How sick is sick enough?

By: Monica Kao

Public health has been defined in a number of ways–most emphasize building health equity in some capacity or another–but of all the definitions that I’ve seen, none place an upper limit on how healthy a community can and should be.  Similarly, none seem to define just how unhealthy a community must be in order to merit public health efforts.  In its most ideal form, public health strives to achieve maximal health in all communities, but the availability of antiretroviral drugs is one example of what public health can look like when resources are limited (as they almost always are).  The study, published by the Lancet, revealed new evidence that antiretroviral triple therapy greatly reduces the transmission of HIV from mother to child.  However, there are several low and middle-income countries that lack sufficient funding to provide antiretroviral drugs to all HIV-infected individuals.  Those individuals whose condition has not yet progressed to AIDS are not considered to be eligible for triple therapy and are forced to seek drug assistance from alternative sources.  In other words, although the triple therapy has been shown to benefit all individuals infected with HIV, individuals must be sick enough to qualify for the drugs.

What does this mean in the context of public health?  Using antiretroviral therapy to reduce the transmission of HIV is clearly an issue that is important to public health, but the criteria for drug assistance seems almost incompatible with its mission to improve the health of the entire community.  Upon closer examination, however, one sees the extent to which the success of public health depends upon the availability of resources.  An antiretroviral drug regimen can cost a person anywhere between several hundred and several thousands of dollars per year, and without adequate funding, health ministries simply cannot afford to provide antiretroviral therapy to all individuals known to be HIV-positive.  Some readers might feel complacent about how the drugs have been distributed–it seems as if the governments of these low and middle-income countries are doing the best that they can with the resources that they do have, and in many ways, it makes sense to give the available drugs to the sickest individuals.  It does make sense…doesn’t it?  Perhaps from an economic standpoint, but it isn’t the only perspective to be considered.

The study itself focuses on reducing HIV transmission from mother to child, and not just on treating HIV.  Imagine two women living in South Africa–both are pregnant and HIV-positive, but one expectant mother has a CD4 cell count that identifies her as having AIDS.  As a result, she gets the antiretroviral therapy that prevents her from infecting her baby during the breast-feeding stages.  The other mother later contracts an opportunistic infection that qualifies her to receive the drug therapy, but not before she infects her baby.  Has justice been done?  It was easy for the South African health ministry to determine which mother was sicker (at least initially), but in using “degree of sickness” as the criteria for who would receive treatment, the ministry also inadvertently decided that one baby’s life was more worth saving than the other’s.  It hardly seems like justice, by any definition of the word.  Reserving antiretroviral drugs for the sickest individuals seems unfair when it could also mean condemning newborns to a life with HIV.

The article raises some tough questions, for which there are no easy answers.  What rights do the mothers and newborns have to antiretroviral drugs that do not belong to them?  How do we equitably distribute resources when there aren’t enough to go around?

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