Issues surrounding scarcity will forever plague international health programs. The bottom line is in donor funded programs there is never enough to go around, and when the stakes are as high as they are in the development arena, this is life and death.
Very much like Deanna Troi’s mission on the bridge – the one she failed five times before realizing she had to send Geordi la forge on a mission she new he would not survive… imagine the following scenario: you have 500 people who need to start ARV treatment in 24 hours in an undisclosed African country. You have enough supplies to treat 100 people. How do you choose who receives the treatment? How do you inform the four out of five people you are not going to treat?
1. Choose those who have the most dependents and the strongest likelihood for maintaining earning capacity.
Great, so you only want to save working age men? While this may have a strong economic argument, especially considering the dynamics of households in this region and the dependency on the male head of household, think of the wonderful reactions this would garner from the women’s movement.
2. Select those who are the sickest and are suffering the most.
Studies yielding empirical evidence are still pending, but would this not reflect a similar incentive in South Africa where they gave cash grants to the HIV positive people? It is believed that infection rates increased as a result.
3. First come first serve basis.
This would give preferential treatment to those who are in close proximity to the health center, and those who have the luxury of being able to stand in line all day: the unemployed. Is this what was intended?
4. Give the treatment option to one person per household, leaving the decision up to the family who the recipient will be.
Once again, the women’s movement! Not to mention the marital strife this would cause…
There is no perfect solution. Either way people will die, and you will be responsible. This is scarcity, this is rationing, and this is the current state of international health. In the end, during this scenario (which actually happened in South Africa in 2004), the health practitioner in charge decided to treat the sickest first, hoping that by the time others started to be symptomatic more supplies would come.
This is the equity – efficiency tradeoff, whereby the aims are to distribute the medicine fairly yet still preserving human capital to maintain people’s livelihoods. There are unlimited ways to do this, yet there is also no solution high in both equity and efficiency.
Such is the way of the world.☼