Volume 197, Issue 3, Supplement , Pages S1-S2, September 2007
For whom the bell tolls
Article Outline
Any man’s death diminishes me, because I am involved in Mankind; And therefore never send to know for whom the bell tolls; it tolls for thee.
John Donne
In June of 1981, a description of the first cases of what are now called AIDS was published in MMWR.1 That report established the Center for Disease Control and Prevention’s (CDC) reputation for tracking the epidemic, a reputation (as reflected in this supplement) that has since solidified and expanded. It also led to a less fortunate idée fixe in the American conscience: that AIDS is an epidemic that only infects “others,” ie, marginalized populations. In the first years of the epidemic, those others were gay males, but later, drug users and members of minority groups joined them. Today, the others are infected people in the developing world.
In fact, the spread of human immunodeficiency virus (HIV), in general, and mother-to-child transmission of HIV, in particular, has bifurcated into two unique epidemics; one in countries with access to highly active therapies, and a much larger one in parts of the world where access to treatment is sporadic at best. The parallel tracks of these epidemics, and the strategies that need to be tailored to the unique circumstances of each are the subjects of this supplement. The message reflected in the surveillance data from the United States is clear. Remarkable advances have already occurred and, from the perspective of mother-to-child transmission of HIV, further progress may focus on simplifying protocols as much as amplifying benefits.2 The protocols in question are not limited to those detailing drug regimens, although efforts to reduce pill burdens and side effects proceed apace. They also apply to protocols for identifying HIV-infected women in the first instance. The message from the CDC and American College of Obstetricians and Gynecologists (ACOG) is unambiguous: it is time to opt out of the opt-in strategy for prenatal testing.3, 4 It is also time to expand and expedite peripartum rapid testing for women with no prenatal care.5 Those women are at particularly high risk and, as more and more women with regular care are identified, they will disproportionately bear the children in the United States who acquire HIV at birth.
The story in the developing world is more complex and more desperate. However, those adjectives were apt descriptors of the AIDS epidemic in the United States in its earliest years. The same commitment that started to change the course of the epidemic in the United States—to learn about and confront the illness—can certainly have a salutary effect in the developing world, and there are reasons for cautious optimism. The infusion of $15 billion over 5 years through The President’s Emergency Plan for AIDS Relief (PEPFAR) program (even with some potentially counterproductive earmarks) presents many opportunities to bring treatments to locales that heretofore had minimal access. In this supplement, the roadmap to progress in the developing word can start to be discerned. The core strategies mirror some that formed the basis for progress in the United States over the last 20 years, ie, surveillance and testing.
In considering the twin HIV epidemics, it would be easy for readers of the American Journal of Obstetrics & Gynecology to focus solely on American women. Accordingly, they might accept as their charge assuring that their patients benefit from the relative bounty of American medicine, that proper medications are prescribed, and that potential toxicities are monitored. However, in holding to this narrow definition of patient care, clinicians would be ignoring the overwhelming epidemic that threatens millions overseas, as well as the less common issue of limited access to therapy in parts of our own country. Thus while they may be providing ethical care in their offices, it would be an ethics writ small.
In that regard it is worth considering one fact that has held true since AIDS was first described: it is a prism through which the social conscience of individuals is refracted. Since the early 1980s, there have been those who saw AIDS as a reason to discriminate, and others who saw it as a reason to fight discrimination. Today, events in Africa may provide a similar litmus test. The killings in Darfur, for example, test our social consciousness. However, Sudan is not the only country on that continent where lives are being laid waste. At this moment, millions of men, women, and children are in mortal peril from HIV. Our obligation to those people does not derive merely from our common humanity, though that alone should suffice. We must also recognize, and appreciate, that what we are now learning about mother-to-child transmission and how, for example, we should treat American women identified as HIV-infected while in labor, is derived from research being performed in Africa. This supplement reinforces the reality that we are interconnected in this epidemic.6, 7
Thus, clinicians should reflect on their obligation to look beyond proper prescribing practices if they want to attain the highest ethical standard of their profession. Several American and European medical organizations have jointly published what they referred to as a physician charter describing the obligations of professionalism, including social justice, noting that, “physicians should work actively to eliminate discrimination in health care, whether based on race, gender, socioeconomic status, ethnicity, religion, or any other social category.”8 To achieve that end, physicians may need to bring their advocacy out of the hospital and into the broader world. Physicians trained in obstetrics and gynecology and versed in the medical arts may feel ill prepared to advocate for the social change required to promote optimal health for their patients. But societal impediments, whether they be the loss of insurance by women in the postpartum period, or the failure of managed care organizations to allow needed procedures or medications, can confound the best of medical plans. No illness is more illustrative of the intertwining of the health of a society with the health of its citizens than HIV, and none has greater need of advocacy at home and abroad. Physicians must start to recognize that the mantle of altruism with which society vests them comes at a cost. They need not be polished lobbyists. But whether by volunteering their time, contributing money, or agitating on behalf of their patients, they need to bring the suasion of the white coat to bear on these important health issues.
Finally, for highlighting the interrelationships between the epidemic at home and abroad, as well as for the remarkable job they have done in laying the groundwork for changing the course of the epidemic in the United States, a debt of gratitude is owed to the Public Health Service. Although thousands of physicians and scientists have participated in that work, there are a few contributors to this supplement whose dedication to combating this epidemic for more than 20 years have been particularly remarkable. For those extraordinary efforts, I would like to end by acknowledging the indefatigable commitment to the health of women and children of Mary Glenn Fowler, Mary Jo O’Sullivan, Lynne Mofenson, and Martha Rogers.
References
- Pneumocystis pneumonia—Los Angeles. MMWR Morb Mortal Wkly Rep. 1981;30:1–3
- McKenna MT, Hu X. Recent trends in the incidence and morbidity that are associated with perinatal HIV infection in the United States.
- . Prenatal and perinatal human immunodeficiency virus testing: expanded recommendations committee opinion. Obstet Gynecol. 2004;104:1119–1124
- Jamieson DJ, Clark J, Kourtis AP, et al. Recommendations for HIV screening, prophylaxis, and treatment for pregnant women in the United States.
- Jamieson DJ, Cohen MH, Maupin R, et al. Rapid HIV-1 testing on labor and delivery in 17 US hospitals: the Mother–Infant Rapid Intervention at Delivery (MIRIAD) experience.
- Dao H, Mofenson LM, Ekpini R, et al. International recommendations on antiretroviral drugs for treatment of HIV-infected women and prevention of mother-to-child HIV transmission in resource-limited settings: 2006 update.
- McConnell MS, Stringer JSA, Kourtis AP, Weidle PJ, Eshleman SH. Use of single-dose nevirapine for the prevention of mother-to-child transmission of HIV-1: does development of resistance matter?
- . Medical professionalism in the new millennium: a physician charter. Ann Intern Med. 2002;136:243–246
Reprints not available from the authors.
PII: S0002-9378(07)00628-X
doi:10.1016/j.ajog.2007.05.014
© 2007 Mosby, Inc. All rights reserved.
Volume 197, Issue 3, Supplement , Pages S1-S2, September 2007
