Honesty is a Virtue

Roger Bate & Kathryn Boateng | 24 Jan 2007
Foreign Affairs

Efforts to improve global health are often crippled by a state of denial. Failure to consider unfashionable modes of disease transmission or use proven but politically unpopular methods in disease prevention and control is illogical, dishonest, and should be exposed.

There was a great deal of media coverage recently denouncing Moammar Gaddafi's regime for condemning to death five Bulgarian nurses and a Palestinian doctor. The Libyan government alleged that these health workers had deliberately infected children with HIV in a hospital in Benghazi. The media graphically detailed the personalities in the case and their tragic circumstances (the nurses were allegedly sexually abused and tortured by the prison guards). But certain crucial parts of the story were only briefly illuminated, such as the fact that the unfortunate Libyan children received the virus not through sexual transmission but through poor clinical and hygienic practices.

Such "iatrogenic infections" account for an unknown but possibly large proportion of HIV infections in the poorer parts of the world. A recent study in the British Journal of Obstetrics noted: "There is mounting evidence that rapid HIV transmission is fuelled by parenteral exposures in health care settings, especially medical injections but also including transfusion of untested blood and others . . . . The common belief that 90 percent of HIV transmission in Africa is driven by heterosexual exposure is no longer tenable." Some studies have shown that as many as 40 percent of African HIV infections are linked to unsafe injections. This means that donor-supported vaccination programs, and possibly even HIV treatment programs (through increased testing), have helped spread HIV.

Far from being highlighted as a logical target for advocacy and action, however, such issues are neglected. Western HIV prevention programs, meanwhile, revolve around promoting safe sexual practices. Depending on what generates the least controversy at home, donor organizations promote policies varying from abstinence to effective condom use. These programs are not pointless, but they are an example of how funding is skewed towards what people in the West want to deliver.

And in their bid to keep the aid flow lines open, at all times and at any cost, host governments in poor countries often simply adopt these policies without paying proper attention to revamping their dysfunctional and severely under-funded health systems — the same systems that too often force medical personnel to re-use needles and transfuse unscreened blood. For lack of safe needles and blood-screening equipment, in other words, health workers have no option but to resort to unsafe health practices in an attempt to save patients' lives. The real culprits are undoubtedly government leaders like Gaddafi who do not admit that their own clinics and outdated practices are to blame for these misfortunes. But almost as culpable are those in the West who know about a major cause of infection and do nothing about it.

There are myriad other examples of failure to adopt sound approaches to disease control. Consider the use of the pesticide DDT in malaria control: Until the WHO and USAID recently reversed their positions on it, DDT's use had been discouraged by Western agencies for over 20 years. Alternative methods of malaria control (such as the use of bed nets) can work, and it is simpler for donors to promote one tool. But the best way to help those dying from the disease is to aggressively use all the weapons in one's arsenal, and there is strong evidence that indoor spraying of DDT can control malaria admirably. Yet given the chemical's poor image, the advocacy community has been slow to support its use.

More foreign aid, both public and private, can help promote public health in poor countries. But that will happen only if care is taken to make sure the aid is directed at appropriate targets and used wisely. No one wants to help spread HIV or combat malaria ineffectively, but that is unfortunately where many aid efforts stand today. This is why, as Laurie Garrett suggests, any credible global health aid effort must involve measures aimed at strengthening local health-care capacity. And developing nations themselves must also do better — for example, by doing away with the large regressive tariffs they impose on the import of essential medicines and medical devices, trade barriers that end up keeping the medicines from reaching the poor.