Helen’s got it wrong

2011-11-18 00:00

WE take issue with Premier Helen Zille’s views on HIV transmission, criminalisation and who deserves treatment.

Last week, Western Cape Premier Helen Zille made various comments suggesting that the provision of health care to those who behave “irresponsibly” should be reconsidered. In her weekly newsletter, the premier noted that over half of the province’s budget is spent on “preventable illness”, while the “scraps” are given to unpreventable conditions. This, she claimed, “has further widened the gap between rights and their essential corollary — responsibility”. Specifically citing people who contract HIV through “irresponsible” behaviour, she rhetorically questioned why “taxpayers must foot the bill without asking any politically incorrect questions …” She later tweeted that “if you duck responsibility, don’t come running to the state when you need treatment”.

A few days later, at a provincial health summit, the premier said that people who knowingly infect others with HIV should be charged with attempted murder.

The premier’s views are possibly popular across the political spectrum, but they are misinformed and unscientific. This debate is repeated periodically.

Here are some rebuttals of the arguments the premier puts forward. Doron Isaacs has written a succinct rebuttal of the criminalisation of HIV. Judge Edwin Cameron has co-authored an in-depth explanation of why criminalisation of HIV is wrong. Gavin Silber has previously argued against the premier’s position when she made similar arguments in 2009. Edwin Cameron and Nathan Geffen debated David Benatar on whether a person contracting HIV through his or her irresponsibility has a right to treatment.

This article first addresses arguments about why the premier’s arguments on responsibility are wrong. We then deal with criminalisation. Finally, we deal with the premier’s concern that HIV treatment is taking resources away from unpreventable diseases.

Why the premier’s arguments on responsibility are wrong.

• The premier’s proposal is unconstitutional

The Constitution says that everyone has the right to access to health-care services and that the state must, within its available resources, realise this right. The Constitutional Court has found that the state, because it has limited resources, can limit the provision of a health service using reasonable criteria, such as how well patients will respond to treatment. It is unlikely that the court would consider the way an illness was contracted to be a reasonable criterion.

• Provision of health care based on “responsibility” is impractical

It is impractical to provide antiretroviral treatment depending on how people contract HIV. Health workers cannot be expected to investigate how their patients became infected. Besides being an invasion of privacy, it is often impossible to determine this reliably.

• The consequences of the premier’s proposal are untenable

Consistently only providing medical care to people based on “personal responsibility” leads to frightening consequences. It would mean cigarette smokers would not get treated for cancer. People who eat unhealthily would not get treated for Type 2 diabetes or heart disease. The same for people who suntan too much and develop skin cancer, or sportspeople who overtrain and injure themselves.

• Treatment based on “responsibility” discriminates against the poor

People who can afford private health care would still be treated, irrespective of how they contracted HIV, or for that matter any other ailments acquired through irresponsible behaviour. It is only poor people who use the public health system who would be affected by Zille’s proposal.

• Providing antiretroviral treatment is an effective way to reduce HIV transmission

Zille laments the large sums of money spent on Aids treatment, as opposed to prevention. However, science shows that HIV-positive people on treatment with an undetectable viral load are unlikely to transmit HIV. Studies in several cities around the world have shown a decline in new HIV cases, as antiretrovirals are scaled up. Providing treatment as widely as possible is not only good for personal health, but is also a critical public-health intervention.

• Withholding antiretroviral treatment has huge costs

People on antiretroviral treatment have almost normal life expectancy. But people denied treatment will frequently get opportunistic infections and need to be hospitalised. Failing to provide treatment will cause poor families great hardship. Parents will be far more likely to die young and there will be more orphans.

Why the premier’s arguments on criminalisation are wrong

• Preventing HIV transmission should be based on science not morals

Moral judgments about responsibility are easily made by people who never have to face the choices about sex that many poor people in this country constantly have to make. Reducing HIV transmission should be based on science, not moralising.

Criminalisation will stigmatise the disease further and discourage people from getting tested and finding out their status. The premier’s response to this is to make HIV testing “mandatory”. Besides the appalling human rights consequences of this argument, the state does not have the capacity to do this.

On the other hand, the programme of voluntary counselling and testing introduced into the health system is resulting in millions of people getting tested.

• People are most infectious just after becoming infected

A challenge of HIV prevention is that people are most infectious just after becoming infected, when they do not know their HIV status and cannot yet determine it using standard tests. Neither criminalisation nor mandatory HIV testing can address this, but scaling up antiretroviral treatment might.

• Criminalisation removes responsibility from uninfected people

• Current laws sufficiently deal with intentional transmission of HIV

Very few people intentionally transmit HIV. Those who do can and should be prosecuted under assault laws. HIV is no longer a fatal disease, but a chronic condition much like diabetes.

• We know of no other sexually transmitted infection, the transmission of which is expressly criminalised

Human papillomavirus is a sexually transmitted infection and the cause of cervical cancer. Its transmission is not criminalised. Hepatitis is often transmitted sexually and is frequently a lifelong chronic illness that is sometimes fatal. Its transmission is not criminalised.

It is inconsistent to demand the specific criminalisation of only one sexually transmitted infection. It would be impractical to criminalise the transmission of most or all sexually transmitted infections.

• It is difficult to determine scientifically who infected whom

• Spending on HIV versus spending on the disabled

The premier argues that HIV treatment takes resources away from other health services, such as those for disabled children. In reference to deaf children, she claimed that “there are protests outside my office every week on almost every conceivable issue. Why is no one out there protesting for the rights of these children? Is it because people with disabilities are not regarded as fully human?”

• The premier has missed opportunities to provide care to the disabled

But both the Western Cape and national governments opposed a court action on behalf of severely mentally disabled children requesting special provisions for their education.

Although the case was brought against the Western Cape government when the ANC was in power, it was only heard in 2010, a year into the DA’s rule. The premier had the opportunity not to oppose the plaintiff’s demands. Instead the Western Cape government argued, shockingly, that “for children who do not qualify for admission to special schools, no amount of education would be beneficial”. The court found for the plaintiff.

Zille’s comments create competition for resources between people with HIV and disabled people for limited public health sector resources. A better strategy would be to look for ways to make the public health system less wasteful and to get the private sector to take responsibility for a greater share of the health burden.

Zille’s prescriptions would violate the Constitution, discriminate against the poor, increase stigma, and ultimately be counterproductive. Her views might be popular, but if they were implemented they would cause terrible harm.

http://www.quackdown.info/article/helen-zilles-views-hiv-are-unsci entific/

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