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August 2005 Management for the Developing World’s Health Crisis
by Cathy Castillo Skilled managers are proving to be as vital as doctors in helping people live longer, healthier lives.You might call measles the canary in the mineshaft of global health. The 2003 SARS outbreak in Asia brought some economies to a screeching halt, and HIV/AIDS continues to exact a staggering economic and human toll. Yet something as seemingly benign as measles rages almost unnoticed through parts of the world, killing about a half-million African children in the average year despite the existence of a vaccine that costs about 20 cents per dose. Like a dead canary, the measles statistic stands out, pointing to the complex issues standing in the way of improving health care in developing nations. Simply having money, vaccines, and demonstrated cures aren’t enough. If the vaccine spoils due to a lack of refrigeration or sits in a refrigerated container on the dock stalled by usurious import taxes or impassable roads, people will continue to die—of newly troublesome scourges like Marburg virus and health threats thought long resolved like measles or tuberculosis. A late winter conference at the Business School, sponsored in part by the student International Development Club, brought together representatives of some of the leading organizations working to improve the condition of health care in the developing world. Their stories and statistics were sobering, and their message to the largely student audience was challenging: Be the generation that causes change. Take on policies that don’t make sense; challenge policymakers to spend money wisely; build systems that work. Today over 62 million people worldwide are affected by HIV/AIDS, including 25.4 million in sub-Saharan Africa alone. In hard-hit Botswana, about 30 percent of the workforce will be lost to the epidemic in the near future, many of them professionals and skilled laborers who are crucial to the country’s growth. Money is available—about $6 billion this year from major aid organizations—yet health planners predict it will take even more—between $10 billion and $12 billion per year—to fight the HIV/AIDS epidemic alone. It is a race to save lives and also to save entire nations, their cultures, and economic structures. One estimate is that in coping with HIV/AIDS alone, each $1 billion in aid that is not spent for treatment will result in another half million preventable deaths. In many cases, funds poured onto medical problems cannot be absorbed by the underdeveloped health-care systems or governments of emerging nations. Simply dealing with the demands of all the agencies providing the funds overtaxes the resources of many nations that may be required to spend an inordinate amount of time on red tape. The government of Malawi alone entertained 500 missions on HIV/AIDS in 2004. In the HIV/AIDS battle, the major funding agencies are the World Bank; the Global Fund for Tuberculosis, AIDS, and Malaria; and U.S. funds available through the President’s HIV/AIDS Initiative. “None of these are coordinated, so the typical scenario is that countries are dealing with these different donor agencies and their different requirements instead of dealing with the problem at hand,” said Debrework Zewdie, director of the Global HIV/AIDS Program for the World Bank. One solution to the bureaucratic sponge soaking up resources is for the governments involved to set their own standards. “The Mozambique government has said, ‘This is our strategy, this is what we want to do. If you don’t want to do this, don’t come to our country.’ And guess what? [Donor agencies] said yes,” Zewdie said. Another solution is the creation of what she calls “three ones,” in which the donor agencies and the recipient government work together as one authority to develop one action framework with one monitoring and evaluation system to cut down on the separate reporting requirements and focus projects on issues important to the country involved. Even if the conflicting demands are resolved, many developing nations still lack the infrastructure to take maximum advantage of health-care funds being provided. Infrastructure needs may lack the cachet of directly halting the spread of AIDS or tuberculosis. The nonprofits themselves struggle with the realization that unless sustainable systems are built, they cannot accomplish their goals. “If in 15 years the [Bill and Melinda Gates] Foundation is still financing vaccine delivery, that will be a failure in terms of the critical sustainability factors,” said Douglas Holtzman, the foundation’s program director for infectious diseases. Patients in the rural United States may have trouble getting to adequate, well-staffed hospitals. In developing countries with bad roads and transportation systems, the problem is far worse. Cameroon has one health-care professional per 400 people in urban areas and one per 4,000 in rural areas. “There is plenty of money for training, but there is no place to train, no buildings to actually manage patients. Physical plant facilities are a big hole, a real gap,” said Nzeera Ketter, director of efficacy trials for the International AIDS Vaccine Initiative. When they seek to improve health care, agencies need to listen to governments, but they also must be cautious of official pronouncements and seek information from the people themselves. Ketter had been warned that AIDS diagnosis and treatment was a controversial issue outside of major cities in Africa, so when a tribal chief asked her about her work she cautiously backed into a discussion of AIDS vaccines. But the chief demanded, “When are you going to do this? Hurry up! My people are dying.” Rather than drop cookie-cutter solutions into localities, agencies addressing health programs need to work at achieving local support. When shipments of a vaccine are unloaded in a slum outside Nairobi the program becomes tangible there, and unlike a promise from a government agency, it opens doors and cuts red tape. In many countries faced with inadequate facilities and shortages of everything from drugs to electricity, the best-trained doctors and nurses have emigrated in search of a better life and better working conditions. The Global Telemedicine Project is trying to bring some of those skills back to the developing world using an Internet infrastructure and volunteer doctors worldwide who can provide care until nations build capacity to take care of themselves. Sometimes building that capacity requires very little medical training. Minimally trained health-care workers can extend the reach of doctors and nurses and reduce burnout, but as more people seek medical attention, more and more medical problems are diagnosed, said Ophelia Dahl, executive director of Partners in Health, a nonprofit addressing inequalities in health-care access. “We also have to make certain that we’re not treating one disease at a time, which is what happens now.” A funding agency may be willing to treat HIV but not tuberculosis. A clinic set up to reduce infant mortality may identify cases of AIDS or malaria that need special treatment. Effective health care must produce an entire suite of services to be truly effective. The economic costs of not improving health-care systems are immense. A World Health Organization study reported that if the AIDS epidemic continues at its current rate, “economic activity in the developing world could decline by as much as $500 billion annually by 2015. This would translate into an aggregate loss in tax and other revenues of between $70 billion and $100 billion” each year, said Timothy Goodman, assistant director for global policy at Pfizer Inc. Goodman uses these statistics to counter arguments that drug companies may not be meeting their fiduciary obligations to boost shareholder value when they donate drugs. Sometimes the need is not to get new drugs to old diseases but rather to get more mileage out of existing medicines. Founded in 2000, One World Health is a nonprofit pharmaceutical company created to develop drug treatments for diseases that affect predominantly citizens of the underdeveloped and developing world—diseases such as malaria and diarrhea. In some cases there are off-patent drugs that could be used to treat entirely new diseases, said Katherine Woo, director of scientific affairs for the company. Effective drugs may even come from veterinary medicine—the mumps vaccine was originally for canine distemper. At present there is no profit incentive to invest in research and development for orphan drugs. One World Health is attempting to use donor money and in-kind help from big pharmaceutical firms to fill that gap. Beyond debates over shareholder value, testing and providing drugs to the developing world raises a plethora of other issues. Institutional barriers complicate drug testing and delay their development. It can take many months to get experimental findings published in a respected academic journal; at the same time, the valuable information from failed experiments may never be shared. And just as sharing data can speed drug development, so can sharing manufacturing or testing facilities. In some cases drug trials can be conducted in developing countries at lower costs, creating an ethical obligation to then make the resulting medications available to patients in those countries. Billions of dollars and millions of people, ranging from volunteers in rural Haiti to research scientists in the United States, are producing results, but the world continues to face huge health problems. Vikram Kumar, director of Dimagi Inc., a firm developing technology interfaces between patients and medical devices, was one of many speakers to directly challenge the student audience. “If you look at the life expectancy currently in Zambia and compare it to our life expectancy in the U.S., we have two lives for every one life of a person in Zambia. It behooves us to spend at least one of our two lives working on important and interesting problems. There is no limitation where you can use your skills.” |
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A Sampling of Projects by Business School AlumsWayne Dunn, Sloan ’97 Project: AIDS Campaign Team Mining, developed for Placer Dome Inc. Serving South Africa, Lesotho, Mozambique, Botswana, and Swaziland, the program helps former miners who can no longer work because of the effects of HIV/AIDS. The project provides counseling, training, and other resources to the miners and their families to help them set up businesses to benefit themselves and their communities. The project is the first private sector program to be honored with the World Bank Development Innovation Award. Tim Bilodeau, MBA ’83 Purpose: Nonprofit collaborates with local health care partners in areas of high child mortality around the world to improve child and maternal health. The organization builds the capacity of local partners to implement and sustain effective child survival programs. Works with pharmaceutical donors to distribute basic medicines including multivitamins, rehydration salts, and antibiotics. The organization works with 13 health care partners and religious relief organizations in nine countries in Africa and Central and South America, and the Caribbean. After the 2004 tsunami it shipped nearly $2 million worth of medicine to Southeast Asia for victims of the disaster. Amy Jadesimi, MBA ’04 Jadesimi has formed a company in Nigeria to see that affordable, high-quality, off-patent medicines are available in that country without relying on public subsidies. The nonprofit organization is dedicated to cutting the death rate from uncontrolled bleeding during childbirth, which currently causes more than 30 deaths a day. Learn More OnlineTranscripts of the keynote address and three panel discussions during the International Development Conference are available online at www.gsb.stanford.edu/news/conferences_global.html.
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