AIDS, Africa and indifference: a confession

Dear Editor,

Dr. Wohlgemut's essay "AIDS, Africa and indifference" shows how easy it is to justify indifference towards the health problems of the global South by invoking demographic negatives (not being black, not having traveled in Africa, and not being destitutely poor) and simplistic separations (Africa is, after all, an ocean's breadth away). Such arguments make AIDS in Africa into a distant, almost fictional nightmare that will hopefully be dealt with by equally distant "higher-ups" in the international community, and one day magically go away if we close our eyes for long enough. The author argues that the clinical and analytical toolkit that medical school arms us with, replete with pathophysiological, epidemiological, genetic, and even ethical reasoning skills, are impotent in the face of these massive global problems. Because of this, he states, "no one will call me to account for my inaction", and unfortunately, he is quite likely correct.

But the rationalization of indifference must not be used to placate our North American apathy. Wohlgemut states that the "downside of globalization" is that "self-interest is still paramount", yet the medical and social science literatures are awash with evidence that globalization should be awakening our sense of global citizenship and galvanizing us into locally and globally relevant action.

The linkages - even within the restrictive, unidisciplinary domains of the biomedical toolkit are abundantly clear. Basic principles of pathophysiology and microbiology demonstrate how unequal access to treatment breeds antimicrobial resistance, since an inability to pay means people cannot take full courses of treatment. Resistance to antiretrovirals has been documented in regions where access to drugs has been sporadic, and DOTS programs which deem the treatment of multidrug resistant tuberculosis "not cost-effective" are fuelling MDRTB epidemics in Latin America. Further, microbes know no borders in this era of globalized air travel, and epidemiological studies have shown that tuberculosis in Canada, for example, is predominantly a disease of the foreign-born.

Wohlgemut closes by musing on what steps Canadian physicians might take to more closely engage with the health problems of the global South. I wish to briefly expand on each of his thoughts:

1. Western medicine is increasingly focused on high-tech medicine and decreasingly relevant to global health: A recent contribution to the British Medical Journal speaks directly to this concern by recounting the story of well-wishing but naïve Western radiologists whose inappropriate training rendered their skills virtually useless in Sub-Saharan Africa . We must develop and foster medical education that is directly relevant to international health. More importantly, we must advocate for the expansion of medical and societal infrastructure in resource-poor regions to decrease the global disparity in health technology.

2. Medical research in the West is increasingly irrelevant to the problems of the global majority. The "10/90 gap" refers to the travesty that less than 10% of global spending on health research is devoted to diseases or conditions that account for 90% of the global disease burden. As students and residents beginning our medical careers, we should seize opportunities to participate in such research. As a whole, the Canadian medical establishment must work to steer the research agenda towards neglected diseases and issues of relevance to the global South through our universities, hospitals and government budgets.

3. Existing monies dedicated to funding global health are grossly inadequate. Herein lies the crux of the problem, as well as the target for our future efforts. Inadequacies in global health inevitably boil down to insufficient funds, yet an examination of the mind-boggling sums our Western governments annually commit to defense budgets and anthrax scares proves that a rethinking of priorities could make a significant difference. An article accompanying Wohlgemut's essay demonstrates the important role that personal activism has a role to play in shifting our governments' funding priorities.

4. A strictly medical approach to HIV/AIDS will be inadequate. Though partially true, this statement is wrought with danger. Culturally appropriate education and prevention programs have their role, but their overemphasis placates us into brooding over the difficulty of treating HIV infection rather than upholding our responsibility to provide known, effective therapies.3 Creating and maintaining long-term access to antiretroviral therapy is imperative, and countless efforts are underway to some day turn this dream into a reality.

HIV/AIDS and other globalized infectious diseases will continue to devastate populations for decades in the absence of a 'magic bullet'. Clearly, Canadian physicians and trainees are not absent from the list of players who must work towards a solution.

REFERENCES: 1. Wohlgemut JP. AIDS, Africa and indifference: a confession. CMAJ 2002; 167(5):485-7.

2. Adje C et al. High prevalence of genotypic and phenotypic antiretroviral resistant HIV-1 strains among patients receiving ARV in Abidjan, Côte d'Ivoire. International Conference on AIDS 2000 abstract TuOrB298.

3 Farmer P. Infections and Inequalities: the Modern Plagues. Berkeley: University of California Press, 1999.

4. Menzies D. Tuberculosis crosses borders. Int J Tuberc Lung Dis 2000; 4(12):S153-159.

5. Scarisbrick G. Medical tourism should be banned. BMJ 2002; 324::S7.

6. Bateman C et al. Bringing global issues to medical teaching. Lancet 2001; 358: 1539-42.

7. Global Forum for Health Research. The 10/90 Report on Health Research 2001-2002. Geneva: Global Forum for Health Research 2002, 2002.

8. Yamey G. Public sector must develop drugs for neglected diseases. BMJ 2002; 324: 698.

9. Neufeld V et al. The rich-poor gap in global health research: challenges for Canada. CMAJ 2001; 164(8):1158-9.

10. Benatar SR. Respiratory Health in a Globalizing World. Am J Respir Crit Care Med 2001; 163:1064-67.

11. Berger PB. The XIV International AIDS Conference: a call for action … now. CMAJ 2002; 167(5):483-4.

12. Farmer P et al. Community-based approaches to HIV treatment in resource-poor settings. Lancet 2001; 358:404-9.