msJAMA Examines Practice of Medicine Across International Boundaries, Addresses HIV/AIDS
Today's issue of the Medical Student Journal of the American Medical Association examines the "purpose, value and challenges of conducting research and practicing medicine across continents," particularly in light of the spread of infectious diseases such as HIV/AIDS. According to the "Editor's Note," in order to "engage in the ongoing debates about U.S. involvement in global health initiatives, it is necessary first to understand the reasons and aims for international health endeavors." The note acknowledges that "[a]ction requires political will and financial commitment" but concludes that "comprehension of the rationale for and barriers to the control of disease at an international level will be equally vital to the improvement of global health" (Modjarrad, msJAMA, 10/2). Several articles in msJAMA pertain to HIV/AIDS. Summaries of those articles appear below:
- "Understanding the Threat of HIV/AIDS": "[I]t is paramount to understand the threat created by HIV/AIDS to political, economic and personal security," John Luo of the Johns Hopkins University School of Medicine writes. Security can be defined as "both the freedom from fear and the freedom from need," Luo states, noting that under this definition, "HIV/AIDS threatens the security of governments and economies around the world because of its ability to simultaneously endanger political stability and depress current levels of prosperity." HIV/AIDS threatens security on a national level largely because it is reducing life expectancy, the "strongest risk factor" for ethnic conflict, genocide, "failure of fledgling democracies" and revolution, according to one study, Luo states. Average life expectancy in sub-Saharan Africa is expected to decline 25% over the next few decades, he adds. Luo concludes, "Still absent from the politicized discussions about HIV/AIDS is a full knowledge of how ameliorating this disease can significantly improve the personal, economic and political security of families and countries at risk. The responses the world formulates against the HIV/AIDS pandemic in the coming years will determine if and how this question is answered" (Luo, msJAMA, 10/2).
- "Toward a More Global Medical Education": "Expanded programs to improve health care in other countries will require more physicians trained in global health," Jeffrey Greenberg and Rebecca Mazar of the University of Pennsylvania School of Medicine write, noting that at present only one-fifth of U.S. medical students have completed an international clinical elective. "The importance of fostering global health solutions stems from the grave and far-reaching consequences" of communicable diseases like HIV/AIDS, tuberculosis and malaria in developing countries, they state, noting that international and domestic groups are increasing their support of health care efforts in these nations. However, only a few medical schools offer training in global health as part of their curricula, and financial support for students who wish to pursue global health is limited. But programs such as the federally funded International Health Fellowship Program -- which helps students seeking to perform an overseas clinical elective -- have demonstrated that students can be persuaded to pursue global health. More than 90% of students who participated in the IHFP survey said they intended to spend additional time working abroad. Greenberg and Mazar conclude that given the "growing U.S. commitment to improving health care in other countries," formal programs providing training in global health and increased financial support for students wishing to pursue careers in global health, could help increase the number of students who choose to serve abroad (Greenberg/Mazar, msJAMA, 10/2).
- "Treating HIV in Resource-Poor Settings": In this perspective piece, Dr. Paul Farmer of Harvard Medical School and Jennifer Singler of the University of California-San Francisco School of Medicine write about their experiences with Partners in Health, a program that provides antiretroviral treatment to HIV-positive individuals in Haiti. Farmer and Singler note that many experts have argued against providing antiretroviral treatment in resource-poor settings such as Haiti because of prohibitive cost and a lack of necessary health infrastructure. However, those arguments are "based not on assessments of established treatment programs, but rather on projected drug costs and a handful of nascent projects," they state. From their experience in Haiti, which is the poorest nation in the Western hemisphere and also has the hemisphere's highest HIV prevalence, they state that treatment in resource-poor settings is both feasible and effective. Farmer and Singler say that although traditional means for assessing the effectiveness of antiretroviral drugs on a patient's health -- such as CD4+ T cell counts and viral load tests -- are not readily available in Haiti, alternative methods provide an effective means of evaluation. Patients are initially evaluated for treatment candidacy based on their frequency of opportunistic infections, weight, neurological status and "severe hematological abnormalities." The progression or disappearance of these criteria is also used to evaluate treatment efficacy. Mortality has been significantly reduced -- Partners in Health has not recorded a single AIDS-related death among ambulatory patients receiving antiretroviral therapy since the program began -- and HIV-related hospitalizations in the area have decreased by almost 50%. Farmer and Singler conclude that an "equally important means" of assessing the impact and success of the program lies in examining the experiences of its patients, many of whom have been able to resume nearly normal lives (Farmer/Singler, msJAMA, 10/2).