Fire, brimstone and AIDS activists

I’m sure many readers are aware that there’s been a bit of a debate lately about spending on AIDS in the developing world. Is AIDS crowding out other infectious diseases, other health issues, other development issues? Or has the AIDS epidemic focused attention on the woeful neglect of health in developing countries, and will it provide a rising tide of funding that will float all boats?

I’ve been copied in on an e-mail thread which discusses these issues, in sometimes extraordinarily vitriolic terms. Participants include the editor of The Lancet, Richard Horton, Roger England, who infuriated many with his “Enough, already” comment about UNAIDS in the BMJ, and a number of AIDS activists. I’ve questioned some of the consequences of activism in my book, but I have to say by far the most sensible comments here come from David Barr, who points out the overwhelmingly positive impact that AIDS activism has had on public health in general.

I myself come in for a bit of stick in this exchange, though largely for things I have never said. I’m curious what the reactions of anyone who has actually read The Wisdom of Whores to this debate might be. So that you can follow the (often shrill) argument more easily, I’ve re-arranged comments in chronological order, so you can read from the top down.

On Behalf Of ellen.verheul@WEMOS.NL
Re: CLARIFICATION – Re: notes from SuRG/H8 mtg June10
Dear Sue,
Thanks for your reply. I fully agree with you that it is unacceptable to rob Peter to pay Paul. Unfortunately this is exactly what is happening, as disease specific results are usually achieved by borrowing existing health systems components (most notably staff and staff time). This leads to robbing Peter to pay Paul, by default. I agree we should stop this.
The very idea behind the IHP was to do something about the multitude of specific disease programmes is driving recipient governments insane, while many of the local priorities don’t get funding support at all. This practice should come to an end. We need more ánd more flexible aid; not another increase of earmarked funding. The civil society principles are sending out a dual and conflicting message: yes, more money for primary health care please, but also please increase funding for our priority diseases. We can see what this means this in full swing, in preparation for the aids conference. When a donor increases the level of flexible funding, it is met by a cry that this is robbing from Peter etc, while instead we should welcome this as an effort to pool resources and achieving results for Peter, Paul and Joyce.
What I saw in a public district hospital in Zambia illustrates this point. There are similar stories from other countries. The few available district nurses are sent to training one after the other: to improve their skills to test, treat and council aids patients. They appreciate this, because it enhances their knowledge and they have the opportunity to meet new colleagues. In their hospital they are now able to provide drugs for free to aids patients, they can spend time to council patients (30 min, much more than they were used to spend on any patient), the aids clinic is nicely painted, the lab is functioning, and they receive extra allowances to top up their meagre salaries. They feel rewarded and their job satisfaction has increased: they are now able to properly treat patients who they could previously not. The aids patients feel encouraged. They get a sense of their right to proper treatment and they start demand these rights. It seems that this disease specific programme is strengthening the local system.
The other patients are waiting in a longer queue, for staff that has less time available because of the additional tasks, and the time spent per patient is very short. They still have to pay for the drugs they are prescribed. The ward is not painted. The nurses are not paid incentives for these ‘regular’ clinics and they treat the patients less friendly. They realise this, and feel guilty about it. But they feel exhausted. Aids treatment coverage is going up, while vaccination rates are going down. The woman in child labour, the child with pneumonia, the aids patient with a broken leg: they don’t get the care they are entitled to. In fact, they are worse off as there is less time available and they are now seen as second-class patients. And the situation is getting worse, as aids organisations are recruiting staff from the public sector and from the private for profit sector, to run the aids clinics outside of the public sector. They find the staff, because they pay higher salaries and offer better working conditions, leaving the public sector behind.
My question is: who is Peter and who is Paul?
I wish that IHP civil society principles could unambiguously speak about health, health services and strengthening health systems so they respond to local communities’ health needs.
I don’t believe in civil society principles that include language that legitimises the call for extra disease specific funding. Disease specific programmes are usually not accountable to the rights of other patients. If disease priorities are to be set, it is by the local community, not by donors. I think IHP should be very clear and outspoken about that.
Warm regards Ellen Verheul Wemos
On Tue, Jun 17, 2008 at 6:46 PM, Gorik Ooms

This post was published on 25/06/08 in Ideology and HIV, Money and AIDS.

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  1. Comment by Rebecca A., 30/07/08, 05:41:

    I _did_ read _Wisdom of Whores_ (and enjoyed it enormously and reviewed it favorably over on livejournal). I agree that in that sequence, David Barr comes off quite well. Gregg’s (?) characterization of your statements (at least in the book) is not on-target. I run into this kind of problem a lot, where someone skims and misses qualifiers and thus completely misunderstands a point or position and that appears to be what happened there.

    I read _Fatal Misconceptions_ immediately before _Wisdom of Whores_ which gave me a weird perspective on UN/global “health” movements, particularly of the we’ll do this one thing but won’t supply you with decent health care AND we’ll in fact take money away from what primary care you have for our current pet project (in _Fatal Misconceptions_, population control). I am, therefore, very sympathetic to people who hope/dream/believe that maybe money sloshing around a particular high-profile concern could be redirected to answer a dire need that is being ignored — but I have a hard time subscribing to it myself.

    I also know — because I’ve only ever lived in the US — that getting people in the US to accept the idea of health care as a basic right is very, very, very hard. Which is going to be a big obstacle to getting the US to (consistently) fund something elsewhere that they can’t even bring themselves to fund at home.

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