We Have Changed

The film project "A Year in the Life: Healing Africa" has just been awarded a grant for educational outreach from Harvard University's Office of the Provost. This is a grant to help develop educational content, and will be used to edit video segments from the film for online and classroom teaching. This material will be piloted at two Harvard Medical School first year classes, 'Patient-Doctor I', which introduces interview techniques and basic patient/doctor skills, as well as 'Introduction to Social Medicine', which is meant to introduce cross-cultural concepts as well as issues involving disparities in health care. The documentary footage should serve as a powerful teaching method in both classes, with the immediacy of film a way to bridge the great gaps in distance and social conditions that exist between the US and sub-Saharan Africa. This grant will ensure an educational audience for the film, and will hopefully act a springboard for further outreach.
This grant fits one of the underlying concepts of the film, namely, that improvement in health care in the developing world doesn't involve a one way street from the rich world to the poor. Rather, the developed world has much to learn from the developing world. The film will portray African agents of change in health care: that is, African doctors, nurses, and community health workers who are addressing crises like AIDS in their own unique ways. There has been a general shift in attitude in much of the public health world, which has gone from a top-down to a ground-up approach to problem solving. Preconceived notions and dogma can cause much harm, both to health care and development (and not to mention good documentary films that hope to achieve some truth and objectivity).

Reading the excellent new book on HIV/AIDS in Africa by Helen Epstein "The Invisible Cure" you are reminded of the power of frank talk. While President Museveni of Uganda deserves much credit for the drop in HIV rates in that country through the promotion of both an open national discussion of HIV/AIDS and promotion of the 'ABCs' (despite an overemphasis on the 'A'), the real story is the openness of the Ugandan people. One of the key points of Epstein's narrative is how Ugandans, from the early days of the AIDS crisis, were able to discuss the problem. This may be in part from the cohesive nature of Ugandan society, one that, despite years of brutal dictatorship under Idi Amin, survived into modern times. This is in stark contrast to other countries, particularly South Africa, where society and families were uprooted by both apartheid and economic forces (especially in regard to the mining industry). In a less cohesive, more fragmented society, such open talk was rare. Add to this the unfortunate denial of all things HIV/AIDS related (from the science to prevention to treatment) by President Mbeki, and a time bomb exploded with tragic effect.
Another interesting thread in the book is the story of loveLife, a nationwide media campaign meant to promote healthy lifestyles for the youth of South Africa. While the program enjoyed some popularity, often employing the methods of Western glitzy advertising and American self-help gurus, HIV/AIDS prevention, the nominal goal of the campaign, was rarely discussed in a frank manner. Donors such as the Global Fund to Fight AIDS, Tuberculosis and Malaria lost interest as well, and it is still not clear how positive an impact loveLife has had in South Africa. What is clear is that real discussions about HIV/AIDS are an effective preventative measure. Media projects that deal with the reality of HIV/AIDS, rather than a preconceived notion of the facts, are more likely to add to this open discussion. This is true of documentary films as well.
And what of an open discussion when it comes to distributing funding for health care? Much of the truth in terms of absorptive capacity and sustainability is on the ground, in places like the clinics and hospitals of Zambia and elsewhere. There is nothing inherently wrong with grand designs for improving the life of millions suffering from HIV/AIDS and other plagues. In fact, such goals are an admirable change from the extremes of the past, either outright neglect or funding with ulterior motives of a geopolitical bent. But an open discussion with those who know best, those in individual countries each with their own culture and unique set of hurdles, is a good place to start.

A number of items in the news recently regarding human resource problems in health care:

"Only 1.3 percent of the world's health workers practice in sub-Saharan Africa, although the region harbors fully 25 percent of the world's disease."
From 'Why Africa Fears Western Medicine' by Harriet A. Washington, New York Times July 31, 2007

"Well, the landscape of the brain drain is largely the landscape of political economy, meaning that people move from resource-poor settings, to less resource-poor settings, and on to places in which resources have been piled up and accumulated. Personnel go, for example from rural Kenya to urban Kenya to South Africa to Canada to the United States. Economics is part of the motivation to migrate, but there is another factor too: clinical frustration. Many health professionals in poor countries don't have the tools they need to do their jobs- the tools they've been trained to use... Many health professionals wouldn't leave if they had the tools they needed to do their jobs....
We need a commitment to strengthening the participation of local people. We need to make sure that traditional birth attendants, village HIV workers, outreach workers, et cetera are properly trained and supplied and paid for their efforts. This would greatly improve health capacity at a basic level and be a big step in offsetting brain drain."
Paul Farmer; interview in Health Affairs- Vol 26, No 4; July/August 2007

And...

News: Medical "brain drain" hindering AIDS battle
By Michael Perry
Reuters
23. July 2007

SYDNEY (Reuters) - The biggest challenge in the global fight against
AIDS is no longer money for drug research and treatment but the lack of
local health services in nations worst-hit by the disease, the World
Bank said on Monday.
While some two million people were now receiving treatment for
HIV-AIDS, the lack of health services in many African and Asian nations was
adversely affecting treatment programs, said Debrework Zewdie, head of the
bank's global HIV-AIDS program.

An absence of proper pharmaceutical storage had seen HIV-AIDS drugs
expire before they could be administered and a "brain drain" of doctors
and medical researchers meant there was a shortage of people capable of
properly implementing treatment, Zewdie told the International Aids
Society conference in Sydney.

"Our most difficult challenge is not funding, but the limited health
system capacity in countries with the highest disease burden," Zewdie
told reporters at the world's largest HIV-AIDS conference, attended by
5,000 delegates from 133 countries.

"There is a desperate shortage of doctors, health care workers and
researchers, who would not only deliver treatment services but also
coordinate local operations."

The World Bank said Ethiopia had less than 2,000 doctors or about one
doctor for every 100,000 people. Papua New Guinea, which faced one of
the fastest growing HIV-AIDS epidemics, had only 284 doctors -- but half
worked overseas.

"We want to reverse the lack of research culture. We want to reverse
the brain drain and bring our doctors home," said Zewdie.

The United Nations says close to 40 million people are infected with
the AIDS virus and that treatment had dramatically expanded from 240,000
people in 2001 to 1.3 million by 2005.

In June, world powers at the Group of Eight (G8) summit in Germany set
a target of providing AIDS drugs over the next few years to
approximately 5 million people.

A report by Medecins Sans Frontieres (MSF) at the conference said that
while there had been dramatic price reductions in some HIV-AIDS drugs,
the newer, less toxic drugs recommended by the World Health
Organisation (WHO) had become more expensive.

"The lack of competition and dramatically higher prices for the
newly-recommended WHO first line (drugs) could mean that people in developing
countries may not be able to benefit from improved treatment...," said
Karen Day from MSF.

The MSF report said some new drugs had risen in price by nearly 500
percent from $99 to up to $487. It said "compulsory licenses" were more
effective in bringing prices down than negotiating price reductions with
drug companies.

In January 2007, Thailand issued a compulsory license to overcome the
patent barrier on a HIV drug, allowing the country to legally import the
drug or produce it locally.

"Just one year ago, treating a patient with a second-line regimen ...
in Thailand cost $2,800 per year," said Kannikar Kijtiwatchakul, a MSF
campaigner.
"Treating that same patient with a second-line regimen will now cost
$695, four times less. But this is still far too expensive for the
majority of people in Thailand, where the average annual salary is $1,600."

Australia said on Monday it would increase funding for HIV programs by
A$400 million ($350 million), bringing its total commitment to A$1
billion by 2010.
The Australian funding will focus on the Asia-Pacific region where some
eight million people live with HIV-AIDS, said Australian Foreign
Minister Alexander Downer.

"We cannot ignore the social and economic consequences of HIV in our
region. It is predicted that without increased and ongoing action, HIV
will have killed 1.5 million people in Indonesia and 300,000 people in
Papua New Guinea by 2025," said Downer.

SOURCE: REUTERS

One of the concerns in global health delivery is that certain diseases, especially HIV/AIDS, get more attention than others. This is an issue in terms of allocation of limited human resources as well. Within developing countries, there is often an exodus of health professionals from poorly paid public health posts to relatively lucrative NGO programs that often focus on one disease, such as AIDS. While there is much truth to this concern, there are two important points to be made. One is that the infrastructure put in place for an HIV program can be used as a platform to address other health issues. The other is that HIV/AIDS truly is an historic, unprecedented phenomenon. The following is a piece I wrote in this regard:

Any event that kills people on the scale of HIV is important, in terms of the number of lives affected. HIV/AIDS, with a death toll of 25 million, now rivals the other great plagues in history, such as the black plague of 14th century, or the 1918 Spanish Flu pandemic. But is it historic? If we define historic as a paradigm shift- that is, as an event that causes a radical change in global thinking, or a radical change in how people deal with each other- then the answer is yes, no, and maybe.
The emphatic yes to the question starts with the early days of the epidemic. Before HIV, marginalized people remained marginalized- at least from a public health standpoint. When tuberculosis had killed a broad spectrum of society in the 1930s and ‘40s, the urgency for tuberculosis therapy was greatly accelerated. But once it became exclusively a disease of the poor and indigent, it was largely forgotten; the last new drug for tuberculosis was developed in the 1960s. Malaria hasn’t been a concern for the United States in over a century. Even now, only 10% of health research spending is directed toward diseases or conditions that account for 90% of the global burden of disease (Global Forum for Health Research, 2000). But with HIV, something different did happen. Of the initial three groups of people affected by HIV, gay men, Haitians, and the IVDA population- all highly marginalized in US society, one made a particularly loud noise. Why did they succeed where others had historically failed?
If HIV had primarily affected gay men in Belarus, we might be having this discussion at a much later date. But the gay men affected were in the United States, where they had access to media (along with some political clout), and a ready tool to fight the scourge, US biotechnology. It is safe to say that if HIV had appeared on the scene 20 years prior, before the discovery of restriction endonucleases and the advent of genetic engineering in the 1970s, an even greater disaster would have struck. However devious the virus, its timing was not. Even so, funding for eventual therapy was slow to come. But attention wasn’t, as the gay men in America organized in extremely vocal and media savvy groups like Act Up (years later mirrored by Treatment Action Campaign (TAC) in South Africa). For example, AIDS activists were able to expedite drug approval by the FDA- decreasing time from drug application to drug approval from 34.1 months in 1986 to 12.6 months in 1999 (NEJM 344; 2001). And so a disease that affected marginalized groups entered global thinking.
The emphatic no to the answer of whether HIV is historic comes from the middle history of the epidemic. Once effective treatment became available in the developed world in 1996 with Highly Active Anti-Retroviral Therapy (HAART), the world fell into its old pattern. Marginalized and un-empowered groups- that is, the impoverished- didn’t have access to life-saving technology. Initially the drugs were prohibitively expensive, even for many in the US (over $20,000 per year). But within a few years the possibility of cheap generics became a reality. Yet the pharmaceutical industry fought the sale of low-cost anti-retrovirals, and were initially supported by other powerbrokers, such as many leading US politicians (including Al Gore), and trade groups. It was not until 2003 that the World Trade Organization (WTO) supported generics. Nearly 10 years later from their development, low-cost anti-retrovirals (ARVs) are finally arriving in sub-Saharan Africa, which carries two-thirds of the world’s HIV burden (UNAIDS, 2005).
The other half of the fight against HIV- prevention- is a complex tale. In this case, the fault of the slow response lay at the feet of the conservative nature of societies everywhere. Most adults have sex, and it is not a marginalized group being ignored in this instance, but an activity marginalized in public discourse. It is the fact that HIV is primarily sexually transmitted that has made prevention so difficult, and attached such stigma to the disease. Billboards promoting condom use now in Lusaka and elsewhere may mean a real change, but if not, HIV will follow the history of other sexually transmitted diseases- albeit, with unprecedented numbers.
Lastly, the big maybe in whether HIV/AIDS is historic is linked to the most recent years of the epidemic, and especially the future. This also ties into whether HIV deserves the attention it is receiving. In recent years, it has been shown that HIV/AIDS can be effectively treated in resource poor setting, in both small cohorts and on national scales. At first it was thought impossible, as the infamous comment by Andrew Natsios of USAID in 2001 illustrated: that in many parts of Africa “people do not know what watches and clocks are.” Dr. Paul Farmer, working in Haiti with an initial small group of patients, applied the lessons of DOTS (Directly Observed Therapy Short Course) from tuberculosis to HIV. He demonstrated high compliance with an anti-retroviral regimen, and 86% of patients had undetectable viral loads. These are numbers that rival the best HIV clinics in the United States. On a wider scale, the treatment and prevention programs of Brazil and Thailand also demonstrate the effectiveness of AIDS programs in developing countries. The Brazilian government mandated free ARVS in 1996, with universal access for their AIDS patients. Four years after the national treatment program was introduced, AIDS-related mortality fell 50%. In Thailand, a prevention campaign, the “100% Condom Program”, decreased incidence dramatically. In male military conscripts HIV incidence dropped from 2.48 per 100 person-years to 0.55 per 100 person years between 1991 and 1993 alone (AIDS; 12(5) 1998). And now the Global Fund to Fight AIDS, TB and Malaria (GFATM), the Presidents Emergency Plan for AIDS Relief (PEPFAR), the Gates Foundation and others are hoping to broaden these success stories.
It is crucial that they succeed, both in terms of the numbers of potential lives saved, and the possibility of changing the old paradigms. If they succeed, the story of HIV/AIDS will be one of how the rich world did pay attention to the poor world and was able to make a difference. This would be unprecedented for both public health and development. And so this epidemic does deserve the kind of response it is receiving. But if a child dies of malaria, is that any different then if it dies of HIV? No. But the fact is the world, for myriad reasons, has decided to pay attention to HIV. Before AIDS, there was no Global Fund to Fight Tuberculosis and Malaria. Tragically, we needed the A.