Tuesday, December 18, 2007

LA TIMES: "Unintended Victims of Gates Foundation Generosity"

If you read just one piece in the mainstream media this week about global health, make sure its "Unintented Victims of Gates Foundation Generosity," by Charles Piller and Doug Smith in the Los Angeles Times.

This may be exactly the wrong season to find out about what happens when charity backfires--then again, depending on how your holiday shopping is going, you may be in exactly the right mood.

"Unintended Victims of Gates Foundation Generosity" looks at the unintended consequences of putting most of your donor dollars in the AIDS basket--something that is troubling more and more public health practitioners on the ground these days. The LA Times is one of the few media organizations that has taken a consistently critical look--both pro and con--at what Bill and Melinda Gates are doing in global health.

Here's an excerpt to whet your appetite. But definitely read the whole thing:

(from the LA Times) . . . Botswana offers an example of how a special Gates initiative, narrowly applied to a specific disease, may have disrupted other healthcare.

In 2000, the Gates Foundation joined with the drug firm Merck & Co. and chose Botswana as a test case for a $100-million effort to prove that mass AIDS treatment and prevention could succeed in Africa.

Botswana is a well-governed, stable democracy with a small population and a relatively high living standard, but one of the highest HIV infection rates in the world.

By 2005, health expenditures per capita in Botswana, boosted by the Gates donations, were six times the average for Africa and 21 times the amount spent in Rwanda.

Deaths from AIDS fell sharply.

But AIDS prevention largely failed. HIV continued to spread at an alarming pace. A quarter of all adults were infected in 2003, and the rate was still that high in 2005, according to the U.N. Program on HIV/AIDS. In a 2005 survey, just one in 10 adults could say how to prevent sexual transmission of HIV, despite education programs.

Meanwhile, the rate of pregnancy-related maternal deaths nearly quadrupled and the child mortality rate rose dramatically. Despite improvements in AIDS treatment, life expectancy in Botswana rose just marginally, from 41.1 years in 2000 to 41.5 years in 2005.

Dean Jamison, a health economist who was editor of Disease Control Priorities in Developing Countries, a Gates Foundation-funded reference book, blamed the pressing needs of Botswana's AIDS patients. But he added that the Gates Foundation effort, with its tight focus on the epidemic, may have contributed to the broader health crisis by drawing the nation's top clinicians away from primary care and child health.

"They have an opportunity to double or triple their salaries by working on AIDS," Jamison said. "Maybe the health ministry replaces them, maybe not."But if so, it is usually with less competent people." . . .


Anonymous said...

Trying to make a change in health status is like trying to make a change in the environment or the economy. Every time we intervene we disrupt the current equilibrium. No matter how deliberate our planning, how well-defined our objectives, or how well-conceived our programs, we are still engaged in well-intentioned meddling. And when we meddle, we can't neither foresee nor prevent all the consequences.

Should that keep us from trying to make a difference? I don't think so. But then the question remains, How can we do a better job of predicting undesirable consequences and/or minimize the collatoral damage of our global health work? That's a bigger question than I can answer.

Christine Gorman said...

Good points. But I think we have to get away from the "something is better than nothing" thinking that permeates so much of global health. These critiques are not new. It's one thing to discover that a particular challenge is harder than you thought. It's quite another to ignore the experience of others and push ahead and do it anyway.