The Common Good
February 2006

The HIV Trade-Off

by David Batstone | February 2006

Is 'cost-effective' the right criterion for judging AIDS drugs?

Karl Barth’s prescription for an engaged Christian is often quoted: Keep in one hand the Bible and in the other hand the daily newspaper. I tweak the advice of the famed Swiss theologian for my own discipline and keep in my newspaper hand copies of two highly regarded dailies: The Wall Street Journal and The New York Times. Most folks read the news that reinforces their own point of view. Absorbing a steady diet of adversarial positions and the statistics that accompany them helps us to identify those idols closest to home.

That’s also why I keep up a subscription to Forbes, the magazine that proudly touts itself as a publication for “the world’s business leaders.” I was leafing through a copy of Forbes recently, and an article caught my eye: “Treating HIV Doesn’t Pay.” The tagline was equally jarring: “It is humane to pay for AIDS drugs in Africa, but it isn’t economical. The same dollars spent on prevention would save more lives.”

The piece penned by Emily Oster, a graduate student of economics at Harvard, applies an economic cost-benefit analysis to a serious social crisis. She pits pouring resources into antiretroviral therapy that may save individual lives against a preventative strategy that would arrest the spread of the epidemic.

Oster does a yeoman’s service by dispelling a widely held myth that AIDS has spread in Africa primarily due to the undisciplined exercise of libido—in simple terms, the idea that Africans have more sex and more sexual partners. While sexual behavior certainly plays into the AIDS epidemic in Africa (as it does everywhere), Oster points out that its transmission can be traced in large part to untreated infections such as gonorrhea and syphilis that create open sores and serve as a hotbed for HIV.

Moving from that assumption, she suggests two measures that would be more effective than treating individuals with HIV. First, shift precious resources to deploy antibiotics to treat sexually transmitted infections that precipitate the spread of HIV. Second, invest in education that will help Africans better understand how HIV spreads and how to act preventatively. Both methods, Oster argues, would be more cost-effective:

“Antiretroviral treatment is around 100 times as expensive in preventing AIDS deaths as treating other sexually transmitted infections and around 25 times as expensive as education.”

Oster is not cruel. She acknowledges that morality and compassion may compel us to jettison a cost-benefit analysis and opt to treat the afflicted with mercy. But she also helps us understand that we may be trading off compassion for more feasible long-term solutions.

The facile reaction to her dilemma is to pretend that we do not have to make such a trade-off. We can invest in treatment, prevention, and education. Surely she’s built a false divide; can’t we just integrate all these efforts into a comprehensive strategy?

The truth of the matter is that health organizations do not have unlimited funds at their disposal. It would be right to point out to wealthy nations the shame of this scarcity in a world of plenty. But a prophetic “should be” does not erase the harsh truth of what exists in front of us. The funds available to health agencies are insufficient to address the crisis.

So how do they best address the spread of AIDS in Africa, India, China, and elsewhere? Oster’s analysis helps, but it also leaves out some serious considerations. The number of lives saved is not the only goal of intervention. A human society can be torn apart by the loss of an entire generation of parents, educators, and leaders. The future of a society depends on both its young and its old, on vitality and wisdom.

It is an even more intangible objective to promote a spirit of compassion and hope in a society. But it is a sacred mystery we deny at our peril. The gift—and sometimes the curse—of being human is our empathetic impulse. To suppress compassion and turn wholly to calculation would tear out the soul of society.

Unfortunately, we are stuck with a tragic dilemma. Everyone’s good dream will break somebody’s heart.

David Batstone is executive editor at Sojourners.

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