Tag Archives: public health

Insite: A Step Beyond a Needle Exchange

The following is a guest post by Shawn Zhou, a country program analyst with the Clinton Foundation on the Clinton Health Access Initiative in Shanghai, China.

An interesting progressive model for combating HIV/AIDS has emerged over the past 5-10 years in Vancouver, BC. Once home to the highest rate of HIV infection growth in North America, Vancouver has seen a significant decline in the spread of HIV among its intravenous drug users. The model they’ve implemented encourages drug users to enter a “safe house”  called Insite, where individuals are free to use illicit drugs while being supervised by nurses, and are offered treatment if suspected of suffering from HIV. Insite is trying to provide an aggressive and controversial model of reaching and treating a difficult and high-risk population….and so far it appears to be working.

According to one of the center’s studies, financed by the United States National Institutes of Health, from 1996 to 2009 the number of British Columbians taking the medications increased more than sixfold — to 5,413, an estimated 80 percent of those with H.I.V. The number of annual new infections dropped by 52 percent. This happened even as testing increased and syphilis rates kept rising, indicating that people were not switching in droves to condoms or abstinence. (Full Article)

There are two key foundational beliefs to the creation of this model 1) As one nurse put it: “people are going to use drugs whether they have clean needles or they don’t.”   2) A Test and Treat system where all patients regardless of CD4 count are treated if they are HIV+ (aka….don’t prioritize patients, treat everyone, stop the spread).

This first fundamental belief is probably the biggest sticking point for those opposed to the program. Fundamentally while this model may appear to encourage drug use, as the article suggests, many other cities worldwide have already adopted free needle exchange programs as a means of encouraging cleaner and safer drug use.

A 1997 study in The Lancet found that in 29 cities worldwide with needle exchange, H.I.V. infection dropped 6 percent a year among drug injectors, while in 51 cities without, it rose by about 6 percent.

By funding a safe house for users, monitored under the careful watch of medical professionals, Vancouver has taken this belief one step further and is trying to manage dangerous behavior in a contained and safe environment.

In 2009, the site recorded 276,178 visits (an average of 702 visits per day) by 5,447 unique users; 484 overdoses occurred with no fatalities, due to intervention by medical staff. Health Canada has provided $500,000 per year to operate the site, and the BC Ministry of Health contributed $1,200,000 to renovate the site and cover operating costs. (Wikipedia site)

This is of course a difficult pill for public officials to swallow, since such clinics and programs are costly and goes against conservative principals. However, regardless of its implications on drug use, the model undeniably offers a safer environment for drug addicts than they previous had, and should probably get strong consideration in other communities in the developed world where drug use and the spread of HIV is rampant. I’m curious to see how this all shakes out as apparently Canada’s supreme court is reviewing law suits to close down the facility.

The Silver Bullet of Conditional Cash Transfers

There is a new paper from DFID (the British overseas development assistance authority) about the usefulness and effectiveness of conditional cash transfers.  I have written a few times about this topic in early 2011 and way back when in 2010 (see here and here) and have always been pretty bullish on the use of them as tools for poverty alleviation.  Conditional cash transfers effectively pay the poor in exchange for meeting certain requirements regarding healthcare and education.  Welfare programs for individuals and families are contingent on achieving certain targets.  For achieving a certain school attendance rate for children, a family will receive a certain amount of money.  For bringing your child to the doctor a certain number of times per year, you get money from the government.

The advantage of these schemes is that they offset the opportunity cost of keeping your child in school, or the actual cost of bringing your child to the doctor.  So, by creating incentives around behavior modification, you can more effectively target the root causes of poverty.  Good decision-making becomes in the best financial interest of families, and mitigates the costs of neglect.

What they do not address are systemic problems.  For example, within education, conditional cash transfers aren’t going to build more schools, improve teacher training, reduce class sizes, or provide additional jobs for people once they get out of school.  Nor will they improve the quality of healthcare delivery or the caliber of physicians.  This gives some people pause.  This is from the report:

Well-designed and implemented cash transfers help to strengthen household productivity and capacity for income generation. Small but reliable flows of transfer income have helped poor households to accumulate productive assets; avoid distress sales; obtain access to credit on better terms; and in some cases to diversify into higher risk, higher return activities. These intermediate outcomes help draw poor people into the market economy on terms that allow them to benefit from and contribute to growth.…

There is robust evidence from numerous countries that cash transfers have leveraged sizeable gains in access to health and education services…However, transfers have had less success in improving final outcomes in health or education.  Cash transfers can help the poor overcome demand-side (cost) barriers to schooling or healthcare, but they cannot resolve supply-side problems with service delivery (e.g. teacher performance or the training of public health professionals). Cash transfers therefore need to be complemented by ongoing sectoral strategies to improve service quality.

The whole notion of a silver bullet is a non-starter for me.   Continue reading