Summary Reimagining Global Health - Chapter 5 & 6 PDF

Preview

Summary

Chapter 5 & 6...

Description

RGH – Ch. 5 & CH. 6 (p. 111-147 – HIV/AIDS) February 16, 2016 Ch. 5: Redefining the Possible: The Global AIDS Response  The Global Age of Global Health o Equity plan created: US President’s Emergency Plan for AIDS Relief (PEPFAR), the Global Fund to Fight AIDS, Tuberculosis, and Malaria, and the Bill and Melinda Gates Foundation o Christian conservatives believed that AIDS was God’s punishment for homosexuality and promiscuity o 2000 – US funded the lifesaving antiretroviral therapy (ART) o Bill and Melinda Gates Foundation is the #1 private funder for global health research and implementation  Focuses on discovery, delivery, and policy advocacy to fight and prevent major global health problems, including enteric and diarrheal diseases, HIV/AIDS; malaria; pneumonia; tuberculosis; neglected diseases; family planning; nutrition; maternal, neonatal, and child health; tobacco control; and vaccine-preventable diseases o New international health policy:  “3 by 5” initiative launched by WHO and the Joint United Nations Programme on HIV/AIDS (UNAIDS) in 2003 – goal of extending antiretroviral treatment to 3 million people living with AIDS in low and middle-income countries by the need of 2005.  Target reached in 2007, not 2005, but it helped to galvanize the global AIDS effort o How did a surge in available resources come about?  In the past global health was institutionalized – cost too much and was not attainable for the majority of those in need  People got used to how it used to be and thought that is how it was always going to be  In the upcoming decade from this - people began to do more and times changed  From Death Sentence to Chronic Condition: AIDS in the Time of Antiretroviral Therapy o In the 1980s and 1990s, AIDS was a death sentence because we did not have the tools necessary to treat the virus – the best we could do was treat the opportunistic infections o Azidothymidine (AZT) was the first drug found to safely and effectively slow replication of HIV in the body - approved by FDA in 1987  This was the only treatment option until 1991 when didanosine came along  Cost $8000/year – only available to those who could afford it  AZT-resistant strains of HIV came along and mortality rates increased steadily in the US from 1987-1995





o AIDS was not high on the agenda of policymakers and people who could afford to help, unfortunately  Few were willing to help, and even fewer were willing to help outside of the United States  Only about 10% of the activist community in the US paid any attention to the global pandemic and effects outside of the United States o 1995 – FDA approved saquinavir – first in the class of protease inhibitors o 1996 – nevirapine – first in the non-nucleoside reverse transcriptase inhibitors (NNRTIs) o 1996 – Eleventh International Conference on AIDS affirmed the promise of these new medications  Here, it was announced that regimens of 3 antiretroviral drugs from at least 2 different classes was effective – became known as HAART (Highly Active Antiretroviral Therapy)  Age-adjusted mortality rate from AIDS decreased 28% from 1995-1996, and more in subsequent years  By 1998, fewer were dying from AIDS than in 1991 One World, One Hope? Different Income, Different Outcomes o Pharmaceutical companies set prices for the HAART at $10,000-$15,000 per person per year – out of the reach of many people o By the late 1990s, many saw that AIDS wasn’t a disease of mortality as much as before and support slowly dwindled o Many prominent voices advocated against treating AIDS with HAART in developing countries because it was not cost-effective  Prevention is more cost-effective  Others said that HAART was too complex to deliver in developing countries (require time-specific administration, etc.) o A study in 2001 by the Bulletin of the World Health Organization followed 150 patients in rural Haiti and found that they adhered to the treatment plan even better than those in the US o They also found that the possibility of receiving treatment encouraged many more to seek out whether or not they were infected o Armed with the above two examples, a small coalition of health providers, policymakers, activities, and academics decried the lack of access to HAART globally o Two principle barriers to provides HAART to HIV+ people  1) high price of antiretrovirals  2) insufficient funding for implementation o Together, the Health Global Action Project (Health GAP) and ACT UP joined forces to lead a worldwide campaign to lower the cost of antiretroviral drugs in poor countries Unpacking the “Cost” of AIDS Treatment: Intellectual Property and Civil Society



o In the mid-1990s, pharmaceutical companies in Brazil began to made generic versions of patented ARV (Antiretroviral) medications and imported supplies from India  70% drop in price of HAART by 2001 o 1997 – South Africa’s parliament approved the Medicines Act that said in the case of a national health emergency, the government could allow both compulsory licensing (generic production of patented ARV medications without permission of the patent holder) and parallel importation (importation of these drugs from countries where they are sold at lower prices)  Many pharmaceutical companies filed suits to overturn the Medicines Act – it undermined the notion of intellectual property and  weakening of incentives for innovation and decreasing funds for pharmaceutical research and development  Advocates of the Medicines Act argued that branded antiretroviral prices far exceed outlays for production, research, and development and prices were high only for profit  After a series of events, the Clinton administration began to support the medicines act and the 39 pharmaceutical companies dropped their claims o Doha Declaration – said that access to medicines could, in certain instances, trump patent protections o Clinton Foundation HIB/AIDS Initiative worked to generate demand, securing agreements from the governments of developing countries to place large orders of generic antiretrovirals at specified prices o Prices fell from 10,000-15,000$ per year in the late 1990s  $87/year in 2002  This eliminated one barrier, but it was still hard to get dedicated funding for HIV/AIDS allocation globally. Strange Bedfellows in the Fight for Funding o 2001 – WHO’s Commission on Macroeconomics and Health published a report that provided evidence that improved health outcomes could boost economic growth o Several global AIDS advocacy organizations popped up around the US o The AIDS lobby – including conservative evangelical Christians, college students, gay rights activities, African Americans, and people living with AIDS – began exerting significant pressure on the federal appropriations process o Franklin Graham (father of Billy Graham) helped to convince Senator Jesse Helms that AIDS afflicted the blameless just as much as the homosexuals, who helms believed to be immoral  Children who contracted it from mother or who were orphaned because of the death of a parent  He eventually helped to sponsor a $500 million initiative to help prevent the spread of the disease from mother  child during pregnancy o Conversion of G.W. Bush during his time as governor of Texas – he was uncomfortable dealing with it because of its link to sex (since he was a conservative); during his campaign for presidency, he said that he would not put AIDS high on his foreign policy agenda if elected

In 2003 – he became one of the great champions of global AIDS relief when he proposed the Emergency Plan for AIDS Relief - $15 billion over 5 years to help fight it in Africa and the Caribbean  This was spurred by decreased drug prices, growing evidence of treatment efficacy in resource-poor settings, grassroots activism, and advocacy by elites  Many other rich countries followed suit After the Golden Age o Since a ton of people were treated, there are still millions who need help o Antiretrovirals can decreased the rate of transmission by 96% - treatment = prevention o Renewed commitment to HIV-control initiatives around the world could slow (or even stop) the pandemic o To treat AIDS, you need a full-time staff, etc. and can help to treat other health priorities  AIDS treatment can be used as a wedge to strengthen health systems 



Ch. 6 – Building an Effective Rural Health Delivery Model in Haiti and Rwanda  This chapter focuses on one model of care based on the approach where AIDS treatment is used as a wedge to treat other health priorities as well  Partners in Health – institution that seeks to strengthen health systems in the rural reaches of some of the most underserved parts of the developing world o Links delivery of high-quality of care to address structural barrier to good health (unemployment, insufficient access to food and clean water, bad health infrastructure, high transport costs, and poor housing  Started in rural Haiti in the 1980s  Was effective because it understood the burden of the disease, but also understood the history, political economy and ethnography of the disease  In the beginning, it was all trial and error and fixing mistakes o Showed that training and research are necessary from the beginning o In Haiti in 2010 – the earthquake caused them to “reimagine” what they could do to help  Haiti: History in Brief o 1919 – Ministry of Public Health and Population was founded – government agency in charge of providing health services o There was war and many of the native Taino people had perished from conquest and infectious disease o The dwindling Taino population was insufficient as the demand for slave labor for sugar and coffee plantations increased  This brutal slave labor system  the largest slave revolt in history – French were defeated and Haiti became the second republic in the Western hemisphere and the first black republic in the world in 1804 o Many former slaves began to own own land and move to rural areas – were careful not to be forced back into slavery and chose control over higher incomes – the peasants were not able to have much power in government, etc.



o International pressure and local misrule paralyzed rural economic development  France demanded repayment for “losses” – capital, land, and bodies of slaves themselves – from the revolution  Haiti paid off debts until 1921  US occupied Haiti for a long time  US leaders rewrote the Haitian constitution to allow foreign ownership of land and to open power in Port-au-Prince  Modern Haitian army created o All of the above things concentrated power in Port-au-Prince and outside of the rural areas o PIH tried to increase export agriculture, but were unsuccessful  During this time, public revenues came mainly from the rural peasantry who toiled, but were cut off from most services and profits o Reign of Francois Duvalier in 1957 further intensified the centralization of wealth and power in the nation’s capital   Duvalierism: focuses on iron rule and not policy – widened the divide between the state and the poor and further undermined the capacity (and will) of the government to provide services for its citizens o During this time, Haiti was facing deforestation  soil erosion and decreased crop yields – Haiti could do little to protect its own agriculture o The Devaliers fled and there was a period of instability and coup o The 1990s was a period of hope – first free elections in Haitian history led to the presidency of Jean-Bertrand Aristide – far-reaching support among the peasantry and urban poor  Military coup forced him out of office but he was reinstated and required to reform the Haitian economy ; he was later forced into hiding by a coup  Haiti was forced under US control Health Care in Haiti o 1/3 of the slaves of one plantation were dead within 1-2 years o The health infrastructure sucked – whites went “home” for healthcare and the blacks, if they were treated at all, were treated in the plantation sick bays o All of the doctors and nurses had fled and a majority of health institutions had been destroyed o Many chronic conditions that are worsened by chronic undernutrition o There is not adequate housing or sanitation o Diarrheal disease was the #1 cause of death among children o Malaria killed people, even though it was eradicated in the surrounding areas o All of this was exacerbated by AIDS in the 1970s  Haiti = one of the epicenters of the American version of HIV/AIDS  PIH tried to confront AIDS in rural Haiti by seeking to adhere to PIH’s mission statement – to draw on the resources of the world’s leading medical an academic institutions and on the lived experience of the world’s poorest and sickest communities





Cange o PIH’s sister organization was Zanmi LAsasnate – launched in 190s in Haiti’s central plateau with a small clinic in Cange – squatter settlement of poor people who had lost everything when construction of a large dam flooded their farm land  Many of the inhabitants of this land were unaware that it would destroy the farmland Acephie’s Story o She was flirted with when she walked to the market to take produce – making money for her family o The Captain – Jacques Honorat – liked her and since he was rich, she accepted that – he had a wife and children, and many other partners –everyone knew that  She got AIDS from him – they were only together for one month  She was unable to go back to school, so began to learn to be a maid for the people living in the city o She began working in the city and began seeing Blanco – a man with similar origins as her own; he was successful and they planned to get married o Acephie became pregnant after 3 years as a maid in the city – this was unsightly for a servant to be pregnant so the owner got nervous and Acephie moved back to Cange – Blanco left her and she had a hard pregnancy, she had many opportunistic infections and was diagnosed with AIDS o She later developed tuberculosis o Her daughter was also infected with AIDS, so were the captain’s other partners and children, and Blanco could have the disease with no symptoms yet and is still infecting other people o Acephie’s father killed himself after Acephie’s death...