Chris Blattman has an interesting post about the campaign to address the AIDS crisis. Some observers believe that the prevalence of AIDS has been completely overblown and that public health dollars are being allocated to this cause without due cause from the "hard evidence." A more detailed discussion is available in last week's Economist. The key phrase from that piece:
"...because of the single issue-activism that AIDS inspires, it receives a quarter of global health aid even though it causes only 5% of the burden of disease in poor and middle income countries. [Observers] also claim that ear-marking money in this way makes it harder to strengthen the health systems of those countries."
A very similar argument can be (and has been) advanced against organizations like Partners for Health.
So why are public health issues dominated by certain issues and not others? There are likely several reasons. First, it's likely easier for the public to identify with a single cause or disease and, therefore, it is easier to raise money targeting that particular condition. Second, diseases in general appear to be sexier than more diffuse problems. For example, one could argue that hunger is the proximal cause of most death and disease in the developing world. Somehow, AIDS, Malaria and diseases that lend themselves to the horrors of the imagination and the (potential) wonders of science are more eye-catching and press-worthy than concepts such as caloric intake and exposure to indoor air pollution (the latter thought to be the second leading cause of death and disease among children in the developing world).
Indeed, I think a lot of the dynamics in attention paid to given public health issues and policy and spending priorities might be explained by theories from political science (Kingdon's issue attention cycle is an example). Does anyone out there know of good work on this subject? I'm sure there is something out there...
Finally, are there ways to take advantage of spillovers from a great deal of attention towards a single disease or issue? It seems natural to me that attention for AIDS among the poor should increase attention to the myriad of other problems facing these societies as well; this simply seems like a matter of advertising to me. Furthermore, I don't see why this couldn't extend to the financial side: if grants to countries are made fungible (within certain bounds and fairly stringent monitoring of usage), there is no reason why AIDS money can't be nutrition money. I'd definitely appreciate your thoughts on these issues.
4 comments:
It's indeed an interesting point, particularly as there's a growing move by the advocacy and activist groups who initially brought global HIV onto the agenda to carry that momentum forward into other aspects of health. The inertia of the HIV bureaucracy is considerable, and certainly there is some truth that an HIV/AIDS "industry" has sprung up wherein well-paid foreign consultants suck up the aid pouring forth from developed nations. I do think that there's a growing realization on the part of many that it makes no philosophical sense to privilege AIDS, as horrid as it is, above other diseases; hopefully this shall translate into increased funding all around.
The peril, as ever, is that people try to make it into a "how we spend our money" kind of question. Which is pertinent, to be sure-I'm not advocating MRIs for all!-but to make the claim that we must chose between adequate primary care and HIV care is, to my mind, a false dichotomy. The money to provide both is not so great that the governments of the world cannot affored it (BOTH developed and developing-0.7% of GDP from the former, 15% of budget from the latter, as promised by the majority of both groups). And indeed, HIV/AIDS care is an important part of primary care.
I'm intrigued that you lump PIH in with HIV/AIDS as a topic-focused group. Though I'm biased on them (several friends with them, etc), my impression is that they do a lot of primary care-certainly true in Haiti, perhaps less so in their Peru/Russia TB endeavors (and now Rwanda HIV project as well). But that's another topic entirely.
James,
Thanks for the comment. You are absolutely right in that the "how we spend our money" question does not necessarily translate into a choice: the Blattman piece mentions a situation where one path is overfunded and the assets are essentially not fungible so as to allow funding in other areas.
But you point out that the funds are thin in general. So here the resource constraint argument is pertinent. In this case, I would argue that the money needs to go towards the highest rate of return, which implies fundamental, basic interventions. You point out that HIV/AIDS is an important part of primary care (and perhaps also, HIV prevention has significant externalities in preventing other diseases as well?). I think the beef many people have is that the evidence-base on whether HIV/AIDS is THE most important public health priority, and whether prevention programs are indeed effective enough at the micro level to warrant large scale investments, is not as strong as advocates would like us to believe. I'm not sure how I stand on the evidence, myself, but, as you said, the issue is worth discussing.
I'd love to hear more of your thoughts, especially on investment vehicles for HIV/AIDS prevention and the externalities for treating/preventing other diseases that likely accrue from these.
-Atheen
Hmmm. Certainly, from a rational standpoint, I cannot and will not say that HIV is the most important public health priority-indeed, on any utilitarian list, it'd be relatively low down in terms of the DALYs or lives spared per dollar spent. I would question whether the money available for HIV is truly available for other diseases-I think that there is some truth that PEPFAR and similar things exist solely because people have pushed for them. Now that they do, of course, it's an opportunity to use that as leverage to push for increased funding for the many, many other improvements required...
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