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One World, Multiple Standards

By José M. Zuniga

July 2004

In July 2000, the global AIDS community gathered at the XIII International AIDS Conference in Durban, South Africa, to "break the silence" and bolster action to stem the devastating impact of HIV and AIDS in the developing world. Four years after this clarion call to mobilize both the political will and resources necessary to expand access to antiretroviral drugs, and to overcome social and political barriers to health and human development for all, we are called upon to ask: How far have we come?

As we gaze back upon the landscape over which we have journeyed since 2000, do we see mountains and gulfs that have been surmounted, or rather a gentle ripple of hills that were but the prelude to greater, forthcoming obstacles? While respect is due the various achievements that have been realized since 2000 in expanding access to care and treatment, I would argue that ultimate judgment about our progress in this respect will only truly be possible by evaluating what is occurring at the point of care for patients -- that point of intersection where the rhetoric of commitment meets (or does not) the beds, food, syringes, drugs, and care providers that collectively help to determine the fate of those who seek access to them. And so, where we have succeeded in focusing global attention on the AIDS pandemic and now prepare to gather in Bangkok this month for the XV International AIDS Conference to plan next steps and organize efforts aimed at ensuring that AIDS remains key among competing global priorities, it is my sincere hope that equal attention will be placed on continuing needs at the point of healthcare delivery, where the "rubber meets the road," as the saying goes.

It is a great understatement to say healthcare delivery in our world varies immensely in quality and availability. But we must address the nascent, ethical questions couched in that statement: Are we willing to accept multiple standards? If not, what does that imply, and subsequently, what does that then further require of us? It is revealing of our ambivalence on this matter that in the very calculus of our international public health efforts (HIV being no exception) we accept as a general precept and variable the very impoverishment of care capacity and the absence of important infrastructure in determining many of our responses and interventions. A common clinical rejoinder to this approach, as has been memorialized in ongoing debate between population versus individual health, is that by accepting these limitations and standards in order to provide some care for all and maximum benefit at the society level, individual health outcomes are very often sacrificed. It is a frustrating toss-up that is perhaps nowhere better exemplified today than through the lens of the global AIDS pandemic.

Where questions of what is required to optimize individual care in resource-constrained settings seem so often to rub uneasily against the imperatives of caring for masses of HIV-positive people, preventing further spread of disease, and accomplishing this feat within the narrow bounds of existing capacity, we face difficult choices. And so, while the progress that we have achieved in dealing with the pandemic bespeaks the fact that more and more of us seem to be appreciating that we are our brother's keeper -- as the spiritual saying goes -- just how well we are keeping him is the question around which I feel we owe greater attention.

As we reach the mid-point of 2004, the lion's share of our collective energy is currently dedicated to expanding access to antiretroviral therapy so desperately needed in most places of the world -- and rightly so. At the same time, however, we must ask ourselves whether we are being equally thoughtful with respect to accompanying care concerns, examining from both clinical and ethical perspectives what patients deserve -- be they in New York or New Delhi -- and in many cases must have, in accessing this life-saving and -enhancing treatment, and maximizing its benefit. Many challenging questions stand before us, and I fear that as we proceed with due haste to expand our treatment efforts in resource-constrained settings we risk allowing the ultimate consideration of patient outcomes and quality of life to be greatly overshadowed by competing arguments for cost containment, rapid response, and social benefit.

While certain of these issues have been raised in objection to our desire to expand access to antiretroviral therapy -- the "developing world is not ready for antiretroviral therapy" argument (which is, incidentally, a view not shared by the International Association of Physicians in AIDS Care [IAPAC]) -- I would agree that the singular merit of this argument is that, yes, indeed, effective delivery of antiretroviral therapy will be a great challenge should healthcare capacity remain as it is in many places. However, rather than accept this state of affairs, as detractors from the antiretroviral therapy expansion movement may do, we are compelled instead to turn this question back upon ourselves and ask how it is that we allow these impoverished conditions to exist. When we adapt our responses too much to fit existing treatment capacity, without working to improve that capacity and the underlying poverty that holds it back, our responses risk being unsustainable or ill conceived. What we are now learning about the use of single-dose nevirapine (NVP) for prevention of mother-to-child transmission of HIV stands as an example.

In raising these points, I contend that the best immediate prescription for this dilemma is increased attention to its persistence. My ultimate concern is that unless we submit these questions to debate, we risk losing sight of the single common denominator that must unite us and guide our various actions as we look to the future: an improvement in the healthcare standards, capacity, and tools necessary to ensure the optimal care of patients, regardless of where they live. I deliberately say "patients" here, not "HIV patients," recognizing that as we expand access to treatment for HIV disease we also risk pitting it against other diseases in our effort to secure and spend scarce resources. This, too, is an imminent danger that we must avoid.

While immediate, ad hoc solutions and interventions may be the tough pill that we must swallow in order to get us further on down the road, I would like to argue that we must accept as a terminal point no less than a single, equal standard of care and treatment for all people living with HIV/AIDS. It is with a view to contributing to global dialogue around this issue of concern that on July 15, 2004, IAPAC will be hosting an official satellite symposium of the XV International AIDS Conference that will be dedicated to examining the global state of AIDS care in 2004. Through this critical opportunity, IAPAC wishes to increase attention to continuing disparities in care standards globally, to examine their implications, and to address the serious needs of patients and care providers alike in ensuring optimal clinical outcomes and, as important, enhanced quality of life.

In ending this month's "Report from the President," I wish to quote from former United Nations Secretary-General Dag Hammarskjöld who, in championing human rights and international development in a manner unlike many before or since him, reminded us that, "to let oneself be bound by a duty from the moment you see it approaching is part of the integrity that alone justifies responsibility." If we have answered the difficult question of whether we accept multiple standards of care in the negative, then it follows that we have admitted responsibility for fostering and creating change. Our duty in redressing these multiple standards still lies ahead, and surely our integrity hangs in the balance. If I may venture a final personal thought, I would opine that the immediate answer is to insist on asking difficult questions, to not shy away from hard wars in favor of easy battles, and to not let our imaginations and actions be bound by the realities of the present.

José M. Zuniga is President/CEO of the International Association of Physicians in AIDS Care (IAPAC), and Editor-in-Chief of the IAPAC Monthly.

Back to the July 2004 issue of IAPAC Monthly.

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