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Rapid Responses: Rapid Responses published:
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Need of a multipronged approach by a coordinating umbrella organization
- Maulik V Baxi (8 November 2003)
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The implementation of antiretroviral distribution projects: asking fundamental questions about public health discourse and priorities
- Sanjay Basu (9 November 2003)
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Tackling Poverty of Resources
- Peter A West (12 November 2003)
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Not the 'worst plague in history', but can we get things right this time?
- Mark Powlson (12 November 2003)
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Re: Not the 'worst plague in history', but can we get things right this time?
- Peter Morrell (25 November 2003)
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Re: Re: Not the 'worst plague in history', but can we get things right this time?
- Mark Powlson (26 November 2003)
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Socio-cultural factors affecting the feasibility of HIV mother-to-child transmission prevention programmes in rural areas of resource poor countries
- Benedetta Allegranzi, Iacopo Baussano, Francesca Gatti, Giovanni Di Perri and Ercole Concia (28 November 2003)
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Maulik V Baxi, Final Year Medical Student, Medical College and Shri Sayaji General Hospital, Baroda The Maharaja Sayajirao University of Baroda, Baroda - 390 001 India
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The point raised by the authors in the paper is worthwhile and the next step should be to explore possibility of developing a larger coalition under one coordinating umbrella organization for AIDS control. While prevention of AIDS has remained mainstream efforts of all health agencies, few of them have paid any attention to treating the existing cases simultaneously. This is because of high cost of treatment of Antiretroviral Treatment (ARV). (1) Many Pharmaceutical companies make the ARV drugs but the cost of them is so high that not only the people who are in need cannot afford them, also at government level, they have remained an impossible option for broader coverage among infected people. The reason behind this is very high margin of profit by the companies. If we want those people dying for want of ART to live some more symptom free years, we have to see that the cost of ART comes down. Another area of concern is young people falling pray to AIDS. This age group that is neither considered fully-grown adult nor they are supposed to be children anymore. There is a constant battle for identity within them which results in aggressive and risk taking behavior, which is so characteristic of young adults. AIDS is more of a biosocial problem than a clinical syndrome in this group. The HIV infection contracted during this age becomes fully blown AIDS by the time they reach the earning age and when they die, they leave behind either a spouse or children, also HIV positive. Thus, it becomes a vicious cycle. (2) POVERTY – RISK TAKING BEHAVIOR – HIV INFECTION – AIDS – DEATH OF THE EARNING MEMBER – POVERTY This model, is seen everywhere now in sub-Saharan African nations and other countries, which have high prevalence of AIDS among their youth. Botswana, Central African Republic, Djibouti, Ethiopia, Kenya, Lesotho, Malawi, Mozambique, Namibia, South Africa, Swaziland, Zambia and Zimbabwe remain the most vulnerable countries (3) where this vicious cycle is most prominently visible and is expected to rise for some time in future based on this model even after full preventive efforts. The need of the hour is to make up our mind and start working on it. The step by WHO of declaring AIDS a global emergency is the one in right direction. We now need combined multipronged approach co-coordinated worldwide under one umbrella organization to AIDS control that should include: 1.Information, Education and communication activities through all channels. 2.Making ARV available to all. May be free of cost in developing countries. 3.Challenging high-risk behavior. 4.Making condoms available. 5.Enforcement of laws on illicit drugs prohibition. 6.Introduction of AIDS education in school curriculum at early stages. 7.Promoting voluntary counseling, HIV testing and referral. 8.Promoting voluntary blood donation among young people. 9.Strengthening financial support. 10.Improving socio-economic environment through excellent planning and execution for upliftment of societies from poverty, ignorance and ill health. References: (1) Floyd K, Gilks C. Cost and financing aspects of providing anti- retroviral therapy: a background paper. The World Bank, Washington DC (Accessed November 3, 2003 URL: http://www.worldbank.org/aids- econ/arv/floyd/index.htm#toc) (2) Baxi MV. AIDS among adolescents: Care is Cure. (Submitted for publication) (3) Joint United Nations Programme on HIV/AIDS. (UNAIDS) Report on the global HIV/AIDS epidemic. Geneva, UNAIDS, June 2000: p.135 Competing interests: Maulik Baxi is Associate editor of Asian Student Medical Journal and Director, Taxila - Centre for Medical Reforms and Research |
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Sanjay Basu, Yale University School of Medicine New Haven, CT 06510, USA
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Once again, Mukherjee and colleagues provide creative, rational and compassionate health service delivery designs for the public health community to model in its response to the worst plague in human history. But Mukherjee’s summary of an HIV response plan is not merely specific to AIDS programming; rather, it offers important lessons to anyone evaluating the state of current discourse and practice in public health circles, and particularly in institutions designing programs for resource-poor settings. Mukherjee and colleagues allude to a number of fundamental questions we often fail to ask about the nature of resource distribution and the design of effective responses to inequalities in health status. Several paradigms of thought used all-too-easily by public health workers and international financial institutions come into question as a result of the work presented by this group: 1) Cost-effectiveness: Rather than existing as a fixed construction or law of nature, the progress of Mukherjee and colleagues in producing effective systems through which to distribute antiretroviral drugs also demonstrates that “cost-effectiveness” is a mutable concept based on social valuations. Antiretroviral drugs have moved in status from “cost- ineffective” interventions to objects the WHO sees as essential to an appropriate public health response to HIV/AIDS, revealing how social pressures affect this “objective” indicator. Too often, medical cost- effectiveness analyses calculate the costs of treating a particular disease and its related diseases, without regard to the issue of how interventions might reciprocate into other realms of economic and social well-being [1, 2]. The use of cost-effectiveness also promotes the idea that health interventions are “competing” for a fixed pool of money, even as the AIDS activist movement teaches us that we should ask critical questions about what determines the overall pot of money and how interventions relate to one another and together improve or fail to improve the well-being of poor populations [3, 4]. 2) Behaviorism in public health programming: Two approaches are often seen as the only options through which to prevent HIV infection. One set of responses consist of risk-reduction measures such as condom distribution, while another set involve risk avoidance measures such as the teaching of abstinence [5]. While the latter are clearly ineffective in numerous settings [6], even the former have questionable efficacy when used alone, without broader interventions that affect the structure of the lives of the poor. Both sets of responses are behavioristic in nature-- they deploy a “health belief model” that assumes people in poverty have enough agency to control the circumstances of their lives. Yet if miners in South Africa are rational in being more worried about a 42% injury rate in their worksites than about HIV, and depressed and often abusing alcohol as a result of their loss of stable marriages in the context migration and life in all-male barracks [7], is simply “educating them” an appropriate intervention to reduce their solicitation of prostitutes? If the promotion of speculative capital and the subsequent crash in primary commodity prices precipitates migration in Thailand and the loss of stable unions, with a decline in jobs available for women who subsequently enter prostitution [8], is a behavioristic approach going to be effective? If injection drug use is the only available means to control poverty- associated depression in New Haven, and the lack of appropriate healthcare resources renders “safe injection” a fantasy, then am I to tell my patients to simply change their “behaviors”? The Ugandan “model” appears to work only in the wealthier settings of Uganda, while the poorer zones where 87% of the population lives still carry the highest burdens of disease; in the few regions that do show genuine declines in incidence among the poor, structural changes in migration patterns and poverty levels appear to correlate more with the resulting decline in HIV rates than do educational interventions [6, 9]. A recent British Medical Journal review of evidence also added that “providing information about health risks changes the behavior of, at most, one in four people--generally those who are more affluent” [10]. The claim of many public health workers is that interventions on any other scale other than that of individual behavior are simply too difficult to perform. Yet “structural interventions” are appearing everywhere on the scene, mostly promoted by activists who do not fear the task of challenging multinational companies to provide better housing and work arrangements for their employees (www.treat-your-workers.org) or push institutions to alter their licensing structures to promote access to clinical resources (www.essentialmedicines.org), or negotiate changes in trade structures to reduce capital flight and subsequent migration that accelerates poverty and living standards that promote HIV risk [4]. To observe the efficacy of such interventions, “operational research” must look outside the domain of individual clinics and behavioral interventions. 3) Inequality: The discourse about the distribution of antiretrovirals is part of a larger commentary on the unequal distribution of resources needed to live a decent life. This is revealed by the focus of many groups of “the South”, who have latched onto the idea of not only distributing antiretrovirals (now a mainstream and mostly-accepted idea outside of some governmental bodies and a few multilateral institutions), but to a broader concern about the distribution of all medicines and other important resources needed for healthy living. Indeed, one concern of those working on medicine access issues is that the true meaning of the term “access” is lost by international institutions promoting technocratic approaches to the problem; rather than seeing medicine access as a metaphor for larger inequalities in access to vital resources, members of these institutions regularly see the issue as a technical anomaly and unique case of market failure [11]. Related to the earlier point about behaviorism in public health, the main concerns of those labeled most “at risk” for HIV infection are concerns about the quality of life and the ability to live well--an issue in part related to access to resources and an environment promoting health (rather than migration, depression and poverty). The attention paid to inequalities in antiretroviral distribution should therefore be harnessed to promote equity in the distribution (or redistribution) of other resources needed to curb the risk of HIV infection and the general well-being of those populations currently living in resource-poor settings. This involves, therefore, an examination of trade structures [8, 12-14]; novel proposals for the development, licensing and subsequent pricing of key commodities [15]; and the re-distribution of services with the promotion of long-term investment rather than short-term capital movement [16-18]. 4) Infrastructure: The claim that resource-poor settings lack the necessary infrastructure to provide antiretroviral therapy is certainly no longer tenable in the face of overwhelming data from numerous pilot projects using directly-observed therapy and other locally-tailored models to provide effective treatment and minimize drug resistance, especially when such programs are nested in the context of social and material support such as transportation and food assistance [19-21]. Infrastructure, as revealed by Mukherjee and colleagues, is not something that suddenly appears, but can be developed simultaneously with the expression of need, and progressively improved as service is provided. Indeed, health problems like HIV/AIDS are an impetus for the building of infrastructure rather than an excuse to claim that insufficient infrastructure exists at present. 5) Health systems research: “Operational research” must ask fundamental questions about local issues--a problem when using a disaster- relief model or a model of AIDS response that is coordinated through just one institution--in order to avoid hegemony and respond to local needs. This is what is meant by “community-based”; as AIDS becomes more institutionalized, responses to it may indeed receive more funding, but a concern that must be dealt with is how such funding can be distributed without hegemonic control over its use, so that it may be used for local needs and so that variability and closeness to those served is facilitated in the design and promotion of new program structures. Mukherjee and colleagues, by questioning common claims about the above issues, provide us with new hope for the future. For this, they deserve much praise and attention. But those they serve also deserve to have these suggestions translated into practice; the specific and effective models reviewed in Mukherjee's paper must be applied quickly into public health practice, and this means not simply promoting further research but working towards the implementation of this research into physical programs (a much-avoided task among public health academics). As one of the authors of the above piece stated at the 2002 Barcelona AIDS Conference, “operational research” can only be performed if there are operations to research [22]. References 1. Meltzer D. Accounting for Future Costs in Medical Cost- Effectiveness Analysis. Journal of Health Economics 1997;16(1):33-64. 2. Blower S, Farmer PE. Predicting the public health impact of antiretrovirals: preventing HIV in developing countries. AIDScience 2003;3(11). 3. Epstein S. Impure Science: AIDS, Activism, and the Politics of Knowledge. Berkeley: University of California Press, 1996. 4. Basu S. AIDS, Empire and Public Health Behaviorism. Z-Magazine, 2003. http://zmag.org/content/showarticle.cfm?SectionID=2&ItemID=3988 5. Green EC, Farmer PE. New Challenges to the AIDS Prevention Paradigm. Anthropology News 2003;44(6):1-5. 6. Lacey M. For Ugandan Girls, Delaying Sex Has Economic Cost. The New York Times 2003 18 August. 7. Campbell C. Migrancy, Masculine Identities and AIDS: The Psychosocial Context of HIV Transmission on the South African Gold Mines. Social Science and Medicine 1997;45(2):273-81. 8. Bello W, Cunningham S, Poh LK. A Siamese Tragedy: Development and Disintegration in Modern Thailand. London: Zed Books, 1998. 9. Parkhurst JO. The Ugandan Success Story? Evidence and claims of HIV-1 prevention. The Lancet 2002;360:78-80. 10. Campbell C, Mzaidume Y. How can HIV be prevented in South Africa? A social perspective. British Medical Journal 2002;324:229-32. 11. Basu S. The Dangerous Deradicalization of AIDS Discourse: Implications for Representative Activism. Z-Magazine 2003. http://zmag.org/content/showarticle.cfm?SectionID=14&ItemID=4398 12. Baker B. Putting Health First in Trade Agreements: The Free Trade Area of the Americas, Access to Medicines, and the Public Health. Washington D.C.: Health Global Access Project, 2002. 13. Basu S. Circumventing the Consensus: The USTR, public health, and bilateral trade agreements. Z-Magazine, 2003. http://www.zmag.org/content/showarticle.cfm?SectionID=13&ItemID=3149 14. Barnett T, Whiteside A. AIDS in the Twenty-First Century: Disease and Globalization. New York: Palgrave Macmillan, 2002. 15. Kapczynski A, Crone ET, Merson M. Global access to medicines and university intellectual property management. Science 2003;in press. 16. Pollock AM, Price D. The public health implications of world trade negotiations on the general agreement on trade in services and public services. The Lancet 2003;362(9389):1072-75. 17. Woodroffe J. GATS: A Disservice to the Poor. London: World Development Movement, 2002. 18. Navarro V. Neoliberalism, "Globalization," Unemployment, Inequalities, and the Welfare State. In: Navarro V, editor. The Political Economy of Social Inequalities: Consequences for Health and Quality of Life. Amityville: Baywood, 2002:33-107. 19. Farmer PE, Léandre F, Mukherjee JS, Claude M, Nevil P, Smith- Fawzi MC, et al. Community-based approaches to HIV treatment in resource- poor settings. The Lancet 2001;358(9279):404-9. 20. McNeil DG. Africans Outdo Americans in Following AIDS Therapy. The New York Times 2003 3 September. 21. Rosenberg T. Look at Brazil. The New York Times Magazine, 2001. 22. Farmer PE. Introducing ARVs in Resource-Poor Settings: Expected and Unexpected Challenges and Consequences. 2002 International AIDS Conference; 2002; Barcelona. Competing interests: None declared |
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Peter A West, Director, York Health Economics Consortium Market Square, University of York, York YO10 5NH
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The authors suggest that mass treatment of HIV in developing countries is both desirable and potentially very beneficial for those countries. But the test of their proposal will be successful implementation of their approach in resource poor countries. Infrastructure to maintain compliance and provide monitoring is likely to require a much greater investment than a single immunisation and the authors simplify the infrastructure problems. Statements such as "Treatment can provide an avenue of contact with the health provider, who can reinforce prevention messages" sound very optimistic to someone who has stood in deserted African hospitals, lacking staff and funding for many years. The letter by Wiggin et al (BMJ 2002;325;838) highlighted many other problems in maintaining complex drug regimes in Africa, from the front line. Mukherjee et al. are wrong to suggest that cost- effectiveness cannot include treatment as well as prevention. And of course treatment has important benefits. But the biggest problem is that resource poor countries are resource poor. I do not believe that it is possible to run one or two elements of a rich Western approach to anything, in isolation, in a poor country, except on a very small scale. Where the scale is small (e.g. airline services) small groups can be highly trained and a system can operate (e.g. BA flight maintenance in Africa) in isolation from the prevailing resource constraints. But mass treatment will require mass poverty eradication, mass education and massive investment in health infrastructure. Each of these things will take a long time and, in the meantime, mass treatment may not be a viable option, whatever its benefits. No one would be happier than me if mass treatment can be shown to work in such resource poor countries as Malawi and Kenya but if it will not, then prevention may be much more viable for some time to come. Competing interests: The author has carried research on HIV prevention in developing countries for the UK government and worked on the cost effectiveness of unrelated (non-HIV) medications for several pharmaceutical companies that make HIV retrovirals. He is not and has not worked on the economics of mass treatment of HIV in developing countries for any pharmaceutical company at any time. YHEC is a research company owned by the University of York. It is currently working for a US NGO on HIV prevention modelling. |
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Mark Powlson, Managing editor, PJL Bedford MK41 7DY
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EDITOR,— It is quite easy to be cynical about health ‘scares’, particularly in view of dystopian projections (as with [n]vCJD and SARS) in which catastrophe is predicted but the end result turns out to be more of a whimper (albeit catastrophic to those immediately affected) than a cataclysm. Nevertheless, effective public health measures no doubt helped in containing those outbreaks, even if the dangers were probably nowhere near as great as first feared. Stabinski et al1 and Mukherjee and colleagues2, following others (although the message does not yet seem to have got through), paint a bleak picture of the impact of HIV/AIDS world wide, particularly in sub-Saharan Africa, which is all to easy to overlook or to minimise when sitting comfortably in the west. What is perhaps most disquieting here is that the feared epidemic has already happened, yet—probably because of the time interval between infection and death, partly no doubt due to its relatively limited (and often, perhaps in some eyes distastefully, sex-related) mode of transmission, and possibly (to all of our shame) because of its geographical location somewhat at a distance from the centres of economic and international political and economic power—adequate response is lacking. I have a dispiriting feeling that when future generations compare and contrast the attention and actions taken when HIV/AIDS first appeared among a relatively small subset of the western population with the attention and actions taken in response to its established and massive presence in parts of the third world, another striking illustration will added to the catalogue of examples of man’s inhumanity to man. As a sorry example of that trait, I would not myself be moved to respond, other than (silently, and with no other action) to cheer the authors on from the sidelines, were it not for the response supporting the original authors by Sanjay Basu3, which claims this episode to be the worst plague in human history. Although I would endorse his other comments in so far as I am able to give any valid opinion, this rather hyperbolic and unprovable claim (humane and laudable though the intent may be) is, in my view, almost certainly untrue; I would not be the first to draw attention to epidemics of plague in Europe as a comparator to the circumstances that have arisen. Nevertheless, this claim appears to me to be near enough to the mark to represent a dire warning that should not be overlooked, hence this response. If the history of the Black Death in Europe in the 14th Century and subsequent epidemics in the 16th/17th Centuries do have anything to teach us nowadays, I believe that it would indicate that the conclusions advanced in respect to HIV/AIDS in the affected areas1-3 are incorrect: black though they paint the picture, they could be far too optimistic. However, consideration of the different aftermaths of European epidemics of plague in the 14th Century compared with the epidemics of the 16th/17th Centuries give some cause for hope—but only if effective action is taken, and taken now. Have we learnt nothing from the lessons of some 500 years in the past? For reasons unrelated to this particular issue I have researched the historical background of plague in England, and to a lesser extent in western Europe, for the Tudor and Stuart period, which also required back- reference to the Black Death in 1348-52; please forgive a brief and somewhat idiosyncratic overview to illustrate the point I wish to make. (Background data can be found in three standard texts4-6; there are many others, including source documents, not listed here; among these Boccaccio’s Decameron, describing the Florence outbreak in 1348, gives one of the most remarkable accounts of infection ever given – see also www.brown.edu/Departments/Italian_Studies/web.) Analysis of the earlier period is impaired because record-keeping at that time was not of the best, and made worse by the epidemic (a problem that was even worse in the pan-European epidemic of the 6th Century, often known as the plague of Justinian, and subsequent epidemics that occurred up to the 8th Century, which I therefore do not consider). Causation of the disease was then unknown (the 1348 Paris Consilium set up by Philippe VI of France felt its origins beyond the wit of man, but ascribed it to a combination of earthquakes releasing pestiferous miasmas and the 1345 astrological conjunction of Saturn, Jupiter and Mars under the moist sign of Aquarius, following solar and lunar eclipses); these beliefs persisted to some extent in the 16th and 17th Centuries, but this latter period saw a trend towards belief in a contagious rather than a miasmic aetiology. Such factors make comparisons difficult and tentative, but are of some interest because they relate to some of the opinions advanced by Stabinski1, Mukherjee2, their colleagues and respondents3,7 and many others, particularly in relation to subsequent societal effects. Before 1348, the population of western Europe was approximately 75 million. After the period 1347-52, with the advent of the Black Death, it was some 50 million; about one-third of the population had died. More specifically, in England, life expectancy in the early 14th Century was 32 -35 years, but fell to about 18 years in the second half of the 1300s; according to manorial and other records at least one-third and quite possibly half the population, across all social classes, died between 1348 and 1352 across the whole of the country (the death rate among clergy, whose risk would be lowered by their social status but increased by their ministry to the sick, can be more reliably considered to be about 42%). Throughout Europe there were no public precautions against plague, and little or no effective societal response. The consequences were dire. There was a regrettable tendency to look for scapegoats; rifts occurred along pre-existing fissures in the social fabric; social norms were broken or exaggerated, with persecution, pogroms and also widespread and communal self-flagellation; lands were laid out of cultivation; industry and trade were devastated, with a huge contraction of demand for goods and services; as wage earners fell ill, starvation and suffering occurred (noting here that children also served as workers/farmers/wage-earners, as they do in sub-Saharan Africa, compounding difficulties when they also fell ill or died—in such economies children are not just there to be educated, westerners take note); and authorities seeking to control or to mitigate the effects were held to be ruthless and bureaucratic to the victims, and also ineffectual. A massive continent-wide economic depression had lasting effects for some 150 years; there were several instances of insurrection with peasants’ revolts in England, France, Belgium and Italy; and international armed conflicts were provoked (although the planned invasion of England by the Scots in 1350 to take advantage of weakness caused by the plague was scuppered when the forces massed for the invasion, not realising the potential risks of such grouping under such circumstances, contracted an even worse outbreak of plague themselves). These events are generally considered to have led directly to the end of feudalism (the overall social structure of the day) and sowed the seeds of the Reformation of the Christian church. However, responses in Europe to the severe outbreaks of plague seen in the 1500s and 1600s give greater encouragement. These outbreaks were not as frequent as they had been in and after the Black Death over the period 1348 to 1479, and it is possible that the infection may have been less virulent. However, large epidemics happened often enough, particularly in towns; although gross nationwide mortality was less, death rates were very high and often killed 10% of the population of a community in the course of one year (as in Norwich in the Great Plague of 1665-66). Although the precise cause of the epidemic remained unclear, and there remained no cure or palliative therapy, the societal reactions were much more advanced and effective than for the Black Death, which probably explains why nationwide mortality was less. In England it is possible to trace many of the groundings of public health provision to the Tudor and Stuart society’s responses to the plague, starting with a royal proclamation on 13 January 1518 set out to control those ‘contagious infections’ which were ‘likely to continue if remedy by the sufferance of Almighty God’ were not given a temporal hand. (Only a cynic might note that, of probably the two prime movers in setting these measures up, one was beheaded and the other died in Leicester on his way to judgment and almost certain execution) Although individual and local consequences could still be catastrophic, the broad societal effects seen as a result of the Black Death (and this is also true of events in other European countries, sometimes in advance of England although differing because of political organisational circumstances, but with similar beneficial effects) did not occur two centuries later precisely because of the setting up of measures that would now be considered to underpin modern public health provision in terms of assessment, recording, responses and social organisation. (In fairness, it should be observed that the measures taken by authorities then do not seem to have been more popular than they were with the Black Death, but were more accepted possibly because of advanced understanding and possibly because they were seen to be more effective.) Historical comparisons can legitimately be questioned because of the many differences between Europe in the 14th Century and Europe in the 16th/17th Centuries, and with both those periods and sub-Saharan Africa now. Transportation, information and weaponry, to name but three factors, are greatly different now as opposed to either previous period, but perhaps it is legitimate to assume that in these respects the two earlier periods were not too dissimilar to each other. Moreover, the cause of this infection is known (although perhaps not universally accepted) and treatment, albeit not curative, exists (but is far from universally available). With all the epidemics of plague the deaths occurred over 1-4 years, whereas currently we are at 20 years and counting; the proportions (33-60%) killed by the Black Death were higher, but those in the 16th/17th Centuries were similar to the proportions reported to be infected in sub- Saharan Africa (8-19% predicted2). Such historical differences are far from comforting, however, as they would appear to offer at least one additional cause of discord and discontent, and several potentially more damaging ways of expressing such disquiet. The true value of such a historical comparison (if any) lays in considering the differences in the responses to and the aftermath of epidemic plague in Europe between the two periods I have outlined. No effective response, as seen for the Black Death, was catastrophic and hugely disruptive. A partially effective response (where the cause of the disease and its effective treatment remained unknown, but measures that we would now consider to be the cornerstones of public health provision were taken) as seen in the 16th/17th Centuries, whilst locally damaging did not have anything like the broader damage seen a couple of centuries earlier. Theoretically, society as a whole should now have the ability to provide an even more effective response to the situation that has arisen in sub-Saharan Africa than Europe did for its own problems 400-500 years ago: is there the will to do so? If history does have anything valid to teach us, it would be that immediate effective action is much better than too little, too late; and that failure to react adequately would lead to widespread and potentially catastrophic social disruption in the affected areas. Assuming such extrapolations to be correct, in a globalised economy it would be complacent and fatuous in the extreme for other countries to feel that they would feel no adverse effects of inadequate intervention in these HIV/AIDS affected areas, quite apart from any humanitarian considerations. It would also be suicidally perverse for leaders of affected countries to cause unnecessary impediments for such interventions, if made available, to be delivered in a locally acceptable way. Remembering Boccaccio, it may be apposite to reflect on two other examples in literature of responses to infection in less severe circumstances: Dr Stockman in Ibsen’s An enemy of the people (1882) and Dr Rieux in Camus’ The plague (1947) may not have made themselves popular with the measures that they instituted at the time, but did have a beneficial effect. Can we? Yours sincerely MARK POWLSON 1. Stabinski L, Pelley K, Jacob ST, Long JM, Leaning J. Reframing HIV and AIDS. BMJ 2003; 327: 1101-02. 2. Mukherjee JS, Farmer PE, Niyizonkiza D, McCorkle L, Vanderwarker C, Teixeira P, Kim JY. Tackling HIV in resource poor countries. BMJ 2003; 327: 1102-03. 3. Basu S. The implementation of antiretroviral distribution projects: asking fundamental questions about public health discourse and priorities. Bmj.bmjjournals.com/cgi/letters/327/7423/1104. 4. Ziegler P. The Black Death. London: Collins, 1979. 5. Herlihy D. The Black Death and the transformation of the West. Cambridge, Mass: Harvard University Press, 1997. 6. Slack P. The impact of the plague in Tudor and Stuart England. Oxford: Oxford University Press, 1985. 7. Baxi MV. Need of a multi-pronged approach by a co-ordinating umbrella organisation. Bmj.bmjjournals.com/cgi/letters/327/7423/1104. Competing interests: UK based, the author has worked in a relatively insignificant way for the health service, journals, government and industry. Although it has occasionally been questioned, he also likes to think of himself as a human being. He claims no particular expertise in HIV/AIDS, public health or Africa, but does know quite a bit about history and literature. And also about marketing and journalism, hence he resisted the almost overwhelming temptation to use the catchy strapline heading 'Can the Black Death help us to prevent black deaths?', fearing that it could provoke a knee-jerk response of condemnation without people taking time to read and to consider the very serious message that he was trying to convey (and might chillingly also prompt some quarters to say 'so what?', if not 'hooray!'). He is not in the habit of making apocalyptic pronouncements (although he acknowledges that it could be tempting), and very much hopes that he is wrong or, if not, that his observations are not counterproductive or might even be helpful. He is prepared to run the risk of appearing to be a fool in public because he feels that that circumstance is less uncomfortable than the circumstances faced by many infected by HIV/AIDS in the developing world, with or without effective intervention. But he hopes that there will be. |
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Peter Morrell, Hon Research Associate, History of Medicine, Staffordshire University, UK
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Sir, It would be helpful if Mark Powlson could give some citations of where historians agree with him that "these events are generally considered to have led directly to the end of feudalism (the overall social structure of the day)." However, he will have his work cut out trying to find any historians who believe the 14th century plagues "sowed the seeds of the Reformation of the Christian church," which seems to have been caused by solely political and religious factors. Perhaps he can supply some citations for that also. Competing interests: None declared |
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Mark Powlson, Managing Editor, PJL Bedford MK41 7DY
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References requested for the Black Death I am far from certain that a rapid response column is an appropriate forum for debating events in the 14th Century, and I note that Peter Morrell has requested evidence elsewhere on the same day (which may be rather harder to deliver). However, it is only fair to be held to account as I myself was questioning an unsupported assertion. I also bear in mind Nature’s criticisms of the BMJ for allowing unsubstantiated questioning of the relation between HIV and AIDS. I am startled to find a historian unaware of the sizeable amount of work which draws attention to the financial and social effects of the Black Death. I attach some references, in addition to the three I mentioned, some of which do indeed refer specifically to feudalism and all of which illustrate the profound social and economic changes directly linked to the Black Death.1-20 I can supply more, but suggest that is done by other means than bmj.com. On balance, it does not seem intrinsically unreasonable that such a profound effect on population had such a profound effect on societal structure – if, of course, it is possible to apply intrinsic reason to historical analysis. Very few people seem to do so. With regard to religion, it can be extremely difficult to find intrinsic reason if one is looking outside a particular catechism. That the Black Death did lead to reappraisal of religious beliefs in various faiths is quite definite.21-33 In some cases it led to reaffirmation, in others questioning. Morrell notes my wording (“set the seeds of”) and politely does not say that these are weasel words which can be led to mean just about anything. As with any historical perspective, one can usually find evidence to support just about any view that you want to, and the egregious confusion of post hoc ergo propter hoc also comes into play. There are in fact several sources that do specifically link the rise of Protestantism to the Black Death, although whether they merit referencing as unbiased sources is open to question; the confounding factors of political machinations by England, Spain, France and the Holy Roman Empire and the multiplicity of Popes (three at one time shortly after the Black Death), the 37 year schism, the advent of Wycliff and the endearing charm of the 1401 Statute of Burning of Heretics were, I accept, more obviously related. One specific reference34 can be found in a chapter which ends with a splendidly trenchant rant (or, if you prefer, understated and reasoned historical analysis) “greed, robbery, oppression, rebellion, repression, wars, devastation and degradation as a fitting inscription on the tombstone of early Protestantism.”; those who savour political correctness will find further delight in the same source’s description of Martin Luther (whom I’m sure that Morrell would agree did have something to do with the Reformation) which notes “His father, Hans, was a miner, a rugged, stern, irascible character. In the opinion of many of his biographers [another splendid example of historical weasel words if ever I saw one, MP] it was an expression of uncontrolled rage, an evident congenital inheritance transmitted to his older son, that compelled him to flee from Mohra, the family seat, to escape the penalty or odium of homicide.” Even an amateur historian such as myself will note that it is possible that The Catholic Encyclopedia may not have a totally objective view of the rise of Protestantism. Having mentioned Nature’s censure of bmj.com it is worth noting that the Black Death has also led to various highly subjective and sometimes frankly delusional conjectures which I do not propose to dignify with references. I hope that Morrell will agree with me that claims that the Black Death were caused by alien visitation or time travel seem inherently unlikely, although that has not stopped people advancing such views, as indeed they have done for HIV and AIDS. Claims that the Black Death was an early form of biological warfare should also be viewed with healthy scepticism, despite the firing by catapult of bodies of infected corpses over walls in various sieges; sadly, conspiracy theorists have also used such analogies for HIV/AIDS, with even less evidence. Many observers have also claimed that the Black Death was not in fact caused by Yersinia (Pasteurella) pestis. This view can be laid to rest by DNA analysis of the remains in a verified Black Death burial pit in France, which proved an identical match to the DNA of Yersinia pestis,35 although sadly there are some people who still dispute this conclusive evidence; again, alas, there is an obvious parallel here with some people’s assertions about HIV and AIDS. I have not yet come across a reference that proves that the Black Death was predicted by Nostradamus, possibly because that engaging old fraud was not born until around 1502, but I dare say that someone somewhere has done so (and, sadly, several have done so with respect to HIV/AIDS). My original point was to question the use of sweeping historical statements in scientific debate, so Morrell does at least have the satisfaction of seeing me hang myself by my own petard. As with the best available source of historical reference, let history now come to a stop.36 1. Herlihy D, Cohen SK. The Black Death and the transformation of the west. Cambridge, MA: Harvard University Press, 1997. 2. Gottfried RS. The Black Death: natural and human disaster in Medieval Europe. New York: Simon and Schuster, 1976. 3. Porter, S. The great plague. London: Sutton (ISBN 0-750925716). 4. Fischer DH. The great wave: price revolution and the rhythm of history. Oxford: Oxford University Press, 1996. 5. Russel JC. British Medieval population. University of New Mexico Press, 1948. 6. Tawney RH. The agrarian problem in the Sixteenth Century. London: Longmans, 1912. 7. Dixon RA, Eberhart EK. Economics and cultural change. New York: McGraw Hill, 1938. 8. Thompson JW, ed. Economic and social history of Europe in the later Middle Ages.1300-1539. New York: Century, 1931 ( See chapter 16, The Black Death). 9. Loudon I, ed. Western medicine: an illustrated history. Oxford: Oxford University Press, 1997. 10. Lipson E. The economic history of England. London: Black, 1959. 11. Cannon J, Oxford companion to British history. Oxford: Oxford University Press, 1997. 12. Ferguson WK. Europe in transition 1300-1520. New York: Houghton Mifflin, 1962. 13. Holmes G. The later Middle Ages, 1272-1485. Edinburgh: Nelson, 1962 (Part 2 chapter 2). 14. Cowie LW. The Black Death and the peasants’ revolt. London: Wayland, 1972. 15. Cohen D. The Black Death. New York: Franklin Weatts, 1974. 16. Ziegler P. The Black Death. Stroud, Glocs: Sutton, 1998. 17. Coulton GG. Mediaeval panorama: the English scene from Conquest to Reformation. Cambridge: Cambridge University Press, 1939. 18. Wallertein I. The modern world system: capitalist agriculture and the origin of the European world economy in the 16th century. New York: Academic Press, 1974. 19. Geary PJ. Readings in Medieval history. Peterborough, Ontario: Broadview, 1989. 20. Tierney B. The Middle Ages: vol 1. Sources of Medieval history, 5th edition. New York: McGraw Hill, 1992. 21. Schaff P. In: The New Schaff-Herzog Encyclopedia of Religious knowledge, vol 5: Reformation. 22. Cohn SK. The cult of remembrance and the Black Death. New York: Fischer, 1986. 23. Marcus J. The Jew in the Medieval world. New York: Athenaeum, 1969. 24. Cantor NF. In the wake of the plague: the Black Death and the world it made. New York: 25. Power E. Medieval English nunneries 1275-1535. New York: Biblo and Tainen, 1964. 26. Hutton E. The Franciscan in England. 1224-1538. London: Constable, 1926. 27. Cohn SK. The Black Death transformed: disease and culture in early Renaissance Europe. London: Artnold (ISBN 0-340706473). 28. Reynolds V, Tanner R. The social ecology of religion. Oxford: Oxford University Press, 1995. 29. Howaii AH. A history of the Arab peoples. Cambridge, MA: Bellknap, 1991. 30. Roth C. The history of the Jews of Italy. New York: Jewish Publication Society, 1946. 31. Lamont JG. The world of the Middle Ages: a reorientation of Medieval history. New York: Appleton, 1949. 32. Knowles D. Religious orders in England. Cambridge: Cambridge University Press, 1948. 33. Stearns PS. The face of Europe. London: Forum, 1977. 34. Various. The Catholic encyclopedia. New York: Appleton, 1908-17. 35. Roault et al. Proc Natl Acad Sci USA 2000; 97: 12800-03. 36. Sellar WC, Yeatman RJ. 1066 and all that: a memorable history of England, comprising all the parts you can remember including one hundred and three good things, five bad kings and two genuine dates. London: Dutton, 1931. Competing interests: As in original letter. |
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Benedetta Allegranzi, MD, Assistant Director, Department of Infectious Diseases Divisione Clinicizzata di Malattie Infettive, Ospedale Civile Maggiore, 37126 Verona, Italy, Iacopo Baussano, Francesca Gatti, Giovanni Di Perri and Ercole Concia
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Mukherjee and colleagues recently underscored the need of urgent actions to implement a comprehensive global AIDS strategy in which prevention and treatment are mutually reinforcing. 1 In particular they highlighted that prevention strategies have little impact on treatment and quality or length of life issues of millions of people living with HIV in resource poor countries. We present the results of our experience in a prevention of mother-to-child transmission (PMTCT) programme in rural Burundi which, we believe, support the authors’ considerations and add further key issues to the discussion. From August 2001 to March 2002, at the antenatal clinic (ANC) of the Kiremba rural hospital (Ngozi, Burundi), after a detailed counselling, we tested for HIV 1325 women with a rapid agglutination test (Serodia HIV 1-2, Fujirebio INC, Tokyo, Japan). We confidentially gave the result to the women the same day and, if HIV-positive, offered to deliver at the hospital and receive single-dose nevirapine for themselves and their newborn, with no charge. Results were confirmed in Italy using ELISA (Anti-HIV Tetra-Elisa, Biotest AG, Frankfurt, Germany). Two women refused testing and only 21 (1.6%) were found HIV-positive. Monthly trends of HIV testing and positivity detection are shown in Table 1.
Despite a constant concourse of ANC attendees across the study period, during the first month 162 women were screened and 9 were HIV-positive (5.5%). The remaining 12 cases were identified during the following 7 months, among 1163 screened women. Among HIV-positive women, 7 came to the hospital for delivery and received nevirapine, 13 refused or were lost and 1 had an abortion. Overall HIV prevalence was very low compared to data reported in 1998 and 2000 among ANC attendees outside the major urban area in Burundi (19.7% and 6.7% respectively).2 Since it was significantly higher during the first month (5.5%) compared to the following period (1.0%), we hypothesized that the women suspecting of being HIV-infected were scared to be identified as such and, as the programme was more and more widely known, they progressively avoided attending the ANC. Interviews of several screened women and local health staff confirmed this supposition and also revealed that in some cases the lack of antiretroviral treatment for HIV positive mothers was a reason for discouraging them from participating to the programme. The limited number of HIV-positive women who followed the programme, further indicates a poor socio-cultural acceptance of the disease and a limited awareness of the extent of HIV MTCT risk. Similarly, in a PMTCT project in Bujumbura, only 42% of women found HIV-positive then referred to the ANC for antiretroviral short-course prophylaxis (ARV-SP). 3 The majority of studies demonstrating the efficacy of ARV-SP for HIV PMTCT were conducted in ideal conditions in urban health care settings.4 On the contrary, in daily practice, especially in rural areas, the implementation of such programmes may be significantly hampered by strong social refusal of the disease and poor acceptance of the purposed intervention measures. Since the perception of the disease and of the needs linked to it may vary from country to country and from urban to rural settings, we believe that an accurate evaluation of the local situation is crucial before the establishment of an HIV prevention programme. To strengthen PMTCT programmes in particular, both community-based educational campaigns, also involving sexual partners and traditional birth attendants, should be undertaken and drugs for prophylaxis and treatment of opportunistic infections and antiretrovirals should be available for HIV-positive mothers.
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Competing interests: None declared |
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