Lately, I have inundated myself with a series of incredibly enlightening lectures from the Technology Entertainment Design (TED) Talks. The goal of the TED Talks is to share ideas on a variety of topics, including politics, arts, and global issues. One in particular is worth discussing here (http://www.ted.com/talks/view/id/143). Emily Oster, a University of Chicago economist, shared her work and ideas on HIV/AIDS in Africa at last year’s TED Talks; however, her argument struck me as particularly, if unwittingly, poorly conceived. Her theoretical abstractions reveal in shameful detail how easily tainted the lens through which the developing world is seen from the outside, and the kind of thinking that underlies the misconceptions that inform the largely skewed global health priorities.

Life expectancy in sub-Saharan Africa today is roughly equivalent to that of Great Britain in the 1840s. Headlines would rather attribute the low life expectancy in Africa to the big killer diseases, with HIV/AIDS topping the list, whereas common, though far less glamorous illnesses like diarrhoea, malnutrition, and respiratory tract infections take many more lives than HIV, tuberculosis, and malaria. It is salutary to note that Britain in the early 1900s achieved significant reductions in childhood deaths from diphtheria, scarlet fever, pertussis, measles, tuberculosis and rheumatic heart disease, all equally deadly diseases, long before vaccines and antibiotics became widely available. There is overwhelming evidence that this decline was due to improvements in nutrition, sanitation, water supply, housing, general hygiene and per capita income, the basic essentials of life that are easily taken for granted by an average Westerner. It explains why it is so easy to lose sight of them as we try to solve the big killer diseases in Africa. Without thinking about access to these basic necessities, alongside our concern for conventional healthcare, and pursuing them with as much vigour, the labourers only labour in vain.

Emily Oster based her first argument on a shaky if not completely false premise, justifying a claim, her own claim, that there was no behavioural change in response to the HIV pandemic in Africa by juxtaposing data from two radically different cohorts --homosexuals in the U.S. and heterosexuals in Africa. High HIV prevalence within a population where there is widespread awareness of heterosexual sex as the predominant mode of transmission will result in increased rate of abstinence from sex or at least a modification of sexual behaviour as an evolutionary compulsion to preserve the species. The logical human weighs the potential benefit of sex against the apparent cost of illness or loss of life. This is especially more so if the sexual act does not hold the promise of procreation, as in homosexual sex, where the benefit of sex might be restricted to immediate gratification. Without an elaborate public health campaign to promote abstinence, HIV prevalence would have reduced on its own. That is what you would expect, but Oster, counterintuitively, says it was not so in Africa. She compares data from gay men in the U.S. in the 1980s, (where the men who had more than one unprotected sexual partner within a month reduced from 85% to 55% in four years) with data from single men having premarital sex and married men having extramarital sex in Africa, which dropped by only 2%.

There are obvious flaws in Oster’s argument apart from subject mismatch. Her homosexual subjects had a reduction in the number of unprotected sexual partners, whereas there was no specification as to the nature of sex amongst the African subjects: protected or not, homosexual or heterosexual. She did not give any idea of the HIV prevalence amongst the said African population(s), so we cannot possibly estimate the cost of sex among the population, and arrive at any predictable behavioural change based on that. We know that HIV prevalence among gay men was about the highest in America in the early and mid 1980s and since the evolutionary benefit of homosexual sex is low, such a precipitous fall in the number of unprotected sexual partners is easily predictable.

However, even if Emily Oster’s subjects were by any chance of logic comparable, and if there was indeed no behavioural change in response to HIV in Africa, her explanation for this – the cost of abstinence is so high that in the presence of low life expectancy, people would rather not bother to live healthy lifestyles, they would rather prefer to expose themselves to the risk of contracting HIV/AIDS since they are going to die early anyway -- is as unconvincing and implausible. Oster demonstrated that in places and within populations in Africa with high prevalence of malaria and high maternal mortality, there was no positive change in sexual behaviour in response to HIV. She did this, totally ignoring two huge, glaringly obvious confounding variables, poverty and lack of basic health services -- leading causes of low life expectancy in Africa, together with lack of adequate sanitation and good water supply, which promote the presence and spread of diseases, and in themselves are inextricably linked to poverty. This is actually where Oster’s greatest mistake lies, and unfortunately, it is what forms the main thrust of her thesis.

M. Khan and colleagues in Burkina Faso found that even within a developing country, the sex network within rural areas is denser, more closely interlinked than in urban areas, and the percentage of those who receive goods for sex is far greater in the semi-rural border area (45%) and urban area (31%) than in the rural areas (12%). This is easily explained. There is far greater homogeneity in relation to poverty in rural areas compared to urban or semi-rural areas, and so there are fewer people who are prepared to offer money or goods for sex. Poverty too breeds idleness, and it is easy to imagine that an idle man will easily have multiple sexual partners in a community where money is not given in return for sex. This explains why poverty may be associated with high levels of sexual activity. In these settings, there is high maternal mortality both from unsafe abortions, and because maternity care is not available. Where poverty abounds and basic health services are not there, mortality from malaria will be high. Where there is no access to basic health services like sexually transmitted infection prevention and treatment and modern contraception, there will be poor awareness of the presence, reality and prevalence of

HIV. Illness and death from HIV is attributed to other diseases, witchcraft, the will of God, et cetera, hence diagnostic, prevention and treatment services, even if available, will suffer low uptake in the absence of these basic health services.

Emily Oster, however, asserts that HIV prevalence rises with increase in economic activity and urbanization. She evokes the oft-quoted high HIV prevalence amongst truck drivers and migrants to support this claim. She also showed that the fall in HIV prevalence in Uganda was closely associated with a fall in the export price of tobacco, Uganda’s main export commodity. All of these are true, if only in part, but yet again, she misses the point. It is not wealth as an absolute quantity that encourages increase in sexual activity, hence HIV prevalence; rather, it is the widening of the gap between the rich and the poor, increased contact between the rich and the poor, and the attendant dynamics, the differential power gradient, that characterises the relationships between the two classes. Much of extramarital and premarital sex is facilitated by an economic advantage of one party, often the male, over the other. With a fall in export price of tobacco in Uganda for example, the gap between the rich and the poor is less, there is less money available to maintain multiple sexual partners and visit commercial sex workers, thereby reducing the sexual network, and also, predictably, HIV prevalence, at least in part.

CASES OF BEHAVIOURAL CHANGE

In contrast to Emily Oster’s argument, there has been behavioral change. Marjolein Gysels and colleagues at the Medical Research Council Programme on AIDS observed and interviewed truck drivers and commercial sex workers at a roadside town in southwest Uganda. Truck drivers are a high-risk group for HIV due to their sexual networking and long periods away from home. They stop at towns along major routes to eat, sleep, and sell goods, and 94% of those interviewed would regularly have sex when they spent the night at the truck stop. Commercial sex work was found to be common but quite hidden and implicit in this setting, and centered around roadside bars; hence intermediaries are often involved in negotiations between drivers and commercial sex workers. However, in the wake of HIV/AIDS, the middlemen on whom truck drivers rely to find women have had an additional role, which is to identify HIV-negative women, and in spite of this, condom use was reportedly high, at 95%, in marked contrast to local men. HIV prevalence used to be very high among drivers and at truck stops. In the study town it was 40% in 1991; 185 in the surrounding district it was 8% in 2001.186 The demand for casual sex however appears not to have decreased among truck drivers in the era of HIV, but there is a general awareness that this lifestyle carries the risk of infection. This shows indeed, that there has been behaviour change in response to the HIV pandemic in Africa, contrary to what Emily Oster will have us believe.

In 2004, 12% of children with malaria died as inpatients at the national hospital in Guinea-Bissau. Special drug kits for children with severe and complicated malaria were introduced, but this did not reduce mortality. In an award winning BMJ study in 2007, Sidu Biai and colleagues tested in a randomised trial of under-five children admitted with malaria, looking at whether removal of prescription charges, strict monitoring of patients, and financial incentives for doctors and nurses could reduce mortality.188 Mortality indeed came down to 5% in the intervention group and 10% in controls, reflecting the crucial role of poverty in mortality from malaria.189 What is particularly interesting about the Guinea-Bissau study was that the only difference between the two groups was that doctors and nurses were given financial incentives in one group and they were not in the other, which alone reduced the mortality by as much as 5%. Given, the drugs were free in both groups, which may explain a fall in mortality from 12% pre-trial to 10% in the control group. Weigh this against the 5% reduction when health workers were given added incentives. From this, it is clear that with just three simple interventions -- if we could make basic health services available, if patients could afford the drugs and other services, and if health workers were well remunerated -- we could cut under-five mortality from malaria by more than half.

It is much the same story with maternal mortality. Obstructed labour and ruptured uterus, eclampsia and other forms of hypertensive disease in pregnancy, obstetric haemorrhage mostly postpartum, puerperal sepsis, and unsafe abortions are still the main causes of maternal mortality. However, in the presence of accessible basic health services, they disappear. In Sri Lanka, the maternal mortality ratio dropped from 550 per 100,000 live births in 1950-55 to 80 per 100,000 live births in 1975-80, and to 58 per 100,000 live births in 2005. This was achieved by introducing a system of health centres all over Sri Lanka, and making quality maternal care services available and accessible to all, including in rural areas. In Sri Lanka, 94% of deliveries in 1993 were assisted by a skilled attendant, compared with 42% in 1999 in Nigeria, which had one of the worst maternal mortality ratios in the world (1,100 per 100,000 live births). This has been replicated in Cuba, where in 1970, the maternal mortality ratio was 73 per 100,000 live births, and in 2000, it had more than halved to 33 per 100,000 live births.196 In 1999, skilled attendants assisted every delivery in Cuba, after maternity care services were made available and free including accessible referral centres for complications.

GLOBAL HEALTH PRIORITIES

Hospital wards in many developing countries are a heartbreaking, pathetic sight. Things you probably cannot possibly imagine could ever happen, take place everyday without the blink of an eye. No matter how bad a patient is, no matter what the emergency, the family usually has to pay for services and procure materials for treatment at the point of service. Usually, there are no provisions for emergency: drugs, intravenous cannula, needle and syringe, investigations, et cetera. The most basic and commonplace of materials, things you would otherwise take for granted, the most routine of investigations like ultrasound scan and x-rays are often procured at great cost, from private pharmacies and laboratories that have clustered around government-run hospitals over the years owing to the ineptitude of the hospitals to run efficient services. Worse still, these hospitals stock the drugs and have the equipment, but the regular story is that the equipment stopped working after a few months, their models are outdated, there are no staff to man them because they are off moonlighting or do not work during call hours or take weekend shifts, or even the bureaucracy of buying the drugs or getting the investigations done in the hospital is enough to push them outside. These patients are also seen by poorly motivated, low paid health workers, with many supplementing their income through moonlighting. These factors contribute to the high mortality in the first 24 hours of seeing a patient, and subsequently. The distance from access and the prohibitive costs of hospital treatment and admission keep patients away, contributing heavily to low life expectancy.

In sharp contrast, some new structures are sprouting in or around hospitals in developing countries. They are highly efficient units, dedicated to single disease programs, often HIV/AIDS, provided and funded by external donors. An AIDS orphan who lives with siblings in squalor without access to insecticide-treated nets and artemisinin-based combination therapy for malaria, whose sister and guardian does not have access to specialised obstetric care in pregnancy, gets antiretrovirals for free at these units. Those with more routine diseases receive poor care and still have to pay. Hospital staff who are supposed to be at their duty posts seeing patients that they were trained and being paid salaries and allowances to see are often busy running those units, with extra remuneration often in hard currency, often surpassing their salaries, at great expense of the system. These hospital staff also get lured into full time employment by these donor-funded programmes, further weakening the already fragile healthcare delivery system, and are busy junketing the world from one conference to another, as well as to conventions, forums, meetings, et cetera. Hospital consultants jostle to be the ones to run the HIV clinics. This is the newest brand of internal brain drain sub-Saharan Africa is experiencing.

Single disease priorities generally weaken health systems. They are extremely wasteful; they duplicate efforts and divert funds unnecessarily, starving whole health systems of funds and personnel. Overall, spending on HIV research, treatment and prevention activities is the most notorious example of this prodigality. In 2006, although Zambia’s entire Ministry of Health budget was only $136 million, the U.S.-funded President’s Emergency Plan for AIDS Relief provided the country with an HIV-targeted budget of $150 million. This unbalanced distribution of health funding occurs across sub-Saharan Africa. Raising HIV/AIDS to the status of the zeitgeist of the times has indeed skewed health priorities at both national – in many developing countries – and, most importantly, at global levels. There is only so much we can achieve, with HIV at the centre of our planning and initiatives. We have succeeded in erecting a great vertical programme for HIV, a totem pole of sort, probably the greatest in history, shorn of the system that currently exists for controlling sexual and reproductive health. HIV has managed to employ its own staff, generate its own funding, systems and facilities. Reorganising these structures is at the heart of solving these problems. We cannot move ahead while we ignore so much. What more evidence do we need, than that with all the spending on HIV, much too little is being achieved.

Healthcare and development are so interlinked that it would be grossly wrong to interpret data without due consideration for the whole picture and connections that are not immediately apparent. It is not enough to have epidemiological data, without the insight to interpret them and discern underlying trends. The world has not changed much since mid-19th century Europe. Diseases related to the lack of clean water and adequate sanitation are the second-biggest cause of under-five mortality, with two million dying every year from diarrhoea. Poverty and the lack of basic social and health services is at the centre of what defines developing countries, and that is really where our attention should be focused in trying to find solutions to problems in these countries; any thinking that as much as puts these as second to any other priority is ultimately bound to fail. Until these form the crux of both local and global public health interest and policy, much of our effort will only continue to result in the proverbial one step forward, two steps back.

Robot  # 1 | 28.07.2008 08:09

...Read the full article.

mulan  # 2 | 30.07.2008 14:48

I agree with your write-up completely. In a recent work on Global health partnerships (GHPs) which are usually single-disease focal and are vertically programmed, I also came to the same conclusion... From available literature, it is clear that early achievements of extending delivery of specific health interventions such as childhood immunisation cannot be sustained unless they become an integral part of national health systems. GHPs sometimes overlook how the health system is situated within the political economy of a particular country. For example, in Nigeria, states have considerable autonomy and resources well above the annual budgets of many countries in the sub-region – however, it is only few GHPs that operate at state level with almost all massing at the federal level. One challenge is to get GHPs to move away from vertical programming to addressing systemic issues which may mean using resources targeted at focal diseases for other health strategies in the system. The symbiotic relationship between GHPs and health systems has led most authors to state that the GHPs should include health system strengthening as part of the support they give to implementing countries. A component of the Stop TB Strategy is to "contribute to health system strengthening" and they encourage national TB programmes and their partners to be pro-active in harmonizing efforts to improve the functions within national health systems and development strategies (www.stoptb.o...). This is laudable but would need to be fine tuned as the inclusion of yet more actors may be counter-productive. Given the burdens GHPs can place on health systems and the constraints health systems place on effective GHPs implementation, a realistic way forward must be to invest more and in an integrated financing strategy. GHPs often pursue their primary objectives without considering the impacts and in seeking rapid results; they often do not make use of recipient health systems especially weak ones like in most developing countries. Some do not make “significant efforts to approach poverty related health problems with a focus on equity and integration” especially in difficult countries like Sierra Leone (Carlson, 2004) or Nigeria. Poverty is at the root of inadequate health care however, there was little evidence that GHPs supported major investments to improve institutional settings and structures in Nigeria, and the effect has frequently been that their activities strained the unstable local health system and diverted human and other resources from their normal channels. With countries that had introduced a system-wide approach (SWAP), similar to Nigeria’s NEEDS, financing GHPs sometimes put their resources into the common budget with other donors in order to harmonise with existing national priorities. They also provide support for ensuring M&E systems produce the information needed; GFATM- and GAVI-related coordination committees improved participation of a wider group of stakeholders concerned with GFATM diseases and with immunisation. However, this has to be framed within issues of availability, acceptability, quality and accessibility of health services; as well as participation and sense of ownership, especially by vulnerable groups and communities in order to be deemed effective overall. This study posits that GHPs may play a strengthening role in providing funding and technical assistance to country disease programmes but also in some cases they are a burden due mostly to the under-resourced health system.