The U.S. hospital safety net is under siege. Today’s New York Times reports on yet another safety net hospital - Grady Memorial Hospital in Atlanta - that is teetering on the edge of disaster. This posting takes up where my December 3 discussion of similar issues at the University of Texas Medical Branch in Galveston left off.
Grady has been serving the poor in Atlanta since 1892. A quarter of Georgia’s physicians have had at least part of their training at Grady. The hospital has 953 beds. The Grady Health System, which includes nine neighborhood health centers, does 921,000 outpatient visits per year.
Grady is in dire straits. It has major managerial problems, including allegations of corruption. A consultant’s strategic plan, presented in June, 2007, is painful to read. Grady is deeply in debt and hemorrhaging money each month. The consultant recommended radical managerial surgery, but the governing board, subject to strong political pressures, put off action. In November the board voted to turn Grady over to an independent 501(c)(3) corporation, but that effort is currently embroiled in complex local politics.
From the perspective of ethics, Grady, like the University of Texas in Galveston, faces a classic dilemma, which will not go away even if Grady solves all of its managerial problems. Like the Galveston program, it could improve its financial status by dropping the biggest money-losers. But doing this would violate the charitable mission for which it was founded. The impact of internal resource allocation choices go beyond what a society as wealthy as ours can or should accept. But the wider community is reluctant to reallocate its own resources, whether through increased taxes or other means.
Our fragmented health system makes it all-too-easy for us citizens and our leaders to avoid responsibility for what happens. Grady can blame the outside community. Politicians can blame Grady’s management. Atlanta can blame the suburbs. One has to suspect that one of the purposes of our stupifyingly complex system is just this – to give all parties deniability about the bad things that happen.
Tuesday, January 8, 2008
Monday, January 7, 2008
Good Politics but Bad Ethics in New Hampshire
On December 20, 2007, in California, 17 year old Nataline Sarkisyan died of leukemia and liver failure. On January 6, in New Hampshire, Nataline’s parents spoke at a John Edwards rally.
Just before Thanksgiving, Nataline received a bone marrow transplant from her brother. Soon after, she went into liver failure. Her doctors at UCLA recommended a liver transplant, reporting their belief that she would have a 65% chance of living for six months. Natline’s insurer, Cigna, refused coverage, reporting that their own medical experts and an outside transplant surgeon concluded that the procedure was “experimental,” and therefore not covered.
Interestingly, in response to the public outcry, Cigna reversed itself on grounds of “empathy for the family.” But Nataline died before the procedure could be tried. It is reported that the local attorney general may press manslaughter charges against Cigna!
I have no expertise about liver transplantation for patients with leukemia who have had a bone marrow transplant. But neither does Senator Edwards. This looks like a situation in which the “left” is making politics out of a tragedy, just as the “right” did with Terri Schiavo.
Every health system has to set limits. This would be true even if Mother Theresa were the health czar. It is entirely reasonable to question the evidence basis for UCLA’s proposal or Cigna’s denial. Similarly, it is entirely reasonable to argue that the bar for evidence should be lower in last chance situations than in other domains of care. But Edwards, who I admire and largely agree with politically, does the public a disservice by presenting the denial as a moral crime.
Edwards favors extending Medicare to a wider range of citizens. If he ends up as president, it will be interesting to see how he addresses the issue of limits. As Oregon Governor John Kitzhaber recognized 20 years ago, universal coverage is impossible without limits. No limits, no universality. It is that simple.
True leaders must be educators. Understanding the ethical necessity for limits is counter-intuitive for those who are not familiar with the health sector. Edwards may have done an effective piece of campaigning yesterday, but he was not providing the kind of ethical leadership that improvement of our health system requires.
This is especially unfortunate. Edwards is a superb communicator -- just the kind of voice we need to help us come to grips with the sad fact that health care limits, well set, are an ethical necessity, not a moral abomination.
Just before Thanksgiving, Nataline received a bone marrow transplant from her brother. Soon after, she went into liver failure. Her doctors at UCLA recommended a liver transplant, reporting their belief that she would have a 65% chance of living for six months. Natline’s insurer, Cigna, refused coverage, reporting that their own medical experts and an outside transplant surgeon concluded that the procedure was “experimental,” and therefore not covered.
Interestingly, in response to the public outcry, Cigna reversed itself on grounds of “empathy for the family.” But Nataline died before the procedure could be tried. It is reported that the local attorney general may press manslaughter charges against Cigna!
I have no expertise about liver transplantation for patients with leukemia who have had a bone marrow transplant. But neither does Senator Edwards. This looks like a situation in which the “left” is making politics out of a tragedy, just as the “right” did with Terri Schiavo.
Every health system has to set limits. This would be true even if Mother Theresa were the health czar. It is entirely reasonable to question the evidence basis for UCLA’s proposal or Cigna’s denial. Similarly, it is entirely reasonable to argue that the bar for evidence should be lower in last chance situations than in other domains of care. But Edwards, who I admire and largely agree with politically, does the public a disservice by presenting the denial as a moral crime.
Edwards favors extending Medicare to a wider range of citizens. If he ends up as president, it will be interesting to see how he addresses the issue of limits. As Oregon Governor John Kitzhaber recognized 20 years ago, universal coverage is impossible without limits. No limits, no universality. It is that simple.
True leaders must be educators. Understanding the ethical necessity for limits is counter-intuitive for those who are not familiar with the health sector. Edwards may have done an effective piece of campaigning yesterday, but he was not providing the kind of ethical leadership that improvement of our health system requires.
This is especially unfortunate. Edwards is a superb communicator -- just the kind of voice we need to help us come to grips with the sad fact that health care limits, well set, are an ethical necessity, not a moral abomination.
Sunday, January 6, 2008
Amazon.com and Organizational Trust
In yesterday’s New York Times, Joe Nocera reports how Amazon rescued his Christmas. The story has lessons for health care organizational ethics.
Nocera had ordered a PlayStation3 for his son, but on December 21 he found that it had gone astray. Amazon was not responsible for the problem – a neighbor, who had signed for the package, left it in a public space from which it was stolen – but Amazon nevertheless got another PlayStation3 to him by Christmas Eve.
Nocera rhapsodizes about Amazon’s determination “to be the most customer-centric company in the world.” He describes how the company has chosen a strategy of “long term value creation” rather than chasing the short term return on investment that Wall Street demands. That strategy has created extraordinary customer loyalty and trust in the Amazon brand.
Amazon is doing what individual clinicians and health care organizations need to do. Without trust, treatment goes nowhere. Without customer (patient) loyalty, organizations go down the tubes.
Nocera attributes Amazon’s ability to resist the short term focus that grips publicly owned organizations to founder Jeff Bezos’ vision and commitment, but also to the fact that Bezos is Amazon’s largest single shareholder. This has made it easier to accept lower current profits for trust-building activities like solving Nocera’s PlayStation3 problem.
Amazon went beyond what its narrow contract with Nocera required – what ethicists call “supererogatory” action. We need to do the same in health care. Excellent clinicians and excellent organizations know that.
The problem with for-profit ownership is not the quest for profit per se, but the short term focus that dominates market behavior. Nocera's story is remarkable for the fact that most of the trust-building interactions were on-line. The only human exchange was on the telephone with a customer service agent. Amazon's blend of high tech/high touch interaction with its customers provides us with a model of how health care organizations can comport themselves to build and hold trust.
Nocera had ordered a PlayStation3 for his son, but on December 21 he found that it had gone astray. Amazon was not responsible for the problem – a neighbor, who had signed for the package, left it in a public space from which it was stolen – but Amazon nevertheless got another PlayStation3 to him by Christmas Eve.
Nocera rhapsodizes about Amazon’s determination “to be the most customer-centric company in the world.” He describes how the company has chosen a strategy of “long term value creation” rather than chasing the short term return on investment that Wall Street demands. That strategy has created extraordinary customer loyalty and trust in the Amazon brand.
Amazon is doing what individual clinicians and health care organizations need to do. Without trust, treatment goes nowhere. Without customer (patient) loyalty, organizations go down the tubes.
Nocera attributes Amazon’s ability to resist the short term focus that grips publicly owned organizations to founder Jeff Bezos’ vision and commitment, but also to the fact that Bezos is Amazon’s largest single shareholder. This has made it easier to accept lower current profits for trust-building activities like solving Nocera’s PlayStation3 problem.
Amazon went beyond what its narrow contract with Nocera required – what ethicists call “supererogatory” action. We need to do the same in health care. Excellent clinicians and excellent organizations know that.
The problem with for-profit ownership is not the quest for profit per se, but the short term focus that dominates market behavior. Nocera's story is remarkable for the fact that most of the trust-building interactions were on-line. The only human exchange was on the telephone with a customer service agent. Amazon's blend of high tech/high touch interaction with its customers provides us with a model of how health care organizations can comport themselves to build and hold trust.
Friday, January 4, 2008
Trust (and lack thereof) in Health Organizations
Without trust, the patient-clinician relationship goes nowhere. Trust encourages us to adhere to the recommendations we receive. And, as the placebo effect shows, trust has powerful healing effects in itself.
But what about trust in the organizations that are increasingly central to healthcare?
An article in yesterday’s Wall Street Journal Health Blog about Morgan Stanley’s “Pharmaceutical CEOs Unplugged” conference reported on CEO claims that the industry is highly trusted. But a recent Harris poll suggests that Pharma is on its way to the dustbin of trust, just as happened to managed care.
When asked "which of these industries do you think are generally honest and trustworthy – so that you normally believe a statement by a company in that industry?" about a series of 17 industries, the winner by far was “none of the above.” 11% find pharmaceutical companies trustworthy. This is better than HMOs (5%), tied with airlines and car manufacturers, and worse than hospitals (28%) and banks (30%). Pharma is trending downward: 2003 (13%); 2004 (14%); 2005 (9%); 2006 (7%); 2007 (11%). When asked "which of these industries do you think should be more regulated by government – for example for health, safety or environmental reasons – than they are now?" Pharma (53%) tied with oil for first place.
With regard to regulation, in 2003 60% of those polled felt that HMOs should be more regulated. This percentage has dropped steadily, to 45% -- the largest change for any industry. But the decreased demand for regulation has come at a high cost to the public – in the form of premium increases as HMOs have backed off from managing care.
To promote quality and efficiency, societies have to manage care. But thus far we have not been able to do this without a fatal loss of trust. By managing less, the managed care industry has bought back some trust, but the cost increases driven by reduced management will not be sustainable for long.
The pressure on Pharma is not yet at the level that was brought to bear on HMOs, but the trend is in that direction. Pharma needs new strategies to rebuild trust. Public relations campaigns won't be enough.
But what about trust in the organizations that are increasingly central to healthcare?
An article in yesterday’s Wall Street Journal Health Blog about Morgan Stanley’s “Pharmaceutical CEOs Unplugged” conference reported on CEO claims that the industry is highly trusted. But a recent Harris poll suggests that Pharma is on its way to the dustbin of trust, just as happened to managed care.
When asked "which of these industries do you think are generally honest and trustworthy – so that you normally believe a statement by a company in that industry?" about a series of 17 industries, the winner by far was “none of the above.” 11% find pharmaceutical companies trustworthy. This is better than HMOs (5%), tied with airlines and car manufacturers, and worse than hospitals (28%) and banks (30%). Pharma is trending downward: 2003 (13%); 2004 (14%); 2005 (9%); 2006 (7%); 2007 (11%). When asked "which of these industries do you think should be more regulated by government – for example for health, safety or environmental reasons – than they are now?" Pharma (53%) tied with oil for first place.
With regard to regulation, in 2003 60% of those polled felt that HMOs should be more regulated. This percentage has dropped steadily, to 45% -- the largest change for any industry. But the decreased demand for regulation has come at a high cost to the public – in the form of premium increases as HMOs have backed off from managing care.
To promote quality and efficiency, societies have to manage care. But thus far we have not been able to do this without a fatal loss of trust. By managing less, the managed care industry has bought back some trust, but the cost increases driven by reduced management will not be sustainable for long.
The pressure on Pharma is not yet at the level that was brought to bear on HMOs, but the trend is in that direction. Pharma needs new strategies to rebuild trust. Public relations campaigns won't be enough.
Thursday, January 3, 2008
Guinea-Pig Ethics
Carl Elliott’s excellent article on “Guinea-Pigging” in the forthcoming January 7 New Yorker (only the abstract is available on-line) educated me about a topic I should have known about already – the inner workings of pharmaceutical contract research organizations.
Over the past decade, pharmaceutical companies have increasingly outsourced the conduct of clinical trials to contract research organizations. CROs are big business. Revenues are estimated at close to $18 billion. The largest 10 firms enrolled more then 640,000 subjects in trials in 2004.
“Guinea-Pigging” is the insider term for the job of research subject in a CRO project. This isn’t volunteering from altruistic motives as patients of mine with HIV and cancer have done to contribute to scientific progress in an area they care about. It is a job, and not an elevated one. A guinea pig for a sleep study described the work as a form of prostitution – “I would sell my body not to slobbering johns who assail the street whore with their unkempt organs, but to slick, white coated neuropsychologists who use thrice sterilized catheters, electrodes…and invasive thermometers to get what they want.”
Readers who, like me, do not yet know in any detail about the recruitment of healthy subjects for CRO studies can visit Guinea Pig Zero, defined as a "jobzine for people who are used as medical or pharmaceutical research subjects." And, as well, websites for large CROs, such as Pharmaceutical Product Development, Charles River Laboratories, and Covance.
CROs are at the heart of the development of new treatments, but they have largely been under the radar in terms of recognizing just how important they have become. Subject recruitment is becoming a worldwide industry. I look forward to learning more about the area in the next few months. We owe Carl Elliott thanks for bringing questions about the ethics of the role -- safety, compensation, and non-exploitation, to the fore.
Over the past decade, pharmaceutical companies have increasingly outsourced the conduct of clinical trials to contract research organizations. CROs are big business. Revenues are estimated at close to $18 billion. The largest 10 firms enrolled more then 640,000 subjects in trials in 2004.
“Guinea-Pigging” is the insider term for the job of research subject in a CRO project. This isn’t volunteering from altruistic motives as patients of mine with HIV and cancer have done to contribute to scientific progress in an area they care about. It is a job, and not an elevated one. A guinea pig for a sleep study described the work as a form of prostitution – “I would sell my body not to slobbering johns who assail the street whore with their unkempt organs, but to slick, white coated neuropsychologists who use thrice sterilized catheters, electrodes…and invasive thermometers to get what they want.”
Readers who, like me, do not yet know in any detail about the recruitment of healthy subjects for CRO studies can visit Guinea Pig Zero, defined as a "jobzine for people who are used as medical or pharmaceutical research subjects." And, as well, websites for large CROs, such as Pharmaceutical Product Development, Charles River Laboratories, and Covance.
CROs are at the heart of the development of new treatments, but they have largely been under the radar in terms of recognizing just how important they have become. Subject recruitment is becoming a worldwide industry. I look forward to learning more about the area in the next few months. We owe Carl Elliott thanks for bringing questions about the ethics of the role -- safety, compensation, and non-exploitation, to the fore.
Wednesday, January 2, 2008
Outpatient Psychiatric Commitment
President Harry Truman only wanted advice from one-armed economists, to avoid being told “one the one hand…but on the other hand…”
I have tried to follow Truman’s guidance in giving talks about ethics. An “on the one hand/on the other hand” talk tends to sedate the audience. If listeners think the speaker is all wrong, at least they are awake and thinking.
But a happy article in a recent Washington Post brings up an issue for which two-armed policy advisors and ethicists are desirable. Susan Wezel, a 50 year old New York woman who suffers from a severe psychotic illness, was required to undergo outpatient treatment under a New York law (“Kendra’s law”) that allows court-mandated treatment. Despite having been hospitalized more than a dozen times in the previous ten years, she has been stable and functioning well for the past 18 months. She now takes medication regularly and credits the law with saving her life. Her husband Chris says "there was nothing I could do to get her into any help before this."
The primary political impetus for laws that allow forced outpatient treatment is fear of the rare but highly publicized acts of violence by persons with psychiatric illness. The New York State law was passed after 32 year old Kendra Webdale was killed by being pushed in front of a subway train by Andrew Goldstein, who suffered from schizophrenia. California passed “Laura’s Law” after 19 year old Laura Wilcox, who was working in a public mental health clinic during a school break, was shot to death by Scott Thorpe, who believed that the FBI was trying to poison him and force him to see an incompetent psychiatrist, and who rejected his family’s pleas that he go back onto antipsychotic medication.
Most psychiatrists have seen happy situations like Susan Wezel’s, in which a gravely impaired person regains access to their innate capacities when the psychosis that has intruded on their function is controlled. Two decades ago a patient of mine voluntarily accepted, albeit reluctantly, injections of an antipsychotic medication. These have continued every four weeks, in very low dose, to the present, and the person has been able to turn life around in a way that brings substantial fulfillment.
Lawmakers ask -- if people can be helped in this way but cannot be persuaded to participate in treatment – why not set the ball of recovery rolling by requiring treatment? Especially if the specter of preventing violence is added to the equation! The argument for outpatient commitment is powerful. But so is the critique, which is based on principle (opposition to coercion) and practice (questions about the efficacy of outpatient commitment).
I come out in favor of cautious and careful outpatient commitment programs, modeled on New York, which has not simply passed a law but has also provided funding to allow treatment of the sort that Susan Wezel has benefited from. But people of good will and good knowledge of the issues will continue to disagree.
The reason for this posting, however, is not the substantive issue, but the policy lesson that comes from the policy debate itself. Many state legislatures – like New York and California, and now Virginia, which has been activated by the Virginia Tech killings – have conducted remarkably thoughtful deliberation – involving gathering data, benchmarking other states, hearing the range of viewpoints, and educative debate.
This has been the kind of educative policy debate we need for sound governance of our health care system. The two key ingredients that allow it to happen are the (a) presence of well-informed advocates and advocacy groups for a range of perspectives and (b) absence of political posturning and virulent self-righteousness that has impeded deliberation in so many areas.
To some extent, our having such well informed advocates has helped to keep demagogues at bay. That may be the key policy lesson.
I have tried to follow Truman’s guidance in giving talks about ethics. An “on the one hand/on the other hand” talk tends to sedate the audience. If listeners think the speaker is all wrong, at least they are awake and thinking.
But a happy article in a recent Washington Post brings up an issue for which two-armed policy advisors and ethicists are desirable. Susan Wezel, a 50 year old New York woman who suffers from a severe psychotic illness, was required to undergo outpatient treatment under a New York law (“Kendra’s law”) that allows court-mandated treatment. Despite having been hospitalized more than a dozen times in the previous ten years, she has been stable and functioning well for the past 18 months. She now takes medication regularly and credits the law with saving her life. Her husband Chris says "there was nothing I could do to get her into any help before this."
The primary political impetus for laws that allow forced outpatient treatment is fear of the rare but highly publicized acts of violence by persons with psychiatric illness. The New York State law was passed after 32 year old Kendra Webdale was killed by being pushed in front of a subway train by Andrew Goldstein, who suffered from schizophrenia. California passed “Laura’s Law” after 19 year old Laura Wilcox, who was working in a public mental health clinic during a school break, was shot to death by Scott Thorpe, who believed that the FBI was trying to poison him and force him to see an incompetent psychiatrist, and who rejected his family’s pleas that he go back onto antipsychotic medication.
Most psychiatrists have seen happy situations like Susan Wezel’s, in which a gravely impaired person regains access to their innate capacities when the psychosis that has intruded on their function is controlled. Two decades ago a patient of mine voluntarily accepted, albeit reluctantly, injections of an antipsychotic medication. These have continued every four weeks, in very low dose, to the present, and the person has been able to turn life around in a way that brings substantial fulfillment.
Lawmakers ask -- if people can be helped in this way but cannot be persuaded to participate in treatment – why not set the ball of recovery rolling by requiring treatment? Especially if the specter of preventing violence is added to the equation! The argument for outpatient commitment is powerful. But so is the critique, which is based on principle (opposition to coercion) and practice (questions about the efficacy of outpatient commitment).
I come out in favor of cautious and careful outpatient commitment programs, modeled on New York, which has not simply passed a law but has also provided funding to allow treatment of the sort that Susan Wezel has benefited from. But people of good will and good knowledge of the issues will continue to disagree.
The reason for this posting, however, is not the substantive issue, but the policy lesson that comes from the policy debate itself. Many state legislatures – like New York and California, and now Virginia, which has been activated by the Virginia Tech killings – have conducted remarkably thoughtful deliberation – involving gathering data, benchmarking other states, hearing the range of viewpoints, and educative debate.
This has been the kind of educative policy debate we need for sound governance of our health care system. The two key ingredients that allow it to happen are the (a) presence of well-informed advocates and advocacy groups for a range of perspectives and (b) absence of political posturning and virulent self-righteousness that has impeded deliberation in so many areas.
To some extent, our having such well informed advocates has helped to keep demagogues at bay. That may be the key policy lesson.
Tuesday, January 1, 2008
AIDS, Global Health Priorities, and Ethics
How could it possibly be ethical to recommend spending less money on AIDS in Africa and other underdeveloped areas?
In today’s New York Times, Daniel Halpern of the Harvard School of Public Health, gives the answer.
Halpern describes how as bad as the AIDS epidemic is, in many countries the lack of clean water, absent sewage systems, and poverty, combine to make easily treatable diarrheal diseases an even larger source of mortality. In Botswana more funds are available than can be assimilated into the AIDS treatment system. And not surprisingly, many of the best health practitioners are leaving lower paying jobs in basic health services to take better paid opportunities in the AIDS sector.
The degree to which we in the developed world have finally accepted responsibility for helping our brethren in Africa and elsewhere represents moral progress. But Halpern argues that we can do better by fine tuning our moral sensitivities:
“It is [important], especially for the United States, the world’s largest donor, to re-examine the epidemiological and moral foundations of its global health priorities. With 10 million children and a half million mothers in developing countries dying annually of largely preventable conditions, should we multiply AIDS spending while giving only a pittance for initiatives like safe-water projects?
If one were to ask the people of virtually any African village (outside some 10 countries devastated by AIDS) what their greatest concerns are, the answer would undoubtedly be the less sensational but more ubiquitous ravages of hunger, dirty water and environmental devastation. The real-world needs of Africans struggling to survive should not continue to be subsumed by the favorite causes du jour of well-meaning yet often uninformed Western donors.”
In January, 2005, when my wife and I visited Mahindra United World College, a school Pune, India, for 11th and 12th graders from around the world, I taught classes on AIDS and ethics. One of the mini-cases I used touched on the topics Halpern discusses so cogently. Here is the case I used with the students:
“The World Health Organization has set a target of treating 3 million persons with AIDS in the developing world by the end of 2005 – the “3 x 5” program. The WHO regards AIDS as an ethical as well as clinical and humanitarian crisis. Since antiretroviral treatment is available how can it be acceptable not to offer it throughout the world?
Leaders in the west are surprised to get pushback on the 3 x 5 program. As a hypothetical example, imagine that an Indian doctor has said the following to the WHO: ‘For you in the west AIDS is the one and only epidemic. For us it is one of many problems. In the health sector we have malaria, tuberculosis, diarrheal diseases and more. If you are so eager to help us why aren’t you paying as much attention to poverty, hunger and unemployment? You want to help us with AIDS but you also want to stop outsourcing which brings us jobs and lets us help ourselves. I believe you are thinking about yourselves with this policy, not about us!’”
Students from developing countries understood the hypothetical pushback immediately. A student from Africa said “this is another example of the west deciding what it thinks is wrong in our countries and what is best for us.” A number of students from India commented, in effect – “we have serious challenges in health and other sectors. AIDS is just one of many serious problems. If the west focuses urgently on AIDS without comparable attention to other needs, it makes it seem that the outsiders do not understand Indian realities.”
I liked the tone of Halpern’s Op Ed piece. He is coaching, not scolding. He gives us credit for the moral progess we have made. Then, as a good coach should do, he asks us to stretch further! Looking back to my visit with the students in Pune, I admire their tone as well. If other young people can coach their elders as wisely the world will be a better place.
In today’s New York Times, Daniel Halpern of the Harvard School of Public Health, gives the answer.
Halpern describes how as bad as the AIDS epidemic is, in many countries the lack of clean water, absent sewage systems, and poverty, combine to make easily treatable diarrheal diseases an even larger source of mortality. In Botswana more funds are available than can be assimilated into the AIDS treatment system. And not surprisingly, many of the best health practitioners are leaving lower paying jobs in basic health services to take better paid opportunities in the AIDS sector.
The degree to which we in the developed world have finally accepted responsibility for helping our brethren in Africa and elsewhere represents moral progress. But Halpern argues that we can do better by fine tuning our moral sensitivities:
“It is [important], especially for the United States, the world’s largest donor, to re-examine the epidemiological and moral foundations of its global health priorities. With 10 million children and a half million mothers in developing countries dying annually of largely preventable conditions, should we multiply AIDS spending while giving only a pittance for initiatives like safe-water projects?
If one were to ask the people of virtually any African village (outside some 10 countries devastated by AIDS) what their greatest concerns are, the answer would undoubtedly be the less sensational but more ubiquitous ravages of hunger, dirty water and environmental devastation. The real-world needs of Africans struggling to survive should not continue to be subsumed by the favorite causes du jour of well-meaning yet often uninformed Western donors.”
In January, 2005, when my wife and I visited Mahindra United World College, a school Pune, India, for 11th and 12th graders from around the world, I taught classes on AIDS and ethics. One of the mini-cases I used touched on the topics Halpern discusses so cogently. Here is the case I used with the students:
“The World Health Organization has set a target of treating 3 million persons with AIDS in the developing world by the end of 2005 – the “3 x 5” program. The WHO regards AIDS as an ethical as well as clinical and humanitarian crisis. Since antiretroviral treatment is available how can it be acceptable not to offer it throughout the world?
Leaders in the west are surprised to get pushback on the 3 x 5 program. As a hypothetical example, imagine that an Indian doctor has said the following to the WHO: ‘For you in the west AIDS is the one and only epidemic. For us it is one of many problems. In the health sector we have malaria, tuberculosis, diarrheal diseases and more. If you are so eager to help us why aren’t you paying as much attention to poverty, hunger and unemployment? You want to help us with AIDS but you also want to stop outsourcing which brings us jobs and lets us help ourselves. I believe you are thinking about yourselves with this policy, not about us!’”
Students from developing countries understood the hypothetical pushback immediately. A student from Africa said “this is another example of the west deciding what it thinks is wrong in our countries and what is best for us.” A number of students from India commented, in effect – “we have serious challenges in health and other sectors. AIDS is just one of many serious problems. If the west focuses urgently on AIDS without comparable attention to other needs, it makes it seem that the outsiders do not understand Indian realities.”
I liked the tone of Halpern’s Op Ed piece. He is coaching, not scolding. He gives us credit for the moral progess we have made. Then, as a good coach should do, he asks us to stretch further! Looking back to my visit with the students in Pune, I admire their tone as well. If other young people can coach their elders as wisely the world will be a better place.
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