Tag Archives: reproductive health

Results in HIV/AIDS interventions: Considerations on the need for a vertical approach in an horizontal world, and vice versa

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Aids day
During Aids-day, the blogs proved that the debate between the believers in a vertical approach and the believers in a geographical approach rages on. I did not write on it before, because it is an issue with ramifications in all directions, and wonderful opportunities for tangents and meandering digressions. Most thinking is black and white: HIV/AIDS needs advocacy and a vertical approach otherwise it does not get the priority it deserves, or all development must be locally generated, and advocates should stay out.
I will try to be brief and as provocative as I can to highlight the need for a more instinctive and competitive approach on this divisive issue.
Conferences
I was working in the HIV/AIDS sector in South Africa, before Mbeki got internet-shavvy, and before the Global Fund For AIDS, TB and Malaria existed. It was a very frustrating experience. The South African government was hailed as one of the few Sub-Saharan governments with a decent policy, but rates of HIV-positive cases kept going up. Donors and the government were subsidizing mostly advocacy and awareness programs, and the responsible officials were often found in international conferences. In short, everything was politically correct, and nothing worked. Until GFATM was created. They had exotic ideas such as “evidence based” interventions. Things were falling into place when the price for drugs dropped too. Alternative reading: until Brazil and MSF got their way and cheap drugs.

Lesson 1: If there is an internationally recognized crisis, focused forceful global action can be useful.
Lesson 2: “Evidence based” interventions might have a bigger chance for success than doing whatever seems right when you are at it.
Lesson 3: Advocates can make a difference. Sometimes for the better.

Reform
Since the UN was created, there have been calls for reform, but here I am talking about 2004, with a donor drive for more streamlining amongst agencies. Smaller agencies should be integrated in the bigger ones. This would lead to more efficiency, as we all know that big bureaucracies, thanks to economies of scale, are more efficient than nimble organisations fighting for their survival. One of the agencies under fire was UNIFEM, The organisation that “provides financial and technical assistance to innovative programmes and strategies that promote women’s human rights, political participation and economic security.” It should have been merged with UNDP. One of the delegates of the G77 berated: all UN-agencies have been created because there was a good reason. So good a reason, that all MS in unanimity decided to create this organisation. Are you really sure that the situation of women has changed to such a degree that we don need this organisation any more?

Indeed only 6 years later, the same donors managed to create a bigger UN-women organisation, that should strengthen the original mandate of UNIFEM, and bring it to a larger scale.

Lesson 4: never thrust a donor (or anyone) that is sure about the next silver bullet
Lesson 5: Sometimes, if something is very important, you need to create a special tasks force to make it happen.
Lesson 6: Development fads come in tides, tides rolling in and out, a new tide rolling in…

Localizing
In the early years when I was working on HIV/AIDS in South Africa, it was amazing how many of the “good practices” were just copy paste from the interventions that were used in the HIV/AIDS communities on the West Coast. A group threatened by exclusion dominated by homosexuality and intravenous drug use, while in Africa victims were often heterosexual middle class. It was only when results were required that the programs got adapted.

Lesson 7: local actors seeking locally adapted solutions based on global knowledge works better than local solutions transplanted to a different ecosystem. Without good knowledge to start with, chances are good nothing will happen at all.
Lesson 8: never thrust donors or iNGOs that they are open for local input. If they think they have a silver bullet, they will push it, claiming it is localised.

Conclusions:

Lesson 9: global institutions should offer global knowledge and try to adapt catalytic operations to local circumstances. Acceptance and rolling out should be up to the local owners of the problem (if they find it is a problem).
Lesson 10: vertical and localized horizontal programs must coexist, and fight for attention. Having a dynamic of competition, where global, vertical programs must prove their mettle, and local horizontal programs are constantly challenged is a good thing.

Lesson 11: as a donor, you invest your money best where it delivers the most. Depending of the situation and the “maturity” of the issue, this can be a global vertical program, or a local operation, or anything in between. You should have thematic and geographical programmes with different goals competing for resources and attention.

Designer Baby

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The knowledge of our genetic code and the technical tools to use it to our own advantage may inspire fear; it threatens the human race’s natural evolution. The consequences of these new technologies are extremely relevant, but are mostly not threatening if regulated. However, the changing science and society will need the moral tools to navigate this uncharted territory.

Nothing new under the sun: Natural Selection

In a way, humans have been genetically designed for a long time; what we see as beauty in male and female — such as beautiful hair or a smooth skin — are indicators of health, and when we have the choice, we tend to choose our partner with properties we want to see in our children.

Traditionally nature had the biggest impact on selection: with a blunt axe, it weeded young children for genetic fitness, but also for simple bad luck — like falling out of a tree without a doctor around. Selection for resistance against child death, pestilence, and disease is strong in the environment. Congenital diseases that show up after 40 are of little relevance in an environment where people rarely live long, and those genes are not eliminated — they accumulate in the gene-pool.

The kind of snapshot product from this evolution is the current homo sapiens. The variation of traits is important, since different pressures in changing cocktails of selection and preference depend on place, environment, and time.

From puck to pit bull

Would humans, when facing the possibility to select their offspring according to their whims, follow the route of the peacock, and go for all kinds of quirks? The choice of dog breeds for pets could make us fear for the worst. The selection of dogs for physical attributes is only marginally limited by nature, and we can see that humans choose for a wide range of forms and properties, apparently with scarce regard for practical needs. Dogs are selected for cute floppy ears — this leads to regular ear infections — or a deformed nose — which can lead to breathing problems. They can be big and hairy or small and hairless, or even the other way round.

However, when looking at the list of the most common dogs in the US (American Kennel Club), common sense prevails: in the first place, the friendly family dog, the Labrador Retriever; in the second place the space-conscious Yorkshire Terrier, and thirdly the trainable guard dog, the German Shepherd. When given a choice on how to chose their best friend, most people apparently choose quite reasonably, yet, there are still 158 different breeds on the list. Still, most dogs are mutts and the healthier for it.

What would the new potential for choice mean in humans? Would we create designer babies with floppy, big ears, cute wide eyes and a snout? Or would we go for a race of Nobel prize-winners, with a brain double of what we have now? A moral code seems to be necessary to protect children from the imagination of their parents or creators.

Health and clones

The blunt ax, killing children with disease and pestilence, has all but disappeared in many nations. Meanwhile, the knowledge of hereditary diseases and how to identify them even before conception, could lead to their elimination within a few generations. Health is more widely defined than what natural selection does; we want our children to live way beyond the age of fertility. This selection is even more stringent in bona fide sperm and egg donor banks. Regulation is needed to guarantee the physical and psychological potential of the genetic material.

It seems like the resistance against childhood illness will probably diminish, as the broad “natural” selection disappears, but the acute genetic problems might also disappear. And as parents choose more than only health factors from sperm or egg donors, we could possibly come closer to selecting our dream partners than the drive to breed a superior race.

However, when we go on selecting against genes for congenital diseases, will we start eliminating genes for for bad looks or stupidity? To what degree can we tamper with the gene composition of our offspring? What is decent, what is unethical, and what is criminal? Our humanity, gene pool, and cultural diversity, is created by the lottery of random processes during the meiosis — the forming of sexual cells. Turning off this process and choosing for uniformity, even for only some people, is a very fundamental choice to limit the by-nature imposed variability. This seems to be one of those moments where it would be better to be safe than sorry.

As far as health concerns go, it will be everyone’s responsibility to choose the outcome, but stronger regulation will definitely be needed. Finally, it isn’t too strong a statement to say that human genes should never be subject to the forces of the market.

Nothing new under the sun: the need to protect the child

Designer babies are already amongst us in their most basic form — by controlled genetic selection. Our impact on the genes of our offspring will grow fast. Terrible abuse is possible, and will probably happen. But as is the case with most scientific progress, if it is timely and properly regulated to protect the weakest from abuse and neglect and the megalomaniacs from themselves, the future seems rather bright.