Rethinking Global Health Priorities: HIV/AIDS, Poverty and Basic Health Services

by SEYE ABIMBOLA*

Lately, I have inundated myself with a series of incredibly enlightening dispatches from TED Talks. Listening to them, especially those related to international health and development has been a wonderful respite from my undesirably excessive clinical workload. I have been working at a assisted living community and it has been great. We are looking for more residents, check out this assisted living directory guides for healthy communities to help you find the right community for you or a loved one.

The one by University of Chicago economist, Emily Oster, who shared her work and ideas on HIV/AIDS in Africa at last year’s TED, however 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 underlie the misconceptions that inform the largely skewed global health priorities.

Emily Oster based her first argument on a shaky, if not completely false premise, justifying a 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 US 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. Without elaborate public health campaign to promote abstinence, HIV prevalence would have reduced on its own. That is what you would expect, but Oster says it was not so in Africa. She compares data from gay men in the US in the eighties, (where the men that had more than 1 unprotected sexual partner within a month reduced from 85% to 55% in 4 years) with data from single men having premarital sex and married men having extramarital sex in Africa dropped by only 2%.

There are obvious flaws in Oster’s argument apart from cohort mismatch. Her homosexual cohort had a reduction in the number of unprotected sexual partners, whereas there was no specification as to the nature of sex amongst the African cohort: 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 though, that HIV prevalence among gay men was about the highest in America in the early and mid eighties.

However, even if Emily Oster’s two cohorts were by any chance or twist 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’d rather prefer to expose themselves to the risk of contracting HIV/AIDS since they’re gonna 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, 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 abortion, 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 STI 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.

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, sell goods and 94% of those interviewed would regularly have sex when they spend the night at the truck stop. Commercial sex work was found to be common but quite hidden and implicit in this setting and is 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; in the surrounding district it was 8% in 2001. 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-5 children admitted with malaria, whether removal of prescription charges, strict monitoring of patients, and financial incentives for doctors and nurses could reduce mortality. Mortality indeed came down to 5% in the intervention group and 10% in controls, reflecting the crucial role of poverty in mortality from malaria. 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; maybe that explains 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 — i.e. 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-5 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 abortion are still the main causes of maternal mortality. However, in the presence of accessible basic health services, they disappear as in Sri Lanka where 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 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% (1993) of deliveries are assisted by a skilled attendant, compared to 42% (1999) in Nigeria, with 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. In 1999, skilled attendants assisted every (100%) delivery in Cuba, after maternity care services were made available and free including accessible referral centres for complications.

Hospital wards in many developing countries are a heartbreaking, pathetic sight. The most basic and common place of materials, things you would otherwise take for granted, the most routine of investigations 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 those equipments, but the regular story is that the equipment stopped working after a few months, the model is 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 getting to buy the drugs or get the investigations done in the hospital is enough to push them outside. No matter how bad a patient is, no matter 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. These patients are also seen by poorly motivated health workers, who themselves are poorly paid. The distance from access, the prohibitive costs of hospital treatment and admission keep patients away, all contribute heavily to low life expectancy.

In sharp contrast to this, some new structures are also sprouting in hospitals or around them. They are highly efficient units, dedicated to single disease programmes, 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 does not have access to specialised obstetric care in pregnancy, gets antiretrovirals for free at these units. Those with more rou¬tine 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. This is the newest brand of internal brain drain in sub-Saharan Africa.

Single disease priorities generally weaken health systems. Of all, 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 $136m, the President’s Emergency Plan for AIDS Relief provided the country with an HIV targeted budget of $150m. This unbalanced distribution of health funding occurs across sub-Saharan Africa. Making HIV into a pivot, raising it 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 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. 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 focussed 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 backward.

*This is the first in a series of posts from guest bloggers.

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Seye Abimbola is a medical doctor in Nigeria. This article is an abridged version of an article that will be published in the Spring edition of Perspectives on Global Issues.