Elimination: What Does It Look Like?
Elimination. There’s a kind of ominous ring this word, but this is what we hear a lot in the world of viral hepatitis, including HBV and HCV. The meaning here is meant to describe a global effort to eliminate hep C as a health threat. With estimates of worldwide infection ranging wildly, suffice to say it is well over 100 million people now living with hep C. Some peg it at around 150-170 million, and no matter which is accurate it is a huge number. Some countries have high prevalence while others claim lower numbers; but to be frank, the collection of data to support these claims is better in some places than others. It begs the question to me about the desire to either inflate or conflate the numbers to serve an agenda, which has nothing to do with healing the sick. The politics of health and money are inseparable in the world of health.
If I sound cynical you would be at least half right. Why? There is history we can look to in how some other infectious diseases have fared in the past. The fact is that there is money and reputations at stake, and small and large fortunes to be made. There are the obvious winners but there are some smaller players in this game and they have stepped up to the plate in large numbers with the advent of new drugs that are highly effective at curing people. The motivations vary as much as the people involved and some even suggest that hep C is “done and dusted” with the discovery of new and more effective drugs. It is not “done and dusted” by a long shot in the opinion of those of us who are working to improve equitable access to care.
Is elimination even possible?
The World Health Organization (WHO) set a timeframe for elimination by 2030, and nearly 200 countries have signed on to their timetable. With the new drugs nearly all people can be cured, but it remains a big IF as to whether people everywhere will have access, nevermind if they are even identified with screening guidelines that will capture all those affected. Despite calls by the CDC in the US for one-time testing of the largest group affected nearly 5 years ago we have yet to see any widespread effort to inform this population outside of drug companies who sell the treatments, and Community Based Organizations who have limited resources and little impact on the general population including the largest at-risk group.
Does elimination include death from hep C caused disease like liver cancer? If I was truly cynical I could imagine this as a strategy when testing and treatment is not a public health priority. The priority appears to be in new cases, which data indicates is the drug using population. If we truly are shooting for elimination we need to stop new infections. The older group identified as being the largest cohort living with the virus, untested, may be assumed to already have such advanced disease they will die without knowing their hep c status. Why test them? This is a form of elimination as unethical as it is.
Some will argue that public health agencies are not tasked with preventing death. For too many years we have heard how slow the progression of the disease is. Whose job is it then? Is it not a public health crisis with so many deaths caused by hep C? I suggest you read the mission statements of public health agencies where you live if you want to know the role they presume to play in the public’s health. Maybe public health is not responsible, but again it begs the question; who is?