Monthly Archives: October 2015

Essential Medicines and the Pharmaceutical Fix, Section 1, Unit 2 - Trying to Help

Pharmaceutical Industry: Good or Evil?

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Bringing attention to certain medications that everyone should ideally have access to by highlighting them as the “essential medications” seems like a good idea. But who gets to decide what medications are essential or non-essential; where do we draw the line? The criteria for the first list of essential medications in 1977 were based on clinical trials of safety and efficacy conducted in the global North (mainly developed countries) and cost-effective analyses in a developed nation’s economy (Greene, p. 19). Does this make sense, considering health outcomes and access to health care are vastly different between developed and developing nations as well as within each category?

As Jeremy Greene explores the (surprisingly) recent history of pharmaceuticals in global health in his article, many questions regarding “essential medications” come to mind. Something that worried me about defining essential medications in the form of a list was that such a list would affect how insurance companies consider coverage for certain medications over others. A focus on medications used to treat common diseases (Greene, p. 18), may pull attention away from essential medications for rare diseases. This could be connected to multiple harmful effects: pharmaceutical companies may not have much incentive to invest in research and development of new medications to treat those rare diseases because such products would only yield small profits from a small market, and health insurance companies may not be inclined to cover treatment involving medications that are not listed as being essential.

Greene mentions the “drug-dumping” of multinational pharmaceutical firms as they purposefully sold their products, some of which had not completed clinical trials and had questionable safety and efficacy reports, in countries with less regulations on the quality of drugs in the 1970s (Greene, p. 16). To me, this situation mirrors that of the tobacco industry, in which major tobacco companies started looking for foreign markets outside of the United States with the rise of foreign demand in the 1960s. Taking advantage of the weaker restrictions on trade and health regulations in developing nations, tobacco companies targeted women and children in Africa and China, for example, to expand their market and increase profits (Brandt, p. 454, 487). In some ways, pharmaceutical companies are just as manipulative and selfish. In response to the South Africa’s Medicines Act of 1997 that allowed for the production of generic versions of patented HIV drugs to make them more affordable to a greater population, thirty-nine pharmaceutical companies filed suit in South African courts just a year later. Furthemore, the U.S. government also expressed its disapproval, even though it later changed its mind in support of the Medicines Act in 1999 following uproar from political activists (Farmer, p. 122, 123)

Nowadays, the “cozy” relationship between doctors and pharmaceutical companies has become controversial. It is no secret that major pharmaceutical companies and doctors often work closely together – drug companies send sales representatives to speak to doctors about new medications and sponsor medical education and research. This has raised questions of conflict of interest – doctors can monetarily benefit from prescribing certain medications, biasing them towards providing certain treatments over others that could be just as effective or more effective (Glover). However, others including cardiologist Dr. Lisa Rosenbaum argue against the stigma surrounding doctor-industry collaborations. In her opinion, such a collaboration could lead to “life-saving therapies whose development requires the combined talents of clinicians and industry” (Rosenbaum). Dr. Rosenbaum contends that the conflicts of interest argument could lead to important viewpoints being discredited or ignored, simply because a doctor happens to work with drug companies

As part of the Affordable Care Act of 2009, the Sunshine Act mandates that all payments over $10 from pharmaceuticals to doctors or hospitals be made public to increase transparency and disclosure (Glover). Even so, there is always the risk of a doctor building close ties with one specific company and endorsing their products at every opportunity, blinding himself to potentially better options available for patients. The Access to Medicine Index (ATMI), implemented in 2008, is another way to keep pharmaceuticals accountable. The ATMI publicly recognizes companies for their efforts to improve access to drugs in developing nations. By ranking countries in order by their commitment to the transnational goal distributing drugs globally at reasonable prices, the ATMI encourages companies to keep up their efforts. Another way of looking at the list and rankings is that the ATMI puts pressure on the companies that ranked low on the list or did not make the list to work towards equal distribution of medications (Greene, p. 27).

Discussion Questions:

  • The Second Model List of Essential Drugs clarified that drugs not listed were not necessarily “inessential” and that the list was mainly meant to be used in the context of developing nations with the goal of making medications more affordable and accessible. Do you feel that the Second Model List of Essential Drugs adequately addressed problems of the first list?
  • While some argue that doctors working with pharmaceutical companies and being financially compensated for prescribing certain drugs will lead to biases that could potentially be harmful to the patient, others firmly believe that we could be losing out on life-saving advancements that may result from such collaborations. What do you think about doctor-industry collaborations? Is there a “happy medium” in this situation?

Course Readings:

  • Brandt, Allen. (2007). The Cigarette Century. New York: Basic Books (p. 448-492)
  • Farmer, A. Kleinman, J. Kim and M. Basilico. (2013). Reimagining Global Health: An Introduction. Berkeley: University of California Press (p. 122-123)
  • Greene, J. A. (2011). Making medicines essential: The emergent centrality of pharmaceuticals in global health. BioSocieties, 6(1), 10–33. http://doi.org/10.1057/biosoc.2010.39

Outside Readings:

UPDATE (on Nov. 25, 2015 at 10:30pm): 

At the end of September, Turing Pharmaceuticals announced a 5000% price hike of their drug, Daraprim (used to treat toxoplasmosis, especially in immunocompromised HIV/AIDS patients), from $13.50 to $750 per tablet, which (unsurprisingly) resulted in a public uproar. As I was following this story, it at first seemed that Chief Executive Martin Shkreli saw nothing wrong with this overnight price increase, reasoning that pharmaceuticals need to make money for drug research and development. (He is quoted as stating, “It is us trying to stay in business” in the New York Times.) Since then, he seems to have finally come to his senses and has announced that the price of the drug will be cut by up to 50% for hospitals only.

However, this shows just how much “power” pharmaceuticals can have over prices of their products and how they can wield this control in a way that affects the public as a whole. This is not an isolated incident in recent news. A similar price increase was applied to cycloserine, a drug used to treat tuberculosis, although this price increase was rescinded soon after. What loopholes in policies regulating pharmaceuticals allowed these significant price increases for important drugs to occur, and how can the government make sure nothing like this happens again?

Dec. 8th, 2015 at 9:50am: Sarah and I have been discussing (in the comments below) about possibly having more interaction between the government (the U.S. government in particular, since several of the major pharmaceutical companies are based here) and an established and reputable international organization such as the WHO. The purpose of this collaboration  would be to ensure that drug companies do not raise prices of their products just to make more profits. Although the WHO, a branch of the UN, does not have any teeth and does not hold direct power over national governments (as we discussed in class), I believe it would be more efficient to utilize an already established organization rather than creating an NGO from scratch, as an NGO would not hold any power over a state’s government and pharmaceutical corporations, either. The WHO would be able to monitor which organizations are engaging in philanthropy by donating important medications that would otherwise be prohibitively expensive to populations in low- and middle-income countries that need the medications, thereby encouraging other pharmaceuticals to follow suit. Because the WHO does have sway over international publicity, the organization could also publish data on what pharmaceuticals have dramatically raised prices on their products, adding to the pressure on these pharmaceuticals to reduce their prices to make their drugs more affordable.

FURTHER UPDATE (on Dec. 7, 2015 at 11:09pm):

I realize I was not very clear about how such pharmaceuticals were “allowed” to raise the prices of their drugs so drastically. Pharmaceuticals like Turing have found a loophole whereby they purchase all rights to the drug and then raise its price. This is perfectly legal, but legality does not always equate to morality, as we discussed in class in the context of corporate responsibility (e.g., Shell’s environmental pollution in the shantytown of Flammable, Argentina). While the connection between the social suffering and corporate responsibility is not as clear-cut in the case of these pharmaceuticals’ price hikes, I believe there needs to be more regulation on drug prices.

According to a Wall Street Journal article from December 5th, 2015,    there will be a congressional hearing on December 9th between the Senate Special Committee on Aging and pharmaceuticals with price jumps, including Turing Pharmaceuticals, to investigate the problem. Hopefully, this will further emphasize the message that we civilians (and most politicians) will not tolerate drastic price surges of important drugs and push forward policies to prevent another occurrence.

Dec. 9th, 2015 at 7:41 pm: Read more on the congressional hearing held this afternoon in Washington, D.C., where Senators Susan Collins and Claire McCaskill, along with specialists in the U.S. health care system such as Drs. Erin Fox and David Kimberlin, criticize four pharmaceuticals that have sharply increased the prices of their drugs out of greed for profits: http://www.theguardian.com/us-news/2015/dec/09/drug-companies-turing-valeant-martin-shkreli-daraprim

Sources:

 

HIV/AIDS Activism and Emerging Infectious Diseases, Section 3, Unit 2 - Trying to Help

Moralizing Bodies: HIV and the Politics of Aid

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In America, the image of HIV/AIDS activism has consistently been perpetuated and co-opted by the primarily upper class, cisgender, gay male members of the LGBTQ+ community. While I have no intention of undermining the experiences of suffering of anyone with HIV, the dominant narrative perpetuated by films like The Normal Heart[1] are wildly under-representative of the complexities and burden of this disease. The reality of HIV/AIDS – that it is one of the largest killers of people in the lowest income countries worldwide such that 66% of all HIV related deaths occurred in sub-Saharan Africa alone in 2014[2] – is one that can’t be ignored.

The privileging of the upper-class, western HIV experience in the understood cultural history of this disease is implicated by the example of Haiti, which Paul Farmer catalogs in his chapter, “The Exotic and the Mundane”.[3] Farmer argues that the spread of HIV in urban Haiti (mostly centered in the suburb Carrefour, home of Port-au-Prince’s redlight district[4]) is a textbook example of the “geography of blame.” Measures of guilt and accusation have been tied to the spread of HIV since it’s initial rise. Though the conservative right in America were quick to blame the “immoral,” urban men who had sex with men (MSM) for the spread of the disease, placing a moral judgment on a biological disease outcome and therefore conflating the biological body with the moral one, seropositive Haitian immigrants in America “denied homosexual activity or intravenous drug use.”[5]

Farmer criticizes American media outlets for effectively blaming Haiti for the American HIV epidemic, exoticizing and alienating the nation, as exemplified by Vanity Fair’s description of Haiti as the “black hole” of our hemisphere[6] in addition to exploiting Haitian voodoo acts as a potential source of transmission[7]. The relationship between cases of HIV in America and Haiti are clear: wealthy American vacationers came to Port-au-Prince and transmitted the disease to local sex workers, who, though many self-identified as heterosexual, would be paid into homosexual activity.[8] This conflated issues of homophobic sentiment in the U.S. with racial, gender, and economic inequality in Haiti. From here, it was found that the largest population of HIV positive individuals in Haiti were female sex workers, and Haiti became the evidence needed to suggest that HIV transmission was “more efficient” from men to women.[9] By 1986, it was impossible to deny that heterosexual activity was an ‘accepted risk factor.’[10]

Soon, a grand sentimental switch occurs in the evangelical right. Franklin Graham convinced the senator Jess Helms that “AIDS afflicted the ‘blameless’ just as often as it afflicted homosexuals.”[11] By positioning AIDS efforts towards that of the blameless, inherently moral children, we quickly saw a huge increase in the political capital of the west in AIDS treatment. The Clinton Administration, which had at first sided with pharmaceutical companies in the debate surrounding South Africa’s Medicines Act,[12] an attempt to provide more affordable, generic versions of antiretroviral therapies to HIV positive individuals, soon sided with the suffering and began providing aid directly to mothers and children who were HIV positive. By applying a moral judgment on those who were deserving of aid, there becomes a complication in the way that medications are transferred.

However, it was also this moral judgment that stirred action from abroad. The 3×5 campaign, which the WHO established as a goal to provide ARV treatment to three million people living with AIDS by the end of 2005, was unique in its efforts of establishing success as a measure of the number of people reached as opposed to the amount of money raised. By humanizing donor support under the framework of the “deserving” ill, we see the perpetuation of the implications of moral medicine. While it took until 2007 for the 3×5 campaign to be completed, it was considered a massive success in “galvanizing” the global AIDS effort.[13] By centering this mission around that of the suffering children – the people behind the disease and not the financial needs of the disease treatments itself – we see a re-affirmation of the complex power structures inherent in the way that the wealthy choose to spend their money – along moral and political lines.

 

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[1] Cast by almost exclusively white males, it is very clear where Hollywood is looking to spend their money insofar as narratives surrounding the HIV crisis.

Murphy, Ryan, Larry Kramer, Scott Ferguson, Julia Roberts, Mark Ruffalo, Jonathan Groff, Jim Parsons, Matthew Bomer, Taylor Kitsch, Julio F. De, Alfred Molina, Cliff Martinez, Adam Penn, Danny Moder, and Larry Kramer. The Normal Heart. , 2014.

[2] The American Foundation for AIDS Reserach. http://www.amfar.org/worldwide-aids-stats/.

[3] Farmer, Paul. Infections and Inequalities: The Modern Plagues. Berkeley: University of California Press, 1999. Print.

[4] Ibid. 103

[5] Ibid. 99

[6] Ibid. 100

[7] Ibid. 106

[8] Ibid. 119, 122.

[9] Ibid. 113

[10] Ibid. 114

[11]Messac & Prabhu, Redefining the Possible: The Global AIDS Response. Reimagining Global Health: An Introduction. ed Paul Farmer. Berkeley, Calif: University of California press, 2013. Print. p 127.

[12] Ibid. 122

[13] Ibid. 114

HIV/AIDS Activism and Emerging Infectious Diseases, Section 1, Unit 2 - Trying to Help

Is some help better than no help at all? How do we handle the complexities of HIV/AIDS interventions in the developing world?

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In her book, Professor Benton writes, “Herein lies the double-bind of HIV exceptionalism: to deem HIV a run-of-the-mill public health problem is to understate one of the most challenging biomedical and social problems of our time.  When we ascribe such enormous cultural weight to the disease, however, it becomes almost impossible to justify sublimating HIV to a broader health care agenda–even in low-prevalence settings.”  Throughout the entire book, Professor Benton highlights how HIV/AIDS in Sierra Leone has become an exceptional disease; almost all health development programs and funding is HIV-related, while HIV prevalence is not actually that high (~1%).  This brings us back to our discussion about unintended consequences–while providing care for HIV/AIDS patients is important, and indeed a ‘good’ thing, through the reading we see that these disease specific health interventions can take away funding from other diseases and health issues that are less ‘sexy’/’attractive’ to donors, and can therefore leave people sick and at risk of mortality and morbidity from diseases that could have been prevented through primary care.

I must admit, I chose this topic to blog about for a reason.  Over three years I have conducted cardiovascular research in Kenya and assessed the rising rates of chronic non-communicable diseases (CNDCs) in the country.  Over the last year or so I have been researching ways to integrate chronic non-communicable disease care with HIV/AIDS care structures that are already in place because of high funding for HIV/AIDS programs.  To me, it makes sense to integrate HIV (which is a chronic disease with proper treatment and adherence to care) with cardiovascular, diabetes, and hypertension care because they require similar things–adhering to drug regimens, living healthy lifestyles with proper diet and exercise, counseling, support systems, etc.  But something that I’ve struggled to answer is that by integrating HIV/AIDS with CNDCs in health care structures, are we undermining the severity and complexities of the HIV/AIDS epidemic?  By integrating care, would we be cutting options for poor persons living with HIV/AIDS, people who are already at higher risk for discrimination, stigma, poverty, etc.?  While there are unintended consequences of creating HIV-only health interventions, what are the possible unintended consequences of integrating care structures?

This relates back to the debate between the primary health care (PHC) movement and the selective primary health care (SPHC) movement.  Although both the PHC and SPHC movements were in some ways trying to address declaration III of the Alma Ata: “Economic and social development, based on a New International Economic Order, is of basic importance to the fullest attainment of health for all and to the reduction of the gap between the health status of the developing and developed countries. The promotion and protection of the health of the people is essential to sustained economic and social development and contributes to a better quality of life and to world peace,” the PHC movement was a horizontal approach and the SPHC movement was a vertical one.  Like the HIV/AIDS programs highlighted in Professor Benton’s experiences in Sierra Leone, the SPHC movement was specifically targeted and in some ways much more practical than the idealistic PHC movement.  This raises the question of how much idealism and how much practicality make up good health policy?  Is practicality more useful in policy-making than idealism?  Were the health gains brought about by the vertical SPHC movement better than what might have occurred from the PHC movement?  In my opinion, while the SPHC movement didn’t address or even come close to attaining access to primary health care for all, I think that the PHC movement was too broad and that without specific funding guidelines would have made even less gains than what actually occurred.  What are the unintended consequences of creating a broad public health intervention, and what are the unintended consequences of creating specific interventions?

I think that the HIV/AIDS interventions described in the Benton book really highlight what we’ve been struggling to find an answer to all semester in class: How can we do something good for health that doesn’t somehow also have unintended negative impacts?  In the book we see that HIV/AIDS funding comprised more than half the country’s health budget in 2004, but in many cases, “HIV exceptionalism actually serves to amplify existing disparities.  On the other hand, it also provides a means by which poorer HIV-positive people can benefit from a health care system that normally privileges the priorities of its wealthy donors.”  Thus it seems to be sort of a damned if we do, damned if we don’t situation–we want to help sick people, but we also don’t want to hurt other sick people in the process of that, so what do we do?

Questions:

  1. In the case of Sierra Leone are there any solutions to the problems created by HIV exceptionalism?  Would strengthening primary health care systems in order to prevent preventable diseases inherently harm people living with HIV/AIDS who already face poverty, stigma, and other inequalities?
  2. When creating health policy and health interventions is practicality or idealism more important/useful?  What are the possible negative outcomes that can occur by using one or the other?
  3. When trying to get funding from donor organizations and donor countries who should be in control of determining what programs are funded with this money?  Is there really anything we can/should do to influence where donors put their money?  Is it bad for programs that have unintended consequences to be funded in the first place?  Should donors therefore just stay out and not help?

Sources:

Alma Ata Declaration.

Benton. 2015. HIV Exceptionalism: Development Through Disease in Sierra Leone. Minneapolis: University of Minnesota Press.

Cueto 2004 The Origins of Primary Health Care and Selective Primary Health Care. American Journal of Public Health 94(11)1864-74.

Farmer, A. Kleinman, J. Kim and M. Basilico, eds. 2013. Reimagining Global Health: An Introduction. Berkeley: University of California Press.

HIV/AIDS Activism and Emerging Infectious Diseases, Section 1, Unit 2 - Trying to Help

The Right to “Rights”: Conducting Illness and Response, Performing HIV/AIDS and Activism

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In several of the class readings that touch on both anthropological and global health perspectives on HIV/AIDS and attempts to control and treat the disease around the world, a theme that arises again and again is the one of “rights.” There is, of course, the apparent “right to know” the HIV-status of someone in your family or community and the right to “know your rights” (Biehl et al., 93) in navigating the HIV-positive identity, amongst other “rights” that seem to illuminate a projected path of dignity after diagnosis, and dignity in disease.

Throughout my own work with patients who must navigate the social circumscriptions of their health statuses and health choices, I have encountered other “rights” that patients either seek to engage: the right to be ill, the right to their identity as it either transforms through illness or does not, and – in an amalgamation of the two – the right to be an ill person. The meanings of these can be nebulous, and certainly fluid between individuals and contexts of illness. They are, however, important to the development of an inclusive and thoroughly caring rubric for the protection of human health.

Since its recognition as a “distinct clinical syndrome” in 1981, HIV/AIDS and discussions about the disease have permeated public concern about health and captured the focus of international health objectives (Farmer, 60-61). Due to its prevalence in the public imagination about transmission, socialized mythologies have arisen, type-casting the apparently susceptible based on initial circumstances of visibility amongst HIV/AIDS victims. Members of the LGBTQ community, Haitians, drug-users, and people believed to be of a certain form and level of sexual activity where they may make sexual contact with these “types” of people (especially through “anal intercourse” [61]) are among some of the people who did, and still do, experience judgment and are inundated with concern (either personal, social, or both) about their HIV-statuses. Additionally, cultural pictures were painted with related assumptions about the lifestyles and habits a person susceptible to or diagnosed with HIV/AIDS enacts; these mythologies continue to reproduce themselves through certain tactics for sexually-transmitted illness screening as well as the marketing particulars of prevention and awareness programs. In Zimbabwe, Dr. Beth Barr reports that the stigma which links HIV transmission to certain behaviors, as well as certain frightening consequences of HIV/AIDS, repels people – particularly sexually active youth – from counting themselves among those in need of screening, protection, and possibly treatment. The co-production of a sort of HIV/AIDS-identity by 1) beliefs about the transmission and progression of the disease and 2) the moral valences of the behaviors believed to be responsible has driven people away from testing and treatment for fear of having to surrender their personhood in exchange for this frightening and unappealing identity (Mwakalyele, 2015).

In HIV Exceptionalism, Benton writes how, in Sierra Leone, there are established ways of appropriately disclosing one’s HIV-positive status, and, thus, how there exist established ways of appropriately enacting HIV-positivity. The performative value of disclosure of one’s status, as Benton discusses (67-88), represents a social process of transforming the identity of the person – from healthy to sick, from presumably HIV-negative to certainly HIV-positive, from one type of person to another type of person (Benton discusses the varied assumptions and cultural valences that orbit “HIV/AIDS” as it has been constructed in the social imagination) – that becomes inscribed on the the biological process of infection and disease within the body.

The social processes that hinge HIV/AIDS onto socially-projected information about identity and conduct, as well as that connect the perceived severity of the disease to equally severe, implicit moral allegations stemming from socialized fictions of AIDS etiology contort the social privilege of those experiencing the disease from all angles: there are intense personal, cultural, religious, interpersonal, public, and bodily sensations that follow diagnosis. The right to retain and mold one’s own identity in and through illness is squeezed through an apparatus of the “rights” of others “to know,” the consideration for the health of the community, and the urgency imbued in certain forms of disclosure. While disclosure proves a sometimes-useful tool to cultivate social support and build trust, it mandates a surrender of control over one’s own health information (Benton, 71), as well as a relinquishment of the way one may be perceived into a realm of public assumption and judgment, where one’s conduct, personhood, and legacy may be discriminated against, misread, and miscarried.

Negotiating a balance between the “rights” to community awareness of infection and the patient’s right to preserve their personhood in a climate of mythology and judgement circling HIV/AIDS may break down barriers of socialized illusions about susceptibility to transmission, and subsequently may not only strengthen prevention but also render every member of a community equal in sharing concern about HIV/AIDS transmission. Thus, each member of a community is called to responsibility in creating an environment of participation and proactivity to support the health of the whole community. Establishing a livable balance for those living with illness between the risk of stigma and the protection of others, reconstructing the cultural storytelling that once seemed to safeguard the uninfected, and cultivating attitudes of shared responsibility and equal susceptibility is integral to true protection, as well as fair and successful distribution of knowledge, prevention, treatment, care, and dignity. This, in my opinion, is activism.

 

Discussion questions:

  1. What concrete problems do you see with the stigma that underlies disease and the effectiveness of appealing to community awareness and/or delivering screenings, treatments, and care?

2. Is it possible to untangle the realities of transmission from the cultural etiologies and local beliefs that are important to respect when developing strategies for responding to infection and disease internationally?

3. What are the dangers of these sweeping cultural mythologies about transmission and susceptibility to disease, which inaccurately depict certain “types” of people as carriers from which the uninfected should distance and protect themselves? How might these forms of storytelling about disease create yet more inequality and prove damaging to overall health in a community?

 

Sources:

• Benton, Adia. 2015 HIV Exceptionalism. University of Minnesota Press.

• Biehl, João, and Adriana Petryna. 2013. When People Come First: Critical Studies in Global Health. Princeton University Press.

• Farmer, Paul. 1999 Infections and Inequalities. Berkeley: University of California Press.

• Mwakalyele, Ndimyake. 2015 Stigma, Complacency Threaten Zimbabwe’s Gains in HIV/AIDS Fight. http://www.voazimbabwe.com/content/stigma-complacency-threaten-hiv-gaings-fight/3013729.html accessed October 20, 2015.

 

HIV/AIDS Activism and Emerging Infectious Diseases, Section 2, Unit 2 - Trying to Help

Defining Efficacy: The Pharmaceutical Industry and Access to Treatment

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During the 1990s and 2000s, HIV/AIDS activism made huge strides in reducing antiretroviral treatment (ART) prices and making HIV treatment more globally accessible. Through extensive human rights campaigns, activism efforts, and support from a host of governmental and supranational bodies, expensive drugs that were once deemed not cost-effective to provide in developing nations were made available to many of the world’s poor suffering from HIV/AIDS. The authors of Reimagining Global Health note that “The lowest available annual per-patient price of the most common first-line HAART regimen in the developing world fell from $10,000-$15,000 in the late 1990s to $300 in 2002 to $87 in 2007” (Farmer et al., 2013). For many infected with HIV, these improvements meant that HIV/AIDS would no longer be a death-sentence, but could be managed as a life-long chronic illness.

Much of this price-drop was attributed to the increased production of generic forms of brand-name treatments. Through partnerships with governments of developing countries and adapted business models, generic drug manufacturers were able to sell generic antiretrovirals at set—and comparatively low—price points (Farmer et al., 2013). This new wave of generic antiretroviral drug production was spurred in part by the passage of the South Africa’s Medicines Act of 1997. This act gave the government the right to allow compulsory licensing of brand-name drugs in the case of a public health emergency, meaning that patented antiretrovirals could be made by generic drug manufactures without permission of the patent-holder. Although 39 pharmaceutical companies filed lawsuits against the act in South African courts, political and social support for the Medicines Act caused them to withdraw their complaint three years later. Indeed, later that same year the World Trade Organization recognized that South Africa had not violated trade agreements concerning intellectual property rights, further solidifying the precedent that public health matters could override intellectual property rights (Farmer et al., 2013).

While the HIV/AIDS movement for access to ART is a truly remarkable example of harnessing social and political forces to make life-saving pharmaceuticals available in resource poor settings, it stands as the exception to the rule. Indeed, as Nicholas King describes in his article “Security, Disease, Commerce: Ideologies of Postcolonial Global Health,” pharmaceutical companies continue to have little incentive in developing effective and affordable treatments targeted at populations of developing nations. Not only is the Western pharmaceutical industry ill-designed to cheaply produce and sell important medicines to developing nations, but these same manufacturers whose product is inaccessible in poor settings continue to fight against the production of cheaper generic alternatives in non-Western countries—despite the public health importance of the medicines and the low-purchasing power of developing nations.

The battle surrounding patent protection is far from over. Recent trade negotiations concerning the Trans-Pacific Partnership—a trade agreement that would link nations including the United States, Japan, Australia, Canada and Chile, among others—are rife with controversy over the issue of pharmaceutical patenting. Many countries in the partnership want the United States to reduce their patent protection from the current 12 years to allow generics to enter the market sooner, while members of United States Congress have asserted they will not support the deal without a strong intellectual property rights component (Weisman, 2015).

Incidentally, the timing of these trade negotiations coincided with another controversial case involving the pharmaceutical industry. In September, the American pharmaceutical company Turing Pharmaceuticals made headlines when they purchased the rights to the drug Daraprim—a drug developed 62 years ago that treats toxoplasmosis—and increased the price from $13.50 a pill to $750 a pill (Pollack, 2015). The increase in price was not due to increased manufacturing costs of the drug, but due to the desire for an increased profit margin on part of Turing Pharmaceuticals. Unfortunately, this case is not isolated, but only one of many in a series of similarly inexplicable price-hikes enacted by drug companies.

How did the precedent set by the successful price reduction in HAART due to generic manufacturing during the early 2000s fail to translate to other life-saving medications? Aside from cases of “public health emergencies,” the pharmaceutical industry has near complete control over the production and pricing of many crucial medicines. Advocates of the pharmaceutical industry argue that a system based on profit-motive supports industry innovation and the production of better, more effective drugs. And yet, how effective can a medicine really be when it is out of reach of those who it would help the most? The efficacy of a medicine should not be measured simply by its biomedical utility, but also by its accessibility. If a pharmaceutical treatment is not available to a population for social reasons, it cannot be available to treat or cure on a biological level—bringing into question how exactly pharmaceutical companies should approach creating “effective” medicines.

 

 

Sources:

Farmer, A. Kleinman, J. Kim and M. Basilico, eds. 2013. Reimagining Global Health: An Introduction. Berkeley: University of California Press.

King, N. 2002. Security, Disease, Commerce: Ideologies of Postcolonial Global Health. Social Studies of Science 32(5-6): 763-789.

Weisman, J. (2015, July 30). Patent Protection for Drugs Puts Pressure on U.S. in Trade Talks. New York Times. Retrieved October 20, 2015, from http://www.nytimes.com/2015/07/31/business/international/pacific-trade-deal-drugs-patent-protection.html

Pollack, A. (2015, September 20). Drug Goes From $13.50 a Tablet to $750, Overnight. New York Times. Retrieved October 20, 2015, from http://www.nytimes.com/2015/09/21/business/a-huge-overnight-increase-in-a-drugs-price-raises-protests.html

 

Discussion Questions:

  • How much control should the pharmaceutical industry have on setting prices for life-saving treatments? If their control should be limited, which governing body should have the power to decide pharmaceutical pricing?
  • How likely is it that another massive activist movement, such as the movement for access to ART for HIV/AIDS treatment, will be able to drastically change the accessibility and affordability of important medicines?
  • Turing Pharmaceuticals argued that their price increase of Daraprim was justified because the drug is not commonly used anymore, and the increased profits generated from this price-hike will allow the company to expand research and development into other more effective drugs to treat toxoplasmosis. Do you agree with this justification? Why or why not?
Alma Alta, Primary Health Care, and Selective Primary Health Care, Section 3, Unit 2 - Trying to Help

Forgotten: Emergency Care in the Context of Public Health Care Frameworks

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In the 1970s and 1980s, discussion around what and how health systems should be implemented sparked a heated debate. In 1978, the Alma-Ata declared that ‘Health for All’ should be the international goal of countries through Primary Health care. Unfortunately, the Alma-Ata failed, likely due to not specifying where how it was to be funded and the inability to hold countries to their commitment. After this, the concept of selective primary health care emerged, a way to package health services in a cost effective manner. Although both of these approaches aim to improve health, neither of them specifically mention emergency care, and where it belongs in the context of these frameworks and life.

Ziad Obermeyer conducted a study in low-and middle-income countries (LMICs) about the emergency care available. In “Rethinking emergency Care is key to ‘Health for All,’” he summarized his findings. He shed light on the fact that people in LMICs still get pneumonia, diarrhea, heart attacks and asthma. Something I think most people don’t realize is that studies consistently put emergency conditions at the top of list of causes of death and disability worldwide. The number 1 cause of death in LMIC is Ischaemic heart disease at 11.5% of deaths in LMIC, while HIV/AIDS was the 4th cause of death at 6.1% (Razzak & Arthur). Despite this, LMICs tend to have a lack of emergent care facilities, leading to an average of 10 times the caseloads of primary care doctors in the region. I believe that because of this, emergency health care should be a part of any country’s health system, even if it wasn’t in the plans of health care in the 1970s and 80s.

In the Alma-Ata Declaration, statement V says that all people should be at a level of health “that will permit them to lead a socially and economically productive life” by 2000. It then explained that the key to this target is primary health care. While I do agree that primary health care is necessary to track and prevent diseases and should be implemented around the globe, Obermeyer states that 10-15% of deaths in Nigeria occur in emergency care facilities. Most of these people are young and generally healthy, so they lose the most productive years of their lives. If primary health care and emergency health care both support preserving a productive, healthy life, then why didn’t Alma-Ata include emergent care?

Included in the principles of selective primary health care is the idea the main disease problems of poor countries can be solved through low-cost technical inventions, as Cueto explains. In this is the philosophy that “international agencies had to do their best with finite resources and short-lived political opportunities” (12). Though emergent health care was not originally discussed when it came to selective primary health care, I believe that these philosophies are very similar to what Obermeyer observed. In higher income countries, a small portion of the national medical expenditures helped emergency care providers focus on improving quality and training. As many providers in emergent care facilities in LMICs don’t have specific training, select LMICs have benefited from this training too.

The end of the Alma-Ata and the Cueto article on selective primary health care both focus on cost-effectiveness and the reallocation of resources. Investing in emergency care could relieve the burden of primary care doctors, allowing them to better serve their community. Emergency care could also alleviate some of the death and disability in LMICs, allowing for a more productive workforce, possibly boosting the country’s economy. Though the Obermeyer article doesn’t suggest a specific intervention, it does mention the opportunity for low cost, quality education of providers. This, along with a possible creation or renovation of an emergency care facility, could be perceived at a cost-effective strategy. As such, emergency health care would be a valuable addition to health care around the world, even if it’s philosophy is the only thing that might line up with other health care strategies.

  1. Should emergency care systems be thought of as separate of primary health care and selective health care, or are they already integrated into this framework? Are emergency care systems necessary if a strong public health care system is in place?
  2. Would implementing an emergency care facility in rural areas be feasible due to the lack of access to them and the number of providers that would be needed? How could communities be involved in the implementation of an emergency care facility or practices?
  3. Would you consider emergency care a magic bullet?
Alma-Ata Declaration. USSR. 6-12 Sepetember 1978.
Cueto, M. “The Origins of Primary Health Care and Selective Primary Health Care.” American Journal of Public Health, 2004. 94(11)1864-74.
Obermeyer, Ziad. “Rethinking Emergency Care Is a Key Part of ‘Health for All'” Brookings. N.p., 25 Aug. 2015. Web. 20 Oct. 2015.
Obermeyer, Ziad, Samer Abujaber, Maggie Makar, Samantha Stoll, Stephanie R. Kayden, Lee A. Wallis, and Teri A. Reynolds. “Emergency Care in 59 Low- and Middle-income Countries: A Systematic Review.” Bulletin of the World Health Organization Bull. World Health Organ. 93.8 (2015): n. pag. Web. 20 Oct. 2015.
Razzack, Junaid, and Arthur Kellermann. Emergency Medical Care in Developing Countries: Is It Worthwhile? (n.d.): n. pag. Web. 21 Oct. 2015.
Alma Alta, Primary Health Care, and Selective Primary Health Care, Section 1, Unit 2 - Trying to Help

We Still Need a Grand Vision

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The WHO defines health as a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity. The Declaration of Alma-Ata cited this definition of health to emphasize the right to health for all and, thus, urge governments to implement comprehensive national health systems. As we discussed during lecture and section, the broad scope of this declaration was greatly criticized. The declaration set unrealistic expectations because it posed immeasurable, and seemingly unattainable, goals to achieve better health for all around the globe. In spite of all these criticisms, primary health care has set the standards for today’s expectations for health systems precisely because it encompasses a grand vision: health as a fundamental right.

The Declaration of Alma-Ata was a great tool for setting the framework around global health; it incited all countries to consider the health of their people and how these people were accessing the health care system. As broad as the overarching mission to implement primary health care was in scope, it served as the foundation for the “Primary Health Care movement,” which has trickled into today’s ambitions. For example, the WHO’s World Health Report of 2008 emphasized placing people and their health needs at the forefront of health care. In addition, the Bill & Melinda Gates Foundation, World Bank Group and WHO just came together in September to form a new partnership, the Primary Health Care Performance Initiative (PHCPI). The PHCPI’s aim is “to support [low- and middle-income] countries in improving the performance of primary health care.” It will help countries monitor, track, and share their key vital signs, which include information about the health system as a country’s priority, service delivery, and the delivery of better outcomes. In this manner, primary health care will continue to address the social determinants of health, but on a country-by-country basis. However, I wonder how exactly these three powerful organizations will work with other countries’ community values instead of imposing their own values.

In addition to addressing social determinants of health, primary health care also focuses on the need to improve value for patients, “where value is defined as the health outcomes achieved that matter to patients relative to the cost of achieving those outcomes.” (HBR) In this manner, we should be able to improve outcomes without increasing associated costs or decrease costs without worsening the outcome, thereby obtaining better health for all. The overall aim is ensure that everyone is achieving the best outcomes at the lowest costs, that we are offering a ‘ preferential option for the poor’. Yet, to what extent is this ‘preferential option for the poor’ influenced by and idealized in Western settings? Primary health care is supposed to avoid the elements of paternalism that are so prevalent among the “magic bullets,” like antiretroviral drugs and regional and global vaccination campaigns.

Magic bullets have the benefit of being simpler and more cost-effective than longer-term goals, but also distal to the social determinants of health. The global eradication of smallpox, for example, failed to address the more pressing concerns that the last communities with smallpox were facing. Further, it raised questions about the ethical implications of taking a vertical approach: How important is it to vaccinate all resistant individuals? Will this actually benefit all global citizens? Should we be more concerned with hazards, like smoke accumulating in houses when someone cooks or water contamination? These more narrow, yet measurable goals that are characteristic of vertical approaches and selective primary health care often detract from the social determinants of health, thereby ignoring the “causes of the causes” that negatively impact health.

Interestingly enough, other kinds of “magic bullets” dealing with HIV/AIDS don’t necessarily avoid social determinants of health altogether, but rather create what Dr. Adia Benton calls “methodological horizontality.” In this way, we do not place our sole focus on the disease and targeted clinical interventions or only promote evidence-based interventions to obtain funding. This combination of vertical and horizontal programmatic approaches allows us to address HIV/AIDS diagnosis, treatment, and follow-up while also conducting other health programming. Would this approach work for all diseases? Can we simultaneously work toward providing truly accessible, affordable, and coordinated primary health care and also address problems that require specialized care?

Discussion Questions:

  1. Do we need a global framework for primary health care? Or can other countries interpret primary health care as they see fit for their needs and, thus, develop nation-specific primary health care?
  2. Can we ever truly eliminate elements of paternalism from our (American) international health efforts?
  3. How can all nations work toward providing truly accessible, affordable, and coordinated primary health care to then be able to address problems that require specialized care?

 

Sources:

Benton, Adia. HIV Exceptionalism: Development Through Disease in Sierra Leone. U of Minnesota, 2015.

Bryant, J. H., and J. B. Richmond. “Alma-Ata and Primary Health Care: An Evolving Story.” Health Systems Policy, Finance, and Organization. By Guy Carrin. Amsterdam: Elsevier/Academic, 2009. 59-81.

Cueto, M. “The Origins of Primary Health Care and Selective Primary Health Care.” American Journal of Public Health, 2004. 94(11)1864-74.

Greenough, P. “Intimidation, Coercion, and Resistance in the Final Stages of the South Asian Smallpox Eradication Campaign, 1973-1975.” Social Science and Medicine, 2005. 41(5): 633-645.

Lerberghe, Wim Van, Tim Evans, Kumanan Rasanathan, and Abdelhay Mechbal. The World Health Report 2008. Geneva, Switzerland: World Health Organization, 2008. http://www.who.int/whr/2008/whr08_en.pdf.

Porter, Michael E., and Thomas H. Lee. “The Strategy That Will Fix Health Care.” Harvard Business Review. 01 Oct. 2013. https://hbr.org/2013/10/the-strategy-that-will-fix-health-care.

World Health Organization. “New Partnership to Help Countries Close Gaps in Primary Health Care.” World Health Organization. 26 Sept. 2015. http://www.who.int/mediacentre/news/releases/2015/partnership-primary-health-care/en/.

Alma Alta, Primary Health Care, and Selective Primary Health Care, Section 2, Unit 2 - Trying to Help

Vertical vs. Horizontal Approach: The drawbacks of each and a need for a merging or “diagonal” approach

13 Comments

When thinking about how to address health problems around the world there were two ideas that seem to arise, vertical and horizontal approaches. The vertical approach being a disease specific top-down approach that makes it easier to obtain funding and measure results and the horizontal approach being a more comprehensive approach that seeks to treat all the underlying issues a population that cause various diseases and health problems but that is more abstract.

These approaches are also intrinsically related to the debate of Magic Bullets vs. Primary Care and even in the debate of Comprehensive Primary vs. Selective Primary Care. The vertical model relies on the use of magic bullets, simple and fast acting biomedical advances, in order to implement their programs. When a so-called magic bullet is available and completely effective a vertical approach would be successful as you can reach many people give them a one-time treatment and solve the specific health problem.

The issue arises because there doesn’t exist a magic bullet for the vast majority of diseases that developing countries face, therefore when global health organizations come into these countries with specific disease approaches they are overlooking the structural factors that give rise to health concerns. Comprehensive Primary Care aims to be the opposite of this; it is basically a horizontal approach. The issue there, of course are concerns over cost-effectiveness. Quick-fix and Magic bullet programs come out with a much better ranking in regards to cost-effectiveness which favors downstream medical interventions and finds upstream interventions, such a school-based programs largely ineffective, because it will take several years for the health effects to take place and even when they do it is not easily measurable.

You see this sort of idealistic approach and mentality at the Alma-Ata conference in 1975, with the desire of “Health Care for all by year 2000”. But this model was ultimately unsuccessful and the Selective Primary Care Model that emphasized GOBI (growth monitoring, oral rehydration therapy, breast feeding and Immunizations) triumphed. Selective Primary Care operates more as a vertical approach even primary care in the name because it emphasized only specific issues. While it was an “interim” strategy there were never plans of shifting to more comprehensive primary care.

These two approaches seem like they would have to be competing ideologies, where only one can be correct. I believe that this is not necessarily true. Because both of these approaches have considerable drawbacks and unintended consequences of implementation, the merging of both these approaches would actually increase the benefits while minimizing the risks and drawbacks. In an article by Gorik Ooms, he addresses this as a need for a “diagonal” approach. He suggests that we should be aiming for “disease-specific results but through improved health systems”. This is an interesting idea and definitely important to consider when planning and designing interventions. I believe it is possible to create a new approach that will be more effective; it will however require funding and commitment. Tore Godal suggests the shifting to a Global Health fund that would “consolidate towards a global health fund with one health sector funding channel”. He argues that with an increase in funding and supplies it is possible through a unified effort to simultaneously achieve disease-specific success while strengthening the health system.

Gijs Elzinga also discusses this in an editorial piece titled “Vertical-horizontal synergy of the health workforce” in which he states that while certain components of vertical programs are vertical in nature there is an interface when it comes to the delivery of interventions. Because intervention delivery requires the greatest number of workforce involvement, there is some room for the interventions to be more integrated into a horizontal system, in which health care workers seek to address all the issues. I think vertical approaches can enhance vertical horizontal collaborations and attempt to decrease the polarization of the vertical vs. horizontal debate. The use of more of the existing personnel of healthcare workers is one way this can be achieved.

I believe the strength in this idea of a “diagonal approach” comes from not shifting to a horizontal approach overnight and the integration of the benefits of each. It is important to change the mentality around our approach as only being able to fit into these categories. Although pragmatism is important when it comes to implementation, we need to think about the long-term results and the programs sustainability. We need to implement programs that have the ability to change over time, shifting its goals with increasing resources.

Sources from Class:

Paul Farmer, e. A. (2013). Reimagining Global Health An Introduction.

Cueto 2004 The Origins of Primary Health Care and Selective Primary Health Care. American Journal of Public Health 94(11)1864-74

Outside sources:

“Vertical–horizontal Synergy of the Health Workforce.” WHO. N.p., n.d. Web. 22 Oct. 2015.

“The ‘diagonal’ Approach to Global Fund Financing: A Cure for the Broader Malaise of Health Systems?” Globalization and Health. N.p., n.d. Web. 22 Oct. 2015.

Discussions Questions:

  1. Do you think merging the different approaches that we have discussed will yield successful outcomes? Do you think it is possible to implement programs like this?
  2. Do you think the idealism of the Alma-Ata Declaration was influential in making change by getting people to talk about health, or did its lack of pragmatism and ability to be implemented render it basically useless?

 

Magic Bullets Redux and Vertical Programs, Section 3, Unit 2 - Trying to Help

Who and What Counts?

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What and who counts? I found myself repeatedly asking this question during each distinct reading, converging the stories, separating them; piece by piece determining what and who counts. There are many different forms of contextual evidence to support what and who counts. If you look generally, of course, the people of impoverished, developing nations — benefiting exorbitantly from foreign and strange aid programs. Except, not very much. A large disconnect exists between what and who counts, whose agenda we are following, and why.

Chapter 1 of When People Come First alludes to a better future, where we have given up on the radical idea that singular-technology can “overcame any obstacle posed by social conditions and processes” (Biehl, 32). International agencies seemed to finally convene and agree upon their ignorance and lack of understanding (or desire to understand) regarding differing beliefs and ways of life. Basic power dynamics of International Givers are established, including the brief history of malariologists, and how “medical technology could only be administered by an elite group of experts.” This act made a clear distinction between ‘us’ and ‘them’ — allowing for critical knowledge and information to be kept private and isolated.

Historically, Sierra Leone has been a place of ramped colonialism and exploration — the birth ground of ‘us’ and ‘them’. In 1807, Sierra Leone became Britain’s first West African colony. At first, the location was idealized, but the rising and ferocious rate of deaths coined a new name — White Man’s Grave. Anyone who went could expect to die, or have something gravely wrong with them. I don’t believe our association between an uncivilized environment and people has ever gone away (Rankin, 3).

In 2005, when the author (Adia Benton) of HIV Exceptionalism attended a strategic-planning meeting for HIV/AIDS in Sierra Leone, she was struck by how prescribed and unoriginal the plan/information was. For example, there was one single reference to war, when refugees were mentioned, but besides that — nothing. This fact, in and of itself, is exceptional; considering the amount and degree of warfare ravaging the land.

This is is not the only issue with Sierra Leone’s AIDS work. 1% of the population is living with AIDS (18% of burden; 40% of disease), which is incredibly disproportional when analyzing others factors and determinants that lead to illness or death (whose agenda?). Additionally, the usual rhetoric for AIDS does not necessarily apply in Sierra Leone (poverty, etc.) — as AIDS does not disproportionally affect the poor. In fact, living with HIV is diversely spread across various socioeconomic classes — yet since this fact has not been taken into account, supports from the foreign and International aid highly favor the very poor individuals with HIV (Benton). As Benton states, “We are attempting to overlap poverty, social inequity, marginalization, etc. — which are not the primary determinants in Sierra Leone. There are different patterns of transmission, different strains. Factors like poverty affect where HIV-positive people seek care, the terms/quality/and efficacy of care, etc.

Benton introduces the concept of biotribalism, the carving up of spaces and distribution of resources according to presence/absence of HIV. At one Press Conference on the awareness and prevention of AID, a man stood up and stated, “How can you tell us that the disease is like any other disease but then treat it like it’s not? We’re having a press conference about it. There’s separate money for treating and dealing with the disease. Isn’t separating it also marginalizing the disease? Aren’t you marginalizing and causing discrimination by making it separate like this?” If social aspects like self-esteem and self-reliance create a healthier population (Biehl), then why are we attempting to control everything, down to there rationing of food?

So, the question begs, why do these efforts exist in isolation? Is it the generous stipends/unique benefits for workers? Is it the exceptionalist drive of living positively with HIV? Is it embedded reliance? Benton discusses how “HIV Exceptionalism amplifies existing disparities”, and I wonder if we have created a system that is un-functionable without foreign help and intervention. A report back to the World Bank in 2007 notes “projects are complex with many participants engaged in activities for which they have little … comparative advantage” (Benton, 46). Are food, natural supports, community supports, medical care, etc. not advantages in a war-torn country like Sierra Leone, with AIDS not nearly as large of a problem as starvation and poverty? Benton discusses those with HIV as a “special group” not necessarily ‘othered’ by stigma/their diagnoses, but because they have access to resources that no other individuals do. So, again, I ask the question, what and who counts?

Update:

In light of all the engaging and interesting comments, and the additional knowledge I have gained from class/readings, I am adding a short update to my blog. In the comment section, Methma asked, “I wonder how we can work to change these ideas of Africa as a “white man’s grave” and the association of an uncivilized environment and people, like you mentioned. Do you think these associations are mostly subconscious now or are they furthered by how we view aid in other countries?”  I believe it is mostly subconscious, but certain pressures and situations bring these inequities into the light. For example, many students chose to write about the difference in treatment between the foreign aid PIH worker who contracted Ebola (and was immediately sent to the US), and the community health worker for PIH (who had to wait two days before being taken to a clinic). This difference in treatment is pronounced and defined, and stands to support our historical notion of Africa being the ‘White Man’s Burden’, and the death of a white body meaning more, and being more of an ‘event’, than that of a black body.

Additionally, I want to clarify that I do not think that focusing on HIV/AIDS in Sierra Leone was a mistake — but wish these programs can be optimized, expanded, and executed properly — so as to reach the most amount of individuals, in the most successful manner. Shreya commented that “beggars can’t be choosers”, but I believe that viewing those in need of aid as ‘beggars’ meds itself to the colonialist view of the poor, desperate bodies in Africa. When discussing Improvising Medicine during Lecture, we spoke about how drastically different cancer is in the US/Botswana, yet those in Botswana were still deserving of decent, humane, and caring medical treatment. Of course, individuals will take what they can get, but we must never stop critically analyzing these interventions. We must continue to interrogate why it feels normalized and appropriate to provide Africans with no-frills care, but take extra caution to ease any ache and pain in a ‘suffering’ woman in the US. These tradeoffs are rooted deeply in colonialism, and have huge impacts and influences on the programs we provide, and the way we facilitate them.

Finally, in my blog post I state, “I wonder if we have created a system that is un-functionable without foreign help and intervention.” Through my continued learning of the PIH model, I am confident that there are solutions, however complex they may be, that can help lessen the dependence on foreign aid and international organizations. For example, PIH helped forge relations between Haiti and Rwanda, which serves as a south-south system of support and resources, capable of sustaining even after foreign aid has left. This is ultimately the goal, though utilizing services like PIH is definitely an essential part of that path.

Discussion Questions: 

1. To what extent is the newer influx/generation of Global Health worked influenced by colonialism and the original views/perceptions of Africa and the African body?

2. In terms of Global Health work, have we applied the concepts of ‘social determinants’ correctly? Biehl discusses a shift in Global Health work, acknowledging that social factors and institutions were not considered greatly enough in terms of disease (we once believe disease caused poverty, etc.), yet in terms of HIV Exceptionalism, it seems as though we are looking at and trying to overlap poverty, social inequity marginalization, etc. — which are not the primary determinants in Sierra Leone. How can we change the way we think about and apply the concept of social determinants?

3. To what extent have our AIDS-related efforts amplified existing disparities in Sierra Leone? Our are tracks traceable?

Sources: 

Benton, Adia. HIV Exceptionalism: Development through Disease in Sierra Leone. Minneapolis: U of Minnesota, 2015. Print.

Cueto, Marcos. “A Return to the Magic Bullet?” When People Come First: Critical Studies in Global Health. By Joao Biehl and Adriana Petryna. Princeton: UP, 2013. 30-54. Print.

Rankin, F. Harrison. The White Man’s Grave: A Visit to Sierra Leone, in 1834. London: R. Bentley, 1836. Print.

Magic Bullets Redux and Vertical Programs, Section 3, Unit 2 - Trying to Help

Unnecessary exceptionalism

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What makes a disease exceptional? In the case of HIV/AIDS, it was the long-term effects on differing demographics that elicited exceptionalism. Because of the multi-generational repercussions of HIV infection and the associated socio-economic impacts, HIV was deemed a cause necessitating an exceptional response, characterized by separate care settings, funding, and sponsoring organizations. However, as the contexts of HIV and HIV care and treatment have evolved, so has the necessity for exceptionalism.

As Adia Denton mentions in her book, HIV/AIDS is disproportionately funded (40% of funding vs. 18% of disease burden) in Africa, where prevention and treatment programs are still largely vertical endeavors. Advocates of these programs cite the “multiple vulnerabilities” of those infected with HIV, including the lingering stigma associated with the disease. These “exceptional” circumstances have been used to justify an entirely different framework of care for HIV, including separate clinics, additional food and other support for those infected, and whole new agencies such as UNAIDS devoted exclusively to the disease (Denton). While the interventions haven’t followed a purely vertical model, as in the example of the guinea worm given by Amy Moran-Thomas where the interventions (filters and larvicides) deliberately avoided addressing any issues other than the precise disease the program was designed to target, their primary focus has remained on treating HIV as a disease so “exceptional” that it could not be done in the context of primary healthcare (Biehl and Petryna).

Whereas this model may have been appropriate during the peak of the epidemic when there was truly no end in sight, today’s widespread availability of ARVs eliminates the need for such a solution. Although ARVs have previously been regarded as a “magic bullet” – a technological solution to the crisis of HIV – their reality is grounded, and should be integrated, within the same foundations as basic healthcare. ARVs don’t erase or reverse HIV infection, but are rather another aspect of one’s long-term medical reality, just like medications for hypertension, diabetes, or any other chronic illness (Smith and Whiteside). The separation of HIV/AIDS care and ARVs from the rest of healthcare is therefore predicated on stigma and perceived exceptionalism rather than foundational differences or necessity. Integrating HIV care into general health care can both bolster continuity of care for those infected and improve and expand the care available to the general population.

Calls for more universal healthcare are widespread but frequently come separately from efforts to address HIV/AIDS, including in the UN’s new Sustainable Development Goals, where “achieve universal health coverage” and “end the HIV and AIDS” are given as two separate targets under the development goal of “Good Health and Well Being.” Expanded focus on healthcare as a whole doesn’t have to mean the end of programs to combat HIV/AIDs, but the two should not be separated as their goal – improving health – are the same (The Conversation). While HIV is a unique disease in its widespread prevalence, multigenerational impact, and disparate effects on various populations, it is not wholly unique in the kind of care it necessitates, and should not be treated in such an exceptional manner.

 

Discussion questions:

  1. In what contexts is a magic bullet or vertical intervention appropriate? Does cost-effectiveness and feasibility of expanding primary care/creating a horizontal intervention affect the decision to implement a vertical approach?
  2. How can we implement health programs in “extreme” contexts (post-civil war Sierra Leone, for example) without making assumptions about the effects of such contexts on health outcomes? Does such a context matter or should interventions be defined by only the end goal – health?

 

Works cited:

 

Benton, Adia. HIV Exceptionalism: Development through Disease in Sierra Leone. Minneapolis: U of Minnesota, 2015. Print.

 

Moran-Thomas, Amy. “A Salvage Ethnography of the Guinea Worm.”When People Come First: Critical Studies in Global Health. By João Guilherme. Biehl and Adriana Petryna. Princeton: Princeton UP, 2013. 207-39. Print.

 

Penfold, Erica. “New Development Goals on Health Need More Work to Be Realistic.” The Conversation. N.p., 21 Sept. 2015. Web. 22 Oct. 2015.

 

Smith, Julia H., and Alan Whiteside. “The History of AIDS Exceptionalism.” Journal of the International AIDS Society. The International AIDS Society, 3 Dec. 2010. Web. 22 Oct. 2015.