World Aids Day: Youth Finding a Voice

Today is World AIDS Day. I read an article in the Huffington Post written by a graduate of Harvard School of Public Health, Rena Greifinger, and some colleagues about the impact of HIV on youth. She discusses a global phenomenon that

"Young people 10 to 24 years old make up one of the most vulnerable, yet historically overlooked populations affected by the HIV pandemic."

But brings the issue close to home -- 330 young people currently living in Massachusetts were infected with HIV at birth.

While the numbers seem small, the stigma surrounding life with HIV/AIDS lends a heavy burden to those affected, their friends and family.

Read the article, it's short, it's personal, and it's inspiring.

Should Prevention Trump Treatment?

I remember when I first started thinking about entering the field of public health. One of my major concerns was whether I needed to become a doctor in order to be respected and influential in the field. I was grateful for the advice I received from faculty (mostly doctors and nurses) at school that the path to clinical practice should not be done if you aren't passionate about becoming a clinician! While that may seem obvious, I think my concern was getting at something much deeper than that -- the enormous tension in public health to work within the health care system (a medical-driven, treatment intensive environment) and to work without it. 

The public health approach to health promotion is fundamentally about prevention. Its goal is to collaborate with multiple sectors to create environments where people can make healthy choices, to develop policies that protect peoples health, and to disseminate new finds and raise awareness about health damaging practices and products. 

Conversely, a clinical approach to health is to screen, identify, and treat disease. These clinical activities are vital and important to improve health of individuals. Ask anyone with high blood pressure, diabetes, or cancer, and they will agree that medicine plays an important role in helping them live their healthiest life possible. 

Sometimes people forget that clinical medicine and public health practice must be work in tandem. For example, when HIV/AIDS work began, there were many who wanted to prevent the spread of HIV/AIDS, but forgot the need to improve access to treatment for those already affected. Expanding access to antiretroviral therapy is now a major part of HIV/AIDS activities. 

The era of public health as a competency only for those in clinical medicine has past. What remains is a (growing?) tension between a growing number of public health professionals with no clinical training who reject the treatment-oriented focus of health work in this country and clinicians who believe that advancements within the health care system will be vital to improving the health of our nation. While both may believe that prevention is necessary, it is unclear whether -- when it really it comes down to it -- both believe that money spent on prevention is worth more than money spent on treatment. 

Our health care system is broken. Training more OB-GYN and orthopedic surgeons is not going to fix it. We need to create incentives for family physicians, primary care practitioners, and midwives. We need to invest more in prevention, in early life care, in parenting support, and healthy community initiatives to reduce violence and increase social capital. 

What does this tension mean for public health? Will it promote dialogue and lead to sustainable change or will it prevent us from accomplishing all that needs to be done to turn our health care system into a health promotion system?

AIDS Sutra: Untold Stories from India

When you see the word AIDS what comes to mind?

Africa? Disease? Death?

Sex? Drugs? Prostitution?

Mothers? Orphans?

Treatment?

We know so much more today about the etiology of HIV/AIDS than when the epidemic began in the early 1980s. In some parts of the world, the stigma of having AIDS or being HIV positive has begun to weaken. We now have effective (albeit expensive and complex) treatment for the disease, more people are more aware of how the disease is spread, and today we know that if certain conditions are met women who are HIV+ can even give birth to babies unaffected by HIV/AIDS. In this day, in this place, one need not equate AIDS with death.

In India 2.5-3 million people are infected with HIV/AIDS. India has the 3rd largest number of HIV+ people in the world, behind sub-Saharan Africa, and the spread of HIV among women is increasing. (click here for more facts -- published 2006)

In many other countries, however, there is still great denial about just how widespread are the effects of AIDS. The Bill & Melinda Gates Foundation's Avahan India AIDS Initiative just released a book entitled "AIDS Sutra: Untold Stories from India". It is a collection of essays that brilliantly portrays the lives of people dealing with AIDS and facing its stigma in India. The stories uncover the brutallity and fear that come with social margnizalization, violation of privacy, and discrimination. 

Two authors, Nikita Lalwani and Sonia Faleiro, and an editor from Avahan visited the Harvard School of Public Health today to discuss the book. It was a fantastic event, with about 30 people in attendance. The stories told by the authors were heart wrenching.

Many Harvard affiliates, such as Jay Silverman and Felton Earls, are committed to preventing the spread of HIV/AIDS as well as serving populations who already have the disease. Though, I want to note that the work of my colleagues really seeks to inform the broader picture of how poverty, gender relations, family violence, and sex trafficking perpetuate the spread of HIV/AIDS beyond what service provision in "high risk" communities can provide. It is fascinating work and its implications are great, as the stories "AIDS Sutra" tell. Not only will understanding AIDS in India help those who are currently suffering, but it will provide a basis for future prevention efforts and cultural change that can halt the epidemic, save lives, and restore hope.