The best medicine for the people
The day before the March 7 edition of the Mail & Guardian came out, I was fortunate to attend a seminar at the University of Cape Town where Nathan Geffen, spokesperson for the Treatment Action Campaign (TAC), presented the research and arguments that were contained in the article Counting the cost of three million lives (March 7). Fortunate because it was an opportunity to question some of the assumptions behind the statistical and policy conclusions, as well as hear the researchers’ views on some of the issues. The experience was far from convincing.
First of all, let’s acknowledge something: the TAC is a lobby group.
It is not morally omniscient and neither is it, judging from statements by the National Association of People Living with Aids (Napwa), representative of the majority of people living with HIV/Aids.
This point is important because the debate around anti-retroviral provision has been tainted (as, unfortunately, have most areas of the HIV/Aids crisis) by the creation of two artificial factions: Aids dissenters and denialists, and everybody else who want the government to provide anti-retrovirals. There is, in fact, also a third group: those who ideally would like the government to provide anti-retrovirals but are concerned that, given the many problems of this country, the money could be better spent. This distortion has been exploited by the TAC and its leaders.
At the seminar Geffen was questioned on whether the money — if it was available — should go towards anti-retroviral provision. His response was that the necessity of providing anti-retrovirals “follows directly from the recognition that HIV causes Aids”. This response blatantly exposes the TAC’s unwillingness to allow for any reasonable debate on the matter and its attempt to maintain public perception of only two positions on the matter.
Furthermore, from a public sector-economics perspective, lobby groups are seen as potentially important in that they draw attention to important but unrecognised social needs, but distortionary because they exist to ensure a greater-than-is-fair allocation of public resources to their constituents. The most powerful of these are often middle class (as many of the TAC’s leaders are) because of the greater time, resources and social connections (especially in the media) at their disposal.
In our country this is especially relevant because it is impossible to meet many of the most basic constitutional rights of citizens. The fact that the TAC has the financial clout to take the government to court does not mean that its case is more important than that of people living in rural poverty.
It is disappointing that one of the most public acknowledgements of Napwa’s existence is in the form of a negative report about an attack on the organisation by the TAC and its allies. Whether the attack is justified is not particularly relevant. What is relevant is that the TAC perspective dominates virtually all media coverage of the anti-retroviral issue (except, of course, for the occasional letter from a raving Aids dissident).
The TAC commissioned the above-mentioned research and, while this does not invalidate its conclusions, having seen some of the assumptions and exclusions made, it is patently clear that it would not be difficult to do plausible research that would come to the opposite conclusion — that anti-retroviral therapy is not feasible. The study assumes, among other things, that viral load counts are not used to monitor patients receiving anti-retroviral therapy, which is within World Health Organisation guidelines, but that CD4 (white blood cell) counts are used instead. It also assumes that patients only go through two stages of anti-retroviral therapy, whereas patients could go through many more but, of course, that would be more costly. These are not unreasonable assumptions per se, but had the researchers’ mandate been to see if anti-retroviral therapy was unfeasible rather than feasible, one questions whether they would have been made at all.
At least one of the researchers has lent her name to public accusations of genocide against the government for its handling of the HIV/Aids problem. Such accusations are at best misplaced and at worst crass and ill-considered. The government has nothing to gain from having a large chunk of its support base destroyed by Aids and, while a senior Department of Health official broke down in Parliament in frustration at the policy dilemma facing the government, the same cannot be said of any of the opposition MPs. The relevance of this accusation is that it indicates a clear bias of at least one of the researchers prior to the research being done — so this is not impartial research.
In his presentation Geffen casually mentioned education, but as Rob Dorrington, one of the Centre for Actuarial Research actuaries, acknowledged: the assumption that people will change their sexual behaviour once they have been through counselling and undergone treatment is a crucial one, because if wrong it would mean “the epidemic will explode”. This would occur because of the increased life expectancy of sexually active HIV-positive people.
All models by nature must make assumptions, but it is important to be aware of the different interpretations that will be made by different researchers with different mandates. Geffen exaggerates his case by comparing orphan and HIV-infection figures from a policy that only treats opportunistic infections with figures from a policy that includes both treatment and prevention — the latter of which the government is in the process of implementing.
Life expectancy gains from highly active anti-retroviral treatment (HAART) are expected to be four to five years a patient, so many more orphans will be over the age of 18 when their parents die, thus reducing the figures. The argument might be made that less orphans implies less government support but, realistically, many of those who would be 18 years and older when their parents die will still require social welfare of some sort.
The TAC had a much stronger argument regarding the mother-to-child transmission prevention programme on both cost and, therefore, moral grounds, because when money is limited, cost and morality are inseparable. The programme is aimed at preventing infection with all the long-term benefits this entails. This, however, is completely distinct from the proposed HAART programme, which can only have short-term effects and whose monetary sustainability and hence moral legitimacy is questionable.
The above are not merely academic concerns. The main issue is a socio-economic one: what is best for the people, given South Africa’s limited fiscal resources? For many (including many HIV-positive people, judging from Napwa’s statements) the roll-out of a HAART programme is not the way to help those worst affected by Aids. The worst affected are those whose decline into Aids is hastened by poor nutrition, lack of access to potable water, adequate sanitation and residence in living areas rife with disease.
Anti-retrovirals will probably reach these people much later than those in the urban centres (where health-care infrastructure is better). But even if they got them now it would do little good (and perhaps some harm) because successful anti-retroviral therapy requires at least basic levels of nutrition.
The government can and should do more to ensure the availability of cheaper generic anti-retrovirals for rape survivors, medical workers (whose work puts them at risk) and those fortunate enough to be able to afford them.
The assumption that we have the money to pay for the TAC’s proposal remains questionable, despite the research, because the issue of fiscal sustainability is not addressed: where will the money come from, other than the deficit, and how will it be repaid?
That said, if the money is available it should arguably be spent on extending social welfare, basic services and supporting subsistence agriculture as well as boosting prevention programmes (that are sustainable) if we really want to help those worst affected by HIV/Aids.
As the World Health Organisation, the United Nations and the Food and Agriculture Organisation said in a recent statement: “A good diet is one of the simplest means of helping people live with HIV/Aids and may even help delay the progression of the deadly virus.”
Sean Muller is an economics honours student at the University of Cape Town