Challenge of Subtype Diversity

The article about subtype diversity was interesting. It is almost discouraging to see the large number of obstacles ahead; eradicating a widespread disease with one strain is already difficult. Now there is a widespread disease with multiple strains (subtypes) that keep mutating and changing or recombining with each other to form others that are sometimes more lethal or more toxic; oh and there is continued developement of drug resistance strains that play into the diversity of the subtypes.
I don't think many people appreciate the extent and complexity of challenges that HIV poses; i certainly didn't and the fact that we do not understand how different subtypes spread in different regions is also a really important factor. It is surprising to think that with all the research that is being done on HIV, we are no where near done. That is something that people need to realize. As our knowledge of this clever virus evolves, so do the virus's techniques it uses to stay alive in an individual and in the population for a long time. So we are basically in a race against HIV. Its not a question just understanding the virus, which is also a crucial component, but it is also the question of being several steps ahead, stopping it before it goes to another level of complexity. Obviously this is a very challenging and difficult feat but so was the idea of eradication smallpox.

Subtype Diversity - post for 12/2 class

I found this article to be very interesting, especially the discussion of the possibilities for an HIV vaccine. I wish I knew more about how the immune system worked so that I could better follow some of the technicalities and nuance. Are there any areas in the world where there are many common subtypes? I would imagine that a place like this would be very valuable to study the relative fitness of the various types. Do certain types out-compete others? Although I guess it is far more complicated than simple competition, due to all the host/virus/environment factors involved. If it was clear that one type is more fit, would we know by now?

On that note, it seems that much more research is needed to fully understand subtype diversity - it is certainly needed for vaccine development! The fact that subtype does not seem to affect clinical progression is promising, but at the same time it seems that it would be ideal to reduce/contain the number of circulating subtypes, especially if we want treatments and vaccines to work as effectively as possible! I'd be curious to know if there are any efforts underway currently to find and contain emerging subtypes. Would this be a valid use of resources, I wonder?

Another question I am very curious about - how were the vaccines tested ethically? The way the author wrote, "In two large, phase 3 trials of a monomeric
form of the external glycoprotein 120, conducted in the United States and Thailand, the protein failed to protect healthy subjects from HIV infection" almost implied that healthy people were infected!

11/17

My research paper actually focused on the ethics of clinical trials in HIV prevention, so the authors' casual dismissal of the subject was somewhat abrupt, in my opinion. However, their focus on treatment rather than prevention at this stage is a realistic perspective. Rationing has been accepted by bioethicists as an inevitability in HIV treatment, but how to implement it is obviously not an easy task. Recognizing that all rationing programs are politically, not simply medically, motivated. Preexisting social and economic disparities in this case have the possibility of being either minimized or further increased. Many disenfranchised propulsions are arguably more at risk for acquiring the infection, especially in developing countries. But the political inner workings of many NGOs and government-funded initiatives such as PEPFAR can often withhold treatment to those who need it as much as they help. PEPFAR appears to distribute aid either arbitrarily or based on political factors, skipping over clearly desperate countries like Zimbabwe because there is no derived political benefit from doing so. Rationing decisions on a lower level of bureaucracy are equally capable of altering the equity of treatment options, based on social standing, ethnic group, or often distance from treatment centers (establishment of "islands of treatment").
I was interested and alarmed by the authors' description of the disparity between developing an adequate healthcare infrastructure, limiting the brain drain and increasing the 'absorptive capacity' of these countries, and their ability to receive the IMF grants that are necessary to decrease the poverty level that causes healthcare disparities in the first place.
Ranking the "who" of treatment priorities is another interesting discussion treated in this article. Selecting pregnant women is a good idea as a means of preventing mother to child transmission, but is highly exclusive as a criterion. Selecting skilled workers is likely to improve human capital resources, which could by aiding the economy in turn help to improve treatment infrastructure overall, but this excludes most of the vulnerable populations in any society (women, children, etc.) Selecting sex workers may be a good means of eliminating one important vector of transmission, but this excludes the people who many would call the 'innocent victims' of HIV transmission.
Finally, the authors suggest that in treating AIDS comes the opportunity to expose and work to eliminate preexisting socioeconomic disparities, human rights violations, and basic inequalities in the developing world. In improving access to treatment, granting one of the most basic human rights and enabling previously vulnerable populations a more level playing field, the AIDS epidemic has the potential to have some positive effects.

Katie Nelson

AIDS care and Treatment in Sub- Saharan Africa; Implementation Ethis

Kesaobaka Modukanele

Global HIV/AIDS

Blog Post for Tuesday November, 17 2009

The impact of the IMF on health care in developing countries.

Along with the obvious geographical boundaries that separate the world today, there exist other boundaries: ‘First world’ and ‘Third world’; ‘Developed’ and ‘Developing’ etc. What bothers me the most, is the idea of a ‘developing world’, which implies that these countries are progressively improving, or rising to reach some basic level of ‘development’. However, with regards to global health – hope of somewhat improving the situation of ‘developing’ countries is based on falsities. The fate of these countries lies almost entirely on the organizations like the International Monetary Fund, whose concerns may sound genuine, but their actual policies are contradictory. For example, although “The IMF acknowledges that poverty reduction is itself a necessary condition for economic growth, and that investments in health and education are crucial to the reduction of poverty”, they insist that in order for ‘developing’ countries to receive aid from bilateral and multilateral donors, or have access to private investment by foreign entities that could help improve access to treatment of diseases like HIV/AIDS, these countries would have to keep their inflation rates low. To these governments, lowering inflation rates restricts national spending in the health sector. In this way, there is a clear shift in the country’s authority to govern its own economy, and in essence, be forced to rely completely on loans from the IMF. Furthermore, while the IMF compels the countries to lower their inflation rates by means of reducing health care expenditure, they also expect them to increase their “absorptive capacity”. This “absorptive capacity” apparently indicates that whatever AIDS treatment program the IMF would be funding will be sustainable. However, increasing absorptive capacity can only be achieved by a substantial amount of spending on health care, which in turn increases inflation! Such policies make me question what the motives of placing such a policy was –as they restricts these countries from making national efforts against diseases through health expenditure. The case of a Botswana is a good example of how this policy makes it difficult to combat HIV/AIDS. Because they complied with all the regulations of the IMF, they struggle to implement programs because of restricted health expenditure, such as hiring sufficient health personnel. Zambia faced a similar issue. By trying to become proactive at improving the national health care and discouraging doctors from leaving the country through monetary incentives, their increased expenditure lead to the IMF suspending them from funding! To me this is a control issue! It is one of the reasons that the term ‘developing’ is deceptive – a word that brings false hope that at some point developing countries will become developed and self sustaining, while organizations like the IMF impose policies that prevent self sustenance and innovation, but rather encourage dependence. Such organizations, whose policies are mostly determined by the leading industrialized countries, the G7 –limit the development of these so-called ‘developing’ countries simply because wealth is concentrated in the hands of the elitist countries only, and decisions that are made do not assimilate the interests of the developing countries.

Readings for 11/18

I was fascinated by the concept in this reading that as medical technology improves, treatment will improve however the challenges faced by the global health field in an ethical sense will keep pase with the trechnological improvements. I also found the quote "So much attention has been devoted to the standard of care in clinical trials that sometimes people living with HIVAIDS in the developing world seem insignificant to developed world bioethicists only when they are the subject of externally funded research." I think one of the key aspects of public health that is often lost in political and organizational decision making is the fact that the large numbers on a page or a computer screen are in fact human beings, who deserve the "best current" treatment, not the "best available." Perhaps this is idealistic in practice, but it should absolutely be the goal of any public health individual worker or organization.

Furthermore, I found the discussion of rationing particularly interesting, as it reprsents a difficult connection between the ideals of public health care system and the realities of limited resources. Limited resources often shape the field of economics as well as public health, thus rendering them closely linked topics.

11/18: The Ethics of Implementation

Frieda Behets and Stuart Rennie's article mentions a lot of important issues surrounding the interventions that have been put into practice to fight the HIV/AIDS pandemic. I especially appreciate that they address the effect international aid angencies like the IMF have on developing countries. One cynical but highly believeable way to look at this situation is that the IMF and other such organizations do not have the people's best interests at heart when they allow a country to sacrifice or reject outside aid money so as not to go above the ceiling income that they set for the country. It is extremely ironic that an organization whose claimed goal is to help poor countries pull themselves out of poverty, would limit how much money that country can earn when it comes to AIDS donations. It is important that we continue to examine the ethics behind AIDS intervention and treatment because AIDS affects other humans and especially with limited resources, it is extremely difficult to decide who or what country will receive money and what country won't. In the ideal world, triaging woundn't have to be a principle concept and there would be no ethical problems but since we don't live in the ideal world, we have to consider how to alleviate the problems in heavily afflicted countries while still respecting the rights of each individual. I personally think, money for treatment should be distributed based on the country with the highest prevalence and infection rates and not artibitrarily or politically which is sadly what happends. PEPFAR is a good example because there are some random coutries that were chosen that even though even a small number of HIV cases is bad, a larger one is worse and other countries with higher prevalences could have been chosen.

Reading Response for 11/18

I found the paradox of IMF "aid" discussed in this article very interesting and also shocking. The way the authors presented the conflict between IMF anti-inflation policies and investment in social services cast the IMF in a definite negative light. I would like to learn more about the justifications behind the IMF policies so that I can better understand the issue and make an informed judgment about this IMF/social services paradox. It does seem pretty ridiculous that a country would be in a position to lose aid by accepting aid!

It seems to me that the best, most moral way to approach all of this is to devote far more resources to the development of infrastructure and the overall health system in underdeveloped settings. I also firmly believe that citizens themselves must take ownership of reform and development of their own countries; impositions from outside continue power structures and colonialist legacies that are usually far from morally acceptable. It appears that powerful countries are still effectively tying the hands of those they are supposedly trying to help through stringent IMF policies and funds that come with strings attached. The complexity lies in what those strings are - the requirement of use of expensive, patented US drugs is an inappropriate imposition of US interests in my opinion, but there are other conditions such as the equitable use of the funds that are far more justifiable. It is due to nuances such as these that there is no rationing consensus, as the authors note.

One of the most interesting and telling ideas in this article was the authors' hope that healthcare providers are not "slaves to the rules." I found this statement slightly contradictory; if the authors are arguing for the necessity of rationing and a rationing ethic to accompany it, how can they advocate bending the very rules that they say must be in place? Though I would tend to agree with them in practice - as a doctor I certainly would not want to turn away a needy patient - I am cautious of their principles. They seem to be saying that the rules are unreasonable enough that it is permissible to disregard them. If this is the case, there should be a different set of rules! I think this hope that providers are not "slaves to the rules" demonstrates an underlying moral/ethical belief that care should be provided to all who truly need it. If that is the moral conclusion, we should be now be working to make that vision possible.