The current debate gripping global health policy brings to mind the sort of facetious question that an idle instigator might toss around a listless bar. “Hey stranger, which would you choose: death by Aids, or death by diarrhoea?”
At the glass tables of the boardrooms that write our fate, I imagine the question is slightly more sophisticated. “Ladies and gentlemen, which would be cheaper for us to avert: death by Aids or death by diarrhoea?”
Over the past year, a wave of anti-HIV sentiment commonly referred to as the Aids backlash has arisen largely from Western academics, journalists and policymakers promoting the view that overfunding of HIV is the cause of underperformance in other areas of health. Their arguments are blurry, but the economics are clear: best price for HIV treatment, a few hundred dollars just for one year. Best-case scenario for diarrhoea treatment: “pennies”, to quote Celia Dugger in the New York Times. So what is it going to be?
At this rate, it might be back to the Nineties. Growing up in sub-Saharan Africa, before I could tell you what Aids stood for, I understood the associations that came with those four letters — the ripple of discomfort when it came up in conversations, the whispers between grown-ups about the neighbour who had been coughing for weeks: “Have you seen her skin? I can always tell by their skin.”
This was the era before treatment became available. HIV was a disease, but not an ordinary one. It was moralised and stigmatised and politicised while the tragedy steadily escalated out of control, until a resolute activist movement demanded the money for medicine to do what it is meant to: treat disease and prevent death.
Other diseases, lacking the benefit of organised advocacy efforts, continued to lag behind as they always had, whereas the global HIV response creaked into action and progressed to the point where it has apparently assumed a “glamorous” aura.
There is nothing glamorous about disease and death of any kind: they are invariably ruthless, impenetrable and incredibly painful, regardless of where you stand in the disease arena. And if you’re living in sub-Saharan Africa, chances are you’re standing pretty close to HIV. You’re probably standing close to child mortality too, and to maternal mortality, and to tuberculosis — and you probably understand that attempts to disentangle these health needs are disingenuous and destructive; though distinct, they coexist within the same people.
The region has an extremely high TB-HIV co-infection rate — above 50% in most of Southern Africa, where more than half of the deaths in children under five are also a result of HIV. Diarrhoea itself is an opportunistic infection linked with untreated HIV.
In this light it would seem obvious that taking resources from one disease to tackle another is irrational and self-defeating. And yet policymakers remain fixated on pitting illnesses against each other, shuffling numbers on spreadsheets in their formulation of half-hearted efforts to address a broader range of health needs with the same meagre pool of resources.
The crumbling state of public health in developing countries is much bigger and much older than HIV, and is rooted in a lack of accountability at all levels. The United States government, now wringing its hands over the money that has been spent on Aids, was for many years directly responsible for vast overexpenditure on HIV treatment by prohibiting President’s Emergency Plan for Aids Relief grantees from procuring cheap generic medicines — to the optimal financial gain of US-based pharmaceutical giants.
Some of the national governments that are leading the calls of dismay over donors’ backtracking on commitments to HIV have, in the past, failed to ensure that donor money is put to good use. Many have even failed to meet their own domestic obligations to funding health.
And so it trickles down: the patient whose immune cell count and physical health are plummeting, who has given up a day’s wages to travel to the nearest clinic and stand in line for hours, only to be told that no new patients are being started on antiretrovirals. Just like the old times. Come back when you get diarrhoea, which should happen soon enough as your immune system crashes. Just pray that TB doesn’t get you first. Its 15 seconds of “glamour” have not arrived yet.
Thus continues the perverse, irrational game of musical chairs that policymakers play with diseases. There is a way out, but it is expensive, and hence undesirable. The powers that be would rather wage wars, curtsy to corporates and debate development in lavish meetings while millions die quiet, unnecessary, statistical deaths on the fringes of their polite financial arithmetic.
Paula Akugizibwe coordinates the TB/HIV treatment literacy and advocacy programme at the Aids and Rights Alliance for Southern Africa