To the Rescue?

With a mix of volunteerism, elbow grease, and paltry funds, public health advocates the world over did their level best to hold back the rising gap in life expectancy between rich and poor nations and control infectious disease outbreaks. Slowly, recognition began to build and key decision-makers began to see the value in tackling several pressing global health issues.

Under the leadership of economist Jeffrey Sachs, a team of economists and scientists pulled together an historic Macroeconomics of Health report, not only calculating the costs of dozens of infectious diseases, but also putting price tags on their prevention and treatment. The Clinton Foundation and Doctors Without Borders successfully negotiated prices for Highly Active Antiretroviral Therapy (HAART) for HIV/AIDS patients from generic manufacturers down to the point where it seemed possible to treat an HIV/AIDS patient for less than US$200 per year. Patent drug manufacturers responded by bringing down the prices of their drugs as well. To support this effort, more than 100 of the world’s most powerful corporations combined forces, creating the Global Business Coalition to fight HIV/AIDS. The Bill and Melinda Gates Foundation alone has committed hundreds of millions of dollars towards health interventions around the world.

In 2001, after Annan’s call for between US$7 and US$10 billion annually to address selected infectious diseases and the Group of Eight leaders’ in-principle endorsement of those funding levels, there was a noticeable shift. The Global Fund to Fight AIDS, Malaria, and Tuberculosis was created, offering an independent, accountable mechanism for funneling money from the wealthy world to the poor. The Global Fund was envisioned as an institution that could capitalize on the capabilities of both the private and the public sector to overcome the drawbacks of both. On the heels of the establishment of the Global Fund, WHO Director General Lee Jong-Wook ostensibly staked his new leadership of WHO on “3x5,” a campaign to get HAART to three million people in poor countries before the end of 2005.

For much of its existence, the World Bank took the position that economic development would naturally create improvements in health but rejected the converse notion that investment in the health sector would produce economic gains for the developing world. The World Bank had a change of heart regarding investment in the health sector: it recently began implementing its Multi-country HIV/AIDS Program for Africa and has become the largest overall funder of health-related programs in the developing world.

In 2002 the Bush Administration decided to pursue a program, PEPFAR, to combat AIDS largely on a bilateral basis in 14 countries. PEPFAR eventually added a 15th country, Vietnam, to its list of African and Caribbean nations. Its target is treatment of 200,000 people by June 2005.

The Results

Despite all these efforts, more people died of tuberculosis, malaria, and HIV/AIDS in 2003 than in any year in history. Drug resistance threatens the 20th century’s successes in battling a range of bacterial and parasitic diseases. Combined, these killers are continuing to reshape societies, producing dramatic demographic changes that threaten local, regional, and global stability. To be sure, it is still early for many of these initiatives. But the prognosis is not improving.

From a programmatic standpoint, many of the current infectious disease treatment and prevention efforts appear very narrow in focus, failing to consider the interconnected nature of these diseases. Tackling only HIV/AIDS without proper attention to tuberculosis means ignoring the number-one cause of HIV/AIDS-related death and allowing continued community spread of tuberculosis. Creating stand-alone HIV/AIDS clinics risks further stigmatizing individuals who visit these clinics, especially in societies that do not discuss HIV/AIDS openly and shun those known to be HIV-positive. It seems the exceptionalism of the international community’s approach to HIV/AIDS may ultimately reduce its likelihood for success and community acceptance.

Worse, there is a glaring lack of available institutional mechanisms capable of organizing and executing the ambitious programs currently being proposed or underway. The result is consistent interagency conflict: agencies are often either repeating others’ work or competing for resources. Health programs are fighting over poor countries’ dwindling pools of health professionals, bogus generic drug makers are knowingly selling poor products, ministries of health are sitting on, or siphoning off, millions of dollars in unspent donor funds for vital programs. Fighting over what remains an inadequate pool of funds for all has led many leaders and donors to complain that too much money is going to one health drive over another. Questions of patent rights versus generics, abstinence versus condoms, treatment versus prevention, faith-based versus secular initiatives, research versus implementation, and a host of other false dichotomies have overwhelmed these health debates.

In poor countries, the sudden plethora of health programs has spawned a seemingly endless stream of donor-mandated forms and a similarly large number of studies to conduct in order to demonstrate implementation and offer accountability. Simply keeping track of the demands of divergent benefactors requires the time and professional skills of a small army of English-speaking paper-pushers. The campaign to treat HIV-positive people with HAART threatens to devour the health talent of entire nations, undermining everything from child immunization programs to control of other sexually transmitted diseases.

Even with the influx of money into global health, key institutions are still struggling to make ends meet. WHO, with a core program budget just exceeding US$400 million, suffers from chronic under-funding. The institution is also suffering from an identity crisis as it struggles to continue providing technical oversight while rolling out its own ambitious large-scale projects such as the 3x5 program. The strain of this dual responsibility is beginning to show. WHO officials reported that the program was “just short” of the July 2004 treatment goal of 500,000, laying claim to all the estimated 440,000 people in the poor world now on the drugs. The likelihood that they will meet their target of three million people on antiretrovirals by the end of 2005 appears to be dwindling. Failure would be a substantial setback that could threaten donor and government confidence levels in WHO and current HIV/AIDS efforts in general.

The Global Fund also finds itself unable to meet its fiscal responsibilities. It has fallen far short of the US$8 billion donation requirements recommended by the WHO Commission on Macroeconomics and Health. To date, the Global Fund has committed only about US$900 million for its next round of grants to poor countries and nongovernmental organizations, though it has received more than US$3.6 billion in applications deemed scientifically sound. Disbursement delays have also hamstrung this fledgling organization. In a 2004 study by Ruairн Brugha and others in the Lancet, all four of the countries surveyed in sub-Saharan Africa cited as one of their main concerns “delayed disbursement of funds and difficulties in managing evolving Global Fund processes.” They also noted that “high expectations of rapid funding, when grant approval the previous year had received much national media attention, led to a crisis of expectation.”