September 23, 2009
The AIDS Epidemic and the Quality of Health Care Services in Africa
Christina Paxson
Dean, Woodrow Wilson School, Princeton
Minutes of the Second Meeting of 68th Year
President Hanson gaveled to order the second meeting of the 68th year at 10:15 before about 90 members. George Folkers led us in singing the invocation. David Mulford gave us concisely crafted minutes for the September 16 meeting of Barksdale Maynard’s fascinating exposition of the Princeton portion of Woodrow Wilson’s life.
There were no guests or visitors.
Jack Reilly announced three additional members emeriti: Stuart Carothers, Rosser Clark, and Theodore Vial.
Jack then asked approval of the list of member candidates, which was given by voice vote, and the following new members were welcomed: Julia Bowers Coale, Eliot Alexander Daley, Jane S. DeLung, Gloria C. Erlich, Luke William Finlay, Alison Wheeler Lahnston, Owen G. Leach, Bradford Mills, Joel Warren Spiegelman, Ralph Norman Tottenham-Smith, Letitia Wheeler Ufford, and Edmund Charles Weiss, Jr.
Ruth Miller introduced, with verve and affection, her good friend Christina Paxson, Dean of the Woodrow Wilson School. With the numerical care of an economist and the sympathy of one long engaged in the study of health care, using numerous tables and graphs she addressed the topic “The AIDS Epidemic and Quality of Health Care Services in Africa,” noting that her presentation is based on five years of research.
She first described the current situation in Africa, noting that most statistics are to some degree unreliable and out-of-date, so no descriptions can be precisely accurate. In 2007, two-thirds of the 33 million HIV- positive people in the world lived in sub-Saharan Africa. AIDS has become an African disease. Although there is wide variation in AIDS prevalence among southern African countries, the worst affected suffer rates that reach 28% . The rate of new infection is declining, but AIDS deaths continue to rise, reflecting the large cohort of older victims. Infection rates have stabilized in most countries, but at widely varying levels; urban Ruanda at 3.1% contrasted with Botswana at 24%. One of the long-term damaging effects of the epidemic has been to skew the structure of population radically in southern Africa; heavy mortality in the 20 to 40 year old cohort leaves a bulging young population and a surviving older population, both groups dependent upon the shrinking middle. The rising child-to-adult ratio has dreadful future consequences.
Although the world-wide AIDS epidemic started in the early 1980s, Dean Paxson pointed out that an effective international response did not commence until 1996 when the first anti-retroviral drugs became available. The three-drug combination called HAART was very effective – extending life span by up to 13 years in advanced countries – but it’s cost of $4,500 per patient per year was well beyond the resource reach of African countries where annual per capita income was $350. Following the introduction of HAART, large sums became available to fight AIDS in Africa; the U.S. PEPFAR program has provided $15 billion since 2004, the Gates Foundation has contributed $6.2 billion, and the Global Fund, supported by governments and foundations, has spent $8.6 billion. In 2007 alone, $10 billion was allocated to Africa, $4.5 billion of that from the U.S. Fortunately, during this period the cost per-year per-person of anti-retroviral drugs has been cut from $4,500 in 1996 to $350 in 2001, to between $90 and $200 now. The introduction of generics and the work of the Clinton Foundation to negotiate lower prices were largely responsible for the sharp cost decline.
This dramatic increase in resources, however, has not yet reversed the scourge of AIDS. Treatment rates still remain low in most of the most severely affected countries. While in Latin America and the Caribbean, 62% of victims are under treatment, in sub-Saharan Africa only 30% are. A further threat to the long-term control of the disease is that the first-line drug treatment is effective for only about ten years. The second-line treatment is now much more expensive, once again beyond the means of African countries. At this delicate point, the question of treatment vs. prevention has assumed moral dimension. Distinguished organizations contend that prevention is much more cost effective than treatment in the long-term control of aids. A Lancet article in 2002 contended that prevention was 28 times more effective than treatment. Nevertheless, the issue of withdrawing funds from treatment, thus limiting the life expectancy of current sufferers in order to prevent others from acquiring the disease is difficult and unresolved. Prevention techniques that show promise include: media campaigns, the education of sex workers, the treatment of sexually transmitted diseases, and male circumcision.
Dean Paxson spoke finally of collateral damage, the spillover effect of the AIDS epidemic in Africa. In areas of high aids prevalence all health care has declined. Not only have available funds been reallocated to AIDS treatment, but health-care workers have died in the epidemic, and prospective workers are reluctant to enter the profession. In addition, reduced family budgets caused by the death of wage earners also limit access to health care. While child care has actually improved in low AIDS areas, in high AIDS areas the health care systems are falling apart with substantial deterioration in pre-natal, delivery, vaccination, and general child care. The reduction in vaccinations could lead to a resurgence of diseases such as polio and tuberculosis that were thought to have been defeated.
The most obvious effect of middle-years AIDS deaths has been the explosion in the number of orphans. Surveys have shown that the conditions in which orphans live vary with the degree of family relationship. The more distant the relationship of the foster family, the lower the level of concern for the orphan. In general, orphans live in reduced-income families, are much less likely to receive schooling, and receive less health care. This neglect of a large portion of the young population, a lingering effect of the AIDS epidemic, will have serious consequences for the long-term social and economic prospects of sub-Saharan countries.
Respectfully submitted,
Russell E. Marks, Jr.
There were no guests or visitors.
Jack Reilly announced three additional members emeriti: Stuart Carothers, Rosser Clark, and Theodore Vial.
Jack then asked approval of the list of member candidates, which was given by voice vote, and the following new members were welcomed: Julia Bowers Coale, Eliot Alexander Daley, Jane S. DeLung, Gloria C. Erlich, Luke William Finlay, Alison Wheeler Lahnston, Owen G. Leach, Bradford Mills, Joel Warren Spiegelman, Ralph Norman Tottenham-Smith, Letitia Wheeler Ufford, and Edmund Charles Weiss, Jr.
Ruth Miller introduced, with verve and affection, her good friend Christina Paxson, Dean of the Woodrow Wilson School. With the numerical care of an economist and the sympathy of one long engaged in the study of health care, using numerous tables and graphs she addressed the topic “The AIDS Epidemic and Quality of Health Care Services in Africa,” noting that her presentation is based on five years of research.
She first described the current situation in Africa, noting that most statistics are to some degree unreliable and out-of-date, so no descriptions can be precisely accurate. In 2007, two-thirds of the 33 million HIV- positive people in the world lived in sub-Saharan Africa. AIDS has become an African disease. Although there is wide variation in AIDS prevalence among southern African countries, the worst affected suffer rates that reach 28% . The rate of new infection is declining, but AIDS deaths continue to rise, reflecting the large cohort of older victims. Infection rates have stabilized in most countries, but at widely varying levels; urban Ruanda at 3.1% contrasted with Botswana at 24%. One of the long-term damaging effects of the epidemic has been to skew the structure of population radically in southern Africa; heavy mortality in the 20 to 40 year old cohort leaves a bulging young population and a surviving older population, both groups dependent upon the shrinking middle. The rising child-to-adult ratio has dreadful future consequences.
Although the world-wide AIDS epidemic started in the early 1980s, Dean Paxson pointed out that an effective international response did not commence until 1996 when the first anti-retroviral drugs became available. The three-drug combination called HAART was very effective – extending life span by up to 13 years in advanced countries – but it’s cost of $4,500 per patient per year was well beyond the resource reach of African countries where annual per capita income was $350. Following the introduction of HAART, large sums became available to fight AIDS in Africa; the U.S. PEPFAR program has provided $15 billion since 2004, the Gates Foundation has contributed $6.2 billion, and the Global Fund, supported by governments and foundations, has spent $8.6 billion. In 2007 alone, $10 billion was allocated to Africa, $4.5 billion of that from the U.S. Fortunately, during this period the cost per-year per-person of anti-retroviral drugs has been cut from $4,500 in 1996 to $350 in 2001, to between $90 and $200 now. The introduction of generics and the work of the Clinton Foundation to negotiate lower prices were largely responsible for the sharp cost decline.
This dramatic increase in resources, however, has not yet reversed the scourge of AIDS. Treatment rates still remain low in most of the most severely affected countries. While in Latin America and the Caribbean, 62% of victims are under treatment, in sub-Saharan Africa only 30% are. A further threat to the long-term control of the disease is that the first-line drug treatment is effective for only about ten years. The second-line treatment is now much more expensive, once again beyond the means of African countries. At this delicate point, the question of treatment vs. prevention has assumed moral dimension. Distinguished organizations contend that prevention is much more cost effective than treatment in the long-term control of aids. A Lancet article in 2002 contended that prevention was 28 times more effective than treatment. Nevertheless, the issue of withdrawing funds from treatment, thus limiting the life expectancy of current sufferers in order to prevent others from acquiring the disease is difficult and unresolved. Prevention techniques that show promise include: media campaigns, the education of sex workers, the treatment of sexually transmitted diseases, and male circumcision.
Dean Paxson spoke finally of collateral damage, the spillover effect of the AIDS epidemic in Africa. In areas of high aids prevalence all health care has declined. Not only have available funds been reallocated to AIDS treatment, but health-care workers have died in the epidemic, and prospective workers are reluctant to enter the profession. In addition, reduced family budgets caused by the death of wage earners also limit access to health care. While child care has actually improved in low AIDS areas, in high AIDS areas the health care systems are falling apart with substantial deterioration in pre-natal, delivery, vaccination, and general child care. The reduction in vaccinations could lead to a resurgence of diseases such as polio and tuberculosis that were thought to have been defeated.
The most obvious effect of middle-years AIDS deaths has been the explosion in the number of orphans. Surveys have shown that the conditions in which orphans live vary with the degree of family relationship. The more distant the relationship of the foster family, the lower the level of concern for the orphan. In general, orphans live in reduced-income families, are much less likely to receive schooling, and receive less health care. This neglect of a large portion of the young population, a lingering effect of the AIDS epidemic, will have serious consequences for the long-term social and economic prospects of sub-Saharan countries.
Respectfully submitted,
Russell E. Marks, Jr.