David Laslett ’09

Major

Operations Research and Financial Engineering

Project Title

Social Welfare and HIV

“I had no idea what to expect as I strolled into the Rixile HIV clinic at Tintswalo Hospital in the rural town of Bushbuckridge, South Africa. I certainly didn’t expect an African clinic with 6,000 patients to be run by a scrawny, Scottish doctor in his late twenties. On my first day, I saw more infectious disease than many will see in a lifetime. But just as ubiquitous as the patient’s suffering was the doctor’s constant struggle to provide adequate care. When a doctor had to redo a blood test after the lab lost the previous sample, I was shocked to learn that this was a common occurrence. One mother died in childbirth when a simple blood transfusion would have saved her. The hospital wasn’t out of blood; the nurses simply couldn’t find it. A year after the government purchased the antiretroviral Tenofovir for its treatment regimen, it summarily pulled the plug and failed to issue a plausible explanation. The Scottish doctor told me once that most of his job was spent trying to diagnose TB. The PPD test is useless in immuno-suppressed HIV patients, growing a TB culture takes 40-50 days, the one x-ray machine is constantly broken, and it is nearly impossible to get patients to produce adequate sputum samples.”

“But amazingly, the doctors persevered. They would all meet for tea in the morning and discuss difficult cases. X-rays and blood vials made frequent guest appearances. Each day, the HIV clinic doctor squeezed in extra time between his patients to consult on patients in other wards. But most importantly, he treated all of his patients with complete respect, even a traditional healer who was convinced that a rival clan had poisoned her food with HIV. If patients were doing well on treatment, he would down-refer them to local community clinics, for he rightly conceived HIV as a manageable, chronic illness that can be treated on the primary care level. He even helped people secure their disability grants, which was often the biggest concern of many of his patients. Successful treatment regimes were ensured be a variety of social and psychological requirements that complimented the science of treatment. Before starting treatment, each patient had to demonstrate psycho-social preparedness. This included having a “treatment supporter” that could pick up the ARV mediation if the patient were incapacitated and disclosing to one’s partner or family. Each patient also had to attend classes about the ARV drugs and the importance of 100% adherence and meet with a dietician and social worker. This model where laypeople are supporting the scientific community in delivering treatment is the emerging model for successful treatment programs in Africa, and it should undoubtedly be extended elsewhere.”

 

“After my time in the clinic, I spent a month at an economic policy research institute, where I looked into the nature of South Africa’s social welfare system and its effect on HIV patients. I discovered the integral role of the disability grant in the health care system, where patients relied on the grant to finance food and transportation expenses. Unfortunately, HIV patients who begin the ARV treatment regime are losing their grants as their health gets restored by the drugs. Stripping patients of their grant after several months of successful treatment, however, is a paradox of the worst kind. It ignores that patients will still need the same food and transportation security to continue their treatment, which for HIV and other chronic illnesses, is a life-long commitment. With regards to HIV treatment, nutrition is especially essential because malnutrition exacerbates the immunosuppression triggered by HIV. Nutritional deprivation also worsens treatment side effects, which are a main cause of poor adherence. Transportation is equally important for adherence since most patients must travel considerable distances to collect their medication from the hospital.  Without drug adherence, drug resistance is inevitable, a phenomenon that will only magnify the HIV epidemic. Since disability grants are not permanent by nature, and since relaxing the eligibility requirements would encourage fraud and distort the labor market, I found that many experts considered it most prudent to address these issues with a basic social grant. A social grant targeted only for those people with HIV would obviously be a stigmatizing nightmare, so the most appropriate solution is a universal, basic income grant.”



Internship Year

2008

Project Category

Health

Organization(s)

Princeton Univeristy

Mentor(s)

Joao Biehl