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The politics of intervention choice: HIV, enteric diseases and Ebola

This piece is, unfortunately, a bit late to the game because my WordPress blogging platform didn’t want to allow me to access my Dashboard (my site was under a spam attack, and thus I couldn’t access it). So, apologies to everyone for whom the debates have moved forward. Anyhow…

A few days ago, I tweeted about the fact that having your own biases or research interests shouldn’t prevent you from advocating for intervention in policy issues that are important. I understand very well the constraints goverments of the world face when choosing policy intervention targets. I’m a public policy specialist, I was trained to realize that policy choices are undertaken under conditions of scarce resources. Obviously, we should aim at executing policy interventions via robust resource allocation through some system of policy prioritization. Coincidentally, policy prioritization is something I’ve been working on for the past few years, and specifically this year, in the area of Mexican climate politics.

If I (or more specifically, if my preferred field of research – the global governance of sanitation -) ruled the world, I probably would have funneled a lot of money towards eliminating open defecation behavior, increasing toilet use, building new toilets in marginalized regions, and preventing enteric diseases’ transmission through proper sanitation and hygienic practices. It’s obvious (given what I study) that this is a type of policy intervention I’m interested in. We fight the spread of enteric diseases (transmitted via fecal-oral routes) through increased access to proper sanitation and hygiene practices. The global burden of disease for diseases related to lack of proper access to water and sanitation is calculated by the World Health Organization (WHO) as about 10%. According to their 2008 data, “water, sanitation and hygiene has the potential to prevent at least 9.1% of the global disease burden and 6.3% of all deaths“.

It would seem obvious that, given this burden of disease, we should funnel lots of financial resources and human capital towards solving the global sanitation crisis. Few things would make me happier. HOWEVER… we can’t just redirect money towards those policy interventions with the highest burden of disease, just like that. Two cases came to mind when thinking about this: Human Immunodefficiency Virus (HIV) and Ebola.

HIV is a disease that has (historically) disproportionately affected men who have sex with men (MSM), many of whom identify as gay or bisexual. In Canada and the United States, high incidence and rising rates of HIV transmission continue to worry epidemiologists. The issue doesn’t only affect gay men in developed countries. HIV transmission rates in African countries worry researchers from all over the world and merit intervention. Of course I would like to channel a lot of money and resources towards reducing HIV transmission, in Africa, in North America and worldwide.

And then we have the case of Ebola, which has taken a toll in the public health systems of several African countries, including Guinea, Liberia, Sierra Leone. The current outbreak has many global health scholars worried. I believe their concern is genuine. Kim Yi Dionne and Stephane Helleringer make solid points on why we need to worry about funneling more resources towards Ebola spread containment, patient treatment and contact tracing. Chris Blattman makes solid points on the “what next” (e.g. the aftermath of what Liberia is experiencing)

The problem is that our current understanding of Ebola and the potential for an exponential increase in transmission rates, is still developing, particularly because current surveillance systems in affected countries may be underestimating current death rates. Tackling the current Ebola outbreak, unlike many other public health concerns, is challenging because the science, the epidemiology, the social determinants, all are complex in and of themselves. Just imagine how difficult the issue becomes when you combine each individual layer of complexity. We know a lot more about HIV transmission and about enteric diseases’ prevention thanks to historical investments we have made on understanding these public health issues. We can’t stop focusing on Ebola because it’s not the biggest global burden of disease, or even one of the most important in terms of actual deaths, but because our understanding is still yet to develop, and because to design a policy intervention that works, we need to understand the social determinants, epidemiology and scientific understanding. We also want to help alleviate the current challenges facing the African countries dealing with the Ebola outbreak. And of course, we need to take into account that all of these factors intertwined affect the politics of intervention choice.

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