Wednesday, November 15, 2006

As soon as I gave my talk in Ireland it was back to Dublin airport for the 1.30 flight to New York, where I had a working dinner that evening.
I was attending the Global Health Advisory Committee of the Open Society Institute (the philanthropic organisation created by George Soros). I’ve been involved with OSI in various ways for about 10 years. Its ethos is based on the concept of an open society, as set out by Karl Popper and interpreted by George Soros, who was his student.
In the region where I work, eastern Europe and the former Soviet Union, it has been one of the very few NGOs working on health. this is remarkable because the former Soviet Union shares, with sub-Saharan Africa, the dubious distinction of being one of only two major world regions where life expectancy is falling. It also has the fastest growing AIDS epidemic in the world. However, the major donors have concentrated their efforts elsewhere so that, as my colleagues Marc Suhrcke and Bernd Rechel have shown, this region get very much less development assistance for health than it should do on the basis of either its economic or its health situations.
OSI’s work focuses on vulnerable populations – the people that are often invisible to the rest of society. They include prisoners, sex workers, drug users, the dying, and minorities such as Europe’s Roma population. OSI has achieved an amazing amount in the relatively short time it has been working in health and is now recognised as a global leader in harm reduction in relation to drugs.
So what were we discussing? A wide range of things, as always. However two stood out. One was the plight of the Roam population in eastern Europe. Some years ago, OSI joined with organisations such as the World Bank to establish the Decade of Roma Inclusion. Progress, especially in the area of health, has been far too slow. There are several problems. One is being able to describe the health problems that the Roma face. Restrictive data protection legislation has made it difficult to conduct the necessary research. However another problem is the legacy of distrust as much research in the past has focussed on the threat seen as being posed by the Roma people to the majority population, such as from infectious disease, rather than the threats that they face from poverty and environmental degradation. However the greatest challenge is how to support the development of Roma leaders who can engage effectively in the struggle to improve the health of their communities, a topic I will return to soon.
The second issue concerned HIV testing. Obviously this must only be done with the consent of those being tested. However should there be opt-out (in which it is assumed that, in certain settings testing will occur unless refused) or opt-in (in which the individual must ask explicitly to be tested). This is a very complex issue and, at its heart, lies the debate about individual autonomy and community responsibility. Op-in respects individual autonomy but will lead to a lower level of testing, with implications for both tracking the epidemic and the provision of treatment. Opt-out is seen by some as potentially coercive. We didn’t reach a conclusion, but what was most interesting was the way in which the issue divided the lawyers (focussing on the individual) from the public health professionals (focussing on the community). A difficult question….