AIDS and Africa. Introduction

Sub-Saharan Africa is the epicenter of the HIV/AIDS epidemic, and in this issue of the Journal, seven authors discuss the moral, social and medical implications of having 70% of those stricken living in this area. Anton A. van Niekerk considers complexities of plague in this region (poverty, denial, poor leadership, illiteracy, women's vulnerability, and disenchantment of intimacy) and the importance of finding responses that empower its people. Solomon Benatar reinforces these issues, but also discusses the role of global politics in sub-Saharan Africa, especially discrimination, imperialism and its exploitation by first world countries. Given the public health crisis, Udo Schüklenk and Richard E. Ashcroft defend compulsory licensing of essential HIV/AIDS medications on consequentialist grounds. Keymanthri Moodley discusses the importance of conducting research and the need to understand a moderate form of communitarianism, also referred to as "ubuntu" or "communalism", to help some Africans understand research as an altruistic endeavour. Godfrey B. Tangwa also defends traditional African values of empathy and ubuntu, discussing how they should be enlisted to fight this pandemic. Loretta M. Kopelman criticizes the tendency among those outside Africa to dismiss the HIV/AIDS pandemic, attributing one source to the ubiquitous and misguided punishment theory of disease. The authors conclude that good solutions must be cooperative ventures among countries within and outside of sub-Saharan Africa with far more support from wealthy countries.     

Publishing Biomedical Research: Roles and Responsibilities

Authors, reviewers, and editors have critical responsibilities to ensure the validity and utility of published biomedical research.     

Community: The Neglected Tradition of Public Health

The dominant language of politics in the United States has been political individualism, with minimal restrictions on property and personal, voluntary conduct. But there are second languages of community that stress cooperation and group action. These second languages include the constitutional tradition for public health. Public health offers a community justification for paternalistic measures that, for example, discourage smoking or require seatbelts.     

The fragile web of responsibility: AIDS and the duty to treat

Arras maintains that the AIDS crisis confronts society with the need to re-examine the proper role and duties of physicians and of the medical profession. He rejects as ethically unacceptable and practically unworkable duties to treat based either on a voluntary, contractual physician patient relationship or on a social contract with the profession. Although a virtue-based approach upholds an individualized duty to treat, it depends upon society's shared concept of the good which is beginning to erode as AIDS is viewed as a problem of a stigmatized minority. Arras concludes that the medical profession and society must decide whether to reaffirm the ideal of self sacrifice for patient benefit or--in keeping with the recent drift to the entrepreneurial, scientific, or bureaucratic models--to accept a self-centered role for physicians that would signify moral failure and set a dangerous precedent.     

AIDS: The Risks to Insurers,the Threat to Equity

The AIDS crisis poses a special challenge for American health care, which depends heavily on private insurance to pay medical bills. Can we provide adequate health care to all who need it and still meet the financial requirements of the private health insurance industry? More insurance carriers are turning to antibody testing in order to eliminate poor risks from non-group, direct-pay pools. Some cost-conscious employers have attempted to fire AIDS patients summarily or to exclude AIDS coverage from group insurance policies. Various remedies are available for spreading the financial risks of the epidemic, such as covering persons with AIDS under Medicare or in state-sponsored health insurance pools. Ethical questions about cost and access may also rekindle the debate about the need for national health insurance.     

The Limits of Compulsion in Controlling AIDS

In this review of two books on psychosurgery, Bloch highlights Elliot S. Valenstein's treatment of the history of the procedure and John Kleinig's appraisal of the clinical and ethical issues involved. Valenstein, in Great and Desperate Cures: The Rise and Decline of Psychosurgery and Other Radical Treatments for Mental Illness (Basic Books; 1986), traces the rise and fall of psychosurgery from its beginnings in the 1930s to its dramatic decline after the 1954 introduction of effective psychoactive drugs. Evaluating the effectiveness of psychosurgical interventions, Kleinig, in Ethical Issues in Psychosurgery (Allen and Unwin; 1985), argues that some carefully selected patients will benefit from these procedures. Bloch also discusses the British 1983 Mental Health Act with its provisions for informed consent and second opinions, and concludes that it generates as many problems as it solves.     

Health Care for Veterans: The Limits of Obligation

The federal government has a generally unquestioned obligation to provide health care to veterans for diseases or disabilities acquired during military service. Much argued, however, is the government's obligation to offer care for nonservice-connected disorders. The Reagan administration has sharpened the debate recently by attempting to impose a means test on veterans over sixty-five who are seeking such care. But the controversy focuses on the wrong issue. Society has a moral obligation to provide adequate health care to all citizens but has no special obligation to care for nonservice-connected health problems of veterans.     

DRGs: The Counterrevolution in Financing Health Care

DRGs may contain costs, but they threaten to restrict access to health care, to compromise its quality, and to impede the development of new medical technologies. Immediate corrections are necessary to ensure that hospitals continue to serve the poorest and sickest.     

Demedicalizing Health: The Kitchen as a Site of Care

Attention to culinary care can enrich the framing of health within medical anthropology. We focus on care practices in six Latin American kitchens to illuminate forms of health not located within a singular human subject. In these kitchens, women cared not for individuals but for meals, targeting the health of families and landscapes. Many medical anthropologists have critiqued health for its associations with biomedicine/biocapitalism, some even taking a stance ‘against health.’ Although sympathetic to this critique, our focus on women’s practices of caring for health through food highlights dissonances between clinical and nonclinical forms of health. We call for the development of an expanded vocabulary of health that recognizes health care treatment strategies that do not target solely the human body but also social, political, and environmental afflictions.