International Association of Physicians in AIDS Care, Journal: April 1998 - Volume 4, Number 4
Hoosen M. Coovadia, MD
Presented by the author at IAPAC's First International Conference on Healthcare Resource Allocation for HIV/AIDS and Other Life-Threatening Illnesses, November 10-11, 1997, in Washington, DC.
I have come here on this early winter morning to this prestigious meeting in Washington, not as a supplicant from the Third World with cupped palms asking for more, nor from Conrad's "heart of darkness" seeking light, but as a colleague, admirer, and--I hope--a friend, to the uniquely vigorous academic institutions of American society. I am here to turn the hard light of scrutiny onto what we ourselves in the poorer countries of this world should be doing but have failed to do, inasmuch as I wish to remind the industrialized world of its responsibilities for the control of the HIV/AIDS epidemics. My task is to say that despite the fact that the most recent figures reveal declining numbers of AIDS cases in the US and Western Europe, we remain inextricably bound each to the other in a global society where diseases know no walls and we are all threatened if a single one of us is in danger. Jonathan Mann rightly observed that "the epidemic cannot be stopped in one country until it is stopped in all!"
I have been asked to speak on "Healthcare Resource Challenges to the World Community." I understand "resources" to include personnel, equipment, technology, financial support, training and education, and most importantly, the assets among you of ideas, imagination, policies, and programs. I take "challenges" to mean an invitation and a stimulus, not defiance and confrontation; the sense I have is that we are here to participate in what the British philosopher Oakeshott liked to describe as "a conversation and not an argument"; not to win individual points of debate but to build a common wealth of solutions to the AIDS pandemic.
There is a common misconception about the degrees of poverty among developing countries and the diversity of the poor within national boundaries and between nations. At one extreme there are people so profoundly poor that they barely manage to sustain life, while others remain poor, but less so. For example on my own continent the GNP per capita (1993) is $90 in Tanzania but $2790 in Botswana and $2950 in South Africa.1 Therefore the "challenges" the AIDS epidemics pose in these countries and their solutions have to be tailored to their individual needs. There is no single or "quick-fix" solution to AIDS for all developing countries. A useful classification of this diversity is that of the UN.2
South Africa together with countries such as Botswana, Brazil, Costa Rica, and Sri Lanka are middle-income countries within the "developing" group. These countries differ in important health indices such as life expectancy, U5 MR, IMR and HIV prevalence rates.1
In brief, the poor countries are not equally unequal and consequently require careful consideration of interventions appropriate for each of them.
The dialogue between North and South on HIV/AIDS bears an exact likeness to the broader discussions on the global economy, world trade, the role of the UN Security Council, and a host of similar large scale issues. The tide of dialogue between the rich and poor nations flows mostly, though not exclusively, in one main direction--from the former to the latter. This generates a culture of medicine in which the language of discourse is dominantly the language of the industrialised countries. This is true whether the discussion is on health research, health services, health economics or health education. It is cruelly true for HIV/AIDS where the overwhelming burden of disease is borne by Africa, Asia and Latin America. For example I have summarised some of the prime messages, given worldwide prominence in the media, arising from the XI International Conference on HIV/AIDS held last year in Vancouver. The themes are heavily weighted to the control of the disease in western countries with but a nodding recognition to the problems of the poor. The recent assertions in the pages of the New England Journal of Medicine on the ethics of intervention studies aimed at reducing MTI transmission of HIV in developing countries reveals a similar pattern.3,4 This is not the right place to recount all the arguments for or against the appropriateness of ACTG 076 to Africa, but simply to make the point that the sovereignty of national opinions derived from local ethics committees, local consultations, and from democratically elected governments was ignored in favor of a view from the West. It is dangerous to assume the moral high ground on such sensitive and difficult matters. We are not immune to doubts on the problems of confidentiality, informed consent and counselling in the context of HIV in our countries; these are reasons for greater collaboration not an excuse for isolation.
This meeting is taking place at a critical point when new combination therapies are threatening to deepen the divisions among people with HIV in the world : those with access to triple therapy and those without. I fear the language of HIV will shift to a preoccupation with the drug management of a chronic disease (like TB, Diabetes) rather than an emphasis on prevention and vaccination; will move to discussions on what is good for a few rather than what can be of benefit to millions.
A challenge to the world community on the pandemic of HIV/AIDS is to change the language of discourse, so that the problems of the majority with this dreadful disease, who happen to live in developing countries, assumes a primacy it does not have at present. From HIV/AIDS we will have to begin to transform the culture of medicine for other diseases so that global priorities carry the stamp of universal agreement.
This culture of medicine has deep philosophical roots and changing it will be an enormous undertaking. Your history and traditions have created a profound respect for the individual, a healthy scepticism of government and a lesser consideration for the rights of collectives. We on the other hand, through circumstance and inclination, have emphasised context and therefore sought to protect the rights of communities to a greater extent than the rights of the individual. We are motivated by Bentham's principle of the greatest good for the largest number. When this conviction comes together with our appreciation of some fundamental social reasons for the accelerated spread of HIV/AIDS in the Third World,5 we are keen to address these social factors as a priority. The demographic and economic impact of HIV/AIDS, the inferior social status of women, the escalating unemployment and the social disruption in sub-Saharan Africa which has led to an increase in commercial sex workers, huge migrations of people within and across national boundaries, rapid and chaotic urbanization, a change in cultural values, a rise in STDs and drugs, and a fall in provision of health services, all demand more than a medical response. D'Cruz-Grote speaks of "Supportive Social and Economic Environments" which are critical for establishing a receptive milieu in which other interventions may succeed.5 The economic environment in which drug purchases and sales occur require attention.
A more flexible approach in developing countries by pharmaceutical companies, in which the US has such a large interest, can make a sizeable impact on HIV/AIDS. The increasing dominance of [pharmaceutical companies] in South Africa has narrowed options for access to healthcare by those who need it and has diminished the role government can play in promoting health for all its citizens.6
This is a challenge that has been taken up by UNICEF and other international agencies for vaccines and can be supported and extended for HIV/AIDS through our joint efforts. I have heard that some moves, initiated by [pharmaceutical companies] producing antiretrovirals, are already under way in South Africa to address this issue.
Therefore, the challenge and the task to combat the social and economic foundations of HIV/AIDS are nothing less than an undiminished quest for the "development" of resource-poor countries. By "development" I mean a process of social change which advances and improves the quality of life. At the center of this transformation is an increasing liberation of the individual and community from a range of constraints, an enhancing of the freedom of choice between different options, and a strengthening of the capacity for self-reliance, self-sufficiency and full participation in social processes. It is heightened access to employment, income, wages, education, healthcare, and social security. Theodore Schultz the Nobel economist has summed this appropriately when he comments that "The wealth of nations has come to be predominantly the acquired abilities of people--their education, experience, skills and health. The future productivity of the economy--will be determined by the abilities of human beings."
Therefore throwing money or drugs alone at HIV/AIDS will not halt the epidemic. Global measures to reduce social and economic deprivation will make a major contribution. To illustrate this, the recent experience in Côte d'Ivoire in using ZDV to reduce MTI transmission of HIV revealed unexpected barriers to success.7 The extremely wide range of factors contributing to the AIDS epidemics require a broad comprehensive set of interventions--in all countries but especially in developing countries. This view should shape the culture of medicine for the years ahead. This approach accords with the nature of HIV in Africa and elsewhere; three concurrent epidemics are unfolding:
Accordingly our interventions should encompass a continuum from prevention to care to development.
It is no use telling the people in Africa that AIDS is another plague like other plagues of smallpox, measles and Black Death, which have appeared as darkened shadows on the landscape of human history. It is no use reminding Africans that these shadows have lengthened but have then finally disappeared. This AIDS epidemic is immediate and terrible and relentless, and therefore it is pointless to anticipate under such circumstances a "victory of memory over forgetting." Like no other, this disease violates the most intimate privacies of man and woman, and pierces the secret life of communities. Given the intensely personal and often furtive nature of this infection, access to individuals and groups of people is critical. Access for prevention, access for detection, access for care and for support.
What shall we do when we reach the people? We know of interventions that work--aggressive treatment of STDs, condom distribution, needle exchange (where appropriate) and educational efforts and mass awareness campaigns. It is worth reiterating that one of the primary challenges to the world community is to promote and fund interventions which are aimed not only at individual behaviour change but also at the social, economic and structural determinants of HIV/AIDS. I have discussed this under the need for broad development initiatives.
Mass awareness campaigns in sub-Saharan Africa, Mexico, Thailand, and India have increased knowledge but behavior change has been disappointing.5 So the challenge to the world community is to uncover and support the most effective methods which can initiate, promote and sustain healthy behaviors, especially sex behaviors, at population level among at-risk groups. I would like to dwell on one particular pathway to encouraging changes in risky behaviour which I believe is worth exploring. This pathway is the route through what we call civil service organizations or community-based organizations, more popularly NGOs (nongovernmental organizations).
South Africa has a rich heritage of many thousands of NGOs--a heritage of the years of anti-apartheid struggle. It was these NGOs which drove the apartheid government into retreat; the same NGOs which mobilized millions in their schools, unions and in their homes; the same NGOs which ensured an authentic people's victory over the forces of racial oppression. We should support and consolidate these same forces against this different war against HIV/AIDS. Throughout Africa these NGOs can ensure an access to communities that governments rarely achieve and their prospects of success are higher because of the confidence communities have in them. They are close to communities, have much local knowledge and experience, can be innovative and flexible in their responses and diverse in their programs.
There is wide acceptance of an enhanced role NGOs can assume, inter alia, in promoting healthy behaviors. A key operational style of NGOs is the ability to establish and work through civil society networks. The participation of people in informal and formal networks, encouraging positive social norms and building high levels of trust, can raise family values and enhance social cohesion, can build what has been termed "social capital".10 We are familiar with financial capital, property capital, and political capital; all these are important surrogate markers of prosperity. However for the many millions of poor who have to depend on the reserves of their own capabilities, "social capital" is particularly apposite to the prevention and care for HIV/AIDS. It is intuitively appealing but does it work? Some evidence suggests it might!
These NGOs should be the focus and catalyst for new partnerships between government, the private sector, and civil society. Indeed these partnerships should extend to global forums such as this, international organizations such as the UN, and national bodies. All these partnerships to be based on mutual respect and an affirmation of the sovereignty of local decisions.
What do the experiences of Africa tell us about healthcare resource challenges which have to be taken up seriously by the world community? I am grateful to Quarraisha Abdool-Karim who sits on the International AIDS Society for sharing the results of a paper to be published by her and her co-authors soon in AIDS.8
National AIDS programs have been established throughout sub-Saharan Africa, usually within ministries of health. This location of the programs has to be examined carefully as AIDS requires the cooperation of a wide range of nonhealth-related institutions. Participation of civil society and other ministries has been minimal. The principles of most of the programs are based on the Global Programme on AIDS of WHO and have emphasized prevention more than care and support. Recently there has been further progress in some countries: budgets for HIV/AIDS have tripled in South Africa, female condom use promoted in Zimbabwe and STD treatment aggressively pursued in Tanzania and Senegal. Screening of blood and voluntary testing sites are becoming more widespread.
Impediments to these AIDS programs are considerable: political commitment often wavers (except for Senegal, Uganda, Côte d'Ivoire and Zambia), broader development stagnates and the capacity to respond to the epidemic is hobbled. For example, annual government expenditure on HIV/AIDS ranges from less than 1 percent to about 15 percent of total health expenditures, a pitiful $0.30 is spent per capita (range $2.96-0.04) and only 12 percent of planned activities on HIV/AIDS were carried out in Tanzania.
In brief, Africa, which has about 13 million of the global total of 20 million HIV prevalent infections,9 has acknowledged the problem and responded, has responded vigorously in only a tiny fraction of countries, has responded slowly and feebly in most, and has to respond by scales of magnitude higher if the epidemic is to be controlled and the human development gains of the recent past protected. I cannot think of a more compelling challenge to the World Community than to participate in the protection of African health and the acceleration of African development which are fundamental to the attainment of not only continental but international peace, democracy, and security.
I wish to add a personal word on the appropriateness of vaccines for developing countries. For myself and my country I must say that we believe the development of a safe, effective, and inexpensive vaccine is the preferred alternative to further refinements to antiretroviral drugs. The indelible impact on our consciousness of the effectiveness, tolerability, durability and cost-efficiency of vaccines against smallpox, poliomyelitis, diptheria, tetanus, measles, hepatitis B and Haemophilus influenzae type b, and the millions of lives saved, make us ardent advocates of immunisation. We are not unaware of the enourmous benefits wrought by antibiotics on the lives of our populations. However it seems clear that the benefits of successful vaccination are cheaper, achieved with fewer side effects, more durable and in some instances permanent. The safety of currently available HIV vaccines is a matter for you to resolve. Andersen and Garnett's11 comments appear particularly useful for vaccine efficacy in developing countries: "In areas of moderate to high transmission, low efficacy vaccines administered at high coverage levels could act to significantly reduce the endemic prevalence of HIV." There is an ethical dilemma posed by the urgent requirement for vaccine studies in developing countries; this is the guideline of CIOMS and WHO on distributive justice which recommends that more dependent communities and countries should not bear disproportionate burdens of studies from which all communites and countries are intended to benefit. We must resolve this together.
As this millennium fades and a new thousand years begin, I anticipate that this conversation will continue without interruption between people from the hidden corners of the world, which are nearly always poor, and where HIV remains a catastrophe, between them and you. And in this conversation I would urge you to make sure that while you hear the eloquence of the powerful, you listen attentively to the subdued but insistent cries of the weak, and are not deaf to the barely audible sounds of the poor, the disabled, and the disorganized. Listen to these voices with your head and your heart, and let us change the world, so that those in daily danger of HIV and those already infected, can believe there is hope for avoidance and protection, there is hope for care and support, there is hope for a cure, but most of all, can say thank God someone cares, someone cares.
1.World Health Organisation. The World Health Report 1996. Fighting Disease Fostering Development. Report of the Director-General. World Health Organisation. Geneva. 1996. 129, 127, 130.
2.World Health Organisation. The World Health Report 1996. Fighting Disease Fostering Development. Report of the Director-General. World Health Organistion. Geneva. 1996. 116.
3.Lurie P, Wolfe SM. Unethical trials of interventions to reduce perinatal transmission of the human immunodeficiency virus in developing countries. N Eng J Med 1997;337:853-6.
4. Angell M. The ethics of clinical research in the Third World. N Eng J Med 1997;337:847-9.
5.d'Cruz-Grote D. Prevention of HIV infection in developing countries. Lancet 1996;348:1071-74.
6.Summers R, Suleman F. Drug Policy and Pharmaceuticals. In: South African Health Review 1996. Health Systems Trust and the Henry J. Kaiser Family Foundation. Durban, South Africa. 99-107.
7.Feinman J. Tackling mother-to-child HIV in Côte d'Ivoire. Lancet 1997;350:1084.
8.Abdool Karim Q, Tarantola D, As Sy Elhaj, Moodie R. Government responses to HIV/AIDS in Africa: What have we learnt? AIDS 1997 (to be published).
9.Quinn TC. Global burden of the HIV pandemic. Lancet 1996;348:99-106.
10.Gillies P. Social capital : recognising the value of society. Healthlines 1997;1:15-17.
11.Anderson RM, Garnett GP. Low-efficacy HIV vaccines : potential for community-based intervention programmes. Lancet 1996;348:1010-13.
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