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Thursday, December 2, 2010

Social Intervention as a Pre-Requisite?

When a doctor sees a patient with schistosomiasis, a common water-born parasitic disease that affects over 250 million children in the developing world, the treatment given is a single oral dose of praziquantel. But the doctor is well-aware that since transmission of schistosomiasis is through water-dwelling snails, the longer-term cure that will prevent that patient from returning next year with the same disease is quite a different treatment -- in fact, a treatment that doesn't involve medicine at all. In fact, the long-term solution lies in water sanitation -- ensuring reliable access to non-contaminated water, combined with continuous mulluscicidal treatments of that water source. Similarly, when a doctor sees a patient with another parasitic disease, such as hookworm, that has oral-fecal transmission, the treatment given is 400 mg of Albendazole. But the answer to ensuring against re-infection in the longer term lies in urban planning and engineering: the installation of a sanitary and effective sewage system. 

Rwandan Boy Infected with Schistosomiasis

Are clinicians and economists alike are too quick to tackle the problems of pandemics like schistosomiasis, hookworms, and other diseases without addressing the basic underlying causes of poverty? What we often call root causes of poverty, such as hunger, malnutrition, lack access to safe drinking water, are perhaps primary conditions that need to be addressed in order to effectively mitigate disease.

Today, much of the global health literature does place more emphasis on holistic poverty alleviation efforts rather than purely clinical intervention. For example, Barnett and Whiteside argue that neither public health nor clinical medicine pays sufficient attention to what does improve health – escaping from poverty, access to good food, clean water, sanitation, shelter, education and preventative care. They go as far as to say that clinical medicine may have large effects on short-term health, but only marginal effects on people’s long-term health. Jeffrey Sachs puts forth the same argument, saying that people studying health systems should widen their perspective to include links with poverty-alleviation strategies, and vice-versa.

© 2009 NEED Communications
Contaminated Water Source in Southwestern Ethiopia

I don’t believe that poverty alleviation is a pre-requisite for clinical intervention. Neither clinical intervention nor social intervention alone can drive progress. The two are inextricably linked. Poor people view and value their health in a holistic sense, as a balance of physical, psychological, and community well-being. This view, consistent with the WHO definition of health as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity,” is remarkably consistent across ages, genders, cultures, and nationalities. In a qualitative study of over 60,000 poor women and men across the globe, the World Bank and WHO found that people overwhelmingly link disease and ill-health to poverty. No probing questions on health or disease were included in the study’s research guides, yet overwhelmingly health was central to poor people’s lives. The implications of these findings are that perhaps it does not even make sense to discuss clinical interventions in isolation. Instead, clinical interventions should be viewed as one piece of the puzzle in larger social interventions.

In his post yeseterday, Adam Schwartz expounded upon this very idea in the context of HIV/AIDS: "If there is funding to provide antiretrovirals to pregnant women with HIV, but no prenatal care, no surgical facilities for emergency caesarian sections, no trained surgeons, and no antibiotics for neonatal infections, then we may erase all the good of our initial interventions." These same sentiments are echoed by Stanford's Dr. Phyllis Tien when she is scaling up HAART distribution programs. She has a laundry list of “prerequisite conditions” that must be met beforehand -- including adequate infrastructure, minimal lab support, relatively informed communities, counseled patients, and access to OI/symptomatic treatment. She argues that without satisfying these basic economic conditions, a clinical intervention will fall short. Poor nutritional status is also a prevalent factor that can exacerbate HIV/AIDS. Malnutrition can plague the effectiveness of ARV treatment, increase vulnerability to infections or increase the severity of those infections. Coupling drug therapy treatment with good nutrition not only strengthens the immune system, but can help delay the disease progression and provide the crucial micronutrients the body needs to fight HIV. So without social interventions that fight the underlying malnutrition in HIV/AIDS patients, the clinical interventions would be significantly undermined.

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