Doctors Without Orders

To improve global health, what we need isn’t just Bill Gates’ billions, but Microsoft’s managers.

This is not a popular position; it is, to be blunt, easier to treat the disease than the cause. For instance, programs for childhood health and family planning, which could revolutionize African public health, have been dwarfed by spending on HIV/AIDS, in spite of the far greater complexity and cost of rolling out such programs. This is not to argue that we should return to the days of limiting interventions based on appallingly small public resources: On the contrary, to fight AIDS effectively, improve maternal and child health, and meet all the other deep-seated public health challenges, we must build out health systems in poor countries. But relying on traditional public health workers will fail. It’s time to shake up the public health establishment and do nothing less than completely reinvent it.

The Global Health Status Quo

The application of modern public health practices in wealthy nations dates back to the mid-nineteenth century, when the physicians like John Snow and Robert Koch finally brought germ theory into fashion and into practice. But public health efforts in poor countries is a more recent phenomenon, dating to the founding of the United Nations after World War II and two of its specialized agencies: UNICEF and the World Health Organization (WHO). Until very recently, public health approaches were bold, largely discrete efforts against a backdrop of scarcity. Projects were humble and bare-bones, costing only a few million dollars each at the most. Even what was arguably the greatest and largest health accomplishment of the last century, the certified eradication of smallpox between 1967 and 1979, cost a mere $23 million annually.

Throughout the 1970s and 1980s, sub-Saharan African governments–where the global health needs were the most acute–spent less than 3 percent of national spending on health. Further complicating matters, the World Bank and others pushed the responsibility for payments onto the patients themselves. This caused a contraction in demand, resulted in poorer health, and set a precedent, the impact of which is still reverberating across the continent. Simply put, to this day in much of the developing world the poor are expected to pay for health care, and those who cannot pay simply don’t receive it. Furthermore, the World Bank has estimated that half of all donor funds targeting health never reach the health centers and hospitals at the end of the line.

Then, at the close of the twentieth century, something surprising happened. The decade-long fight to deliver AIDS drugs to the developing world began to propel an entire global movement forward, a movement that would finally deliver billions of dollars to that pandemic, and at the same time draw massive media and public attention. The AIDS push soon spilled over into other areas. It was in this climate that the Global Fund to Fight AIDS, Tuberculosis and Malaria was proposed at the G-8 summit in July 2000, after lobbying by U.N. Secretary General Kofi Annan and a group of heads of state, in large part to address the troubling reality that global public health was failing to deliver off-the-shelf solutions to the poor of the world. Meanwhile, scores of private organizations, including behemoths like the Gates Foundation, began opening the taps for global public health projects, irrigating a vast field of NGOs.

But with more resources did not come new approaches to utilize those resources, and, in spite of some battles won, the war is still being lost. It is not enough to spend money to buy drugs and treatments; the infrastructure to deliver them isn’t there. Although the possibility of treating AIDS in resource-scarce environments had been discussed for years (and had already been performed successfully in 2000 by Partners in Health in Haiti and Doctors Without Borders elsewhere), momentum for scaling up AIDS treatment in developing countries was lacking. Resources in sub-Saharan Africa were so poor, and the obstacles so large, that the head of the U.S. Agency for International Development, Andrew Natsios, cynically noted that Africans did not even have the watches needed to take their AIDS drugs at the correct times. Despite the extraordinary efforts placed on the availability of anti-retroviral drugs in poor countries, perhaps 1.4 million people in sub-Saharan Africa receive them while an additional three million annually are in immediate need (two million of whom will die this year) and an additional three million infections occur annually. In short, drugs alone–no matter how good they are–don’t solve the problem.

While global programs continue to increase in scope and funding, substantial resources continue to fuel the quixotic search for magic bullets. We continue to seek vaccines, simple-to-administer solutions, and panaceas like rapid state-of-the-art diagnostics, technology-driven surveillance systems, and other breakthroughs to solve global health’s ills. These efforts are reflected in the priorities of the Gates Foundation and National Institutes of Health, which recently launched their annual “grand challenges in global health to harness the power of science and technology to dramatically improve health in the world’s poorest countries.” Today’s goals are lofty, and clearly scientifically driven: the search for new vaccines and nutritional improvement through promoting a single staple plant capable of delivering all optimal bio-available nutrients, for instance. But while few would contest the notion that the eradication of AIDS will require an effective vaccine, such magic bullets on their own have never changed the course of public health history. To name but one example, oral rehydration therapy–a simple solution of sugar and salt and water that can rehydrate even desperately ill people–has taken decades to gain widespread utilization in spite of its simplicity. There are no simple solutions to global health challenges. Tools may be improved–and that’s laudable work–but what is most needed is improved training for the technicians who are currently unable to make use of the effective interventions already in hand.

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