HIV-Positive in Philadelphia vs. Uganda

“What does it mean to say that one life is “worth more” than another? Aren’t all lives infinitely precious? Well, no, at least not in any sense that’s at all useful for making hard policy decisions about things like job safety and access to medical care.

Economists measure the value of a life by people’s willingness to pay for safety. Suppose you’d willingly cough up $50,000—but no more—to shave one percentage point off your chance of being killed in an accident. Then (except for some technical adjustments I won’t go into) we infer that the value of your life is 100 times $50,000, or $5 million.”

In economics, everything must have a value attached to it.  There is no such thing as “invaluable.” Intangibles like life, liberty, and the pursuit of happiness have some value at which the opportunity cost of having them becomes too high.  This is the value of abstract concepts.  But, according to the article quoted above from Slate, a life is worth $5 million.

Thinking about this reminded me of something interesting I heard while I lived in Nairobi.  I met someone who was working at a hospital in Uganda as an HIV counselor, disclosing the status of the test to the patient.  He was finishing up his Masters of Public Health at UPenn and worked during the year at a clinic in Philadelphia, doing the same work.   I asked him, between the two groups (Ugandans and Philadelphians), who took news harder?  Without question, he said, the people he worked with in Philadelphia.

HIV prevalence in Uganda, 1990-2007

I did not expect to hear that.  In the United States, anti-retroviral drugs allow people who can afford them the ability to maintain a normal life expectancy.  The drug cocktail that contained a regimen of dozens of pills per week has been concentrated to a single pill – Complera – taken daily, which keeps the virus from turning into full-fledged AIDS.  In other words, while it is no doubt traumatizing to learn you are HIV-positive, I wrongly assumed that, because it is no longer a death sentence, the personal devastation would not be nearly as severe.

In Uganda, on the other hand, HIV could very much be a death sentence, particularly for the poor.  Anti-retrovirals are available for free through clinics and churches, but the availability of these and other ancillary services, like counseling or support groups, are limited.  Even though the HIV incidence in Uganda has declined from 15% in 1990 (one in eight people) to ~5% today (one in 20), it is not a small problem, particularly when you consider that the incidence is much higher in slums and other communities where unemployment is high and prostitution common.

Despite these facts, my friend told me that people he spoke with about their condition reacted calmly, almost with a sense of resignation and practicality.  They would want to know what they needed to do, what drugs they needed to take, and then move on.  While people in Philadelphia would break down under the weight of the realization that they contracted the virus, people in Uganda seemed to look at it as another problem to deal with and move on with their lives.

I don’t know why this is the case or whether I can extrapolate any conclusions beyond this localized case (which I only heard about through a single conversation).  But I thought about it a lot.  One theory is that HIV/AIDS in parts of Uganda and, to a greater extent, Sub-Saharan Africa, is just a part of life.   People contract the virus with a high-enough frequency that people know other people with the virus, and they understand the implications contracting it will have on their own life.  Maybe in Philadelphia the feeling that you are alone in this might make it more difficult to deal with, especially when you have so many preconceived notions about what life with virus entails.  So, in Uganda, maybe understanding the day-to-day implications causes people to accept the consequences.

Maybe it is exactly the opposite.  Maybe people in Philadelphia can really understand and conceptualize the extent to which their life will be different after contracting the virus.  It means taking one pill every day for the rest of your life, and disclosing your status to all potential sexual partners.  It places a huge amount of responsibility on your shoulders, not only for your own life, but those of others as well.  And in this hospital in Uganda, maybe the patients don’t understand at all just the significance of contracting the virus.  It could be that this is their first time in their lives they have been to the hospital and cannot really process the gravity of the situation.

Another theory is that poorer Ugandans who contract the virus have so much to deal with already that the added weight of knowing they are positive is an afterthought compared with the immediate concerns – specifically, how to make money and buy food for your family.  This is not to diminish the problems of the Philadelphians.  It is only to say that immediate concerns about the here and now trump those of the future, particularly when the treatment is offered free of charge.

And lastly, and maybe most controversially, maybe people in different countries and different socioeconomic levels place a different value on life.  Economists would say that every life is worth $5 million.  That, of course, is context-dependent.  It is an abstract idea that cannot be quantified.  But governments do place a specific value on the lives of their citizens.  I don’t know what it is in Uganda, but it is probably a lot less than $5 million.

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