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:
- 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?
- 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?
- 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.
Rebecca, thank you for bringing your own related research into your blog post. Your idea about integrating cardiovascular care with HIV/AIDS care structures is something that I had never thought about before. It makes a lot of sense to integrate that in because they both require similar care regimens. As well, you mentioned HIV/AIDS care and research already being very well funded programs. The one question about whether integrating these other diseases with HIV/AIDS care would take away from the poor patients already living with HIV/AIDS is an interesting question. I don’t know what the answer is, but one thing I was thinking might work is looking at it on a country-by-country basis. So in other words, looking at the United States and seeing which diseases are more prominent in the United States right now. Now you aren’t going to take away HIV/AIDS programs altogether, so simply adding cardiovascular disease would only take away from a portion of the funding. Cardiovascular disease research also of course has their own funding to contribute; they just don’t have quite enough. If you are able to integrate the two, you would still have the HIV/AIDS treatment programs, you would simply be adding another program for a disease that at this point is more prominent in the United States.
This question is a very complicated one, however, in that there are so many factors that go into integrating public health programs. There would then have to be a limit on how many programs could be integrated into the same framework. One such factor is the relatively new study of chronic diseases associated with HIV/AIDS, and how HIV/AIDS might be risk factors to developing cardiovascular disease or other chronic diseases. I read a study entitled Cardiovascular Disease and HIV Infection, from the NIH that explains some of these risk factors. They explain “HIV-associated inflammation and immune activation are important mediators of cardiovascular risk” (Triant, 2013). So here comes the question of what kinds of programs you are trying to integrate, because I would argue that it would be more beneficial and receive less push back if it was for cardiovascular disease associated with HIV infection than if it were solely cardiovascular disease. Regarding your other question about doing something good for health without having negative impacts, I do not think that we have yet found a way to do that. Even with your ideas, while they are very good ideas, I think there would still be negative impacts. Because so many factors play a role and there are just so many things to take care of, I do not think we can put any public or global health program into effect without having some sort of negative consequences, or at least negative push back at this point in time. I think there would have to be a lot of work done to figure out how to possibly apply programs without having any negative consequences.
Source: Triant, Virginia A. “Cardiovasuclar Disease and HIV Infection.” HHS Author Manuscripts (2013): 199-206. Print.
Hi Kelly,
Thanks so much for your thoughts. I really appreciate your feedback on what you think the best ways to integrate cardiovascular disease care with HIV/AIDS care are. You suggested that it might be best to create an integrated program to target HIV associated cardiovascular disease. I think that’s a very good idea, but I also wonder about the people who have cardiovascular disease who do not have HIV/AIDS. Would they react similarly to how undocumented immigrants reacted in France in the Tiktin article when they wished for HIV/AIDS so that they could gain legal status? Would Kenyans who had cardiovascular disease but who didn’t have HIV/AIDS wish that they did have HIV so that they could receive treatment? Would they even go to efforts to infect themselves with HIV as reported in France? I do think your idea, however, is a good one despite the consequences that could still arise from it. It fits nicely with the idea of Strategic Essentialism or the nail soup analogy that Professor Benton spoke about in her guest lecture. Chronic disease care structures (such as cardiovascular disease programs) could build up around the targeted HIV interventions. So even though HIV could be the main target, in order to offer relief to co-morbid HIV patients, the cardiovascular programs would improve as well.
Thanks again for your great ideas!
Best,
Rebecca
Hi Rebecca,
Thanks for posting an intriguing read on the blog. You pose some very difficult questions to answer.
1. The question of whether the funding and treatment plans present in Sierra Leone are hurting other primary care initiatives is a debatable one. I do not think that the plan in Sierra Leone is hurting plans for other causes because such initiatives do not exist, and by redistributing the funds that are earmarked for one cause to other initiatives one may be ruining the chances of getting further funding into the country for any cause. If funds allocated towards general health promotion were used for funding HIV specifically, only then would it be considered a disservice to the people in the nation.
2. By gaining entry into the community for HIV initiatives, one may have gained access to the people who are typically resistant to foreign intervention. By establishing a relationship with them and gaining their trust, albeit through an HIV initiative, I feel a channel to promote health education is opened up, which otherwise could have been impossible. That said there is a bigger benefit than what appears at single glance at HIV exceptionalism.
3. It is only fair that the donors get to decide how and where their donations get used unless it is a non-discretionary fund that is donated with a clear understanding that the recipient gets to allocate, as per their needs. Unless the program is clearly illegal and unethical, as in drug dealing or trafficking, any other program that is funded with good intentions should be permitted to bear ground. It is important to understand that any program will have its pros and cons and different outcomes, not always positive.
Shreya! I did not consider the way that HIV initiatives can open a channel for further interventions, but that’s super on point!!
Another concern, perhaps, is that with transparency about shifting from HIV to general health comes a potential fluctuation in patronage. General health is less “exciting” than HIV…but perhaps there can be some form of coordination between HIV programs and general health funding that would not violate the agreements/contracts made by the governments and organizations to the groups they are “beholden to” (donors, their citizens)…
Clearly, integration poses a challenge for maintaining transparency and respecting technical rationale versus doing what is most effective as quickly as possible for the government, the organization, the donors, and the communities who are suffering. I think the shift from HIV initiatives to more general health promotion would also take a lot of time. And, yes, maintaining the trust of donors (organizations, citizens, etc.) is important, but people are suffering, so perhaps its better to lose a little than lose nothing for the sake of speed (playing with the ‘a little bit of help vs. no help at all’ rhetoric).
Ideally, I think the best solution would be a gradual integration based first in coordinated action among the government and the aid organizations. The funding issue has really got my goat here–how long would it take to properly fund a general health initiative? Or even an initiative to have more coordination and more integration (rather than total integration)?Better coordination among NGOs and the existing health infrastructure is suggested by Farmer in Ch.7 of Reimagining Global Health–this was in reference to Haiti, though. I want to suggest, based on what Farmer argues, that coordination of all the health systems in place, whether it is local infrastructure or an aid program, could be enough to fill some of the gaps left by exceptionalism without the consequence of losing donors/funding.
Hi Sylvia,
I agree that coordination of all the health systems in place is really necessary to improve health of a state overall, and could definitely fill in some of the gaps left by exceptionalism. Do you have ideas about how you can build this coordination though? Since the chapter you bring up refers to Haiti, a very small country, is this kind of coordination possible in other larger developing countries? What type of resources would you need to build coordination between care structures in a country? I honestly have no idea how expensive some sort of coordinated system would be, or how exactly you would implement it.
The idea of coordinated care brings up the idea of something that we struggle with here in the US–electronic records. As technology improves, we can create electronic medical histories that can be accessed by your PCP, your OBGYN, your cardiologist, your dermatologist, etc. and create a coordinated system of care where there are records of your surgeries, medications, etc. While this sounds like a good idea in theory, there has been quite a bit of backlash about privacy and what might happen with some sort of breach.
Do you think we can use our own experience with coordinated care in the US to help build coordinated systems in developing health care structures? Do you think that the US health care system is even coordinated?
Thanks for your ideas!!
-Rebecca
Hi Shreya,
Thank you so much for your response! I think you brought up a really interesting point that targeted interventions such as this HIV intervention can help foreign health workers to build relationships with the local community, which may not happen without these targeted programs. These health workers can then assess the other issues that exist in the area–such as chronic disease–and come up with strategies to address these problems. I think as the double burden of disease increases in many developing countries, health workers are doing just that. Even though many internationally funded health programs focus on HIV or TB, more and more countries are beginning to recognize how big a role chronic diseases play in mortality and morbidity in developing countries. Perhaps this is because of the idea you explained in your post.
Thanks again for all your interesting thoughts!
-Rebecca
Hi Shreya,
Thank you so much for your response! I think you brought up a really interesting point that targeted interventions such as this HIV intervention can help foreign health workers to build relationships with the local community, which may not happen without these targeted programs. These health workers can then assess the other issues that exist in the area–such as chronic disease–and come up with strategies to address these problems. I think as the double burden of disease increases in many developing countries, health workers are doing just that. Even though many internationally funded health programs focus on HIV or TB, more and more countries are beginning to recognize how big a role chronic diseases play in mortality and morbidity in developing countries. Perhaps this is because of the idea you explained in your post.
Thanks again for all your interesting thoughts!
-Rebecca
Hello Rebecca,
Thank you for your post. It gives the reader a lot of food for thought. I think the idea of integrating care for HIV/AIDS with that for CNDCs is a move towards the ‘diagonal’ approach that we have touched upon in class. One of the unintended consequences of the HIV/AIDS program in Sierra Leon has been that it has become so successful that it has eclipsed a lot of the other problems that are equally if not more prevalent. By using the resources available for HIV/AIDS, if a broader care program can be created, I think it would have a significant positive impact on the health outcomes of the population as a whole. I don’t think moving towards achieving better primary care will harm people living with HIV/AIDS.
As for the debate between practicality and idealism, I think idealism can help guide practicality. Indeed, the Alma-Ata was too abstract and broad to be implemented in a concrete manner, but I think the conversations it started were what spurred successful interventions like the SPHC. Going back to the first point for a moment, I think the SPHC is a good example of why integrating and expanding vertical interventions is important. While the SPHC was successful at meeting its goals, its effects could not be sustained as no lasting structures were developed. By integrating other kinds of programs with the program for HIV, we can prevent a similar situation from repeating.
Hi Harsh,
I really liked your comment on how idealism aids with practicality. I agree that this paradox exists. Idealism is great because it helps us think big and get ready to change the world in a broad way, and practicality allows us to narrow our focus so that we can actually create impact and effects. I do think that it is really important–like you mentioned–to combine vertical and horizontal approaches so that changes are lasting, and the problem doesn’t recreate itself as soon as the intervention is over. Thanks for your thoughts!
-Rebecca
Rebecca,
I really enjoyed your post! I think your idea about incorporating other types of health initiatives into the already existing framework of well-funded HIV/AIDS initiatives is a very important approach to consider. Ideally, this approach would merge the benefits of both vertical and horizontal approaches by continuing to attract funding while also addressing the collective health needs of a population rather than narrowly focusing on one disease. As you point out, primary health care goals are often too idealistic and vague to effectively implement. Perhaps this is a reason why it would be a stronger approach to start with an established HIV-specific program and to amend it gradually to incorporate other needs so that over time it begins to resemble a primary health care model. Hopefully, by doing this, funding could be maintained, organization could remain strong, and other health goals could be met without losing the HIV progress achieved through the initiative’s original focus. I believe this approach would be very reasonable in a place like Sierra Leone where the HIV prevalence is low, so that the majority of health care funding could be employed to the benefit of the majority of the population.
Your idea to incorporate a cardiovascular health program into the anti-HIV program in Kenya raises another approach to broadening the use of HIV resources to benefit the fight against several specific other diseases rather than to provide for health in general. Perhaps the incorporation of several health programs into an HIV framework would be more feasible if the overall goal were not to create a primary health care system, but simply to share the HIV resources with a couple of other important initiatives. I wonder, like Kelly, if there is there a limit to the number of programs that can be incorporated before the initiative loses the benefits of a vertical intervention, which include clarity of organization, straight-forward management, and available funding. Either way, I think that analyzing the elusive “diagonal approach,” as you are, should be a priority of global health scholars.
Thanks,
Mira
Hi Mira,
Thanks so much for your insightful comments. I also had the similar question arise of how many programs can be incorporated into an initiative before it loses the benefits of a vertical intervention. In my own research I wanted to address chronic diseases within the HIV care structure. Chronic disease, however, is a super broad term and encompasses so many illnesses that my advisor and I decided to narrow it. I chose diabetes, hypertension, and cardiovascular disease. Even those diseases might be too many things to focus on, and perhaps this integrated intervention might lose clarity of organization, available funding, and straight-forward management that you mentioned were components of a vertical intervention. I hope it doesn’t, but thank you for bringing up that it’s an important thing to consider how practical something is while trying to expand an intervention!
Thanks,
Rebecca
This was a really cool post to read, congratulations on your work! You raise a bunch of very important questions. You said you were struggling with was whether you were undermining the HIV/AIDS epidemic through your work, and I don’t think that’s the most useful question to ask. Instead, I think what you should be asking yourself is, by integrating NCD care with HIV/AIDS treatment, are you contributing towards more sustainable health care in Kenya? I think the answer to that is yes. In section we explored the Ebola crisis and all the funding that went into containing it – there, it was treated only as an epidemic – and once the immediate crisis was over, funding was stopped. While the HIV/AIDS crisis continues, if you can somehow anchor the crisis and contextualize it within the other health problems in the region, you are not at all undermining the epidemic.
I think Harsh answered another question of yours very eloquently: “idealism can guide practicality.” The idealism should always be kept in the background and used as the foundation for goal creation. The concept of SMART goals really resonates with me – goals that are specific, measurable, attainable, realistic and timely – because you can achieve them and then create another one under eventually the idealist goal is achieved.
Your question about donors and whether or not they should have some say in where their money goes is a very interesting one. I think it would be foolish and arrogant for a rich white man in the US to think he knows how to solve HIV/AIDS in Africa. Donors obviously want to maximize their impact, and for this they need guidance and advice from medical and developmental experts. I wonder if health organizations like the WHO have panels that advise and consult all kinds of potential donors.
Hi Ria,
Thanks so much for your insightful comments! I really liked what you said about SMART goals and how idealism can be combined with practicality to create the most effective, impactful, and positive health changes.
You raise an interesting question on how donors actually choose what the fund and decide where their money goes. I assume that they work with various stakeholders when planning where to put their money. I worked at The Center for Global Development this summer as a global health policy intern, and once of the working group meetings I attended and took notes for was on global mental health. Representatives of potential donors, such as Johnson&Johnson and the BMGF were there, but there were also representatives from the World Bank, the Nigerian Ministry of Health, the Columbian ministry of health, and professors from universities, and experts on mental health including Vikram Patel. I think the best/most successful donor organizations definitely put a lot of research and effort in choosing how to fund programs. However, I wonder if this kind of collaboration and discussion among stakeholders only happens with big donor organizations? What about the smaller organizations–how are they deciding where and how to spend their money?
Thanks again for your thoughts!!
-Rebecca
Hi Rebecca,
Thank you for your post! You’ve opened up some important dialogue regarding how health interventions should be delivered in developing countries. The questions you pose are challenging but necessary toward our understanding of global health.
With regards to question one, there needs to be a balance regarding specifically treating HIV/AIDS and strengthening the general health care system. In class, Professor Mason referred to this as a “diagonal” approach to health care. I love how you mentioned in your article about your research and how HIV/AIDS care overlaps with that of many other diseases. I think we should utilize this to strengthen how we deliver care for chronic non-communicable diseases. Every disease, including HIV/AIDS, has social implications. While HIV/AIDS may have a great deal more stigma, it is important that we don’t neglect diseases such as hypertension and diabetes. A balance must be struck between a horizontal and vertical approach towards health systems. We can use SPHC to strengthen PHC, if we manage our finances and resources appropriately.
Secondly, we need to achieve a balance between idealism and practicality. While Alma Ata, serves as an example of idealism in global health, it did not result in any concrete change. And when focusing on practicality, we lack the passion and vision integral to global health.
To address your third question, while unanticipated consequences in global health are inevitable, donors should have a clear idea of how the money they provide is going to affect local populations. They should ensure that the voices of local people are not silenced in the process of trying to “help.” We can influence donors by educating them of the complexities which exist within regions and the importance of understanding how their money might perpetuate existing inequalities.
Hi Divya,
Thanks so much for your comments. I think you made some really great points! I was particularly interested about your thoughts on donors and how donors can perpetuate existing inequalities without intending to. I think we’ve seen this in health interventions over and over again. It’s a bit cynical, but I wonder if we will ever be able to help some people without hurting others in global health interventions. With smallpox eradication, we helped so many by preventing them from getting a horrible disease, but we also violated the rights and dismissed the voices of so many people that we forced to be vaccinated. It creates this big controversy on which is worse: to help or not to help?
Thanks again for your thoughts!
-Rebecca
Hi Rebecca,
I think that question has been the main take away from the course- is it better to help or not help? As seen in the case of Idi, who struggled to create change- our initiatives may have unintended consequences. However, I fundamentally believe that part of being human is to try and hope, regardless of the outcomes. Medical anthropology can help us make wiser choices about the ways in which we help and the effects of our actions, but I will remain optimistic in that doing something is better than apathy.
I seem to agree with everyone that idealism is preferable. What I want to add is that idealism is how we “expand the definition of the possible” (again, quoting Farmer).
It is not just about providing a framework from which to set goals. I agree with Divya, who cites passion and vision as important drivers in global health. I want to add that Idealism encourages going above the call of duty and expands the view of the organizations. It encourages more creativity than practicality, which I perceive as a positive.
I also think an attitude of idealism and to constantly push for growth and improvement and to, at least in the beginning, set something to strive for, is important. If I just had one job to do and it was very pragmatic, I may not think to look at other ways to improve the situation or other things that can be done. In other words, I think being to pragmatic leads to being stuck.
If a purpose can be established that has idealistic appeal, that will lead to more effective, focused action in the longterm. Not only can idealism guide practicality, as Harsh notes, I think that practicality guided by idealism has more potential and is more focused and organized than practicality alone.
Sylvia,
Thanks so much for your thoughts on idealism! I found it very interesting that you said that you think being “pragmatic leads to being stuck.” I agree that if you are so focused on the details and don’t take a step back to look at the big picture, that can be a big problem and your intervention won’t be nearly as successful. I agree that pragmatism and idealism need to be combined to create a successful health intervention. In the same way that too much pragmatism can lead to lack of success, I think that too much idealism can lead to the same thing. One really needs to find a balance when he/she is designing an intervention, and that is why the diagonal approach has proven so effective.
Thanks,
Rebecca
Hi Rebecca,
Thank you for not only writing a really interesting blog post, but also for sharing very thought provoking questions! While there is always the risk of an unanticipated consequence, I believe that the integration of HIV/AIDS care with CNDCs in health care structures will not only will further help those living with HIV/AIDS, but also serve as a better model for global health projects in general. By integrating HIV/AIDS care into the primary health care system those suffering from HIV are more likely to be relieved of some of the stigma they face from the community. I did some volunteer work in Kenya also, and I remember that one of the physicians working at an HIV clinic saying that the biggest problem they faced was getting people to come to the clinic in the first place. The reason why was that if someone from the community were to see another person headed to the HIV clinic, they then obviously knew that they were suffering from HIV. Therefore, I believe that through integrating HIV treatment into CNDC care, there is far greater potential for people to seek HIV treatment. Furthermore, I think this more horizontal approach will result in people in the affected communities to be more receptive to international efforts. Similarly to the issues discussed with the guinea worm disease, initially a problem that HIV campaigns faced was that for some of the people in the communities in which HIV was present, HIV wasn’t their most immediate threat. However, an integration HIV care into other health care systems will demonstrate that it is not just HIV that global health efforts are trying to tackle, but a lack of access to healthcare in general. Additionally, HIV treatment is already integrated into primary healthcare systems in the West, so why not elsewhere? I would imagine that there may be resistance (from donors) to move towards an integration model as it would run the risk of erasing the ‘HIV-industrial complex.’ Certainly, the amount of success HIV campaigns have had is very encouraging, however, a harder effort to raise money for HIV once it has been integrated into primary health care structures, isn’t a reason to not do so.
Which brings me to your second question of practicality vs. idealism. I think that Harsh’s answer hit the nail right on head. Indeed, it would be naïve to say that idealism should govern all initiatives, yet it is important to note that what we deem as practical or impractical is in part determined by how we prioritize issues in the global health field. If consensus in the global health field on the integration of HIV into CNDC healthcare ensued, donors and project leaders would find a way to make such a campaign practical.
Thanks again for a great post!
Hi Pauline,
Thank you for your comments. I am encouraged to hear that you think it does make sense to integrate the care structures in this particular case. You raised a good point on how raising money for this after integration of CNCD care with HIV care might be a challenge. What do you think are some of the best ways to address this challenge? How can we change the ways donors define success/failure? One of the biggest problems of public health interventions is that since they focus on prevention, there are less existing statistics about the what if questions. In other words, when primary care interventions are created as a mechanism for prevention, we have no way of actually saying what would have happened if the intervention did not exist. How do we combat this challenge in global health and still create “attractive” numbers for donors and aid?
Thanks,
Rebecca
Hi Rebecca,
Your blog post and discussion questions bring up some really interesting and challenging ideas about intervention in global health. The third question you pose is particularly intriguing to me and it’s something that I keep coming back to in all of our discussions. Is it better to take donor money even if the donors influencing the projects are poorly informed of the project they’re funding? Is it better to do nothing at all?
While I don’t have a definite answer to this question, I have to believe that it is better to have funded programs than nothing at all. Benton addresses the dangers of exeptionalizing a disease in her book and is critical of vertical programs. Moreover, this question makes me think of Prof. Moran-Thomas’ guest lecture about guinea worms and the notion of the western intervention deciding what constitutes an ’emergency’ in a country. While I completely agree that exceptionalizing a disease is problematic and inefficient, as clearly seen in the story of Christiana in Benton’s work, if there were no programs at all, wouldn’t that be worse for everyone?
In an ideal world, global health interventions would not exceptionalize a particular disease and thereby diminish primary care and treatment for other serious diseases. However, the pragmatist in me is reminded of Idi’s story from a few weeks ago. She focused on helping the individual as opposed to alleviating the suffering of a whole population, a seemingly insurmountable task. I think this idea applies to this question because by accepting money from donors for projects that may be misguided, despite unintended consequences, they might very well help a few people. Ideally, donors would be informed and want to fund projects that are more useful and not exceptionalize diseases as this has harmful unintended consequences, but I think that perhaps in this situation the benefits of donor programs outweigh the unintended consequences .
Hi Jessica,
I completely agree with you that an intervention funded by donors who might not be completed educated and could be slightly misguided still seems better than no intervention at all. I have had similar discussions about other forms of aid such as voluntourism. Even though voluntourism isn’t very sustainable and might be misguided, isn’t it still better than if no one tried to help at all? In my opinion yes, but perhaps other people have different opinions!
-Rebecca
This is also a question I think about a lot. As we’ve talked about, almost every (good) intervention is going to have some (negative) unintended consequences, so it’s hard to argue that doing nothing would be better. Some negative unintended consequences don’t necessarily discredit the good work done. However, I think it’s extremely important for people doing these interventions not to get complacent, to constantly self-evaluate and critique their own work, and not to ignore negative consequences by just focusing on the good things they’ve accomplished. I think the only time intervening is worse than doing nothing is if the intervention has a lot of unintended consequences that go unnoticed or ignored due to complacency or even arrogance, which I think unfortunately happens more often than we realize (I personally think most voluntourism ventures fall into this category).
Hey Rebecca!
Thanks so much for writing this blog post, on this particular topic. The questions you asked are incredibly dynamic and complex, but really hit the target on the concepts we’ve spoken about all semester. In section today, we did the mock case study for the Ebola funding situation. My group grappled with the ‘best’ intervention, and eventually came to something much like you are describing – an integration of the ‘exceptional’ disease with community health centers focusing on primary care as well. There is incredible benefit with linking these together, much like you mention with HIV/AIDS and CVD.
However, I think the more important point is what the existing consequences are for integrating and focusing on PHC as well as the exceptional disease. Does this and will this affect access to care for lower-income individuals living with the exceptional disease? I think the potential benefits and consequences of this type of integration is critical going forward with Global Health work; especially considering the entirely-too-vertical approach of many health interventions.
As Jessica brings up, from our guest lecture, the concept of ’emergencies’ was brought forth. What exactly is an emergency? Who can determine what the emergency is? Allowing for more access to PHC as well as treatment for the exceptional disease, could allow individuals to determine their own emergencies, and empower their medical choices.
Hi Stefanie,
Thanks so much for your thoughts! I am really interested in your ideas on medical emergencies. It is true that perhaps by combining PHC and care for the “exceptional” disease, individuals might feel more empowered and feel like they have more say in their health care. Perhaps had there been an integration of PHC in the guinea worm eradication program, Ghanaians may have felt better about the intervention because they could tell doctors and medical personnel that they felt other diseases qualified more as emergencies than guinea worm. Would this have taken away from guinea worm eradication success though? It’s definitely possible. Would there still have been the same kind of financial support for the program from donors? I’m not sure…
Thanks again for all your thoughts! You raised some really interesting points!
Best,
Rebecca
Hi Rebecca,
Thank you for your post — you ask many insightful questions that are extremely difficult to give a straight answer to because AIDS is an issue that is incredibly nuanced. I’ve been thinking a lot recently about the questions you posed about the unintended consequences of a vertical approach to disease. While I think it is wonderful for those who are suffering from AIDS and all of the baggage that comes with it to have full and total access to treatment, it seems morally wrong when the rest of the community, that may be suffering from the burden of many other diseases, does not have access to the same level of treatment or help by virtue of having a different disease. It is especially complicated by the fact that there is such a low overall prevalence of AIDS. Once again, it disturbingly comes back to numbers and the idea that broader effect, instead of a higher quality effect, appears better on paper.
At the same time, if an organization decides to intervene in a particular place and gives incredibly preferential treatment, how will that affect perception of the disease, the organization, etc? In fact, won’t that cause people to wish they were sick, wish they had that particular illness, just in order to gain access to help? Ultimately, I think that the vertical approach will have more unanticipated consequences, many of which will have to do with the lack of attention paid to almost every single other problem and patient in a community.
Fortunately, there are many places and ways in which organizations are taking a diagonal approach, creating a model where, though specific attention is paid to diseases like AIDS or TB, exceptionalism does not have to preclude the treatment of other people in the community.
Hi Zoe,
Thanks so much for bringing up some really great points. I agree that exceptionalizing a disease can create some pretty unfortunate consequences. In the TikTin article we read in the later half of the semester we saw that undocumented people in France were wishing they had HIV (and some people were even rumored to infect themselves with the disease) so that they could get citizenship status and stay in the country. It’s very interesting that these well-intentioned interventions can have such negative effects for some people. Overall, do you think it is still better to have these narrow, vertical interventions than to not intervene at all? I personally think that some help is better than none, but I would love to hear your thoughts!
Thanks again for your comments!
Best,
Rebecca
Hi Zoe,
I really enjoyed reading your post! With regard to your first question, I disagree that strengthening primary health care systems in order to prevent preventable diseases would harm people living with HIV/AIDS who already face poverty, stigma, and other inequalities. I believe one of the reasons why poverty, stigma, and other inequalities even exist in the first place is because there’s a lack of conversation of HIV/AIDS in the community. I can understand the logic that preventable programs might take those living with the disease out of the conversation, but it certainly wouldn’t mean they would still suffer from poverty and stigma. In fact, I would expect the opposite. Normalizing HIV/AIDS can be accomplished by talking about ways to prevent it. At least, it can be accomplished more easily than by the alternative of not talking about preventative measures at all. In our American context, we see a lot of publicity for ways to prevent contracting HIV/AIDS. But we rarely hear about ways to handle the disease once it is transmitted to us. And yet, I don’t believe that those that have HIV/AIDS in America feel a stigma from getting treated. That said, there is still a stigma attached to those who have HIV/AIDS in the US, but it plays more a role in their sexual lives, which I believe comes from the very real fear that they can spread their illness through unprotected sexual intercourse. Though still damaging, at least the stigma isn’t so strong that those living with HIV/AIDS feel like they can’t turn to medical professionals.
Finally, to answer the question: “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?” I would say that those who donate should absolutely have a say in where there money goes, but they shouldn’t helicopter over issues that, quite frankly, they no less about than those who spend their entire lives studying. But I would never say donors should stay out. A donor likes to see where his or her money is going, and the progress that is expected to come about from the donation. To restrict a donor from keeping up with any further developments bankrolled by the donation may compromise the donation in the first place.
Hi Chad,
Thanks for your comments on the post! I agree that prevention efforts and just general conversation about HIV/AIDS can help reduce the stigma associated with the disease. However, I disagree that people living with HIV/AIDS do not feel a stigma with regards to seeking treatment. While the stigma may not be as strong as it is in a place like Kenya (and it is very hard to compare this type of experience), I think it is fairly common for people living with HIV/AIDS to feel stigmatized and at times hide their status from people. While I am not sure about exact statistics, I have heard that many adolescents and young adults feel this stigma the strongest, and oftentimes do not adhere to care or follow-up for treatment as much/as well as they should to control the disease.
I agree that integrating care structures and building primary health care can strengthen health as a whole, and perhaps it can reduce some stigmas associated with certain diseases. However, I think in the particular case of HIV/AIDS, stigma prevention programs and education programs should still exist, and separate efforts can be made to reduce stigmas.
Thanks again for your post!
Best,
Rebecca