual infection or a tooth abscess. I continued to work. Anyway, what doctor could I see about this, and even if I could get a correct diagnosis, would there be available medicine for whatever I had? It was all very doubtful. Eventually I stuck it out, got on the Air France flight to Paris with a massive lump under my chin, and flew back from Paris to Chapel Hill. By that time, the lump increased in size again, my head was aching and I started feeling chills. After a trip to UNC's Infectious Disease clinic, a diagnosis of lymphadenitis was established, and I was put on antibiotics. A few more days in the Congo, and I might have developed septicema.

I could have, using my privileged position and if I had worked hard at it, eventually found a suitable doctor, a correct diagnosis and the right drugs. And in the end, I could count on a flight out, a high-quality clinic and medication inexpensive relative to income. Which made me think: what happens to the Congolese who develop lymphadenitis? My guess is that some (most?) are powerless to do anything but watch the infection grow and eventually die from it. A horrible, unnecessary and unjust death.

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Wednesday, January 14, 2009

AIDS, gay men and Africa

Authorities in many African nations are deeply troubled by the prospect of having men who have sex with men in their midst. While living in South Africa a few years ago, I remember a heated debate in the letters to editor section of the Mail and Guardian about whether homosexuality was a purely imported phenomenon, something alien and originating from the fleshpots of (say) southern California, and dropped recently into Africa. The idea was that if it was something new and foreign, it could hopefully be returned to sender, like an unwanted package. But it eventually appeared that the phenomenon wasn't really new or entirely foreign to Africa. So what couldn't be denied would have to be repressed; while not unAfrican, the behavior was nevertheless an abomination. Many African churches have joined with political authorities over the years in their attempts to condemn and marginalize the sexual behavior of gay African men. In most African countries, homosexuality is still illegal.

Last week, the New York Times reported the sentencing of nine men in Senegal to eight years in prison for 'unnatural acts.' The men were arrested in the house of a leading gay HIV/AIDS activist in Dakar. The events in Senegal join a long list of repressive political actions against gay men in African countries, including Nigeria, Gambia, Burundi and Uganda. Now there is a lot that one could say, from a human rights or social justice perspective, about the political treatment of men who have sex with men in Africa. But there is also a public health ethics perspective: demonization of homosexuality is counterproductive in the fight against HIV/AIDS in Africa, just as it was in America during the early days of the epidemic. Condemnation and criminalization simply drives the behavior underground, away from prevention and treatment services, increasing risks of HIV transmission. The conclusion is hard to avoid: the HIV/AIDS epidemic has forced African countries to deal with homosexuality in their communities, but many have failed to develop responses that are justified from a public health point of view or even reflect basic human decency.

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