On World Health Care, Spend Smarter
Monday, July 2, 2007; 12:00 AM
If the newly empowered Democrats -- and many Republicans -- have their way the 2008 Federal budget will be loaded with money for global health efforts, many of which have languished during the Bush administration due to conservative opposition to spending on family planning, reproductive health and other sexually-charged themes. The increases, which have already passed out of House and Senate appropriations committees and are heading on a possible collision course to the White House, total $6.5 billion of the total $34 billion foreign operations/aid proposed budget -- or more than 1-out-of-6 foreign aid dollars. That represents almost a billion dollar increase over FY07 spending for global health, or a 30% jump.
If the President signs the budget, this jump in foreign aid spending on health will be one of the largest year-to-year aid increases in U.S. history. Current restrictions on how AIDS prevention money is spent, and gags that currently prohibit the use of foreign aid for certain family planning and reproductive health programs will be eliminated. A total of $6.342 billion will be directed to HIV/AIDS, tuberculosis and malaria, continuing the U.S. trend of emphasis on the three big infectious diseases. But other long-overlooked programs for improving women's chances of surviving childbirth, providing poor people with clean drinking water and family planning will enjoy vast increases.
Combining the private philanthropy of the Bill & Melinda Gates Foundation and the public funding provided by our Federal government, the people of America will, in 2008, be providing health efforts the world over with more money than has ever previously been available -- by far. Moreover, Americans lead the world in total giving (though not for per capita giving) for global health. Let's be sure that we spend it properly.
The Global Health Program of the Council on Foreign Relations is currently engaged in studies of health programs -- some of them quite controversial -- that do not currently enjoy serious fiscal attention from donors, asking how strong the merits of the programs are, how they might be expanded, and what roadblocks currently obstruct their full implementation.
Our overwhelming finding to date is that all life-saving programs, no matter how simple and obvious their potential implementation may seem, suffer from the enormous global deficit in skilled healthcare workers. The World Health Organization estimates there is currently a critical deficit of 2.4 million doctors, nurses and other healthcare professionals, meaning that people are already suffering and dying for lack of this pool of talent. To go beyond crisis needs, implementation of such laudable efforts as the President's Emergency Plan for AIDS Relief (PEPFAR) HIV treatment programs, drug-resistant tuberculosis control and malaria bed net distribution will require, at a minimum, another 2 million trained personnel.
One of the suggested health campaigns reviewed by the Global Health Program is provision of adult male circumcision to decrease individual likelihood of sexually acquiring HIV infection. Some recently published studies performed in Africa suggest circumcision may offer an impressive 60 percent margin of protection against HIV infection, which is well below consistent condom use and complete sexual abstinence, but far better than any other currently available interventions for men. Ambassador Mark Dybul, who runs the PEPFAR program, told the Council that he would provide funds for circumcision programs if the governments of the 15 countries PEPFAR works with requested such support. But strong concerns have been raised regarding the quantity and skill level of medical personnel required to perform this bloody surgical procedure. Though the procedure itself is inexpensive, adult circumcision risks exposing both healthcare workers and patients to blood-borne infections, including HIV. Diverting scarce health talent to large circumcision campaigns could impede other public health and clinical efforts.
In contrast, the seemingly expensive 3-dose vaccine for human papilloma virus (HPV) infection, despite its current $360/person price tag, offers rich opportunities for improving the status of girls and young women and radically reducing the global burden of incurable cervical carcinoma. Two manufacturers have developed products that are safe and highly effective. In Council discussions, it was revealed that the companies plan to offer tiered pricing of their HPV vaccines, bringing costs down for developing country use to levels that might be attractive to donors. The Global Health Program found that implementation of HPV vaccination campaigns that target 11- 14 year old girls could open the public health door to a now hard-to-reach population. If HPV vaccination efforts were coupled with other services for these pre-adolescent girls, the impact could go far beyond cancer prevention. Such suggested services include provision of legal identity cards, training in personal savings and use of banks, education regarding safe sex and how girls can say no to unwanted advances, and general health work-ups for a usually missed population.
A third intervention examined by the Global Health Program was the use of auto-disable syringes to prevent spread of hepatitis B & C and HIV -- as well as a host of other microbes -- in clinical and pseudo-medical settings. WHO estimates some 19 billion needle injections are delivered into human beings every year for allegedly medical purposes. At least 40% of those injections involve re-used syringes. Horribly, this means that medical practitioners are actually spreading disease. Because of such practices India, Egypt, Pakistan, China and Russia have very high rates of hepatitis infections, often exceeding 10% of all adults. The problem is felt in rich countries, as well. In the U.S., for example, a recent Johns Hopkins study found that 99% of surgeons-in-training had suffered a needlestick injury on the job, and a New York City anesthesiologist is being sued by patients who allegedly contracted hepatitis C infection as a result of his re-use of a syringe.
Multiple forms of auto-disable syringes are available, which either lock into place after an injection, or cause the needle to permanently retract in the syringe. Thanks to UNICEF and Gates Foundation efforts over the last decade nearly all child vaccinations in poor countries now involve auto-disable syringes. But more than 90% of all injections are given for curative purposes, and few of them involve safe syringes. In discussions with manufacturers, inventors, and large health program administrators the Council learned that conquering the re-use of needles in curative settings will prove far more challenging and costly than was the case with immunizations. Nevertheless, if achieved, universally safe injections could save annually 1.3 million lives and over $535 million in direct medical costs.
The Council is now preparing analysis of the pros and cons of administering a partially effective AIDS vaccine worldwide, and obstacles to global availability of corrective eyeglasses. The later appears a particularly prominent case of "low-hanging fruit", as inability to see properly costs the world an estimated $3 trillion/year in lost education opportunity, low worker productivity, accidents and deaths. Correction of eyeglass-correctible vision problems requires no new technology, no high-end medical personnel, and in most cases can be achieved with very little cost.
Making a mistake in how overseas programs are funded when the stakes are in the thousands of dollars can be a trivial matter: Not so, when individual USAID or UN efforts err in how they spend hundreds of millions of dollars. This isn't just a matter of fiscal responsibility -- grievous miscalculations or missed opportunities in health planning can cost lives.
Laurie Garrett is the Senior Fellow for Global Health at the Council on Foreign Relations and directs a Global Health Roundtable Series, "Can U.S. Foreign Aid Support What Works for Global Health?". Periodic updates will be added over coming months.