The Challenge of Global Health

Laurie Garrett

From Foreign Affairs, January/February 2007

Summary:  Thanks to a recent extraordinary rise in public and private giving, today more money is being directed toward the world's poor and sick than ever before. But unless these efforts start tackling public health in general instead of narrow, disease-specific problems -- and unless the brain drain from the developing world can be stopped -- poor countries could be pushed even further into trouble, in yet another tale of well-intended foreign meddling gone awry.

Laurie Garrett is Senior Fellow for Global Health at the Council on Foreign Relations and the author of Betrayal of Trust: The Collapse of Global Public Health.

SHOW ME THE MONEY

The recent surge in funding started as a direct consequence of the HIV/AIDS pandemic. For decades, public health experts had been confronted with the profound disparities in care that separated the developed world from the developing one. Health workers hated that inequity but tended to accept it as a fact of life, given that health concerns were nested in larger issues of poverty and development. Western AIDS activists, doctors, and scientists, however, tended to have little experience with the developing world and were thus shocked when they discovered these inequities. And they reacted with vocal outrage.

The revolution started at an international AIDS meeting in Vancouver, Canada, in 1996. Scientists presented exhilarating evidence that a combination of anti-HIV drugs (known as antiretrovirals, or ARVs) could dramatically reduce the spread of the virus inside the bodies of infected people and make it possible for them to live long lives. Practically overnight, tens of thousands of infected men and women in wealthy countries started the new treatments, and by mid-1997, the visible horrors of AIDS had almost disappeared from the United States and Europe.

But the drugs, then priced at about $14,000 per year and requiring an additional $5,000 a year for tests and medical visits, were unaffordable for most of the world's HIV-positive population. So between 1997 and 2000, a worldwide activist movement slowly developed to address this problem by putting pressure on drug companies to lower their prices or allow the generic manufacture of the new medicines. The activists demanded that the Clinton administration and its counterparts in the G-8, the group of advanced industrial nations, pony up money to buy ARVs and donate them to poor countries. And by 1999, total donations for health-related programs (including HIV/AIDS treatment) in sub-Saharan Africa hit $865 million -- up more than tenfold in just three years.

In 2000, some 20,000 activists, scientists, doctors, and patients gathered in Durban, South Africa, for another international AIDS conference. There, South Africa's former president, Nelson Mandela, defined the issue of ARV access in moral terms, making it clear that the world should not permit the poor of Harare, Lagos, or Hanoi to die for lack of treatments that were keeping the rich of London, New York, and Paris alive. The World Bank economist Mead Over told the gathering that donations to developing countries for dealing with HIV/AIDS had reached $300 million in 1999 -- 0.5 percent of all development assistance. But he characterized that sum as "pathetic," claiming that the HIV/AIDS pandemic was costing African countries roughly $5 billion annually in direct medical care and indirect losses in labor and productivity.

In 2001, a group of 128 Harvard University faculty members led by the economist Jeffrey Sachs estimated that fewer than 40,000 sub-Saharan Africans were receiving ARVs, even though some 25 million in the region were infected with HIV and perhaps 600,000 of them needed the drugs immediately. Andrew Natsios, then director of the U.S. Agency for International Development (USAID), dismissed the idea of distributing such drugs, telling the House International Relations Committee that Africans could not take the proper combinations of drugs in the proper sequences because they did not have clocks or watches and lacked a proper concept of time. The Harvard faculty group labeled Natsios' comments racist and insisted that, as Sachs put it, all the alleged obstacles to widespread HIV/AIDS treatment in poor countries "either don't exist or can be overcome," and that three million people in Africa could be put on ARVs by the end of 2005 at "a cost of $1.1 billion per year for the first two to three years, then $3.3 billion to $5.5 billion per year by Year five."

Sachs added that the appropriate annual foreign-aid budget for malaria, TB, and pediatric respiratory and diarrheal diseases was about $11 billion; support for AIDS orphans ought to top $1 billion per year; and HIV/AIDS prevention could be tackled for $3 billion per year. In other words, for well under $20 billion a year, most of it targeting sub-Saharan Africa, the world could mount a serious global health drive.

What seemed a brazen request then has now, just five years later, actually been eclipsed. HIV/AIDS assistance has effectively spearheaded a larger global public health agenda. The Harvard group's claim that three million Africans could easily be put on ARVs by the end of 2005 proved overoptimistic: the WHO's "3 by 5 Initiative" failed to meet half of the three million target, even combining all poor and middle-income nations and not just those in Africa. Nevertheless, driven by the HIV/AIDS pandemic, a marvelous momentum for health assistance has been built and shows no signs of abating.

MORE, MORE, MORE

In recent years, the generosity of individuals, corporations, and foundations in the United States has grown by staggering proportions. As of August 2006, in its six years of existence, the Bill and Melinda Gates Foundation had given away $6.6 billion for global health programs. Of that total, nearly $2 billion had been spent on programs aimed at TB and HIV/AIDS and other sexually transmitted diseases. Between 1995 and 2005, total giving by all U.S. charitable foundations tripled, and the portion of money dedicated to international projects soared 80 percent, with global health representing more than a third of that sum. Independent of their government, Americans donated $7.4 billion for disaster relief in 2005 and $22.4 billion for domestic and foreign health programs and research.