The Curse of Generosity

The source: “The Challenge of Global Health” by Laurie Garrett, in ___Foreign Affairs___, Jan.–Feb. ­2007.

When the Gates Foundation, Harvard University, and two giant pharmaceutical companies se­lected tiny Botswana for a collaborative AIDS treatment program, they were accused of picking an easy target. Nearly seven years later, no one is starry­eyed any longer.

Botswana, wealthy by African standards, has diamonds, modern highways, a growing middle class, a concentrated population of 1.5 million, the lowest unemployment rate in the region, a supportive government, and, at 37 percent, the highest HIV infection rate in the world. It also has no medical school, a worsening nurse shortage, and few labs or clinics. It took five years to roll out AIDS treatment. After a year, 55,000 people were being treated out of an HIV-positive population of 280,­000.

At the moment, the Botswana AIDS program is considered a ­success—­but with HIV infection rates rising and medical personnel fleeing, a precarious one. Even so, ­“can-­do” Botswana provides a simplified case study of the challenges of spending unprecedented bil­lions of dollars to conquer the diseases of the ­poor.

At first glance, the outpouring of cash from govern­ments and private donors to im­prove global health seems like the most generous, hopeful, and vi­sion­ary event of the 21st century. But the largess could easily be dribbled ­away.

The global health aid bonanza is now paying for “largely uncoordinated” efforts to treat high-profile diseases rather than public health in general, writes Laurie Garrett, senior fellow at the Council on Foreign Relations and author of Betrayal of Trust: The Collapse of Global Public Health (2000). “There is a grave danger that the current age of generosity could not only fall short of expectations but actually make things worse.”

How so? Much of the money is donated for specific diseases, such as AIDS, and can’t be used for anything else. Pregnant women whose HIV is controlled by medicine sometimes fall prey to lep­rosy and hepatitis when latent infections surge but AIDS clinics can’t treat those diseases. Doctors say ­HIV-­positive children die of ­vaccine-­preventable diseases, such as polio and typhoid fever, while AIDS clinics are treating only their HIV ­symptoms.

The world is short more than four million health care workers, and popular disease-specific programs such as malaria erad­ication suck away doctors and nurses from yesterday’s crises, tuberculosis and river blindness. Moreover, a vast number of doctors and nurses emigrate to the West every year. In Ghana, 604 of 871 medical officers trained in the country in the past decade now practice overseas. In Zimbabwe, only 360 of the 1,200 doctors trained during the 1990s remain in the country. In Zambia, only 50 of the 600 doctors trained over the last 40 years remain.

Foreign salaries also tend to destabilize such governmental health systems as do exist, as well as local economies. Trained workers are lured from public clinics to work on ­donor-­sponsored AIDS or avian flu programs, crippling the government’s ability to deal with other ­diseases.

Instead of a “hodgepodge of targets,” Garrett writes, the world health community should focus on two things: reducing the maternal death rate and increasing life expectancy. Maternal mortality decreases when safe, clean facilities are staffed with well-trained personnel and sup­plied with anti­biot­ics. Life expectancy increases in direct relation to the availability of safe water, suf­ficient food, immun­izations, and the control of mosquito populations to prevent malaria and other insect-borne diseases. Treating AIDS or wiping out polio is not enough. Unless a coordinated system with long-term support is set up, many Africans may be saved from death due to AIDS only to die from other infectious diseases.