Midway in the Journey

January 24, 2007

by Laurie Garrett

Laurie Garrett is Senior Fellow for Global Health at the Council on Foreign Relations.

Six-and-a-half years ago, former South African President Nelson Mandela rallied the troops in the AIDS war, summoning them to a twenty-first century campaign for justice and survival. The fight to get anti-HIV medicines to people in poor countries, he told the XIII International AIDS Conference, was a matter of morality.

A few months later, economist Jeffrey Sachs framed Mandela's battle cry in stark political terms, declaring at a Harvard University press conference, "I have a plea to our administration and members of Congress: Go ahead, have debates about our fiscal future. But take 15 minutes out of your schedule and vote $1.5 billion into the budget for global AIDS and save millions of people. And then go back to the debates." Sachs continued, challenging President George Bush: "We have to understand that the highest priority right now is to knock on the door at the White House. That's where the sticking point is, bar none, right now."

A few days later, in a speech to the Aaron Diamond AIDS Research Center in New York, Sachs told HIV scientists that they needed to take the battle up a few notches, addressing not only treatment for HIV but also a broad panorama of public-health crises. "One can cost out the scale of resources needed to address these interlocking crises, from measles to AIDS," he said, giving the following annual donor expenditure figures for conquering public health crises in Africa: $2-3 billion for malaria; tuberculosis, $2-3 billion; child mortality diseases — "with major infrastructure development" — for $3-4 billion; HIV prevention and treatment, $2-3 billion; community support for AIDS orphans, $1 billion. For a grand total of $10 to $14 billion per year, Sachs argued, "I believe that this really can happen."

Sachs is a hero. He pushed and shoved — and, frankly, embarrassed — the wealthy world into taking action on a previously unimaginable financial scale, translating Mandela's moral plea into dollars and sense.

Giving backbone to his 2001 calculus, meanwhile, was the experience Paul Farmer and his Partners In Health had in building health programs and distributing anti-HIV and tuberculosis drugs in Haiti and Peru. Farmer is also a hero. He pushed public health and medical communities to go beyond hand waving toward actual implementation of vital life-saving programs in the most desperate, war-torn nations.

In the six years since Sachs and Farmer, along with thousands of activists and healthcare workers, started their campaign, the results have been remarkable: Billions of dollars are now on the global health table where a few years ago there were only millions. (Of course, I wholeheartedly agree with Sachs, de Waal, and Farmer that still more fiscal resources are needed.)

But this escalation in global generosity and programs has come at a breathless pace, with no time for collective reflection or serious assessment. The war on AIDS has — thankfully — propelled the entire global health movement to a grand scale. But it is being executed chiefly by devastated local government systems, underpaid and overburdened health-care workers, and a plethora of previously miniscule NGOs and faith-based groups.

"Across Africa," de Waal writes in his book, AIDS and Power, "people suspect that coercion is lurking, and retain a deeply embedded resistance to external citadels of expertise and their projects of extending bureaucratic power. The future AIDS response may be part of a project of liberalization-through-aid, but equally it could become another doomed-to-fail foreign intrusion or a prop to authoritarianism."

In his landmark speeches on AIDS, Sachs implied a vision quite different from what has occurred to date. He spoke of the need for a global scale of management, leadership from the U.S. Centers for Disease Control and National Institute of Health, a central drug procurement fund for bulk purchasing, and the idea of "Donors, rather than putting money into their pet projects here and there . . . pool[ing] their resources into a common global fund."

Although the Global Fund to fight AIDS, Tuberculosis and Malaria was created about 18 months after Sachs' speech, it has proven unable to select a new leader and represents only a small percentage of the overall global-health budget, targeting just three diseases. There is no central drug-purchasing center (nor one for medical supplies and diagnostics), so the market for these products in poor and middle-income countries remains irrational and incentives for development of low-per-unit-cost products are all but nonexistent.

With so much money and human energy on the table, why are we still thinking so small? Farmer is correct in saying that a holistic view is not only possible, but also required. I recall him proclaiming at a 2002 meeting in Heidelberg, "If you want to stop HIV in Haiti, give women jobs."

Getting to sustainable, just, and fiscally rational approaches to global health crises requires global leadership and innovative thinking. On this point I must take issue with Roger Bate and Kathryn Boateng, who doubt that the WHO can step up to the plate. Although it is certainly true that the WHO is a weak institution that has made serious miscalculations in this arena, what alternative leader or organization would they suggest take the reins? The very suspicions and fears that de Waal eloquently describes lurking in the minds of health leaders in recipient nations mandate that the WHO — and only the WHO — take the lead, for it is the only health institution that tries to give equal voice to all countries, rich and poor alike.

But to do the job properly, the WHO needs serious reconstruction work. It is too soon to assess Margaret Chan's leadership, but even if it is impressive, the WHO is likely to remain an imperfect institution. Still, it could exercise the power of the pulpit to corral well intended but often competing NGOs, donors, philanthropies, and local government agencies into following a shared strategic vision.

To be successful, in turn, any such vision must draw from the business world and think on a scale commensurate with a multi-billion-dollar budget. To that end, de Waal misses the point of the Doc-in-a-Box concept: It is a mental exercise, intended to imagine a way to integrate community health workers (or Farmer's accompagnateurs) on the ground into a massive global system of volume purchasing and distribution, data retrieval, training, and management.

A final note on what I believe is an unfair swipe by Bate and Boateng against poor countries for allegedly under-spending on health. As I pointed out in my essay, nearly every one of the targeted countries has significantly increased the percentage of its GDP spent on health over the last three years. So their criticism is out of date.

As health budgets have risen to 4-5 percent of GDP in many countries, I am compelled to once again quote a prescient Jeff Sachs from 2001: "Since 1980 Africa has experienced virtually a total collapse of its public health systems. Even if these countries, despite debts, mobilized 4-5 percent GNP for public health we would be talking about the princely increase of $10-$12/year. This is, in essence, a continent of 600 million people that has been living without public health systems for a generation or more."

The world's poor and sick do need help, and the world's rich should continue to give and even increase their giving. But they should do it in such as way as to produce the beneficial results everyone is eager to see.