Author Archives: Monica Kao

About Monica Kao

My name is Monica and I am currently a junior at Saint Louis University studying Public Health.

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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Injustice in the health care industry

By: Monica Kao

I’ll be the first to admit that, when it comes to the inner workings of health care and its ongoing reform, I know far less than I actually should.  This is despite having taken HMP 130: Contemporary Challenges in Health Care just last semester.  It’s not that I don’t understand the importance of the topic–I realize that the policy changes being debated right now will affect me (and the things that I do in my future career) on a daily basis–but frankly, health care reform is complicated and incredibly overwhelming.  Reading about it can be boring and confusing–disheartening, even.  It’s easy to be ignorant about health insurance and policy, just like it’s easy to be ignorant about a lot of things that make us feel uncomfortable.  But this piece about health insurance was hard to ignore.  A seventeen-year-old girl in need of a liver transplant died not because of a lack of available organs or substandard care, but because her insurance company refused to pay.  To add insult to injury, the insurance company took extreme measures to protect its image (a spy at a funeral, what?) and to discredit the negative media attention that resulted.  Hey, call me naïve, but I had always thought that health insurance was in place to help us–to defray the costs of medical procedures and the like–and so it’s incredibly jarring to read stories like Nataline’s, or others about rescission.  Where is the justice in a practice that involves looking for ridiculous loopholes to justify canceling someone’s policy retroactively?  Victims of rescission, who rely upon insurers to help them through their time of need and poor health, are saddled with medical debt and even more problems than they had before they decided to seek medical care.

The truth is that health care and health insurance is a matter of social justice.  For-profit insurance companies know that the people least likely to fight policy rescissions and to take legal action against them are the ones who don’t know what their rights are, who can’t afford to seek legal counsel, and who don’t know who to turn to.  In other words, the least educated, the poor, and the marginalized.  Sound familiar, public health students?  These insurance companies are knowingly targeting those populations that will allow them to get away with what they’re doing–which, in case it hasn’t been made clear enough, is profiting at the expense of other people’s health or even at the expense of their lives.  It’s morally reprehensible, and yet all of us allow it to happen because it’s easy for us to be ignorant about complicated policies that may not even seem relevant to us right now.  The overhaul of the health care system will affect all Americans; young or old, rich or poor, healthy or sick.  And so in the context of health care policy, who makes up the community?  We do.  All of us.  We as public health students, as SLU students, as men and women for others–we express such concern for the condition of others all around the world, for reducing health disparities and building health equity, for improving the quality of life; yet, Nataline’s story demonstrates that there are examples of social injustice within our own community.  As public health students, health care policy should matter to us, and it should matter a lot.  As I’ve already admitted, I am neither familiar nor comfortable with the politics of health care, but I do recognize that public health is greatly reliant on health care policy and I know that I won’t be able to take the easy route for much longer.  Someday, these reforms will catch up with us and although I hope that all of my readers are lucky enough to enjoy impeccable health for the remainder of their lives, there’s always the possibility that we might have to learn their true meaning the hard way.  If we expect our community to help us defend our rights and to keep our medical debts from dragging us into bankruptcy, we must also accept responsibility for our community.  Most of us will never be policymakers, but all of us are stakeholders in the changes being made, and we have a responsibility to be informed ones at that.  I’m resolving to try and learn more about health care reform, and although I might regret this later, I encourage you to hold me to it.  Ask me what I’ve read or learned recently, or better yet, tell me what you think.

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