Limited good and limited vision: multidrug-resistant tuberculosis and global health policy
Limited good and limited vision: multidrug-resistant tuberculosis and global health policy
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DOI：
10.1016/j.socscimed.2004.08.046
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发表时间：
2005-08-01
影响因子：
5.4
通讯作者：
Farmer, P
中科院分区：
文献类型：
--
作者：
Kim, JY;Shakow, A;Farmer, P
世界上近三分之一的人口感染了结核分枝杆菌，这种细菌会导致结核病。大多数感染者从未生病，但如果获得有效的治疗，患病的人可以康复。本文讨论了某些伦理和人种学问题，在这些病例中，患者感染的结核分枝杆菌菌株至少对治疗通常所依赖的两种最有效的药物具有耐药性。在大多数贫穷国家，这种耐多药结核病（MDR-TB）患者直到最近才被认为是“无法治愈的”。除了长期处于不健康状态之外，他们还面临着将抗性菌株传染给他人的风险。在本文中，我们讨论了“成本效益”的逻辑，国际卫生政策制定者利用这一逻辑来证明在资源贫乏的环境中治疗耐多药结核病是不可可行的。我们认为，这些多年来在公共卫生政策中占据主导地位的分析存在缺陷，因为它们忽视和隐瞒了获得卫生服务的社会决定因素，而且往往依赖于假设而不是证据。我们认为，仅仅基于对个别情况下具体干预措施的成本效益分析的政策可能是短视的，而且由于它们没有充分重视影响健康生产的社会、政治、经济、流行病学和病理生理因素，最终将阻碍在有效的全球结核病控制方面取得进展。(c) 2004 Elsevier Ltd.版权所有。
Almost a third of the world's population is infected with Mycobacterium tuberculosis, the organism that causes tuberculosis disease. Most of those infected never fall ill, but individuals who do can recover if they have access to effective therapies. This paper discusses certain ethical and ethnographic issues raised by cases in which patients are infected with M. tuberculosis strains resistant to at least the two most powerful drugs on which therapy is usually based. In most poor countries, people with such multidrug-resistant tuberculosis (MDR-TB) were, until very recently, considered "untreatable." In addition to being consigned to a permanent state of ill health, they were also at risk of transmitting their resistant strain to others. In this paper we discuss the logic of "cost-effectiveness," which international health policy-makers utilized to make the case that treatment of MDR-TB is not feasible in resource poor settings. These analyses, which have held sway in public health policy for many years, are flawed, we argue, because they ignore and conceal the social determinants of access to health services and often rely on assumptions rather than evidence. We propose that policies based solely on analyses of cost-effectiveness of specific interventions for individual settings can be short-sighted and, because they do not pay sufficient attention to the social, political, economic, epidemiological and pathophysiological factors influencing the production of health, will ultimately hinder progress toward effective global TB control. (c) 2004 Elsevier Ltd. All rights reserved.