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?
- 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?
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.