They Call It “Patient Selection” in Khayelitsha: The
Experience of Médecins Sans Frontières–South Africa in
Enrolling Patients to Receive Antiretroviral Treatment for
a1 University of Pennsylvania,
a2 Médecins Sans Frontières (MSF)
In 1999, Médecins Sans Frontières (MSF) set out to
explore and demonstrate the feasibility of preventing and treating
HIV/AIDS in a so-called resource-poor, economically and socially
disadvantaged setting. The first MSF mission to incorporate antiretroviral
(ARV) treatment into its HIV-AIDS-oriented medical program was undertaken
in Bangkok. The second project was launched in Khayelitsha where MSF has
been providing ARV treatment for persons with HIV/AIDS since May 2001.
Khayelitsha is an enclave of some 500,000 inhabitants, most of whom live
in corrugated-iron shacks, without running water or electricity.
Unemployment is extremely high; crime and violence (including robbery,
domestic violence, rape, and murder) are rampant. The general prevalence
of HIV/AIDS is 26%, measured among pregnant women. The tuberculosis
incidence rate is one of the world's highest for open-space sites
(1,380/100,000). Unsurprisingly, TB/HIV coinfection is very high
too: 63% of those with TB are also infected with HIV. a
a Renée C. Fox made two field research trips to the
Khayelitsha HIV/AIDS project in connection with her ongoing
sociological study of Médecins Sans Frontières, which
centers on moral dilemmas associated with medical humanitarian action. Her
research has been supported by grants from The Acadia Institute, the
Honorable Walter H. Annenberg Chair in the Social Sciences Research Fund
at the University of Pennsylvania, and the Andrew W. Mellon Foundation in
the United States, and from the Nuffield Foundation in the United Kingdom.
We express our gratitude to Nicholas A. Christakis, M.D., the late Willy
De Craemer, Ph.D., Robert L. Klitzman, M.D., and especially to Judith P.
Swazey, Ph.D., for their astutely critical and encouragingly helpful
comments on earlier drafts of this article. Disclaimer: Patients'
consent and permission to publish are not required, because no research
was conducted on patients, and the cases described in the article do not
reveal the patients' identity or breach their privacy.