The review of the UN Millennium Development Goals (MDGs) this fall
poses an opportunity to focus on and galvanize interest in health development.The
MDGs are a framework of 8 goals, 18 targets, and 48 indicators with
a target goal for attainment of 2015. These development goals were adopted
by a consensus of experts from the United Nations Secretariat and the
International Monetary Fund (IMF),organisation for Economic Co-operation
and Development (OECD),and the World Bank.
While health is directly reflected in three of the eight MDGs and eight
of the 18 accompanying indicators, progress is choppy. Of course, the
linkage of health as the foundation for the achievement of all the MDGs
may seem to be an obvious antecedent as well as a sequela for development.
No single pathogen or disease, however, appears to be ravaging unabated
more than HIV/AIDS. HIV/AIDS continues to pose a significant drag on
development indicators of those countries most affected. It has become
a fundamental threat, not only to the health —and survival —of
more than 25 million currently infected individuals in Africa, but also
to the entire health system and workforce as well as overall governance,
security, education, debt relief, economic development, and peace.
For the world to be successful in achieving the MDGs, new ideas and
interventions will need to be developed and brought to scale. This issue
pervades debates on the role of government versus that of the individual
—interventions that are either social change or individual behavior
change; if programs should be vertical or horizontal,and if interventions
should be biological or behavioral, in fact all sides of the issue need
to be addressed. Dr.Tim Evans (2005), Assistant Director General, at
the World Health Organization (WHO) presented the evidence to inform
future policy and proclaimed: ‘‘We need to move beyond simplistic
orthogonality ’’in our approaches to public health programs.
Our goal should be to address interventions in line with the WHO ’s
statement in its Ottawa charter: ‘‘Healthy choices need to
be the easy choices.’’These interventions need not only be
easy in terms of self-efficacy, but they also must be socially acceptable
and popular.In the case of HIV / AIDS, the actions in Uganda and Thailand
to stem the epidemic have been heralded as successful due to the political
will, extensive campaigns to increase awareness of HIV, multiple levels
of behavior change interventions, and popularizing the use of condoms.
These are examples where individual responsibility can have its full
effect in a society where governments,private interests, and other sectors
work together to support individuals making healthy choices. The MDG
Goal 6 to ‘‘Combat HIV / AIDS, malaria, and other diseases
’’and Target 7 ‘‘To have halted by 2015 and begun
to reverse the spread of HIV / AIDS’’ are paramount to galvanize
success. The indicators to gauge this success present important measures
of how the world and this generation respond to the greatest challenge
since the Plague more than 700 years ago:
- HIV prevalence among pregnant women aged 15 –24 years (UNAIDS-WHO-
UNICEF),
- condom use rate of the contraceptive prevalence rate (UN Population
Division),
- condom use at last high-risk sex (UNICEF-WHO), and
- percentage of population aged 15 –24 years with comprehensive
correct knowledge of HIV / AIDS (UNICEF-WHO).
(The last indicator is a knowledge indicator, based upon the theory
that knowledge will lead to change in behavior and disease transmission.
It is defined as the percent-age of population aged 15 –24 who
correctly identify the two major ways of preventing the sexual transmission
of HIV [using condoms and limiting sex to one faithful, uninfected partner
],who reject the two most common local misconceptions about HIV transmission,
and who know that a healthy-looking person can transmit HIV.)
If such success centers around condom use as disease prevention, it
should be incumbent on the public health community to reframe this as
an intervention similar to a microbicidal to prevention infection (e.g.,
soap for a minor cut / wound), oral antibiotic for infection, statin
for cholesterol / heart disease,and aspirin for cardiac disease and
related primary and secondary prevention.
If condoms were viewed and proclaimed as disease prevention,rather
than as a controversial barrier contraceptive technique, we may be in
a different place on review of the MDGs in 2015.
When Karol Wojtyla became Pope in 1978, AIDS had not yet been identified.In
the time that he occupied the Holy See, the disease became a global
epidemic, now killing more than 3.5 million people a year,with about
40 million people infected.
During Pope John Paul II ’s tenure,the condom was viewed solely
as a contraceptive by the Vatican. According to Sophie Arie reporting
in the Lancet (April 23, 2005).
The Catholic church ’s footsoldiers around the world spread
the myth that condoms do not prevent the spread of disease because
they are full of little holes.The message confused and intimidated
many believers, gave reluctant condom users a perfect excuse, and
inspired ultra-Catholic governments to ban or withdraw funds for distribution
of condoms or information about them (p.926)
The Church doctrine was followed in the Philippines where condoms were
heralded as an ‘‘agent of Satan,’’and in Chile leading
Catholic television channels have refused to air AIDS programs that
advise the use of condoms. In Kenya, the Arch-bishop proclaimed that
condoms actually give people AIDS, and, in Zambia, the distribution
of condoms in schools was banned. South Africa’s Cardinal attacked
the government earlier this year for its latest condom awareness campaign.
Additionally, others at various levels carried the message forward.
The condom message is a challenge for communicators to frame,as governments,
donors, and nongovernmental organizations, Catholic and other denominations
proclaim the anticondom message.This sole link of the condom to contraception
often overshadows opportunities to help millions who have been infected
or, worse, will be infected by HIV. Although many may ignore the message,
in developing countries, the contraceptive belief over a concomitant
disease prevention role of the condom appears to be working directly
against public health and the MDGs.
With a new Pope —Pope Benedict XVI —some hope there will
be an opportunity to reframe the use of condoms as morally legitimate
—as disease prevention and life preserving,rather than a pre-HIV
/ AIDS-era solo reference as a barrier contraception.
Finally, in the last decade we have another example of success in approaching
a scourge of a communicated disease —tobacco. HIV actually has
a lot in common with tobacco: they both kill, have exposure components,
and require a large public health response to limit their harm. A recent
article by Derek Yach and colleagues, (2005) in the British Medical
Journal (BMJ) presents ideas related to tobacco that could be adapted
to HIV infection.The 12 lessons are presented herewith to consider for
addressing HIV.(Lessons 8 and 11 will need to be adapted to change the
independent variable from tobacco to HIV.)
- Address the issue of individual responsibility versus collective
or environmental action early and often
- Evidence of harm is necessary, but is not sufficient to motivate
policy change
- Decisions to act need not wait for evidence of the effectiveness
of interventions
- Fully implement interventions known to be effective
- Real and perceived needs and concerns of developing countries need
to be addressed even if they involve going beyond the initial scope
of the risk being addressed
- The more comprehensive the package of measures considered, the greater
the impact
- Broad based, well networked, vertical and horizontal coalitions
are key
- Change in support for tobacco control took decades of effort led
by media savvy and politically astute leaders
- Modest, well spent funds can have a massive impact, but without
clear goals funding may not be sustainable
- Complacency that past actions will serve well in the future may
retard future progress
- Rules of engagement with the tobacco and food industries need to
be different and continually under review
- Risk factor envy is harmful — a joint approach is needed
At this point in the new millennium,reaching some of these goals in
our lifetimes seems impossible.It is hoped that,the MDGs will continue
to raise important issues on the global agenda.Yet,the time is right
to apply an evidence-based approach to health,working together to move
beyond historical silos with preconceived notions of the ‘‘right
way ’’to address disease and development.The continuous input
of an evidence-informed, ethical communication and advocacy approach
for an enhancing social and political environment for health and well-being
is a development goal we should advance.
References
Evans,T. (2005,May). Oral Presentation at the Women, Children and Newborn
Health: Make every mother and child count Joint European Commission
WHO meeting. Brussels.
Yach, D., McKee, M., Lopez, A.D., & Novotny, T. for Oxford Vision
2020. (2005). Improving diet and physical activity: 12 lessons from
controlling tobacco smoking. BMJ 898 –900.doi:10.1136 =bmj.330.7496.898
_____ Scott C. Ratzan MD, MPA, MA is Editor-in-Chief of the Journal
of Health Communication: International Perspectives. He also is
Vice President, Government Affairs, Europe for Johnson & Johnson
with academic appointments at George Washington University School of
Public Health, Tufts University School of Medicine, Yale University
School of Medicine, The College of Europe, and University of Cambridge.
