Questioning Fundamental Assumptions

BY RICHARD SKOLNIK

One of the most important lessons that I have learned professionally is the importance of questioning fundamental assumptions. This lesson arose on a number of occasions, both when I worked at the World Bank and afterwards.

One of the most interesting examples of this was the work we did on HIV at the World Bank not long after anti-retroviral drugs (ARVs) began to be used in high-income settings.  A lot of the discussion around HIV in low-income countries at that time focused on how ARVs would never be affordable or cost-effective for use in these countries. This was painful but “obvious” to everyone, since most of the countries on which we worked spent very little per person per year on health and ARVs at that time cost more than $10,000 per person year of treatment.

For the most part, this notion was accepted in the development community. In retrospect, this is slightly surprising. By this time, pharmaceutical donation programs already existed for leprosy and onchocerciasis and could have served as models for how to get drugs to low-income countries. Yet, at least initially, no one talked about a similar approach for HIV.

The world began to look at this differently only when a number of early HIV advocacy groups and advocates made the failure to provide AIDS affected people in low- and middle-income countries into a moral and ethical issue. Essentially, they felt it was immoral to give access to lifesaving AIDS drugs to people in high-income countries, while denying them to people in low- and middle-income countries.

Thus, they helped lead the world to reject the idea that “these drugs would never be affordable” and instead asked “what it would take to make them affordable.” This led to the development of donation programs for AIDS drugs, as well as negotiated prices, and finally to generic anti-retroviral drugs that were often developed and approved on a compressed timetable.

A similar issue arose over the treatment of people affected by drug-resistant TB. The official position of the World Health Organization at the time was to focus TB treatment on people who carried the most contagious form of TB that could be treated successfully with anti-TB drugs. The prevailing wisdom at the time was that by doing high quality treatment for this group, in a very cost-effective manner, that one could cure the overwhelming majority of TB patients and avoid the development of new cases of drug-resistant TB. This premise was strengthened by the fact that treating drug-resistant TB was difficult clinically and very expensive.

Many of the same people who advocated on behalf of lowering the price of drugs for HIV also advocated for the treatment of people suffering from drug-resistant TB.  They believed that ignoring patients with drug-resistant TB was morally unacceptable and epidemiologically unsound. Thus, they began to demand the treatment of drug-resistant TB, call for lower prices of second-line TB drugs, and established programs to “show the world” how patients with drug-resistant TB could be successfully treated.  In a relatively short period, partly enabled by these advocates, the world changed its approach and began to treat people with drug-resistant TB more actively.

The lessons of both of these cases are clear. First, if you stick forever to the same assumptions and approaches, you will never enable needed change. Second, there can be great value in being unwilling to accept commonly taken approaches that do not adequately serve the poor and to ask instead what needs to be done to better meet the needs of these people.  Finally, coupling your interest in enabling change with efforts to discover and implement more appropriate approaches can be a powerful way to alter commonly held assumptions and get key stakeholders to accept “another way of doing business.”