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.

A 2006 World Bank report, meanwhile, estimated that about half of all funds donated for health efforts in sub-Saharan Africa never reach the clinics and hospitals at the end of the line. According to the bank, money leaks out in the form of payments to ghost employees, padded prices for transport and warehousing, the siphoning off of drugs to the black market, and the sale of counterfeit -- often dangerous -- medications. In Ghana, for example, where such corruption is particularly rampant, an amazing 80 percent of donor funds get diverted from their intended purposes.

Another problem is the lack of coordination of donor activities. Improving global health will take more funds than any single donor can provide, and oversight and guidance require the skills of the many, not the talents of a few compartmentalized in the offices of various groups and agencies. In practice, moreover, donors often function as competitors, and the only organization with the political credibility to compel cooperative thinking is the WHO. Yet, as Harvard University's Christopher Murray points out, the WGO itself is dependent on donors, who give it much more for disease-specific programs than they do for its core budget. If the WHO stopped chasing such funds, Murray argues, it could go back to concentrating on its true mission of providing objective expert advice and strategic guidance.

This points to yet another problem, which is that aid is almost always "stovepiped" down narrow channels relating to a particular program or disease. From an operational perspective, this means that a government may receive considerable funds to support, for example, an ARV-distribution program for mothers and children living in the nation's capital. But the same government may have no financial capacity to support basic maternal and infant health programs, either in the same capital or in the country as a whole. So HIV-positive mothers are given drugs to hold their infection at bay and prevent passage of the virus to their babies but still cannot obtain even the most rudimentary of obstetric and gynecological care or infant immunizations.

Stovepiping tends to reflect the interests and concerns of the donors, not the recipients. Diseases and health conditions that enjoy a temporary spotlight in rich countries garner the most attention and money. This means that advocacy, the whims of foundations, and the particular concerns of wealthy individuals and governments drive practically the entire global public health effort. Today the top three killers in most poor countries are maternal death around childbirth and pediatric respiratory and intestinal infections leading to death from pulmonary failure or uncontrolled diarrhea. But few women's rights groups put safe pregnancy near the top of their list of priorities, and there is no dysentery lobby or celebrity attention given to coughing babies.

The HIV/AIDS pandemic, meanwhile, continues to be the primary driver of global concern and action about health. At the 2006 International AIDS Conference, former U.S. President Bill Clinton suggested that HIV/AIDS programs would end up helping all other health initiatives. "If you first develop the health infrastructure throughout the whole country, particularly in Africa, to deal with AIDS," Clinton argued, "you will increase the infrastructure of dealing with maternal and child health, malaria, and TB. Then I think you have to look at nutrition, water, and sanitation. All these things, when you build it up, you'll be helping to promote economic development and alleviate poverty."

But the experience of bringing ARV treatment to Haiti argues against Clinton's analysis. The past several years have witnessed the successful provision of antiretroviral treatment to more than 5,000 needy Haitians, and between 2002 and 2006, the prevalence of HIV in the country plummeted from six percent to three percent. But during the same period, Haiti actually went backward on every other health indicator.

Part of the problem is that most of global HIV/AIDS-related funding goes to stand-alone programs: HIV testing sites, hospices and orphanages for people affected by AIDS, ARV-dispersal stations, HIV/AIDS education projects, and the like. Because of discrimination against people infected with HIV, public health systems have been reluctant to incorporate HIV/AIDS-related programs into general care. The resulting segregation has reinforced the anti-HIV stigma and helped create cadres of health-care workers who function largely independently from countries' other health-related systems. Far from lifting all boats, as Clinton claims, efforts to combat HIV/AIDS have so far managed to bring more money to the field but have not always had much beneficial impact on public health outside their own niche.

DIAMONDS IN THE ROUGH

Arguably the best example of what is possible when forces align properly can be found in the tiny African nation of Botswana. In August 2000, the Gates Foundation, the pharmaceutical companies Merck and Bristol-Myers Squibb, and the Harvard AIDS Initiative announced the launching of an HIV/AIDS treatment program in collaboration with the government of Botswana. At the time, Botswana had the highest HIV infection rate in the world, estimated to exceed 37 percent of the population between the ages of 15 and 40. The goal of the new program was to put every single one of Botswana's infected citizens in treatment and to give ARVs to all who were at an advanced stage of the disease. Merck donated its anti-HIV drugs, Bristol-Myers Squibb discounted its, Merck and the Gates Foundation subsidized the effort to the tune of $100 million, and Harvard helped the Botswanan government design its program.

When the collaboration was announced, the target looked easily attainable, thanks to its top-level political support in Botswana, the plentiful money that would come from both the donors and the country's diamond wealth, the free medicine, and the sage guidance of Merck and Harvard. Unlike most of its neighbors, Botswana had an excellent highway system, sound general infrastructure, and a growing middle class. Furthermore, Botswana's population of 1.5 million was concentrated in the capital city of Gaborone. The national unemployment rate was 24 percent -- high by Western standards but the lowest in sub-Saharan Africa. The conditions looked so propitious, in fact, that some activists charged that the parties involved had picked an overly easy target and that the entire scheme was little more than a publicity stunt, concocted by the drug companies in the hopes of deflecting criticism over their global pricing policies for AIDS drugs.