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.

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