Happy Thanksgiving!

Same gate, new country

After traversing four European cities in 13 days, I have arrived and settled into my new home in Durban. While I have traveled to Durban numerous times before, the visible and abject poverty never fails to unsettle me each time I return. The side of the highway from the airport is littered with tin-roof shacks that house entire families. And as I pull up to 8 Musgrave Avenue—my current spacious apartment—and make my way through two sets of wrought-iron security gates, I am painfully aware of my privilege. I have a sneaking suspicion that this feeling won’t go away anytime soon.

I first arrived at this same gate just over six years ago to volunteer at the Sinikithemba AIDS Clinic of McCord Hospital. That summer, I lost my heart and soul to the spirit of South Africa. I witnessed true strength and courage in the face of enormous challenges: devoted health workers motivated by their faith and commitment to caring for others; children orphaned by AIDS and infected through vertical transmission of HIV; patients, who in the face of great stigma, never give up the will to live; and communities of “Gogos”, the Zulu word for grandmother, caring for young children. Most importantly, I witnessed the transformation that successful HIV prevention and life-saving drugs make possible.

Six years later, significant strides have been made to decrease the rate of new infections and increase access to care and treatment in South Africa. This progress was made painstakingly clear in US Secretary of State Hillary Clinton’s visit to South Africa earlier this month, part of an eight-nation African visit. On her trip she discussed the PEPFAR transition, what Reuters described as “symbolic of Pretoria’s shift from being a pariah to a global player in fighting the disease.” Secretary Clinton commended President Zuma and Minister Motsoaledi for putting the policies and systems in place to get 1.7 million people on treatment.

Despite signs of progress, it’s important to not lose sight of the enduring unemployment, poverty, crime and TB, among many other factors, which compound South Africa’s HIV epidemic and hinder prevention, treatment and care efforts. These ongoing socioeconomic challenges are a critical component to South Africa’s holistic and comprehensive AIDS response.

As I arrive on the same steps as I did six years ago (and many times since then), I am keenly aware that I have returned to a very different country—economically, politically, socially and epidemiologically.

 

Goosby acknowledges role of health economists

I am currently strolling through Western Europe en route to South Africa. Therefore, in lieu of a longer post, I am linking to Amanda Glassman’s account of Eric Goosby’s speech at the recent International AIDS Economics Network (IAEN) meeting. PEPFAR administrator Goosby delivered, in my opinion, fantastic and well-timed remarks about the role of health economists in the sphere of global health and HIV.

Goosby to Economists: Step Up!
August 1, 2012

By Amanda Glassman

Economists are not global health’s most popular human resource. They usually show up to dampen enthusiasm by nattering on about budget constraints, trade-offs and incentives. In the HIV/AIDS field in particular, health economists and their work have been viewed with profound skepticism. At a recent debate, talking about choices and budget constraints was labeled “dangerous” to fundraising by one participant.

Yet a new view of the contribution of economists to global health is emerging. At the International AIDS Economics Network (IAEN) meeting earlier this month, Ambassador Eric Goosby gave a terrific overview of the policy questions that need to be addressed by the field and the role that economists need to play in improving the efficiency and effectiveness of the HIV/AIDS response. In his words:

How do policy makers decide where funds should be invested?  How do we measure value for investment in health systems in the absence of standard indicators?  Can we assess prevention benefit while accounting for the treatment benefit as well?  How do we achieve allocative efficiency—that is, putting our money where it will have the greatest impact?

These questions underscore the importance of economic analysis for the next phase of the HIV response.  Together, we need to establish and implement a research agenda for economic analysis and apply the results to the global HIV response.  We will need to adapt to these more complex intervention models and press for stronger metrics to better define value for the expenditures being tracked.  Most of all, we will need collaborative strategies to help countries collect and apply economic data for their program planning.

(…)

Economic analysis provides us with results that show us how to make programs more efficient; provides accountability for our programs to those who support this work, and supports advocacy to policy makers who have to consider the economic dimensions of investments.

(…)

You as the health economists focused on this work have an amazing opportunity, together, in dialogue with program leadership, to move this forward, to understand it better, so we can increase our effectiveness at dropping morbidity and mortality and I want to end today with a challenge to all of us to step up to it.

(…)

Those of us who have a little grey hair or lost some of it know that this is a different time. We have seen … economic pressures … push more people in policy-making positions into conversations that have brought central cost-effectiveness analysis, comparative effectiveness, looking at the variation across our implementing colleagues/partners in their ability to do the same work, the same outcome, with less money. In very many ways I think this economic severity has pushed us dramatically into what I think is the correct alignment of thinking.

Medical communities have had a lot of distrust of cost-effectiveness analysis. I know all of you in this room have butted up against your clinical colleagues who saw that every time you came with a cost effectiveness analysis, a service provision capability, a testing modality, CT scan vs MRI, suddenly those services became more difficult to access from a clinician’s perspective. And from a clinician’s perspective, seeing a body of patients in front of them, it is not the correct spot or locus of a cost effectiveness analysis. Economic analysis really needs to be part of a policy discussion that doesn’t involve or corrupt the patient-provider relationship.

So I think that we have evolved in this moment where now, from my perspective, economic analysis becomes a tool for us to preserve program and expand program to drop more morbidity and more mortality. And I really do think it’s a glimmer moment where the window has opened for you [economists] to establish your relevance but do it with compassion and consideration in how you speak about it. Cost-effectiveness analysis is not a perfect fit to a medical model; but it is an essential fit. And I think you are really at the forefront of harmonizing that integration with clinical, programmatic, and health system decision-making to preserve program and services for the population we are supposed to serve.

Enough said.

Introducing Global Health Beat

This morning I am flying to Durban, South Africa (well, by way of Europe, for 2 weeks!), to begin a 9-month Fulbright grant in Public Health. I will be conducting independent research on the costs, benefits and impacts of HIV treatment models in South Africa.

Some food for thought

South Africa’s complex history of apartheid has shaped a landscape of enduring socioeconomic inequality and a legacy of apartheid that will live on for decades. Nevertheless, South Africa has moved forward to create a unified, democratic, “rainbow nation.” South Africa is warm, vibrant and sophisticated, I place I will feel privileged to call home. Travel the beautiful Durban beaches, Cape Town rocky coastline and Drakensburg Mountains; read about the prolific South African-based scientific research being conducted.

Despite this extraordinary progress, HIV threatens the social fabric of the country, as well as its economic and political viability. South Africans have responded to this challenge and demonstrated their will to tackle the epidemic. AIDS activists, including members of Treatment Action Campaign and others, successfully lobbied for publicly provided AIDS treatment in the early 2000s and continue to campaign for HIV education and treatment literacy to reduce AIDS stigma. They have also played a vital role in challenging the system of HIV treatment delivery.

However, 12 years after the historic Durban AIDS conference and on the heels of the first conference to return to the United States in 22 years, and we still have not turned the tide on the epidemic. South Africa is currently burdened with the most number of people in the world living with HIV and is continually challenged to meet an incredibly high demand for treatment—both for individuals and public health (more on that later). Rhetoric is not the answer.

To add fuel to the fire, PEPFAR has recently begun transitioning from financial to technical support to South Africa. In an era of constrained resources and fiscal austerity, research on ways to optimize public health dollars spent and find additional system-wide efficiencies is particularly timely.

My research

For too long, South Africa’s health policy was not adequately aligned with the health workforce and infrastructure landscape—doctors are largely concentrated in the urban hospitals and in the private sector and are in short supply in rural, disadvantaged communities where nurses run most clinics. Until 2010, initiation and management of HIV treatment, which is called antiretroviral therapy (ART), was limited to doctors practicing at accredited sites. Although publicly provided ART is free, infrastructural and resource constraints imposed substantial indirect costs on patients, including transportation costs and lost income from missed days of work. Large public hospitals accrued long waiting lists for ART and patients got sick and died waiting for treatment.

Recognizing the lingering effects of apartheid, pilot projects emerged across the country to “decentralize” HIV services to primary heath clinics through nurse-provided treatment. The results were impressive. In a study of one program in Lusikisiki township in the Eastern Cape province, TAC and Médecins Sans Frontières (MSF) showed that for every health outcome—ART adherence, viral load, mortality, loss-to-follow-up—patients managed by nurses performed as well or better than patients managed by physicians. In light of the encouraging results from these pilot sites, South African national policy is catching up. This small body of research led to policy guidance in April 2010 recommending that nurses provide comprehensive HIV/AIDS services at the primary health clinic level.

Over two years have passed since this landmark policy change, and I want to understand the costs, benefits and impacts on the health care system, individuals and communities. My research will be based at CAPRISA (Centre for the AIDS Programme of Research in South Africa), a preeminent research institute, performing rigorous studies that are guiding the development of progressive interventions and policy. Quarraisha Abdool Karim, an absolute rock star in the global health field who co-directs CAPRISA with her husband Salim, will mentor me.

I hope to use this blog as a platform to discuss global health policy and research in South Africa and beyond as well as my experience as a Fulbright student. It will be most successful if it is interactive, so please leave comments or email me if you have suggestions (Jamie.alex.cohen@gmail.com).

Thanks for reading!