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.

Donor states need to find ways not only to solve the human resource crisis inside poor countries but also to decrease their own dependency on foreign health-care workers. In 2002, stinging from the harsh criticism leveled against the recruitment practices of the NHS (the United Kingdom's National Health Service) in Africa, the United Kingdom passed the Commonwealth Code of Practice for the International Recruitment of Health Workers, designed to encourage increased domestic health-care training and eliminate recruitment in poor countries without the full approval of host governments. British officials argue that although the code has limited efficacy, it makes a contribution by setting out guidelines for best practices regarding the recruitment and migration of health-care personnel. No such code exists in the United States, in the EU more generally, or in Asia -- but it should.

Unfortunately, the U.S. Congress has gone in the opposite direction, acceding to pressure from the private health-care sector and inserting immigration-control exemptions for health-care personnel into recent legislation. In 2005, Congress set aside 50,000 special immigration visas for nurses willing to work in U.S. hospitals. The set-aside was used up by early 2006, and Senator Sam Brownback (R-Kans.) then sponsored legislation eliminating all caps on the immigration of nurses. The legislation offers no compensation to the countries from which the nurses would come -- countries such as China, India, Kenya, Nigeria, the Philippines, and the English-speaking Caribbean nations.

American nursing schools reject more than 150,000 applicants every year, due less to the applicants' poor qualifications than to a lack of openings. If it fixed this problem, the United States could be entirely self-sufficient in nursing. So why is it failing to do so? Because too few people want to be nursing professors, given that the salaries for full-time nurses are higher. Yet every year Congress has refused to pass bills that would provide federal support to underfunded public nursing schools, which would augment professors' salaries and allow the colleges to accept more applicants. Similar (although more complex) forms of federal support could lead to dramatic increases in the domestic training of doctors and other health-care personnel.

Jim Leach, an outgoing Republican member of the House of Representatives from Iowa, has proposed something called the Global Health Services Corps, which would allocate roughly $250 million per year to support 500 American physicians working abroad in poor countries. And outgoing Senator Bill Frist (R-Tenn.), who volunteers his services as a cardiologist to poor countries for two weeks each year, has proposed federal support for sending American doctors to poor countries for short trips, during which they might serve as surgeons or medical consultants.

Although it is laudable that some American medical professionals are willing to volunteer their time abroad, the personnel crisis in the developing world will not be dealt with until the United States and other wealthy nations clean up their own houses. OECD nations should offer enough support for their domestic health-care training programs to ensure that their countries' future medical needs can be filled with indigenous personnel. And all donor programs in the developing world, whether from OECD governments or NGOs and foundations, should have built into their funding parameters ample money to cover the training and salaries of enough new local health-care personnel to carry out the projects in question, so that they do not drain talent from other local needs in both the public and the private sectors.

WOMEN AND CHILDREN FIRST

Instead of setting a hodgepodge of targets aimed at fighting single diseases, the world health community should focus on achieving two basic goals: increased maternal survival and increased overall life expectancy. Why? Because if these two markers rise, it means a population's other health problems are also improving. And if these two markers do not rise, improvements in disease-specific areas will ultimately mean little for a population's general health and well-being.

Dr. Francis Omaswa, leader of the Global Health Workforce Alliance -- a WHO-affiliated coalition -- argues that in his home country of Zambia, which has lost half of its physicians to emigration over recent years, "maternal mortality is just unspeakable." When doctors and nurses leave a health system, he notes, the first death marker to skyrocket is the number of women who die in childbirth. "Maternal death is the biggest challenge in strengthening health systems," Omaswa says. "If we can get maternal health services to perform, then we are very nearly perfecting the entire health system."

Maternal mortality data is a very sensitive surrogate for the overall status of health-care systems since pregnant women survive where safe, clean, round-the-clock surgical facilities are staffed with well-trained personnel and supplied with ample sterile equipment and antibiotics. If new mothers thrive, it means that the health-care system is working, and the opposite is also true.

Life expectancy, meanwhile, is a good surrogate for child survival and essential public health services. Where the water is safe to drink, mosquito populations are under control, immunization is routinely available and delivered with sterile syringes, and food is nutritional and affordable, children thrive. If any one of those factors is absent, large percentages of children perish before their fifth birthdays. Although adult deaths from AIDS and TB are pushing life expectancies down in some African countries, the major driver of life expectancy is child survival. And global gaps in life expectancy have widened over the last ten years. In the longest-lived society, Japan, a girl who was born in 2004 has a life expectancy of 86 years, a boy 79 years. But in Zimbabwe, that girl would have a life expectancy of 34 years, the boy 37.