The Top Five Controversies in Global Health

by Alanna Shaikh

Published January 01, 2009 @ 07:44PM PT

(photo credit: Augapfel)

What could be controversial about global health, you ask? Treat the sick people. Keep the healthy people healthy. Discover new cures and vaccines. It’s one of the few fields where we actually know what works and how to go about doing it. And you are right. All of these things are true. Except – there is a limited amount of money available to spend on global health. So, every choice you make has both winners and losers. If you spend money on HIV, you’re not spending it on polio. If you spend it on women, you’re not spending it on men. Every decision disappoints some people, and rightly so. Ergo, controversy.

Single-issue funding

There is a lot of funding out there for vertical programs - health programs which target a single disease. The US has two – the President’s Malaria Initiative, and the President’s Emergency Program for AIDS Relief. There is also the Global Fund for AIDS, Tuberculosis, and Malaria, which is limited to just three diseases. When you focus on a single illness, or a just few, you can measure your efforts, and measure your results. It’s quantifiable. You can work to eradicate a disease, like we did with small pox. You can evaluate the amount of money you spend compared to the rates of the disease you’re fighting. Donors like this kind of data; it’s a clear indication that their funding has an impact.

However, plenty of global health experts think that fighting a single disease is inefficient. It doesn’t build the capacity of the health system as a whole, and it can distort the entire health sector. Health care providers and services are pulled into the area where there is money. If all your doctors are treating tuberculosis, who takes care of the children with pneumonia?

HIV/AIDS – prevention vs. treatment

The question of how best to fight AIDS is a constant debate. The appropriate balance between spending on prevention and spending on treatment is hotly contested.

Since AIDS cannot be cured, prevention is essential if we want to reduce prevalence of the disease. It’s been conclusively proven that funding is more effective when spent on prevention. Providing treatment for sexually transmitted infections is also a cost-effective way of slowing the spread of AIDS. In addition, discussions of prevention are complicated by debate over whether AIDS is best prevented by promoting abstinence, fidelity, condom use, or all three.

At the same time, there are ethical and pragmatic reasons we can’t just ignore the people who are already infected with AIDS. Morally, we have a responsibility to provide treatment for people if that treatment exists. In a practical sense, if there is no treatment provided for HIV, people have no incentive to get tested for the infection. HIV treatment is needed both for its own sake, and to bring people living with AIDS into the health care system and encourage them not to spread the disease to others.

Generic drugs for HIV

Producing generic versions of the anti-retroviral drugs (ARVs) needed to treat HIV would be a rapid way to reduce the cost of treating a very expensive disease. It has the support of a number of governments in the developing world, as well as UNICEF and the World Health Organization. Pharmaceutical companies throughout the developing world are already working to develop generic ARVs.

This effort was strongly opposed by the US and Europe-based pharmaceutical companies that developed the anti-retrovirals. They stand to lose a lot of money if they are not the only manufacturers of HIV drugs, and they argue that this is unfair to them after they already spent the money to research and test the drugs. Furthermore, they argue that effective HIV treatment requires the close monitoring of complicated combinations of drugs, which many countries lack the infrastructure to do.

Abortion
This is so very controversial I almost left it out of the post from sheer terror of the response I’d get. Should we support safe abortion? Should we support-post abortion care, even if we don’t provide any support for abortions?  Should we support providers or organizations who provide abortions if they promise not to do it with our money? What about providers or organizations who just provide referrals for abortion?

There are women in extremely high-risk pregnancies who may die if they carry a child to term. There are women with seven malnourished children, pregnant with an eighth they can’t afford to feed. And there are women, especially in the former Soviet Union, who use abortion because they think it is cheaper, safer, and easier than contraception.

Catholics and Buddhists believe that life begins at conception. Muslims believe it begins at quickening. Hindus have a whole range of views. And 67,000 women die every year from unsafe abortions. It is clear that abortion has a role in women’s health. It is equally clear that no one can agree upon what that role is.

Millennium Development Goals
The Millennium Development Goals (MDGs) are a set of development targets agreed upon by world leaders in September 2000. By the year 2015, the leaders pledged to:

1. Eradicate extreme poverty and hunger.

2. Achieve universal primary education.

3. Promote gender equality and empower women.

4. Reduce child mortality.

5. Improve maternal health.

6. Combat HIV/AIDS, malaria, and other diseases.

7. Ensure environmental sustainability.

8. Develop a global partnership for development.

The goals are important. There is no controversy about that. The problem is that no one thinks we’ll actually achieve them by 2015. Opinion varies ferociously among global health experts as to whether setting impossible goals is gutsy and ambitious, or setting everyone up for a disappointing failure.

Some argue that the MDGs are aspirational, and provide a valuable goal to drive country efforts forward. The ONE campaign argues that “By setting time-bound, measurable targets for achieving results in areas like child and maternal health, education and access to water and sanitation, (the MDGs) injected new momentum into the fight against global poverty.” Others think that the inevitable failure of the MDG efforts will discredit international assistance and efforts to improve global health. Michael Clemens and Todd Moss, for the Center for Global Development, fall into the second camp. They state that the MDGs may end up “undermining the cause by over-reaching on the targets and over-selling on the efficacy of aid.”