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Treating HIV Doesn't Pay?

Written by David Batstone

I was leafing through a copy of Forbes recently, and an article caught my eye: "Treating HIV Doesn't Pay." The tagline was equally jarring: "It is humane to pay for AIDS drugs in Africa, but it isn't economical. The same dollars spent on prevention would save more lives."

The piece penned by Emily Oster, a graduate student of economics at Harvard, applies an economic cost-benefit analysis to a serious social crisis. She pits pouring resources into antiretroviral therapy that may save individual lives against a preventative strategy that would arrest the spread of the epidemic.

Oster does us a yeoman's service by dispelling a widely held myth that AIDS has spread in Africa primarily due to the undisciplined exercise of libido -- in plain terms, the idea that Africans have more sex and more sexual partners. While sexual behavior certainly plays into the AIDS epidemic in Africa (as it does everywhere), Oster points out that its transmission can be traced in large part to untreated infections such as gonorrhea and syphilis that create open sores and serve as a hotbed for HIV.

Moving from that assumption, she suggests two measures that would be more effective than treating individuals with HIV. First, shift precious resources to deploy antibiotics to treat sexually transmitted infections that precipitate the spread of HIV. Second, invest in education that will help Africans better understand how HIV spreads and how to act preventatively. Both methods, Oster argues, would be more cost-effective:

"Antiretroviral treatment is around 100 times as expensive in preventing AIDS deaths as treating other sexually transmitted infections and around 25 times as expensive as education."

Oster is not cruel. She acknowledges that morality and compassion may compel us to jettison a cost-benefit analysis and opt to treat the afflicted with mercy. But she also helps us understand that we may be trading off compassion for more feasible long-term solutions.

The facile reaction to her dilemma is to pretend that we do not have to make such a trade-off. We can invest in treatment, prevention, and education. Surely she's built a false divide; can't we just integrate all these efforts into a comprehensive strategy?

The truth of the matter is that health organizations do not have unlimited funds at their disposal. It would be right to point out to wealthy nations the shame of this scarcity in a world of plenty. But a prophetic "should be" does not erase the harsh truth of what exists in front of us. The funds available to health agencies are insufficient to address the crisis.

So how do they best address the spread of AIDS in Africa, India, China, and elsewhere? Oster's analysis helps, but it also leaves out some serious considerations. The number of lives saved is not the only goal of intervention. A human society can be torn apart by the loss of an entire generation of parents, educators, and leaders. The future of a society depends on both its young and its old, on vitality and wisdom.

It is an even more intangible objective to promote a spirit of compassion and hope in a society. But it is a sacred mystery we deny at our peril. The gift -- and sometimes the curse -- of being human is our empathetic impulse. To suppress compassion and turn wholly to calculation would tear out the soul of society.

Unfortunately, we are stuck with a tragic dilemma. Everyone's good dream will break somebody's heart.

*A longer, original version of this essay is published in the March edition of Sojourners magazine.

Comments

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Rachel Myren - Alternate Solution

2006-02-16 02:17:45
Call me an idealist, call me naive, call me whatever.... I choose hopeful. But it is my belief that the overlooked solution to the tragic dilemma of this article is simply increase funding. Clearly there is not be enough money to fund all that is desperatly needed in aid for Africa in the current budget but it does not have to be that way. It is a waste of time and lives to debate how and where the money should be spent when neither solution is adequate. Should I put out the house fire with the cup of water or the cup of sand??? if these are my choices I should choose the one that is closest and fastest to implement and then quickly turn my attention to calling in help from a fire department, or dare I say a Government? Anyone wanting to read what inspiring words Bono had to say to the presisent and many other powerful people at a very recent National prayer Breakfast follow this link http://www.data.org/archives/000774.php

Rev. Jennifer Brooks - Treating HIV

2006-02-16 07:52:35
Thanks for your wise and thoughtful words opposing a mere "cost-benefit" analysis. But Oster's argument falls short on economic grounds, too, because there's an economic "cost" to HIV. Teachers, government workers, laborers stricken and untreated cost millions of dollars in GDP and can lead to failure of a country's economic infrastructure. Yes, prevention is important and fairly cheap, but if we don't help Africa treat HIV we could see a catastrophic failure of civil society--with disastrous consequces for the world economy. What's the balance on that cost-benefit analysis? There's not only an ethical reason to treat HIV, there's a practical reason as well.

Arden C. Hander - ...Uganda & the Bush regime...

2006-02-16 09:43:47
Billboards touting 'chastity' abound in Uganda at the expense of even the cheapest forms for prevention [i.e., condoms]. Why? This is the pseudomorality of the ReligiousRight as it flexes its muscles into U.S. Aid & other governmental policy decisions, readily adopted by the current regime but hardly in the national interest or representative of the majority of us. When public policy panders to such blackmail, we get what we have now. Understanding this should mandate our marching orders to scrap this regime pronto & respond more appropriately. There is nothing wrong w/chastity as a piece of the jigsaw, but that it should DRIVE all policy is reprehensible. Bush agrees, however, which is the problem, & it's similar to the hypocrisy of the Terry Schiavo affair which was opposed by 85% of all Americans, hardly a partisan response. It's also like Wal-Mart's rightist pharmacists & administrators refusing to dispense birth control pills & thus impose their pseudovalue on the public at large, except that can be righted by making another choice of supplier, however inconvenient. Yet those in Uganda & Africa are captive. Compassion is just a word devoid of meaning in the Bush regime. It would be nice if the problem would disappear by billboard advertising, but that's silly. Any preconceptions we own must be postponed slightly as true education is provided as a component of treatment. Pious piffles can come later but hopefully never. Public policy and private religious diatribe, even if sincerely held, just do NOT mix. Neither Africans nor Americans should be held hostage any longer. The costs of waiting are immense.

Terri Poster-Taylor - Treating HIV: treatment vs. pr

2006-02-16 09:49:19
I have spent the past 15 years working in the health care community with People with HIV/AIDS. I am not a healthcare provider, but an administrator. I am certified as an HIV/AIDS Community Educator. I was a founding member of the HIV Health Planning Council and the first co-chair of the council. I believe that increased funding for PREVENTION is the answer, not treatment. In the early years, we did not have anti-retroviral drugs, so we relied on education and prevention. We started to see results, in decreased transmission among men who have sex with men; needle exchanges started to see a decrease in injecting drug users transmissions; and the heterosexual transmission rates remained low. Once the new drugs hit the market, much of our prevention work was forgotten. People started thinking that now there is a drug that will allow them to live longer and feel better,so they went back to their old habits. Many older gay men lament the younger generation of gay men who no longer use condoms; who have multiple partners and who don't know, or don't care, about the ravages of HIV on the gay population in the 80's and 90's. Heterosexual transmissions are up in numbers, too, because many straight people still believe that this is a "gay" disease. At every turn, prevention workers are blocked by the religious right who want only abstinence taught. Abstinence is correct: it will prevent transmission. But the majority of the population does not take the religious stand of no sex before marriage. EDucation, Education, Education is the answer, whether in the USA or in Africa. In Africa, the transmission is mostly heterosexual; woman need to be empowered and educated. This subject is much too complicated for a blog; just a few of my thoughts based on my years of expereince.

David Dunn - AIDS & Marijuana

2006-02-16 11:08:44
Marijuana is probably the best treatment for AIDS. It stimulates the appetite.

Too, live hemp seeds have all the amino and essential fatty acids the body needs in right proportions. It helps strengthen the immune system.

Kirsten - to explore these concepts furt

2006-02-16 11:11:31
I highly recommend the book "Mountains Beyond Mountains" by Tracy Kidder. It does not directly deal with AIDS, it is the story of Dr Paul Farmer, and his quest, or passion to help the poor of Haiti. A calling which extends to trying to affect world policy as it relates to the treatment of TB. The book relates to this discussion because, amongst other issues, it raises a discussion around costs of treatment and our differing treatment of the poor. Also it is a well written, inspiring, challenging and ultimately hopeful book. One thing I took out of it is that one must take the opportunities that present themselves to be an agent for good. Sometimes this requires some discomfort or sacrifice. (Certainly in Dr. Farmer's case it did!) But we each have some place in our life that we can be a change agent using who we are and what is right in front of us, and we should not shy from this. To get a little bumper-stickery on the subject: If we are not part of the solution, we are part of the problem.

Steve Meloan - Mr. Spock should not rule

2006-02-16 16:05:52
It raises some very interesting points
and difficult moral quandaries. But I couldn't agree more with your
conclusion. If we were all Mr. Spock, the cost-effective route would
be the obvious one. But even he sometimes chose the less logical but
more human path.

KS Huang - Naivete and Compromise?

2006-02-17 01:19:02
Reading over the responses, I cannot say that my thoughts change much, but I do feel that simply saying "increase funds" is naive. However, listen to my proposal and perhaps I shall be labeled as such as well.

Because the problem as it stands is that there are not enough funds to support treatment, prevention, and education, why do we not distribute the responsibility? For example, one group focuses on treatment, another on prevention, and another on education. This way, all bases are covered, and no increased funding is needed. I'm thinking of holes in this solution, but really, I cannot come up with any. In fact, I think it's an optimal one because it not only leverages the efforts of each group, but also helps refine each focus and the group's practices so that we have experts in each topic.

KS Huang - Naivete and Compromise (cont.)

2006-02-17 01:29:53
Sorry, I forgot to add this. This is what would really show my own idealistic naivete.

I feel like the root of the problem is not a dearth of funds, but rather, the politicizing of health care. As Maslow and pretty much any average person can tell you, one of the most important things in life is health. It is hard to focus on self-actualization or helping others or pretty much anything if your own health is not good. I'm not sure where I came up with/heard this idea first, but I have started another book by Paul Farmer (the author brought up in Kirsten's comment) called Infections and Inequalities, also about health care in the Caribbean. And as any healthcare nut will tell you, health care should be a human right, rather than the societal privilege it is today.

So how do we remedy this? In a classic easier-said-than-done attitude, we stop judging who deserves health care and who does not. I realize that this will lead to a very socialistic (perhaps even bordering on communistic when taken to more extreme levels) view and application of health care, but I do believe that, like many things, given the chance, people will see that this is the simpler solution.

marta - ahem; poverty,gender and power

2006-02-18 13:21:04
Here's the response from a friend (phd researcher in the field) i emailed your article to; bringing attention to the deep layers of challenge on the "prevention" / education side of the equation, which I feel deserve the stronger weighting in the funding argument.

"Thanks for the article, it's always good to know what's out in the press. Apparently (and quite unfortunately) Ms. Oster is unaware of poverty, gender and power dynamics in southern Africa. Women have neither the social, political, nor legal privileges that men have (land and property go to men, not women). Many many women become infected within marriages, yet married women cannot (and do not) question their husbands fidelity. It is common for men to have many young mistresses and these young women (girls) engage in sexual relations to ensure that they have something to eat. The rate of HIV is high, so these situations infect multiple young women. In a conversation I had with a nurse from Botswana I learned that even though this type of situation is very common (an older married man having many young mistresses), it is socially unacceptable to talk about sex in public and to provide sex education (even in health care settings). This nurse had a paid job in a hospital to develop educational programs; the problem was the daily hospital routines were overseen by older nurses who would not tolerate such "inappropriate" conversations, so she was not allowed to administer her program (even though that was her job). This catch 22 is completely ingrained in the culture. Men have the power (financial and social) and thus more resources, so in a resource-poor setting, they call the shots; and the cultural framework sets up (even) women to propagate practices that disempower and put women at risk. Going against the cultural norms results in violence toward women and social isolation. Oh, by the way, there are also a variety of myths floating around ( i.e., sex with virgins will cure HIV and "dry sex" with virgins is even more likely to cure HIV [sadly, this just increases the risk that the virgin will get HIV). All of this has been recognized in the public health arena for years (a big topic at the 2000 International AIDS conference). It has been recognized that empowering women is one of the single most important ways to curb the spread of HIV in Africa, but that is a huge and daunting task that will take a very long time to achieve (people who have power are not likely to give it up easily and cultural norms never change quickly because of this). In the meantime, all we (Westerners) can do is improve the lives of people who have HIV with medications (which, by the way, are oftentimes tested in African countries [another huge topic--the ethics behind testing a drug in a country that will ultimately not be able to afford that drug, is not trivial). In my opinion, when economists like Emily Oster put forth their convictions about ways to spend money in the medical arena, they have a very serious obligation to understand the medical and social situations on which they are commenting and, more importantly, the potential repercussions. They are influencing public opinion with their economic models (that ignore social reality), which influences how money is spent, and regressing (10 to 15 years) what public health practitioners (like me) have worked hard to achieve. Irresponsible research is released all the time. The opportunity to become famous for the work apparently outweighs the repercussions to society. sigh."

Paul Schryba - It's the economy, stupid

2006-02-18 15:50:57
The truth is that our American economy is
burdened by military expenditures (principally the Iraq war) and tax cuts. As long as Bush and the Republicans are in the White House, and Americans are into materialism as our primary value, we will not do much.

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