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.

But it soon became apparent that even comparatively wealthy Botswana lacked sufficient health-care workers or a sound enough medical infrastructure to implement the program. The country had no medical school: all its physicians were foreign trained or immigrants. And although Botswana did have a nursing school, it still suffered an acute nursing shortage because South Africa and the United Kingdom were actively recruiting its English-speaking graduates. By 2005, the country was losing 60 percent of its newly trained health-care workers annually to emigration. (In the most egregious case, in 2004 a British-based company set up shop in a fancy Gaborone hotel and, in a single day, recruited 50 nurses to work in the United Kingdom.)

By 2002, the once-starry-eyed foreigners and their counterparts in Botswana's government had realized that before they could start handing out ARVs, they would have to build laboratories and clinics, recruit doctors from abroad, and train other health-care personnel. President Festus Mogae asked the U.S. Peace Corps to send doctors and nurses. Late in the game, in 2004, the PEPFAR program got involved and started working to keep HIV out of local hospitals' blood supplies and to build a network of HIV testing sites.

After five years of preparation, in 2005 the rollout of HIV treatment commenced. By early 2006, the program had reached its goal of treating 55,000 people (out of an estimated HIV-positive population of 280,000) with ARVs. The program is now the largest such chronic-care operation -- at least per capita -- in the world. And if it works, Botswana's government will be saddled with the care of these patients for decades to come -- something that might be sustainable if the soil there continues to yield diamonds and the number of people newly infected with HIV drops dramatically.

But Kwame Ampomah, a Ghana-born official for the Joint UN Program on HIV/AIDS, based in Gaborone, now frets that prevention efforts are not having much success. As of 2005, the incidence of new cases was rising eight percent annually. Many patients on ARVs may develop liver problems and fall prey to drug-resistant HIV strains. Ndwapi Ndwapi, a U.S.-trained doctor who works at Princess Marina Hospital, in Gaborone, and handles more of the government's HIV/AIDS patients than anyone else, also frets about the lack of effective prevention efforts. In slums such as Naledi, he points out, there are more bars than churches and schools combined. The community shares latrines, water pumps, alcohol -- and HIV. Ndawpi says Botswana's future rests on its ability to fully integrate HIV/AIDS care into the general health-care system, so that it no longer draws away scarce doctors and nurses for HIV/AIDS-only care. If this cannot be accomplished, he warns, the country's entire health-care system could collapse.

Botswana is still clearly somewhat of a success story, but it is also a precariously balanced one and an effort that will be difficult to replicate elsewhere. Ampomah says that other countries might be able to achieve good results by following a similar model, but "it requires transparency, and a strong sense of nationalism by leaders, not tribalism. You need leaders who don't build palaces on the Riviera. You need a clear health system with equity that is not donor-driven. Everything is unique to Botswana: there is a sane leadership system in Gaborone. So in Kenya today maybe the elite can get ARVs with their illicit funds, but not the rest of the country. You need a complete package. If the government is corrupt, if everyone is stealing money, then it will not work. So there is a very limited number of African countries that could replicate the Botswana experience." And despite the country's HIV/AIDS achievements and the nation's diamond wealth, life expectancy for children born in Botswana today is still less than 34 years, according to CIA estimates.

BRAIN DRAIN

As in Haiti, even as money has poured into Ghana for HIV/AIDS and malaria programs, the country has moved backward on other health markers. Prenatal care, maternal health programs, the treatment of guinea worm, measles vaccination efforts -- all have declined as the country has shifted its health-care workers to the better-funded projects and lost physicians to jobs in the wealthy world. A survey of Ghana's health-care facilities in 2002 found that 72 percent of all clinics and hospitals were unable to provide the full range of expected services due to a lack of sufficient personnel. Forty-three percent were unable to provide full child immunizations; 77 percent were unable to provide 24-hour emergency services and round-the-clock safe deliveries for women in childbirth. According to Dr. Ken Sagoe, of the Ghana Health Service, these statistics represent a severe deterioration in Ghana's health capacity. Sagoe also points out that 604 out of 871 medical officers trained in the country between 1993 and 2002 now practice overseas.

Zimbabwe, similarly, trained 1,200 doctors during the 1990s, but only 360 remain in the country today. In Kadoma, eight years ago there was one nurse for every 700 residents; today there is one for every 7,500. In 1980, the country was able to fill 90 percent of its nursing positions nationwide; today only 30 percent are filled. Guinea-Bissau has plenty of donated ARV supplies for its people, but the drugs are cooking in a hot dockside warehouse because the country lacks doctors to distribute them. In Zambia, only 50 of the 600 doctors trained over the last 40 years remain today. Mozambique's health minister says that AIDS is killing the country's health-care workers faster than they can be recruited and trained: by 2010, the country will have lost 6,000 lab technicians to the pandemic. A study by the International Labor Organization estimates that 18-41 percent of the health-care labor force in Africa is infected with HIV. If they do not receive ARV therapy, these doctors, nurses, and technicians will die, ushering in a rapid collapse of the very health systems on which HIV/AIDS programs depend.

Erik Schouten, HIV coordinator for the Malawi Ministry of Health, notes that of the country's 12 million people, 90,000 have already died from AIDS and 930,000 people are now infected with HIV. Over the last five years, the government has lost 53 percent of its health administrators, 64 percent of its nurses, and 85 percent of its physicians -- mostly to foreign NGOs, largely funded by the U.S. or the British government or the Gates Foundation, which can easily outbid the ministry for the services of local health talent. Schouten is now steering a $270 million plan, supported by PEPFAR, to use financial incentives and training to bring back half of the lost health-care workers within five years; nearly all of these professionals will be put to use distributing ARVs. But nothing is being done to replace the health-care workers who once dealt with malaria, dysentery, vaccination programs, maternal health, and other issues that lack activist constituencies.

Ibrahim Mohammed, who heads an effort similar to Schouten's in Kenya, says his nation lost 15 percent of its health work force in the years between 1994 and 2001 but has only found donor support to rebuild personnel for HIV/AIDS efforts; all other disease programs in the country continue to deteriorate. Kenya's minister of health, Charity Kaluki Ngilu, says that life expectancy has dropped in her country, from a 1963 level of 63 years to a mere 47 years today for men and 43 years for women. In most of the world, male life expectancy is lower than female, but in Kenya women suffer a terrible risk of dying in childbirth, giving men an edge in survival. Although AIDS has certainly taken a toll in Kenya, Ngilu primarily blames plummeting life expectancy on former President Daniel arap Moi, who kept Kenyan spending on health down to a mere $6.50 per capita annually. Today, Kenya spends $14.20 per capita on health annually -- still an appallingly low number. The country's public health and medical systems are a shambles. Over the last ten years, the country has lost 1,670 physicians and 3,900 nurses to emigration, and thousands more nurses have retired from their profession.