Good Choices vs. Bad Options

Last weekend I spent four days in Chicago with a close friend – the city of my birth, and always a good time – eating, drinking, and being merry. Despite all the decadence, we squeezed in a run along Lake Michigan, lots of fruits and veggies, and several discussions about food and health. We both acknowledged that, for several reasons, we are in a position to make “positive” choices about what we eat and the lifestyle choices we make. Having two friends who have become stellar marathon runners (one of which is making her début running Boston later this month!) has certainly had an impact on our choices too. Last month this blog looked at the impact of social networks on health and the very human quality of judgment towards obesity. Both of these elements contribute to our societal beliefs that our personal choices regarding lifestyle and our bodies are either good or bad, making some of us better than others. As with everything else human, these distinctions regarding our bodies are not so black and white.

Many people in the United States believe that they should not have to pay for the care to those individuals who have made detrimental health choices (i.e. smoking, overeating, etc.). A NYTimes article earlier this week lays out recent survey results post the passage of new health care laws. It also discusses how this is not a new sentiment in this country, or in others for that matter. And remember, in the U.S. we have already been paying for other’s care (primarily those uninsured) through compulsory emergency room services. It is easy for some to say that we shouldn’t help someone with lung cancer because they smoked for 20 years, but is it as easy for us to say that an HIV positive individual should not receive ARTs because they had unprotected sex, once? The most positive improvements in AIDS and TB treatment worldwide have come when health organizations stopped negatively judging why these diseases continue to spread and instead looked for positive means of changing the socio-political and environmental structures that contribute to the personal options and choices often required for transmission.

Likewise, back here in the U.S., simply stating that people who overeat, without examining the personal and cultural stimulus for this, should not receive treatment partially paid for by tax payers, is harsh and denies the fact that we all make choices based on our circumstances, and sometimes those choices may not be “right” in someone else’s eyes. Even the WHO has recognized that social determinants of health have a major impact of our health “choices” and “options” – good and bad. Personal responsibility is important, but so is social responsibility. Helping others is just as human as judging them. It’s no joke that talking with our friends, and eating with them, have positive impacts on our well-being. Let us also strive to have these interactions lead towards health improvements for more of us and not be so concerned by the right and wrong of it.

*Image is author’s own: Kathryn in Chicago.

Scaling Without Judgment

This past weekend, I had the pleasure of taking in a pristine March day in the Swiss Alps. Surrounded by skiers and snowboarders, there was an aura of good health. I don’t know if it was the sunshine and smiling faces or the men and women of all ages continually moving, but it was definitely a rarefied community lacking in judgment – everyone was participating in an accepted, healthy, activity (it should be noted, that these observations were made as I enjoyed myself from the comfort of a snow tube). Returning to the U.S., I was already thinking about the perceptions, stigmas, and prejudices we all have about each others health and lifestyle choices – the NYTimes was thinking about this too, and published an essay Monday discussing the unpleasant, tricky, and frustrating stigmas and prejudices which, more than ever, surround individuals both medicine and society deem as obese. Peers, employers, strangers, and even doctors – whether they know it or not – present their negative perceptions of overweight individuals, creating a schism between thin people and fat people.

Yes, there is a level of personal responsibility required in all decisions made about our bodies. However, these decisions are made within a cultural structure which is often out of our control. Assuming all overweight individuals are “awkward, unattractive, ugly, and unlikely to comply with treatment” is hurtful, disheartening, and does not help. Stigma and compliance issues are not unique to obesity in developed countries and are important factors in HIV/AIDS and TB, women and child health, and disability care.

This blog has discussed the impact social networks have on health – social networks include our society as a whole. Overweight individuals are avoiding the judgments of our larger social network by not seeking out doctors and medical support. This trend will add further challenges in our struggle to curb obesity. Judgment and prejudice, unfortunately, are part of human nature. For those of us working to improve the health and well-being of those around the globe we must work especially hard to think without judgment and to understand stigmas in the broader context. There are tremendously high mountains to scale to improve our health and while we do not and can not work and live in communities free from judgment, we can do our part to promote good health, without judging ourselves.

*Image is author’s own: view from Mt. Titlus, Switzerland.

Ending AIDS Forever?

AIDS could effectively be eradicated within the next decade according to a number of public health professionals. Dr. Brian Williams of the South African Centre for Epidemiological Modeling and Analysis (Sacema), giving a talk at the American Association of the Advancement of Science (AAAS) annual meeting over the weekend, stated his belief that universal testing and therapy (through ART regiments) in high-risk regions, could end the disease within five years.

A Sunday Times article nicely summed-up the plan: that universal testing and therapy, while initially quite costly, would cut transmission from person to person as well as slowing the spread of other diseases which are co-infection concerns, such as TB. By starting individuals on ART early, within the first year of infection, their chances of infecting others would be significantly lessened, and the disease would die out. Currently, only about 12% of HIV-positive individuals worldwide take ART drugs.

The most effective ways for this type of program to work would be to ensure annual testing, access to drugs, and taking ARTs correctly. This is where “compliance” comes into play. Being compliant means to be excessively obedient. Compliance is often cited as a reason for why certain treatment programs are unsuccessful – patients being non compliant. Quoting Dr. Williams: “Compliance in Africa is actually much better than in developed countries, because in the latter HIV tends to affect intravenous drug users and other marginalised groups, whereas the victims in Africa are just poor.” Is Dr. Williams implying that “the poor” are, for whatever reason, more easily compliant? Either way, trials in several African countries on this type of detection and treatment protocol are set to begin this year.

Seen as one of the high-risk regions for AIDS, Africa has without a doubt felt the burden of HIV/AIDS heavier than anywhere else on earth. Despite their exposure and burden, there remain strong stigmas towards the disease and those infected – keeping people from getting tested, learning about the disease, and seeking out what treatments may be available to them. These stigmas will not disappear overnight if universal treatment is presented. Additionally, there are many local and international organizations working very hard on innovative and socially tangible means for combating AIDS and stigmas. How would these existing structures fit with a plan for universal therapy? Would they too find themselves needing to be “compliant”?

The financial and policy needs behind such a plan are mind-boggling, and would require an extreme degree of coordination. Eradicating AIDS within the next decade is a goal we should all strive for, but through collaboration and not compliance alone. As Sir Mark Walport of the Wellcome Trust simply stated, we have “no way of knowing how acceptable or effective such a program would be.”

Interestingly, the Sunday Times also ran an article on the growing evidence that long-term ART regiments, or the extended life they provide, may be causing dementia and pre-mature aging. If this is the case, universal therapy could bring an entirely new set of health concerns to already strained communities, health systems, and regions.