Lethal Decisions by Arthur J. Ammann

Author:Arthur J. Ammann [Ammann, Arthur J.]
Language: eng
Format: epub
Tags: Social Science, Disease & Health Issues, Medical, Aids & Hiv, Health Policy
ISBN: 9780826503886
Google: RbwpEAAAQBAJ
Publisher: Vanderbilt University Press
Published: 2021-04-30T05:48:55+00:00

23

Guidelines Can Become Rules

WHO IS WHO?

WHO is viewed as the major international organization dealing with global health and responsible for developing guidelines for the prevention and treatment of disease worldwide. The organizational structure is complex and its interaction with other UN organizations confusing. Their headquarters are based in Geneva, Switzerland, with six regional offices throughout the world and 147 individual country offices. The WHO headquarters in Geneva alone include a staff of eighteen hundred workers—there are eight thousand additional public-health experts, including doctors, epidemiologists, scientists, managers, and administrators scattered through hundreds of regional offices around the world. Its size, complexity, and insulation in decision-making have been a source of major criticism. Approximately 80 percent of WHO’s current budget comes from wealthy countries, foundations, other multilateral bodies, non-governmental organizations, and private interests, such as pharmaceutical firms. Often the donated funds come with strings attached, requiring WHO to focus on specific diseases such as malaria and polio and leaving less room for flexibility or a rapid-response structure, which perhaps explains their delays in addressing the rapidly emerging Ebola virus epidemic in 2014 (WHO 2016).1 But the slow response was not unique to Ebola; it was also evident in the emerging AIDS epidemic. An internal WHO memo in 1983, two years following the description of AIDS, stated that the organization did not need to be involved in AIDS because “[AIDS] is being well taken care of by some of the richest countries in the world where there is the manpower and the know-how and where most of the patients are to be found.”2

DON’T TREAT THEM UNTIL THEY ARE REALLY SICK

In 1997, WHO published its first, much-delayed “Informal Consultation” on the treatment of HIV infection, which immediately sparked controversy—and with good reason. With an apparent paucity of expert scientific and economic opinion, WHO based its 1997 recommendations and its subsequently expanded 2002 guidelines on the short-term financial costs of treating millions of HIV-infected individuals. It was likely they were using what is now considered to be an outdated analysis of medical costs—cost-benefit, rather than the more realistic (and compassionate) cost-effectiveness analysis, whereby the long-range impact of investing in health care and stopping a rapidly expanding HIV epidemic is analyzed.

But the major difficulty with their guidelines was their unprecedented recommendation to treat only those individuals with advanced disease and to withhold treatment from millions of HIV-infected people. To put this into perspective, an international group of advisers headquartered in Geneva, Switzerland, with little to no responsibility for the care of patients with HIV/AIDS, no direct responsibility for their welfare or responsibility for the consequences of their decisions, assembled guidelines under which tens of millions of HIV-infected individuals worldwide should be treated, including when treatment should be started and what drugs should be used. The guidelines were meant to apply to countries affected by the HIV/AIDS epidemic regardless of the number of patients within those countries and regardless of whether the countries were economically advanced or extremely poor.

WHO treatment guidelines contrasted sharply with what was happening in practice in the United States.

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