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.

The OECD and the G-8 should thus shift their targets, recognizing that vanquishing AIDS, TB, and malaria are best understood not simply as tasks in themselves but also as essential components of these two larger goals. No health program should be funded without considering whether it could, as managed, end up worsening the targeted life expectancy and maternal health goals, no matter what its impacts on the incidence or mortality rate of particular diseases.

Focusing on maternal health and life expectancy would also broaden the potential impact of foreign aid on public diplomacy. For example, seven Islamic nations (Afghanistan, Egypt, Iraq, Pakistan, Somalia, Sudan, and Yemen) lose a combined 1.4 million children under the age of five every year to entirely preventable diseases. These countries also have some of the highest maternal mortality rates in the world. The global focus on HIV/AIDS offers little to these nations, where the disease is not prevalent. By setting more encompassing goals, government agencies such as USAID and its British counterpart could both save lives in these nations and give them a legitimate reason to believe that they are welcome members of the global health movement.

Legislatures in the major donor nations should consider how the current targeting requirements they place on their funding may have adverse outcomes. For example, the U.S. Congress and its counterparts in Europe and Canada have mandated HIV/AIDS programs that set specific targets for the number of people who should receive ARVs, be placed in orphan-care centers, obtain condoms, and the like. If these targets are achievable only by robbing local health-care workers from pediatric and general health programs, they may well do more harm than good, and should be changed or eliminated.

In the philanthropic world, targeting is often even narrower, and the demand for immediate empirical evidence of success is now the norm. From the Gates Foundation on down to small family foundations and individual donors, there is an urgent need to rethink the concept of accountability. Funders have a duty to establish the efficacy of the programs they support, and that may require use of very specific data to monitor success or failure. But it is essential that philanthropic donors review the relationship between the pressure they place on recipients to achieve their narrow targets and the possible deleterious outcomes for life expectancy and maternal health due to the diversion of local health-care personnel and research talent.

SYSTEMS AND SUSTAINABILITY

Perched along the verdant hillsides of South Africa's KwaZulu-Natal Province are tin-roofed mud-and-wood houses, so minimal that they almost seem to shiver in the winter winds. An observant eye will spot bits of carved stone laying flat among the weeds a few steps from the round houses, under which lay the deceased. The stones are visible evidence of a terrifying death toll, as this Zulu region may well have the highest HIV prevalence rate in the world.

At the top of one hill in the Vulindlela area resides Chief Inkosi Zondi. A quiet man in his early 40s, Zondi shakes his head over the AIDS horror. "We can say there are 40,000 people in my 18 subdistricts," he says. "Ten thousand have died. So about 25 percent of the population has died." In this rugged area, only about ten percent of the adults have formal employment, and few young people have much hope of a reasonable future. Funerals are the most commonplace form of social gathering. Law and order are unraveling, despite Chief Zondi's best efforts, because the police and the soldiers are also dying of AIDS.

In such a setting, it seems obvious that pouring funds into local clinics and hospitals to prevent and treat HIV/AIDS should be the top priority. For what could be more important that stopping the carnage?

But HIV does not spread in a vacuum. In the very South African communities in which it flourishes, another deadly scourge has emerged: XDR-TB, a strain of TB so horribly mutated as to be resistant to all available antibiotics. Spreading most rapidly among people whose bodies are weakened by HIV, this form of TB, which is currently almost always lethal, endangers communities all over the world. In August 2006, researchers first announced the discovery of XDR-TB in KwaZulu-Natal, and since then outbreaks have been identified in nine other South African provinces and across the southern part of the continent more generally. The emergence of XDR-TB in KwaZulu-Natal was no doubt linked to the sorry state of the region's general health system, where TB treatment was so poorly handled that only a third of those treated for regular TB completed the antibiotic therapy. Failed therapy often promotes the emergence of drug-resistant strains.

There is also an intimate relationship between HIV and malaria, particularly for pregnant women: being infected with one exacerbates cases of the other. Physicians administering ARVs in West Africa have noticed a resurgence of clinical leprosy and hepatitis C, as latent infections paradoxically surge in patients whose HIV is controlled by medicine. HIV-positive children face a greater risk of dying from vaccine-preventable diseases, such as measles, polio, and typhoid fever, if they have not been immunized than do those nonimmunized children without HIV. But if financial constraints force health-care workers to reuse syringes for a mass vaccination campaign in a community with a Vulindlela-like HIV prevalence, they will almost certainly spread HIV among the patients they vaccinate. And if the surgical instruments in clinics and hospitals are inadequately sterilized or the blood-bank system lacks proper testing, HIV can easily spread to the general population (as has happened in Canada, France, Japan, Kazakhstan, Libya, Romania, and elsewhere).