July 5, 2005
Would you want an HIV-positive nurse?
The topic of HIV-positive nurses came up in conversation the other day.
The current class of nurses at the Johns Hopkins School of Nursing, I was told, has one gay, male, seroconverted student in its ranks.
My immediate question: Is this student planning to nurse HIV-negative patients? Because I, for one, certainly hope not -- for a good number of reasons, he might be better off serving HIV-positive patients.
In fact, given the numbers of HIV-positive intravenous drug users in Baltimore -- including some that apparently deliberately stick doctors with needles -- you could make a case that HIV-positive nurses could carve out a little specialty niche treating HIV-positive patients.
A true story:
Accidents in health care happen all the time. One of our housemates, a medical doctor from Britain, while working at Johns Hopkins Hospital was deliberately stuck with a needle by an HIV-positive drug addict in a rage. Our badly shaken doctor friend had to immediately receive an anti-viral cocktail of drugs.
The best assumption in a profession such as nursing that involves intimate contact is that Murphy's law will prevail.
My sailing party was told, for example, by the Johns Hopkins international clinic before our trip to Thailand not to get so much as a manicure on the beach because of the risk of being nicked by infected clippers. (See 
An Amateur's Guide to the Planet p. 140.)
What if an HIV-positive nurse has a nick from shaving, scratches it, and then fiddles with an intravenous line?
What of hundreds of other similar scenarios?
Further, the issue of nosocomial diseases -- ailments caught while in the hospital -- is a growing one. In "Data Show Scourge of Hospital Infections," the Washington Post reported July 13:
Nationally, the Centers for Disease Control and Prevention in Atlanta has estimated that as many as 2 million infections are acquired in hospitals each year, resulting in 90,000 deaths, said Denise Cardo, director of the Division of Healthcare Quality Promotion.
Add HIV as a long-shot problem to this the list.
It's sad to read the position of the American Nurses Association, which views the matter as one of "protecting the workforce" rather than avoiding unneeded risks to patients:
PROTECTING THE WORKFORCEWorkplace issues of HIV-Positive Nurses
The number of nurses with HIV in the United States or globally is not known. There is also little scientific evidence regarding health care workers transmitting HIV to their patients during care. What is known, however, is that the use of highly active, antiretroviral therapy has dramatically improved the health of HIV-positive persons, which has led to HIV being viewed as a chronic condition and not a terminal disease. Although this shift in prognosis is good news, it has created new workplace concerns, including HIV-positive nurses fearing the loss of their jobs due to employer discrimination and/or patient concerns.
We have the usual dipsy-doodle "modern" thinking leading to advocacy of HIV-positive nurses. First, there is the notion that stigma = bad. The reluctance of patients to be treated by someone with a chronic infectious disease comes from an unwillingness to face even a small risk of contracting a disorder that requires an intensive drug regimen and safe-sex practices for life. Is this so unreasonable? It seems to me patients have a reasonable right to decline treatment by health professionals with HIV.
There is the further modern notion that everyone needs to be "self actualized," as described in the now-discredited heirarchy of human needs by Maslow. (See a wonderful debunking of Maslow in 
One Nation Under Therapy, by Christina Hoff Sommers.)
So it is now ostensibly more important for a nurse to "do her thing" (or "do his thing" in the case of male nurses) than for a patient to be protected against preventable risks.
See as an example an "Ask the Experts" email to an outfit called "The Body: The Complete HIV / AIDS Resource:"
Q: I am a HIV postitive nurse. What kind of work can I do now? Should I not work in the hospital setting or be restricted from other areas of nursing? Nursing was my calling and I am torn between ethics and confidentiality.A: Response from Ms. Breuer
Who told you that nurses with HIV couldn't work as nurses? It isn't true!
First, check with your own employer's policy on bloodborne pathogens and disclosure. Unless you are performing blind invasive procedures, you may not face restrictions.
Then take yourself quickly to the Web site of the Association of Nurses in AIDS Care, ANAC, and learn from their extensive experience with HIV+ nurses. You have LOTS of options within nursing: www.anacnet.org
Nurses are quite often exceptionally kind people who want to make the world a better place. I say that knowing a fair number of nurses as housemates. No doubt this explains this kindliness to those who are sick.
However, the first obligation of a medical professional is to care for patients, and to do no harm! Especially to those who already face risks of getting sicker in the hospital (due to the phenomenon of nosocomial, or hospital-contracted, infection; a related term is iatrogenic, which means illness caused by medical action).
One also must note a certain anti-intellectualism to remarks such as that by the American Nurses Association above, that "The number of nurses with HIV in the United States or globally is not known. There is also little scientific evidence regarding health care workers transmitting HIV to their patients during care."
Well, a search of the medical literature might just tell us the reality of such a scenario. In just a few minutes, you can learn the following from Google:
Apparently there may have been six cases of transmissions by health-care provider to patients in the United States (involving the notorious dentist in Florida) and one case in France (an infected orthopaedic surgeon).
It just seems obvious that one's risk of contracting HIV declines as one assiduously avoiding contact with members of high-risk groups.
And it seems as though involuntary contact with HIV-positive health-care providers is about to become another potential vector.
My area of expertise, such as it is, involves the HIV risks of casual travel sex by female travelers (to be explored in my forthcoming book, 
Romance on the Road. I can readily crank out a 20-citation bibliography of warnings in respected medical journals for women to avoid sexual contact with strangers during their travels, and if passion strikes, to use a condom bought from a Western manufacturer, and to roll it on themselves.
Question for the medical profession:
Are there two kinds of HIV out there?
One that is menacing and lurking in clever seducers in foreign countries, the other, benign and safely encapsulated in that caring man (or woman) in the nurse's scrubs attending to my health care?
Hospitals (and nursing schools) should put the concerns of the patient, not the nurse, first. But that is not the way it is now. The hospital, not you the patient, decides if an HIV-positive nurse is to be in an operating theatre or not. Check out these complicated guidelines in Scotland on what sorts of assignments HIV-positive nurses can receive.
Wouldn't it be simpler to have HIV-negative nurses work with HIV-negative patients? I will grant the following points: That in many places (such as right here in Baltimore), the risk of a health professional getting HIV from a patient, in circumstances such as occured with our housemate who was a resident, is greater than the risk of a patient getting HIV from a health professional.
Still, it seems the right of the patient to make an informed choice. At least one HIV-positive nurse doesn't see it that way, as Operating Theatre Online (scroll down to "HIV-positive NHS worker fights for right to privacy") described of a worker in Britain's National Health Service:
An HIV-positive worker in the NHS is fighting a landmark legal action that could prevent those he has treated knowing that they could have been in contact with the virus. The worker is reportedly claiming that his right to privacy should supersede the rights of patients he has treated to know of his condition. If his claim is upheld in law, the case could have "serious implications" for the way in which the NHS handles such cases. The worker won an injunction on Saturday (17/11/01) to prevent a newspaper publishing his name or the branch of medicine he works in, although the newspaper said he worked in a field that involved the routine wearing of rubber gloves to prevent the transmission of infection. (From The Guardian 19/11/01; p.8)
Well, there you have it: A medical worker's right to privacy supercedes the risk to the patient, at least in one medical worker's mind.
Ideally, nursing schools should address the question of what chronic, communicable diseases are acceptable in students they accept, hospitals should try to make sure only 100 percent healthy nurses treat patients, and patients should have a right to know a hospital's policy toward HIV-positive staff, especially for invasive procedures.
If the demographic of nursing schools is going to increasingly include gay men, or other risk populations, as seems to be anecdotally the case, this question of policy will attain increasing importance.
- posted by jbelliveau at 9:02 AM in Culture
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July 4, 2005
Africa, poverty and Live8
I enjoyed watching parts of the Live8 concert on MTV, especially the generally superior lineup from London. Seeing Pink Floyd looking way older than even the Rolling Stones -- that's David Gilmour and Roger Waters, above, but playing brilliantly, was a highlight.
Madonna, who strikes me as a very confused person straining to achieve predictable sacrilegiousness in her videos, did well to perform holding the hand of a beautiful Ethiopian woman, Birhan Woldu, below, who had been on the brink of starvation as a 3-year-old and now attends college, due to efforts to combat the effects of famine.
In Philadelphia, Linkin Park teamed with Jay-Z, and like many of the other artists, seemed to put their all in the performance.
Their call to eliminate poverty in Africa, and prevent 30,000 deaths a day from its effect, is a worthy, noble and necessary one. Let's just hope the musicians and concert organizers fail in their attempt to get the G8 to increase aid to the continent. MTV interviewed plenty of 20-something, dreamy kids who said essentially how jazzed they were that by watching U2 play for free, world poverty would end.
Here's what I envision when Bob Geldof, Bono and others call for debt relief in Africa: More money for the kleptocrats who already steal most of the so-called Western aid.
More aid = more Mercedes tooling around Lusaka, Kampala, Windhoek and other capitals.
For a brilliant article on what Africa, and most of the developing world, really needs -- a crackdown on corruption, private property rights, the rule of law -- see this terrific article, Live8: a triumph for sentiment, not for results, by Allister Heath, in the BusinessOnline:
The history of Africa since the 1960s is the history of groups of elites seeking the political kingdom with the primary purpose of enriching themselves, Mbeki says. To rectify this situation, he believes that Africa's poorest people must be empowered through the institutions of the free society: property rights and markets: It is necessary that peasants who constitute the core of the private sector in sub-Saharan Africa become the real owners of their primary asset: land. To enable such ownership, freehold must be introduced and the so-called communal land tenure system, which is really state ownership of land, ought to be abolished.
Heath notes that "Sub-Saharan Africa suffers from the highest average customs delays in the world; Estonia requires one day for customs clearance versus 30 days on average for Ethiopia."
Some additional excellent reading on this topic:
The Wealth and Poverty of Nations, by David Landes. Could something as simple as cultural attitudes toward thrift, honesty and persistance, as well as a systematic approach to science, explain the gulf in rich and poor nations that grew after the Industrial Revolution?
Dark Star Safari, by Paul Theroux.
Theroux returned to Africa after serving in the 1960s in Malawi to find backsliding everywhere. He lambastes the professional anti-poverty workers in their gleaming, air-conditioned Land Rovers playing CDs on state-of-the-art sound systems. He returns to the school where he taught to find it decrepit and his former house in disrepair. Where are the Africans stepping forward to teach their own children, to build, to repair, he wonders, as he concludes that many aid efforts are futile, doomed until Africans themselves decide it is time to have good government, good schools and decent housing.
The solution to Africa's poverty must come from Africans, Heath also concludes:
There is an urgent need for Africans to boost their inter-regional trade, partly to reduce their dependency on commodity exports to the West. Ask an African business person what needs to be done and chances are that very high on their list will be facilitating internal African trade by sweeping away bureaucracy and taxes. The facts speak for themselves: it costs the same to clear a 20-foot container through the ports of Abidjan or Dakar as it does to ship it all the way to a north European port.... The West can help by tearing up its trade barriers and scrapping its deadly export subsidies; but not by handing out cash. If only those demonstrating in Edinburgh this weekend were to accept this, they would actually be helping to make poverty history. Instead, despite their good intentions, they may inadvertently be helping to prolong Africas misery.
- posted by jbelliveau at 9:10 AM in Culture
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