The Moral Economy of AIDS

A man waits for for his results after being tested for HIV/AIDS at a government run Voluntary Counseling and Testing Center in Kibera in Nairobi Photograph by Tony Karumba/AFP/Getty Images

There was a lot of good news at this year’s International AIDS conference, which wrapped up in Washington, D.C., last week after headliners from Bill Clinton to Elton John spoke of progress in battling the disease. There was even talk of an AIDS-free generation, thanks to a combination of advances, from further steps toward a vaccine to evidence that the antiretroviral drugs used to treat the disease also help prevent patients from infecting others. Particularly exciting was news that the total clinic-level cost of providing a year’s worth of antiretroviral drugs—which can keep people with the disease alive indefinitely—had dropped to $200 in some African countries.

But despite that progress, there was still disagreement over the effectiveness of the global AIDS response, highlighted in a debate (summarized here) between, on the one hand, economist Jeffrey Sachs and Michel Sidibe, the head of the U.N. AIDS program, and, on the other, two health economists—Mead Over (full disclosure: a colleague) and Roger England. About three-quarters of U.S. health aid goes to HIV/AIDS, but that money could save more lives if spent on other diseases that are simpler to prevent or treat. The debate focused on the question: Should we use resources for antiretrovirals at a cost (including overhead) of perhaps $350 per patient per life year saved (PDF) if we could use those resources to provide a course of drugs to cure victims of tuberculosis at a cost of $5 to $50 per life year, or of extending childhood immunizations at the cost of $2 to $20 per life year?

The moral issue is one popular with philosophy teachers. There’s a train track. On the track, 10 poor innocents are tied down, struggling to get free. But a train is fast approaching. It’s going to crush the people before they have any chance to escape. You’re standing by a railroad switch and can, with the press of a button, move the train onto another track before it crushes the 10 innocents. But just down the line on that track are two innocents, tied down, struggling to get free. Do you press the button?

Many activists say that even posing the question about choices in a world of scarce health resources is wrong and unhelpful. It pits those advocating for more vaccinations against those lobbying for increased antiretroviral expenditures when they should be united in the struggle for more global health funding overall. But it is nonetheless a choice we are making.

Simply, millions of people are dying unnecessarily for lack of $350 a year or less. It may be those who don’t get AIDS treatment, or those who don’t get other treatments because the available money is being used to buy antiretrovirals. It doesn’t matter, actually. The world has put a price on life at somewhere below $350 a year. Ministers of finance and health and development officials are left with the unavoidable duty of deciding how to spend resources, but whatever they decide, people are going to be dying from causes we can prevent for a lot less than the cost of a new smartphone.

If more money isn’t forthcoming, the ministers and development officials may choose to minimize deaths next year by prioritizing vaccinations or TB treatment or road safety improvements over new antiretroviral treatments. That’s if they have a choice in the matter.  With some aid programs, if ministers or officials don’t spend the money on HIV/AIDS, they might not get the money at all. That’s because it is ring-fenced in funding agencies such as the U.S. president’s Emergency Plan for AIDS Relief, which is obligated to spend 80 percent of its $6.6 billion budget (PDF) on the disease.

Such programs are the result of an incredible, unprecedented activist movement that persuaded donor governments to spend billions on international HIV/AIDS programs—money that otherwise probably wouldn’t have gone to global public health at all. That movement has saved—and continues to save—hundreds of thousands if not millions of lives.

But it would be an insult to those very same activists to suggest they value the life of someone with HIV who would die without antiretrovirals 17 times more than they value the life of someone who would die of a vaccine-preventable disease, or seven times more than they value the life of someone who would die of TB without treatment. The shortage of resources for global health creates no less painful a moral dilemma for them.

If anything could open treasury accounts in the rich world to provide a larger flow of resources to global health, perhaps it is to get policy makers in those countries to think through these gut-wrenching decisions that limited funding (and lack of funding flexibility) forces doctors and ministers and activists alike to make every day. To return to the philosopher’s dilemma about the innocents on the train tracks: Must the developing world be forced to choose between killing two or 10? Shouldn’t we try to stop the train instead?

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