Patching Africa’s Health Crisis

The numbers are staggering. Of nearly 40 million people in the world infected with HIV, almost two-thirds live in sub-Saharan Africa. Every year, more than two million Africans die of AIDS. But at the same time, even more Africans, mainly children, die from diseases that modern medicine long ago tamed. For instance, according to recent World Health Organization and UNICEF estimates, the annual death tolls in sub-Saharan Africa for pneumonia and malaria are nearly one million each. Diarrheal diseases and measles combine for another million deaths in the region.

Meanwhile, with governments, foundations, corporations, and individuals worldwide pouring billions of dollars into global health initiatives at unprecedented levels — including the five-year $15 billion U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) — opportunities to save lives and reduce the devastation of disease across Africa have never been better. 

But the infusion of money raises questions: what portion should go to reducing the mortality of diseases we think of as curable — pneumonia, malaria, cholera, measles — as opposed to tackling the more complex problem of HIV/AIDS? And of the money dedicated to HIV/AIDS, how much should go to improve and implement efforts to reduce the spread of the virus and how much to research on a vaccine or to providing antiretroviral therapy, which costs hundreds of dollars per person a year in developing countries? 

In sum, is all this new money being spent in the right places? Both Jonathon Simon, a School of Public Health associate professor of international health and director of the Boston University Center for International Health and Development, and Gerald Keusch, an SPH professor of global health and director of BU’s Global Health Initiative, say it’s not.

Jonathon Simon, an SPH
associate professor and
director of the BU Center
for International Health
and Development.

BU Today: Over the past few years, the world has committed billions of dollars to fighting infectious disease in Africa. Are the priorities on target?
Simon: Not in the least. We’re primarily responding to HIV, and while it’s certainly the dominant issue on the continent, we’re not taking advantage of the potential successes we could have against other major illnesses, like pneumonia and malaria, where we already have effective tools and technology and are not dealing with something as difficult as HIV.

Where could the most lives be saved?
Simon: I would argue that probably 80 percent of the millions of annual child deaths in Africa are preventable with known tools and technologies. For instance, we’ve had oral therapy for diarrheal diseases for 25 years, and we still have over a million deaths from diarrhea every year worldwide. And while we need to discover a way to build an HIV vaccine, we don’t need to discover how to distribute more mosquito nets to ward off malaria. We already know how to manage pneumonia — if you get the right antibiotic, in the right dose, into the right kid, at the right time, you’re going to take a lot of the mortality out of it. That’s a systems question: can you get the appropriate antibiotics out to the communities?

Do you agree, Professor Keusch?
Keusch: More or less. We talk about neglected diseases, but the truly neglected agenda is capacity building, health-care systems, and

Gerald Keusch, an SPH
professor and director of
BU’s Global Health Initiative.

surveillance. For instance, we need more balance between money spent for drug research as opposed to resources used to build the infrastructure to deliver care. We need health facilities in rural areas where people can reach them. We need trained health workers in those facilities. We need a system of trained people to monitor what’s going on at those peripheral levels and a logistics system to bring the necessary pharmacy products to those facilities. We need the capacity to triage, and refer patients who need more advanced, more sophisticated care up the line. We need to make the public hospitals look like something that you’d want to put a family member into, and eliminate corruption. The families of patients often have to bribe the nurse or whoever the health worker is to give the medicine. And that individual usually steals some drugs to sell to somebody else. It’s not because they’re inherently corrupt, but because there’s not a system to pay them.

Why aren’t the dollars used to fight infectious disease in Africa better spent?
Keusch: Well, to some extent, there’s a need for donor agencies to be seen as doing something useful. And it’s the sexy announcements about a new drug, rather than building a rural clinic or a system to get a drug to those clinics, that attracts attention. So, I think that’s part of it.

Simon: Also, in terms of the imbalance towards HIV/AIDS, there’s a community associated with this disease — that’s people living with AIDS, that’s program personnel, that’s research scientists, that’s a big, global pharmaceutical industry — with a lot of political clout.

You know, in 2001, we had a special session at the United Nations on HIV. We’ve never had a special session on diarrheal disease or pneumonia. There’s a real power in the political movement that has made HIV truly a global issue. And I think there are good reasons for that. It is an important issue. But we don’t have the lobbies for child survival. We don’t have a diarrhea lobby, you know, or a pneumonia lobby.

And is that global movement to fight HIV pushing the right agendas in terms of funding treatment versus prevention?
Simon: I don’t think so. Until we turn the tap off on new HIV infections and get prevention to work, this pandemic will outrun us, both virologically and financially. The PEPFAR funding legislation mandates that the majority of the money be used basically for drugs, and we have done a tremendous job getting more people around the world on treatment with antiretroviral drugs. But I think that in our rush to scale up treatment, prevention has taken a second seat.

Last year, four million people were infected with HIV worldwide, and three million died. So, we added a million people to the global rolls of those infected with HIV. In other words, in the year in which we had our greatest success in fighting this disease, we still got a million behind. We have to continue to treat, but we need a reemphasis towards effective prevention services.

Keusch: Still, you could see treatment as step one in a prevention agenda, in the sense that if people see that they’re likely to survive, then they have more of a stake in changing their behavior, which reduces transmission. So there is that aspect to treatment, but not if you’re handicapped when you give out pills by not being able to engage fully in the prevention agenda, which fundamentally starts with education about sex. And there’s a gag rule with PEPFAR, so that if you’re taking that money, you really can’t do programs related to reproductive services, sex education, safe sex — all the tools that are available for a more effective prevention strategy.

Simon: Still, treatment is not prevention. There is an assertion that treatment fuels the success of prevention programs, because now that we have treatment, people are more willing to come for testing and counseling and more willing to change their behaviors. But it’s still just an assertion that’s never been proved, to my mind. Treatment and prevention are complementary, but a dollar spent on treatment is not the same as a dollar spent on prevention.

Keusch: But the problem is that all the dollars spent on prevention didn’t prevent. For many years, everything went to prevention, and we never spent any money on treatment, because the big drug companies controlled the drugs and prices. It was just unaffordable. And then it started to change. People said, we’ve got a whole bunch of people who are sick. What are we going to do for them?

The Rockefeller Foundation held a conference in 2001 that began to shift this agenda, and then drug prices started to come down as the generics became available. Before then, we basically abandoned almost all of the people who died of AIDS, millions of deaths over the course of the epidemic. And most of those were in Africa. They died lonely deaths. And the global community really did nothing, because it was focused on this prevention agenda.

How could HIV prevention work in Africa be more effective?
Simon: Part of the reason we haven’t made as much progress with prevention, and in this I’ll agree with Gerry, is that it is hard to do prevention successfully. We don’t have the approaches that we can just get off the shelf and say, here, take this one and it’ll work. They have to be customized, because the strategies we might try with 16-to-21-year-old heterosexual young men may be very different from what we try with 30-to-39-year-old men who have sex with men or strategies for married women in a society that limits their ability to control their own sexual activities.

We haven’t put enough money into learning what prevention works, into doing the tough work to get some behavioral change in sexual practices, an area that’s very hard to change. But I would start with instituting routine HIV testing, giving people the opportunity to opt out, but making it part of routine health service provision. That is the start of any successful prevention program, because if I know I’m negative, I have reason to try and stay negative. And if I know I’m positive, I may be willing to change my practices to minimize transmission to other people. We have got to get serious about prevention if we’re going to blunt the epidemic in Africa or anywhere else in the world. As it is, we’re losing this fight.

Do you think the United Nations Millennium Development Goals to halt and begin to reverse the spread of HIV, malaria, and other infectious diseases around the world by 2015 are attainable?
Keusch: They didn’t seem like reachable goals in 2000 when they were adopted, and they’re no more reachable now. Countries that have resources are moving along. For them it was a matter of commitment and political will. Countries that didn’t have any resources are not going to reach those goals, and all of that was predictable. We have to have a long-term perspective to fight infectious diseases in Africa. If you’re committing just three to five years to a program, don’t even start, because this problem is going to be with us for more than 50 years. The Millennium Development Goals are political goals. And in the real world, you’ve got to get your politics and politicians lined up. So I think these goals are a good thing. I think stretch goals are a good thing. They push you — although they ought not to be so far out of reach that they seem disingenuous or discouraging.

Simon: I’m a pragmatic guy. I like goals that are tough but attainable, that stretch people and systems to work very hard to attain them but are not just rhetorical exercises or grand statements. You know, the world community made a commitment to the Millennium Development Goals but failed to do what was required at the global level, the national level, and the community level. We’ve spent a lot of money on health and development in the last 10 years, more than I ever thought I would see in my professional life. I think we’re running into issues of systems, physical and human infrastructure, and political commitment. We face a lot of challenges. But there’s a lot of money circulating in the world right now. Could we spend more? Probably. Do we need to spend what we have better? Absolutely.

This article was originally published in the winter 2006 issue of Bostonia.

Chris Berdik can be reached at cberdik@bu.edu.