Aids vs Cancer. You choose.
I almost got hit by a car this afternoon. I was debating with Jennifer Holt, our Deputy Director, about our former colleague Rod Nixon’s “Condom & Smokes” idea. In a nutshell, Rod is planning to launch a project that distributes condoms by packaging them with cigarettes. The cigarettes act as a delivery mechanism, making sure the condom gets to where it’s needed, namely a truck stop bar on the road to Mombasa at 2am on a Saturday.
It’s a fascinating idea because, to use Rod’s words, this will:
(a) overcome distribution challenges, thereby contributing to both HIV/AIDS prevention and family planning objectives in weak states; (b) reduce stigma associated with purchasing condoms in the village and settlement, since the purchase of the condom will be masked in the purchase of the companion product; and (c) contribute to the normalisation of condoms in the community.
Back to the debate. The problem is obvious. Cigarettes are also a pretty good delivery mechanism for something else: lung disease and cancer. We were discussing the ethical issues involved in this project and whether a good outcome could justify a concurrent bad outcome (ie. prevent aids but get cancer). We’re both pragmatic enough to believe that every choice comes with some negative aspects and that if the good outcome was large and overwhelming likely, then it would justify the risk of a smaller negative outcome that is far less frequent.
But aids vs cancer? That’s a stark choice.
Can the social benefit of condom distribution be gauged accurately enough that you could say “If we distribute 200,000 condoms in the Nyanza province of Kenya, it will prevent x cases of HIV.”? I may get Kavya-the-intern on that one. (By the way, she’s been promoted. So were accepting new intern applications.) Assuming you could measure the benefit of the condoms accurately, how would you measure the increased likelihood of cancer? That data is readily available, but I suspect it can’t easily be applied to the Africa context. Because, sadly, African life expectancy is the worst in the world. In some places, like Zambia, it can be as low as 42 years. Africans simply aren’t living long enough to get cancer.
I was taking the position that if you could help lower the death rate from AIDS but there was a direct correlation with the increase in cancer it would still be worth it. In other words, if you could prevent 23 cases of aids, but those 23 people then went on to get cancer and die, it would still be worth it because they would presumably die later in life and therefore there was a net benefit. Sounds harsh, but ask yourself, if you could choose between dying in 5 years from AIDS or in 20 years from lung cancer, which would you pick?
But here is the problem, the thought that stopped me in my tracks as I was crossing 42nd Street: what if 23 different people got cancer? In other words, you prevent some people from getting aids, but in the process other people who weren’t going to get cancer did. Then what?
I don’t know the answer. But I do know I narrowly avoided getting hit by a car as I stood dumbly thinking about it. What do you think?
NB: Rod’s concept is much more nuanced than my overview suggests and proposes to distribute condoms in the packaging of a series of different types of consumer products. We just focused on the most interesting one, smokes.