Public health requires perseverance. A mutation in a virus responsible for avian flu or in the parasite that causes malaria can instantly change the course of a disease -- who gets infected, where, and how. Many other changes, in politics, economics, leadership, geopolitical stability, funding, even weather can impact progress treating and preventing diseases. Technology also changes the course of disease, although promises of technology advances sometimes provide more sustained satisfaction than the actual technology fulfillments. In the fight against AIDS, for instance, [romises vaccines one-upped promises of retroviral treatment for all, which in turn supplanted promises of prevention through education and condoms. Ths means that progress on the ever devastating HIV/AIDS pandemics takes even more perseverance than many less lethal threats. It's morbid to think there may never be a silver bullet for the HIV/AIDS crisis, but at the least, many more strategies will be tested en route to stanching the devastation of the virus.
Despite global discouragement, there are always optimistic moments, like ten years ago when education and prevention through condom use and social marketing was the crux of HIV/AIDS fight. In September, 1998 Washington Post reported on the "remarkable success" of the new strategies.
Across the world, the paper said, HIV infection rates were decreasing. In places like the Dominican Republic, Brazil, and Uganda, and the Ivory Coast, and in Tanzania,, where a three year trial aimed at decreasing sexually transmitted diseases had "reduced HIV transmission by 40 percent". An administrator from the AIDS Control and Prevention (AIDSCAP), Brian Atwood, told the paper: "this agency has made a global contribution....over the years, we've learned so much about this..."
Learning about the risk of AIDS doesn't necessarily change sexual practices or result in long term success. The AIDSCAP program ran through the 1990's and despite the successes, suffered many obstacles. Any program can be derailed by staff turnover, stigma around disease, misunderstanding of disease etiology, uneven programming, funding shortages, interruptions, and politics.
Today in Tanzania infection rates are lower than places like South Africa, averaging at about 8%, but overall life expectancy has decreased by 8 years due to AIDS. While HIV infection in urban areas declined by 16.65% from 2000 to 2005, in rural areas infection rates have markedly increased. Other critical economic development measures have also regressed in Tanzania, for instance literacy rates dropped from 80% in 1980, to 60% today. In one survey of adults, 52% of women and 62.5% of men believed that a teacher who has "the AIDS virus but is not sick should be allowed to continue teaching."
Now, an experimental trial in Tanzania will attempt to attack this complex knot of problems underlying the HIV/AIDS epidemic with a market solution. The Financial Times wrote last weekend about a project in Tanzania that would pay people who practiced safe sex. The trial participants would take regular tests for sexually transmitted diseases like gonorrhea, and be paid about $45 if they remained disease free. The control arm of the trial would not be paid. All would be treated for any infections. Sexually transmitted diseases increase the risk of becoming HIV infected and Tanzania has long focused on this connection.
The project is sponsored by the World Bank, William and Flora Hewlett Foundation, the Population Reference Bureau and the Spanish Impact Evaluation Fund (affiliated with the World Bank). The Financial Times quoted Carol Medlin, a researcher on the project from the University of California, San Francisco, who said: "We hope this 'reverse prostitution' will make people think hard about the long-term consequences of their short-term behaviour."
The move is controversial -- can paying people for intrinsic choices motivate them? Can the complex set of problems underlying AIDS epidemics, involving everything from public health infrastructure, to politics, social norms, economics, and leadership, be resolved by motivating personal choices with money? In an accompanying editorial ("Cash for safe sex; Bribing Africans to be careful is bizarre - and worth a try"), the Financial Times suggested that the scope of the problem warrants such an attempt: "In the face of an appalling Aids epidemic, we should overcome our unease." Should we?
Leave a comment