I've been thinking a lot about the Argentine policy that provides free testing for HIV/AIDS, as well as free medication to anyone with the disease. Specifically, I've been wondering if this is an efficient way to use limited national resources for the betterment of society. Also, should or could this policy be implemented in the US? I don't have a firm answer to these questions, but based on my own limited experiences (and refraining from weighty health statistics), I'd like to share my thoughts.
Free testing for HIV/AIDS is a no-brainer to me. Someone who thinks they may have HIV should have any and all obstacles removed from getting tested so they are fully informed of the risk they pose to others. But I now have a new reason to support free testing. The majority of people who have come into the clinic for an HIV test have been young women of reproductive age. The sad truth is many of these young women were victims of sexual assault and rape. Abortion is not legal in Argentina (a topic I'm not going to touch.) All of this is important because, with proper treatment, a baby born from an HIV positive mother will not get HIV. Women in this situation should be encouraged to get tested as early as possible so that HIV does not pass to the next generation. That's where free testing come in. I believe anyone would agree this is cost-effective way to prevent a deadly disease from taking an innocent life (no matter how you define innocent).
The policy of providing free treatment causes me more internal debate. Argentina is not a fully developed country. While it has tremendous natural resources, decades of political instability have led to higher inflation, lower unemployment, and more poverty than the US and Western European nations. Can it really afford to be giving away expensive anti-retrovirals to HIV patients? More important to me (and to the potential convertibility of this system to the US), does treating the HIV patient really fight the source of the problem or does it merely extend the life of those in poverty. I was leaning towards the latter, until I went to a community prevention meeting last week and realized the logic of Argentina's system.
In Argentina they start off with the realization that the people infected with HIV and AIDS tend to be the poorest citizens. Then they take the moral stance that these people deserve treatment they otherwise cannot afford, so the state offers it for free. By using tax money to pay for AIDS treatment, it means everyone has a stake in the disease. It gives an incentive for all people in a community, both the rich and poor, to work towards prevention. I believe it takes a community effort to fight this disease because only the community has access to many of the root causes: violence at home, teenage drug abuse, dangerous teenage sexual habits, etc.
In the US, people need insurance to afford retrovirals. But the majority of HIV/AIDS patients are poor and the majority of the poor do not have insurance. As Paul Farmer wrote, "[HIV] has spread along the path of least resistance, rapidly becoming a disorder disproportionately striking the poor and vulnerable." I believe when a community fails to invest in treating uninsured HIV victims, there is less incentive for the community to prevent them from passing on the virus. You can think of the US as a big community, or if that's impossible (understandably so), think of the community of New York City. There's certainly no shortage of millionaires in NYC, but there are also over 78,000 people KNOWN to be living with HIV or AIDS in 2008. If citizens had to directly pay to keep these people alive with antiretrovirals, maybe they would care more. Maybe people would use their business contacts to disseminate more AIDS information or pressure schools to provide more rigorous sexual education or even set up free condom vending machines. Who knows? The point is people would do something if they had a stake in the disease.
Am I becoming a socialist now that South America has a hold on me? I doubt it. I just think AIDS is something that concerns us all. And maybe we need stronger action for people to realize this fact.
Wednesday, April 8, 2009
Tuesday, April 7, 2009
Day Trip to Punto Lara
This past weekend, a few of us FSD interns got together for a day trip to Punta Lara. We heard it had a nice Nature Reserve, which seemed like a good way to spend a beautiful Saturday. It's also easily accesible from La Plata, right on the busline. So vamos.
We went to the Nature Reserve, but it was closed. Sometimes things are closed for no real reason in Argentina. Oh well.
So we walked around, but the beaches were pretty dirty. It's a river downstream of Buenos Aires, so I guess that explains why.
Then we sat and thought for a while.
So we did what Argentines would do: drink Quilmes and eat choripans.
We went to the Nature Reserve, but it was closed. Sometimes things are closed for no real reason in Argentina. Oh well.
So we walked around, but the beaches were pretty dirty. It's a river downstream of Buenos Aires, so I guess that explains why.
Then we sat and thought for a while.
So we did what Argentines would do: drink Quilmes and eat choripans.
Sunday, April 5, 2009
Sharing Strategies for HIV Adherency
I've been working with my host organization for two full weeks. I feel like I'm finally starting to get a feel for the place and develop a routine. The clinic is open from 8AM to 8PM, but most of the doctors work 4 hours shifts. I normally arrive a little after 3:30PM . This gives me a chance to chat with some of of the doctors hanging out in the kitchen before they work the last shift of the day. Everyone is very friendly and they LOVE drinking mate. (As a general rule, the easiest way to make friends in Argentina is to drink mate and talk about Futbol.) There are a variety of talented people that work in El Centro de Referencia. Besides the general doctors, there is also a Psychiatrist, a social worker, and an infectious disease researcher.
My supervisor, Dr. Cueto, usually arrives a little after 4 PM and gets started with his patients right away. I shadow him the entire time, occasionally leaving the room when patients want more privacy. I don't get offended when this happens; in fact I'm amazed that most patients are comfortable discussing very personal issues with me around. Shadowing Dr. Cueto for two weeks has helped me get to know a few of the returning patients who come in for HIV treatment. One of the biggest problems I have observed, and something I am becoming interested in, is the problem of adherency.
The municipality of Buenos Aires has a law that demands all HIV and AIDS medication to be administered free of charge. Unfortunately, this doesn't mean everyone who needs these medications will take them properly, or at all. For most Americans (myself included), it's hard to believe that free, life-sustaining medication would be willfully rejected with such frequency. But here in Argentina, a country accustomed to political and economic crisis, uncertainty is a way of life. In just the time I've been here, inflation has caused a 50 cent increase in the price of a bus ticket. Also, the Government recently decided to move up their October Senatorial election to June (much more on that in a later post.) This instability most affects those in or near poverty (like the majority of HIV patients), and it becomes a mindset they cannot escape from. If nothing is stable in your life, how do you learn dependability? Many do not and often fail to commit to a job, a family, or taking medication that will keep them alive.
The idea for my project is to identify patients who do not fit this trend. There must be several patients that manage, despite hard circumstances, to take their medications every single day. I want to know how these few patients do it, and then I want to help them share this information with others. My first task is to create a list of questions that will identify patients who successful adhere to their treatment. I need to keep in mind that many will not be truthful, so the questions should be detailed but not so detailed they become confusing. Then I will conduct the interviews. I will probably need to study vocabulary related to the questions and bring a a tape-recorder. Finally, I will hold a follow up session for patients who show strong adherency. I will have them discuss strategies for success and organize their responses into a pamphlet that I can publish and distribute. This will allow other patients to learn from their peers instead of doctors. It may even inspire them to work harder once they see that success brings positive attention.
I think this is a fairly manageable project, but as I said before, it is Argentina and I should expect the unexpected. One final point: last Friday confirmed how important the topic of adherency is, not just to the individual, but to public health. There was an AIDS patient who said he was taking his medications regularly, but was not responding to them. The doctors at the clinic ordered a genotyping analysis that was sent all the way to Stanford University. As it turns out, this patient developed a form of AIDS resistant to several drugs. Dr. Cueto is convinced this happened because he stopped taking his medication for a long periods of time. These expensive tests and the risk of unleashing drug resistant forms of the AIDS virus into the population would be unnecessary if this man simply took his medication everyday. But then again, it's never really that simple here.
My supervisor, Dr. Cueto, usually arrives a little after 4 PM and gets started with his patients right away. I shadow him the entire time, occasionally leaving the room when patients want more privacy. I don't get offended when this happens; in fact I'm amazed that most patients are comfortable discussing very personal issues with me around. Shadowing Dr. Cueto for two weeks has helped me get to know a few of the returning patients who come in for HIV treatment. One of the biggest problems I have observed, and something I am becoming interested in, is the problem of adherency.
The municipality of Buenos Aires has a law that demands all HIV and AIDS medication to be administered free of charge. Unfortunately, this doesn't mean everyone who needs these medications will take them properly, or at all. For most Americans (myself included), it's hard to believe that free, life-sustaining medication would be willfully rejected with such frequency. But here in Argentina, a country accustomed to political and economic crisis, uncertainty is a way of life. In just the time I've been here, inflation has caused a 50 cent increase in the price of a bus ticket. Also, the Government recently decided to move up their October Senatorial election to June (much more on that in a later post.) This instability most affects those in or near poverty (like the majority of HIV patients), and it becomes a mindset they cannot escape from. If nothing is stable in your life, how do you learn dependability? Many do not and often fail to commit to a job, a family, or taking medication that will keep them alive.
The idea for my project is to identify patients who do not fit this trend. There must be several patients that manage, despite hard circumstances, to take their medications every single day. I want to know how these few patients do it, and then I want to help them share this information with others. My first task is to create a list of questions that will identify patients who successful adhere to their treatment. I need to keep in mind that many will not be truthful, so the questions should be detailed but not so detailed they become confusing. Then I will conduct the interviews. I will probably need to study vocabulary related to the questions and bring a a tape-recorder. Finally, I will hold a follow up session for patients who show strong adherency. I will have them discuss strategies for success and organize their responses into a pamphlet that I can publish and distribute. This will allow other patients to learn from their peers instead of doctors. It may even inspire them to work harder once they see that success brings positive attention.
I think this is a fairly manageable project, but as I said before, it is Argentina and I should expect the unexpected. One final point: last Friday confirmed how important the topic of adherency is, not just to the individual, but to public health. There was an AIDS patient who said he was taking his medications regularly, but was not responding to them. The doctors at the clinic ordered a genotyping analysis that was sent all the way to Stanford University. As it turns out, this patient developed a form of AIDS resistant to several drugs. Dr. Cueto is convinced this happened because he stopped taking his medication for a long periods of time. These expensive tests and the risk of unleashing drug resistant forms of the AIDS virus into the population would be unnecessary if this man simply took his medication everyday. But then again, it's never really that simple here.
Wednesday, April 1, 2009
El Centro: First Day
As I sat next to my supervisor, Dr. Cueto, in his office, I was able to look across the room into a crowded waiting area. I expected each visit to be brief and to the point: a quick how are you doing, let's take a look, here's what you need. This seemed to me to be the best way to manage such a large volume of patients. After all, it was already 4 PM (Dr. Cueto has a private dermatology practice during the day), and these patients ARE getting free health care. That's why I was taken aback when the first patient sat down and started talking, and talking, and talking some more. Now let me remind you that my Spanish is far from perfect and I couldn't understand everything that was being said. But I thought I heard her mention something about her grandchildren. Then she reached into her bag, pulled out a large photo of her grandaughter, and showed it to Dr. Cueto as he smiled proudly. She then reached into her bag again and pulled out a baby outfit with the Gimnasia logo (one of the two local Futbol teams in La Plata). This provoked a different response from Dr. Cueto because he is a die-hard fan of Estudiantes (the other, rival team from La Plata).
This was not an isolated incident. Dr. Cueto talks to each and every patient on a personal level. This particular woman had been coming in for HIV treatment for years, but he expresses the same amount of interest in patients he meets for the first time. I eventually came to the conclusion that providing this type of personal attention makes his job more manageable, not more difficult; even though we didn't leave the office until 9 PM.
Within the span of a few hours the following patients came into the clinic: a teenage girl who was sexually attacked and awaited an HIV test, a twenty-year-old man afraid to tell his family he has HIV, and a woman with AIDS who is homeless but does not want to stay at a group shelter. Clearly, the patients who come to this clinic have problems that go beyond health. Most have been living on the margins of society their entire lives, and HIV is just one more thing they have to worry about. By simply treating each "case" that comes in, without getting involved in the human element, it could be very easy to burn out. Treating illnesses all day does nothing to change the underlying imbalances in the world that create them. No matter how fast you dispense medicine, there will always be more people out there getting sick. One might feel like Sisyphus rolling his rock up the hill each day only to see if break apart into little pieces. But if you treat the person and try understand his or her individual struggles, the work you put in has more of a purpose. You will be able to take part in, and therefore appreciate, the life you help sustain. Of course this all comes at a price. Opening up yourself emotionally to patients that will likely pass away in a matter of years can be very difficult, and I understand why many avoid it.
This has been a lot to take in and has given me much to think about the past few days. There is no doubt that I will continue to learn a lot from all of the doctors at this clinic. I hope that I can prove my worth my starting a good project. I already have some ideas, but stay tuned till next time for more.
This was not an isolated incident. Dr. Cueto talks to each and every patient on a personal level. This particular woman had been coming in for HIV treatment for years, but he expresses the same amount of interest in patients he meets for the first time. I eventually came to the conclusion that providing this type of personal attention makes his job more manageable, not more difficult; even though we didn't leave the office until 9 PM.
Within the span of a few hours the following patients came into the clinic: a teenage girl who was sexually attacked and awaited an HIV test, a twenty-year-old man afraid to tell his family he has HIV, and a woman with AIDS who is homeless but does not want to stay at a group shelter. Clearly, the patients who come to this clinic have problems that go beyond health. Most have been living on the margins of society their entire lives, and HIV is just one more thing they have to worry about. By simply treating each "case" that comes in, without getting involved in the human element, it could be very easy to burn out. Treating illnesses all day does nothing to change the underlying imbalances in the world that create them. No matter how fast you dispense medicine, there will always be more people out there getting sick. One might feel like Sisyphus rolling his rock up the hill each day only to see if break apart into little pieces. But if you treat the person and try understand his or her individual struggles, the work you put in has more of a purpose. You will be able to take part in, and therefore appreciate, the life you help sustain. Of course this all comes at a price. Opening up yourself emotionally to patients that will likely pass away in a matter of years can be very difficult, and I understand why many avoid it.
This has been a lot to take in and has given me much to think about the past few days. There is no doubt that I will continue to learn a lot from all of the doctors at this clinic. I hope that I can prove my worth my starting a good project. I already have some ideas, but stay tuned till next time for more.
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