Can market solutions to an intractable public health problem like AIDS work? Can paying people for intrinsic choices motivate better choices?
AIDS, Malaria and Public Health
Public health requires persistence and creative solutions. Public health is tenuous, and a mutation in a virus responsible for avian flu or a malaria parasite that can drastically change the course of a disease -- change who gets infected, where, and how.
Many other changes, in politics, economics, leadership, geopolitical stability, funding, even weather can impact progress treating and preventing diseases. Technology also changes the course of disease, although talk about technology advances sometimes provides more promise than the actual technology once it comes to fruition. In the fight against AIDS, for instance, promises of vaccines trumped promises of retroviral treatment for all or prevention. It was as if public health gave up on any solution accept a vaccine.
It's morbid to think there may never be a silver bullet for the HIV/AIDS crisis, but its also damaging to over-promise a technical solution like the vaccine that's so speculative. Despite global discouragement about the AIDS vaccine's recent setback, there are always optimistic moments, like ten years ago when education and prevention through condom use and social marketing was the crux of HIV/AIDS fight.
AIDS Long Road
The AIDS crisis seems so untenable however, that its understandable that the AIDS vaccine be touted with such determined optimism. In September, 1998 Washington Post reported on the "remarkable success" of the new prevention strategies. Across the world, the paper said, HIV infection rates were decreasing. In places like the Dominican Republic, Brazil, and Uganda, and the Ivory Coast, and in Tanzania,, where a three year trial aimed at decreasing sexually transmitted diseases had "reduced HIV transmission by 40 percent". An administrator from the AIDS Control and Prevention (AIDSCAP), Brian Atwood, told the paper: "this agency has made a global contribution....over the years, we've learned so much about this..."
Learning about the risk of AIDS doesn't necessarily change sexual practices or result in long term success. The AIDSCAP program ran through the 1990's and despite the successes, suffered many obstacles. As with many of these programs, success can easily be derailed by staff turnover, sociological shifts such as stigma around disease or misunderstanding of disease etiology, uneven programming, funding shortages, interruptions, and politics.
According to the report, today in Tanzania infection rates are lower than places like South Africa, averaging at about 8%, but overall life expectancy in the country has decreased by 8 years due to AIDS. While HIV infection in urban areas declined by 16.65% from 2000 to 2005, in rural areas infection rates have markedly increased.
Other critical economic development measures have also regressed in Tanzania, for instance literacy rates dropped from 80% in 1980, to 60% today. In one survey of adults, 52% of women and 62.5% of men believed that a teacher who has "the AIDS virus but is not sick should be allowed to continue teaching."
Rewarding Behavior
Now, an experimental trial in Tanzania will attempt to attack this complex knot of problems underlying the HIV/AIDS epidemic with a market solution. The Financial Times wrote last weekend about a project in Tanzania that would pay people who practiced safe sex. The trial participants would take regular tests for sexually transmitted diseases like gonorrhea, and be paid about $45 if they remained disease free. The control arm of the trial would not be paid. All would be treated for any infections. Sexually transmitted diseases increase the risk of becoming HIV infected and Tanzania has long focused on this connection.
The project is sponsored by the World Bank, William and Flora Hewlett Foundation, the Population Reference Bureau and the Spanish Impact Evaluation Fund (affiliated with the World Bank). The Financial Times quoted Carol Medlin, a researcher on the project from the University of California, San Francisco, who said: "We hope this 'reverse prostitution' will make people think hard about the long-term consequences of their short-term behaviour."
The move is controversial -- can paying people for intrinsic choices motivate them? Can the complex set of problems underlying AIDS epidemics, involving everything from public health infrastructure, to politics, social norms, economics, and leadership, be resolved by motivating personal choices with money? In an accompanying editorial ("Cash for safe sex; Bribing Africans to be careful is bizarre - and worth a try"), the Financial Times suggested that the scope of the problem warrants such an attempt: "In the face of an appalling Aids epidemic, we should overcome our unease." Should we?
