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Incentivizing Health: A Case for Health as a Human Right

Art Lenahan

I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s blade or the chemist’s drug . . . I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person’s family and economic stability.  —Dr. Louis Lasagna, Hippocratic Oath: Modern Version, 1964

In this essay, I aim to critique the neoliberal approach to healthcare in favor of a human-rights-centered approach. Applying the ideas of the human rights discourse to health in development, I will make the claim that healthcare predicates and transcends economic development—that is, health is a condition of social and economic forces, which, if developments are to take place, must be dealt with in a human rights framework. Furthermore, incentive to participate in healthcare programs cannot be conceived in terms of capital alone. The problems of health are, in this way, related to the problems of development in the general sense. I will largely draw upon the writings of Paul Farmer and the work of the Comprehensive Rural Health Project in Maharashtra, India, to support this claim and as a prospective way to forward health development.

The Peculiar Problem of Tuberculosis

To begin, we look to tuberculosis as a case study of the ways in which physical pathologies are linked to socioeconomic development. According to 2008 World Health Organization (WHO) indices, tuberculosis kills an average of 480 people per 100,000 population per year in Africa. The world health statistics for people living in the ‘low income’ bracket are comparable: an average of 410 people per 100,000 population per year die of pulmonary tuberculosis (WHO 2010). It is important to note that these cases concern only those who die of tuberculosis—many more contract and suffer through it. Today, tuberculosis is one of the most common and yet easily preventable causes of death throughout the “developing” world.

Like any disease, the distribution of tuberculosis (TB) is uneven. Let us take Russia as an example. Despite a long decrease in the prevalence of TB in Russia throughout the 20th century, rates of TB increased by a factor of two or even three between 1990 and 1996 (Farmer, 2005: 127). To understand why this happened, we need to look at how TB exposes connections between economics and physical ailment.

Mycobacterium tuberculosis is a form of bacteria that thrives on lung tissue. It is most commonly and easily treatable with common antibiotics such as rifampin, which has been widely and cheaply available for decades. TB spreads via airborne particulates—that is, a single cough can spread the disease across a room. According to Paul Farmer, “if left untreated, each smear-positive pulmonary tuberculosis patient can, in turn, infect a dozen or more new contacts each year” (Farmer, 2005: 119).

However, the discontinuous application of antibiotics kills many but not all of the bacteria. This artificially selects for the bacteria which are most resistant to the antibiotics, those whose DNA contains mutations which allow them to resist the drug. These mutated types become more common until the infection is untreatable with the common antibiotics, and expensive second-line drugs must be employed. “Haphazard therapy,” Farmer says, “is one of the best ways of inducing the tubercle bacillus to acquire drug resistance” (Farmer, 2005: 117). This drug-resistant form is referred to in medical circles as multidrug-resistant tuberculosis, or MDRTB.

Let us now return to Russia. Since the collapse of the Soviet Union in the early 1990s, discontinuity of TB therapy is more and more common. According to Paul Farmer, a specialist in TB, MDRTB is often caused by “commonplace drug stockouts or the patients’ failure to take their drugs” (Farmer, 2005: 118). In the times of the Soviet Union, there was a relatively stable TB infrastructure in place which was able to treat patients equitably and effectively. In the era of capitalism, rates of TB are skyrocketing, and MDRTB is more and more commonplace.

TB peculiarly mirrors inequalities within health infrastructure. The people who are marginalized are not only more at risk to die from TB after it has been contracted, but also to contract TB in the first place. According to WHO indices, an average of only 8 “high-income” people per 100,000 population die per year. This is just over 1% of the global average among “low-income” people (WHO, 2010). Furthermore, the people without access to adequate resources are more at risk to contract MDRTB because it is caused, in many cases, by the inequitable distribution of basic medical care. MDRTB requires a longer term of treatment and more expensive medications, as second-line drugs often cost one hundred times more than the original antibiotics (Farmer, 2005: 122). The percentage of MDRTB cases out of all tuberculosis cases has thus swelled greatly as the health infrastructure and economy of Russia has weakened (Farmer, 2005: 118).

In light of this, it is tempting to ask: Is it cost-effective to take a preventative approach to MDRTB (and thereby TB)? In Russia, the answer is no. In prisons there, European development organizations use an approach called DOTS (Directly Observable Therapy, Short-course) as a cornerstone of TB treatment. DOTS relies on a basic regimen of rifampin and other antibiotics to treat TB. However, most TB-positive Russian prisoners continue to be treated with first-line antibiotics even after they test positive for drug resistance. According to Dr. Farmer, DOTS treatment for MDRTB often does more damage than good, since it only serves to reinforce the bacteria’s resistance (Farmer, 2005: 124, 132).

Compare this to the MDRTB outbreak in New York City in the early 1990s. There, public health officials used claims of cost-effectiveness to justify the billion-dollar expenditure to cull the disease. Between 1991 and 1994, 1,279 cases were recorded by the New York State Department of Health (Frieden et al., 1995). According to Tom Frieden, who now serves as the director of the US Center for Disease Control, each case of TB resurgence after the initial outbreak

...cost more than $20,000 in 1990 dollars, for a total exceeding $400 million. In addition, as many as one third of patients with tuberculosis were rehospitalized because of inadequate follow-up... Care will be required for those who become ill in the years and decades to come. These costs easily exceed $1 billion and may reach several times that amount (Frieden et al., 1995).

The irony, it seems, is that cost-effectiveness seems to apply only to the rich and powerful in the minds of public health officials.

TB shows us the clear and causative chain of subtle and complex interactions between economics and disease pathology. It is important now to contextualize public health development in the age of neoliberal economics, to see how public health development must not be understood primarily in terms of economics.

Noncompliance: The Limits of the Free Market

In the case of TB, it is clear that superficial and longstanding notions of “cost-effectiveness” fall apart. To treat the marginalized populations in an effective, thorough, and expensive way is actually more cost-effective than cutting corners to save money in the long run. This logic of prevention already has a well-established place in the modern world in the form of environmental protection. In this segment, we will look at the roles of choice and compliance in both the neoliberal and human rights approaches to development.

The philosophy of neoliberalism is so widely and unquestioningly followed in modern development that it takes the form of a doctrine. The claims of this doctrine are clear, as in the words of Paul Farmer:

individuals within a society are viewed, if viewed at all, as autonomous, rational producers and consumers whose decisions are motivated primarily by economic or material concerns (Farmer, 2005: 5).

In neoliberal philosophy, choice exists in a vacuum, a cost-benefit analysis of every financial aspect of life for the individual. However, this approach does little to explain the issue of noncompliance—that is, seemingly voluntary refusal to participate in or to complete a development project.

In their analysis of the issue of noncompliance, Emma Crewe and Elizabeth Harrison point out two ways of framing participation in neoliberal terms. The first of these “barriers” relates to sociocultural rules. In their essay “Seeing Culture as a Barrier,” Crewe and Harrison cite the example of farmers in Malawi. There, it is considered witchcraft for one farmer to produce a greater harvest than his neighbors, the penalty for which is sometimes death. This social leveraging mechanism incentivizes low productivity, which counteracts the efforts of development programs to increase fecundity (Crewe, 2005: 233).

Another example of cultural rules as barriers comes from my own research on family planning practice in the Ahmednagar district of the state of Maharashtra, India.Many men there report a desire to have as many children as is necessary to produce a boy, despite understanding the economic and health-related disadvantages to having many children. At the same time, many NGOs across India deal with family planning in terms of women alone, mirroring the men-streaming of gender in development as described by some economists (Chant, 2005; Lenahan, 2010). The realities of gender as a cultural barrier thus bar the effectiveness of public health and family planning programs (Lenahan, 2010). Both of these examples show that incentive is not always economic in nature, and that it must be negotiated on its own terms for any related economic goal to be developed.

The second barrier relates to a lack of usable knowledge regarding public health where this is a central issue. After all, medicine relies on a vast store of knowledge and research which requires great care and specificity to execute. Furthermore, the preventative approach relies heavily on basic medical education. For instance, participants in the Comprehensive Rural Health Project in Maharashtra are taught to make a mixture of water, lime juice, salt, and sugar to combat dehydration in infants. This basic knowledge has greatly contributed to lowering the infant mortality rate of the region (Arole, 1994). We will return to this later. For now, Crewe and Harrison link the ignorance issue to programs which introduce aquaculture into areas where fish have never been consumed. That these programs tend to fail is the fault of “developers” more so than “locals,” they claim; the programs must work intimately with the community to ensure success (Crewe, 2005: 233). Farmer supports this stance, reporting that within his own work, “the outcomes were related to the quality of the program rather than the quality of the patients’ ideas about the disease” (Farmer, 2005: 150).

Indeed, the issue of noncompliance cuts to the heart of the relationship of a public health program with its participants. There are often structural reasons a person does not comply with their drug regimen, rooted in his or her socioeconomic context. I cite Farmer in full, since his experience with this phenomenon is direct:

Certainly, patients may be noncompliant, but how relevant is the notion of compliance in rural Haiti? Doctors may instruct their patients to eat well. But the patients will ‘refuse’ if they have no food. They may be told to sleep in an open room and away from others, and here again they will be ‘noncompliant’ if they do not expand and remodel their huts. They may be instructed to go to a hospital. But if hospital care must be paid for in cash, as is the case throughout Haiti, and the patients have no cash, they will be deemed ‘grossly negligent’ (Farmer, 2005: 151).

Furthermore, the mechanisms by which programs assign noncompliant status must be examined. Often, physicians determine who is compliant and who is not. In the past, studies have shown a poor history of physicians’ ability to determine noncompliance in relation to antiretroviral distribution among AIDS patients (Sollito et al., 2001), tending

...to rely partly on social, behavioral, and psychological characteristics (including past history of nonadherence) in their assessments, even though studies show that demographical and behavioral factors are not reliably predictive of adherence (Farmer, 2002: 483).

Cost-effectiveness appears here once again. Public health programs in contexts like poor neighborhoods in New York, where medical budgets limit access to supplies, often use history of compliance to determine which patients receive treatment and which do not. This ignores the strong socioeconomic causes of compliance.

In sum: “Those least likely to comply are usually those least able to comply” (Farmer, 2002: 483). Drs. Arole describe the issue in terms of setting up public health for the poor in rural Maharashtra, where “health was not a priority for the poor at all... The majority of people were preoccupied with their very survival. Regular employment and the availability of food and water were their main concerns” (Arole, 1994: 75). In cases of noncompliance, participants are often rooted in contexts which do not allow them to comply, or which highly incentivize noncompliance. Again, incentive is not bound to economics alone. It seems apparent that noncompliance is better handled as an issue of social equity than as one of cost-effectiveness. I turn now to the Comprehensive Rural Health Project in Maharashtra, India, as a case study for the role of equity in public health.

The Comprehensive Rural Health Project

Dr. Arole has taken on somewhat of a mythical status among the people of Jamkhed, so much that the very mention of his name incurs hospitality. He and his wife, Dr. Mabelle Arole, founded CRHP in Jamkhed in the early 1970s after graduating from Johns Hopkins University Medical School. Their goal was to provide comprehensive primary care to the Ahmednagar district of Maharashtra, which at the time showed some of the lowest health indices in India. CRHP is now internationally regarded as a paradigm for rural healthcare.

In 1972, when Drs. Arole first came to Jamkhed, the infant mortality rate—widely considered one of the most important public health indices—was 176 per 1,000 live births. It is now only 18 per 1,000 live births. In 1973, only 3% of mothers knew about home remedies for infant diarrhea, one of the leading causes of death among infants in the developing world. Now, 99% of mothers know these remedies (Arole, 1994: 211-17). According to the research I have conducted, 99% of women in the Ahmednagar district regularly practice some form of birth control, the most common form being tubectomy. The average number of children per household in CRHP’s region is 2.125, and 81.25% of parents have fully immunized their children (Lenahan, 2010).

It is easily arguable that CRHP’s success lies in its methods. The organization aims to provide comprehensive primary care to the surrounding rural community. Today, over 40 villages are included in the range of CRHP’s coverage. In its early days, CRHP was a pioneer in outreach-style primary care. The organization trains one woman from each village in basic health. This woman, known as the Village Health Worker (VHW), is chosen by means of a vote in her community (Arole, 1994).

The democratic style of selection for VHWs allows them to act as mediators between the organization and the community. Each VHW carries a small toolbox, containing the basic tools needed for everyday health in the villages: disinfectants, gloves, family planning products ranging from condoms to oral contraceptives, iron supplements for diarrhea and pregnancy, instant diabetes tests, blood pressure apparatuses, and basic childbirth equipment. The VHW restocks her kit at the hospital about once a month. The VHWs are essentially nurses who are prepared to deal with many health problems in the field—they refer the remainder to the hospital for surgery. For instance, VHWs teach new mothers to make the electrolyte-heavy concoction described above to fight infant dehydration, which is a driving factor behind the lowering of the infant mortality rate.

However, according to Bebibai Mohurkur, the VHW from the village of Kusurgaon, the true litmus test of a new VHW’s skill is her ability to deliver a child. Though this is easily her most difficult task, it also serves to prove her worth to the community. This skill has even led to a transcendence of caste boundaries; even poor women of the lowest caste are so well trusted in their capability to deliver a child that rich high-caste women are likely to call on them (Lenahan, 2010; Bebibai Mohurkur, 2010).

This aspect of the VHW’s work—that they are able to cross lines of gender, caste, and income—is perhaps their greatest asset. The VHWs can enter and navigate their native village environment in a far more effective way than could any foreign doctor. Only women are allowed to be voted in as VHWs, and CRHP encourages the employment of low-caste, poor women (Dr. Shobha Arole, 2010). Similarly, CRHP works under a strong ethic of equity as a solution to the issues of integrating with the community. In the words of Dr. Mabelle Arole,

We had started looking for community participation in the villages, but had found that no truly representative community exists there. The lines drawn by caste, economics, and the need for power have kept such a community from forming. We would have to find new ways to help people step across those lines and begin to dissolve those lines before true participation could be achieved (Arole, 1994: 77).

CRHP encouraged equity in the community in several ways. First, and perhaps most importantly, they used poor and disadvantaged women as outreach agents. Second, during a program to collect local investment to build wells in each of the villages, wells were placed only in the low-caste areas of the villages. This forced the rich and high-caste people to walk into the poorer sections of the community, and thus strengthened bonds between neighbors (Arole, 1994: 123). Third, CRHP organized farmers’ clubs and women’s support groups within each village, whose purpose was to set up local microcredit institutions. The community as a whole invests in these projects, and the money is loaned back out on the basis of a majority vote (Arole, 1994: 109-10).

Equity within the community is thus a major driving force behind CRHP’s success. CRHP uses the community outreach strategy to break through the barriers of ignorance and cultural rule. The VHW’s familiarity with the community and ability to educate are her primary tools. In this way, health comes to be treated as a human right, whose currency is education more than capital.

Conclusion

As we have seen, health issues cannot be conceptualized in terms of economics alone; they must be dealt with in context and on their own terms. According to Dr. Paul Farmer, most of the issues faced by the poor in developing nations are not expensive to cure. Maladies such as tuberculosis, infant dehydration, iron deficiency take the lives of millions of people a year but these are easily preventable diseases (Farmer, 2005). Even in expensive cases such as MDRTB, preventative measures are the more cost-effective solution.

To treat health as a human right is thus an effective way to navigate the difficult cultural barriers to development. Furthermore, incentive is not a force of economic autonomy alone, but is in fact made conditional by a web of social realities. The incentives which govern the health trajectories of the people who experience marginalization are multifaceted and complex, and defy the easy social philosophy of neoliberal capitalism. The problem of noncompliance in public health programs is thus a symptom of the capitalization of medicine. By treating health as a human right and taking equity as a doctrine, the Comprehensive Rural Health Project has succeeded where many other programs have failed, and may provide an important model for future health projects around the world.

 

Bibliography

Arole, Raj and Mabelle, M.D.s (1994). Jamkhed: A Comprehensive Rural Health Project. Jamkhed, MA, India: Comprehensive Rural Health Project Publishing.

Arole, Shobha, M.D. Personal Interview. Conducted 4:00 PM May 8 2010.

Bebibai Mohurkur. Personal Interview. Conducted 5:15 PM April 30 2010.

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Crewe, Emma and Elizabeth Harrison (2005). “Seeing Culture as a Barrier” IN The Anthropology of Development and Globalization, 232-234. Malden, MA: Blackwell Publishing. Editors: Marc Edelman and Angelique Hauregard.

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Lasagna, Louis (1964). “The Hippocratic Oath: Modern Version.” Accessed Dec 1 2010 at <http://www.pbs.org/wgbh/nova/doctors/oath_modern.html>. Tufts University, 1964.

Lenahan, Arthur (2010). “The Invisible Staff: Men, Reproductive Health, and Power in Rural Maharashtra.” Unpublished ISP.

Solitto, Sharmon et al. (2001). “Should Physicians Withhold Highly Active Antiretroviral Therapies From HIV/AIDS Patients Who Are Thought to be Poorly Adherent to Treatment?” IN AIDS, 15, 153-159. Secondary.

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