When it comes to the HIV-AIDS pandemic, generosity isn't enough. Wealthy nations' contributions to fight the disease are unwittingly and unnecessarily exacerbating another crisis in some poor countries: the staggering shortage of health care personnel. African doctors and nurses are leaving public-sector jobs in droves to take more lucrative positions in foreign-funded HIV-AIDS programs. Public hospitals and clinics are being stripped of staffers; rural and slum outposts are being abandoned. The United States, the world's largest donor in the HIV-AIDS crisis, must also take the lead in supporting primary health care infrastructure and nourishing Africa's overwhelmed, underpaid nurses, doctors and other health workers.
Malawi, a painfully poor southern African country with upward of 850,000 HIV-infected people, shows what happens when well-meaning but myopic donors fund AIDS-only initiatives. Doctors from the capital's Lilongwe Central Hospital reported recently that it is hemorrhaging personnel from its wards. The 970-bed facility employs only 169 nurses to staff 520 positions. Its six laboratory technicians are doing the work of the 38 once employed there.
Where have all the health care workers gone? Tens of thousands have succumbed to a global "brain drain" and are working in clinics and hospitals in the United States, Britain and Canada. But an increasing number have been hired by nongovernmental organizations or foreign universities that are setting up HIV-AIDS prevention and treatment projects in Africa.
Programs to achieve universal access to AIDS treatment are desperately needed, and they do require trained medical staff. But if resources are drained from poor communities or diverted from other health priorities, deaths from different causes could mount, leaving some communities worse off than before the donors arrived. Compounding the problem, the donor community itself is sometimes directly responsible for bone-deep cuts in health sector personnel and stringent caps on national health care budgets. In AIDS-stricken Kenya, for example, more than 4,000 nurses and several thousand other health workers are unemployed, thanks to macroeconomic constraints championed by the International Monetary Fund and foreign donors.
President Bush boldly committed to provide AIDS treatment to 2 million people over the next five years -- a welcome departure from the previous decade, when the United States did not provide antiretroviral treatment to a single African. But reaching those goals requires much more than buying drugs and training Africans to use them. The fact is, there are not enough local health care workers in Africa to meet even modest treatment goals. Consider Botswana, with a third of a million HIV-positive people. Several years ago the Gates Foundation and other donors provided enough resources to treat everyone in the country. But a crippling shortage of health care workers at every level, among other problems, has limited the rollout of antiretrovirals to only 21,000 of the 110,000 who need them now to stay alive.
It won't be easy, but there is another way. First, U.S. AIDS czar Randall Tobias should announce his intention to meet not only ambitious treatment objectives but goals of equity and sustainability. If treatment numbers alone drive AIDS policy, the United States could end up serving those easiest to reach -- the urban well-to-do -- while the few health services available to the poorest of the poor will be raided and degraded. Embedding AIDS programs into primary health care, adding basic health care to new free-standing treatment initiatives and keeping a scorecard on the distribution of resources among the poorest areas of AIDS-burdened countries would help reverse that trend and provide resources for other health needs as well.
Second, the president should ask Congress for the additional billions of dollars required every year to help build the health care infrastructure needed for both HIV-AIDS treatment programs and overall public health. Some of that money should be given to support the World Health Organization's "3 by 5" initiative, a strategy to provide AIDS treatment to 3 million people by the year 2005.
Third, Tobias should jettison an outworn axiom of development policy: that foreign donors should not provide remuneration for civil servants, including health care workers, because it inevitably fosters dependency and ultimately is unsustainable. The AIDS pandemic in Africa is such a death spiral that entire countries have become unsustainable. It is past time for the United States to provide resources not just to American universities, contractors and nongovernmental organizations but to African health workers themselves in the form of health insurance and care, salary enhancements where possible, school fees, and housing allowances. These resources should be targeted to all underpaid nurses, doctors, pharmacists and health workers, not just those providing AIDS services.
Today the biggest limiting factor for AIDS treatment in the developing world is the paucity of trained health care workers. As one worried U.S. executive branch official said privately, "We're going to run out of people before we run out of money." President Bush and his AIDS team can clear that obstacle by giving more resources directly to African nurses, midwives and doctors, especially those who provide care through fragile public health systems to the people who need it most: the destitute and the marginalized.
The writer is U.S. policy director of Physicians for Human Rights and its Health Action AIDS Campaign.