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Do No Harm: The Global Health Challenge

Speaker: Laurie Garrett, Senior Fellow for Global Health
Presider: Gideon Rose, Editor, Foreign Affairs, and Peter G. Peterson Chair, Foreign Affairs
January 25, 2007
Council on Foreign Relations

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GIDEON ROSE:   Hi there.  This is Gideon Rose. 

OPERATOR:  Okay, Mr. Rose.  You may begin. 

ROSE:  Okay.  Great.

Hi there.  This is Gideon Rose, managing editor of Foreign Affairs, and I welcome you to our conference call with Laurie Garrett to discuss her article in Foreign Affairs, “The Global Health Challenge.”

Laurie, as all of you know, I am sure, is one of the world’s foremost authorities on global health matters.  She has won every prize there is to be won, many of them multiple times, is a brilliant writer and explainer and explorer of subjects that are really life-and-death questions around the world.  And we’re delighted to have her in the magazine again and to be able to showcase her work for you today.

Let me also say, before we get into the discussion, that as an additional way of highlighting her work and bringing the questions to the fore, we have a special online feature that’s now up on the website, in which Paul Farmer and Jeff Sachs and various other global luminaries address the article, give their thoughts on the subjects in question, and dialogue with Laurie, where she has a contribution as well, about what to do about these various questions.  So if you’re interested in these subjects, you should go to the website and check out the online thing as well, for your daily fix of Garrett.

With that, let me open this up, first to my discussion with Laurie and then we’ll bring you in.

Laurie, we have this big article in Foreign Affairs, which everybody has read, of course.  But to refresh their memory, why don’t you give a very short precis of the highlights of your argument?

LAURIE GARRETT:  Thank you, and thanks for listening in, everybody.

You know, the bottom line is that about five years ago we were debating -- we, the global community -- were debating whether a few tens of millions of dollars were sufficient sums to deal with HIV, malaria, tuberculosis, maternal mortality, child mortality, a huge laundry list of problems. 

And virtually every global health program you could think of was operating on a shoestring budget, basically as cottage industries, with most of the ministries of health, the government functionaries in poor countries, severely stressed and rather low on the totem pole in the power of their governments.

Flash forward five years and we’re talking about having billions of dollars on the global health table, some of it in terms of direct cash, some of it in very low-interest loans, some of it debt forgiveness, and some of it, frankly, a sub-component of the tsunami relief monies. 

Nevertheless, it’s somewhere in the ballpark, though nobody’s exactly sure, of 17 billion (dollars) and may even be as high as 20 billion (dollars) for 2006.  And all trends indicate that the funding cycle is going to continue to go upwards, and that’s a good thing.  And by no means am I arguing that we should go back to the bad old days when there was no money in the global health pot.

The problem is that this has grown at such a pace that there has, number one, never been a moment to really reflect in terms of global health leadership on how are we spending this.  Are we doing the right things?  Are we addressing the right problems, and are we addressing them in the proper manner?

And worse yet, a huge percentage of that money is earmarked -- in fact, the majority of it is earmarked -- to very specific, narrow disease problems.  We have a deficit of 4.3 million health care workers in the world.  Sub-Saharan Africa has a deficit of more than a million.  And that deficit of health care workers is growing because the wealthy world is aging, and its health needs are becoming more and more complex, requiring more intense nursing attention. 

So we’re sucking away meager health talent from the poor world, and when I say “we,” I’m speaking of the collective wealthy world.  And we’re doing so at a(n) ever-increasing pace, and they -- their ranks cannot be replaced on the ground in their home countries at any kind of commensurate pace.  Worse yet, they too are dying of AIDS, tuberculosis, malaria and a host of other diseases in their home countries.

So we’re now facing ugly situations on the ground, where, you know, NGOs and well-meaning organizations that now have seen their budgets double, sometimes tenfold in the last five years, are on the ground competing for this finite pool of skilled local talent, skilled doctors, nurses, people who know how to manage money, people who know how to administer hospital systems and so on.  They’re competing for them, often paying -- offering salaries that well exceed what these people can earn working for their own governments, and thereby also hastening people’s departure from generalized health programs, tunneling them into very narrow, specific uni-disease -- maybe two-disease, if you’re lucky -- programs, with the result that programs that don’t have glamor here in the wealthy world, that don’t have political constituencies fighting on their behalf are losing personnel and therefore suffering. 

And in some countries, I’m arguing, we’re already seeing the result, with -- including increased child mortality, maternal mortality, women dying in pregnancy or pregnancy-related deaths, because there aren’t lobbies out there fighting for diarrheal diseases in children.  There isn’t even much of a lobby fighting to protect the health of women going through childbirth.

So bottom line is that unless we develop a much more global view, a view that recognizes the need to have strong global leadership and strategic planning and a view that incorporates business models and thinks about how to get the situation on the ground operating with real systems approaches rather than you need disease approaches exclusively, we’re going to see this whole moment of generosity turn into something rather sour, perhaps even claiming increased mortality.

ROSE:  Well, this is a very powerful set of arguments, as you can see.

As I mull the issues -- and we were going through this, Laurie, and as I followed the discussions that have emerged since the article was published, it struck me that there are four separate points along the road from the impulse to give to the outcomes that occur that seem to be blockages.  And I’m curious if you could talk a little bit about this.

Some people -- and this -- I have in mind here someone like Jeff Sachs -- focuses on the need to give more; in other words, the implication is that the real problem here is that we’re still just not giving enough.

Other people -- and I have in mind here Alex DeWaal’s comment -- focus on the need, in effect, that the donors just won’t give for the general things you’re talking about; in effect, that they’re so fixated on their own ways of thinking that the reality is they’ll only give for disease-specific programs and sexy things.  And, much as I might lament that, that’s a reality and we need to deal with it some way.

People like Paul Farmer focus on the implementers, the practitioners on the ground who all too often, unlike his organization, Partners in Health, don’t horizontalize, as he puts it, the aid that is given in vertical ways; in other words, Farmer argues that smart practitioners on the ground can subvert even silly stovepiped donor instructions and give the kind of care you’re talking about on the ground.

And then finally, some of the people from AEI -- Roger Bate and his partner, Kathryn Boateng, have argued that, you know, the local capacities that you would like to build are very hard to be built, they’re very hard to construct on the outside and the problem really lies in the states on the ground.

And so in some ways you have a whole spectrum of problems here ranging from stingy donors to misguided donors to clueless practitioners to states that are screwed up on the ground.  Could you talk a little bit about those problems at the various levels and see which of those do you think of as being the most important or are they all important?

GARRETT:  Well, to some degree, every one of them is correct.  But if you focus on them as individual problems, you don’t end up at a place that gets you to solutions.

Jeff Sachs is right; we need more money, and that’s been his mantra ever since he first jumped into this pool of the global health issue about six years ago.  And it’s been more money, more money, more money, and he’s really led the charge on saying that there should actually be a direct percentage of GDP annually, that the wealthy world is essentially taxed to give to the poor world to deal with health-related issues.  He’s right, we need more money.  But one of the things that, you know, where I differ with classic economists is that if money -- I know, I’ve seen it on the ground, and I’m sure some of the people listening to this call have seen it on the ground -- throwing a lot of money at a problem can make the problem much worse if you don’t understand what you’re doing and if you don’t have the big picture in mind and real strategic goals.

And there I think that Alex DeWaal is partially correct, that donors are at fault.  And I do think that the U.S. government is culpable, that the British government is culpable as the two really huge donors, the EU, all the wealthy world.  And the individual wealth -- the sort of Warren Buffetts and Bill Gates and the Bonos and so on -- have a responsibility, if you give on a real scale, to follow through with what happens to that money.

There’s been a tendency to think that the follow-through is just about sort of accountability as in, you know, a bunch of CPAs at the World Bank are going to make sure that nobody stole the money.  But that’s -- that needs to happen, but that’s not what I’m talking about.

I’m talking about a higher level of social responsibility.  You know, right now the Bush administration, for example, has the PEPFAR program.  That’s the president’s plan for AIDS relief.  And under the PEPFAR program, which the president announced three State of the Unions ago, the goal is to spend $15 billion over five years to address HIV and just HIV, with a little ancillary side issue occasionally for TB or malaria, in 15 targeted countries.  And if you follow the PEPFAR strategy on the ground, you can see example after example after example, all over those 15 countries where a program is getting very, very heavily funded to deal with HIV\AIDS, and that’s great, but it’s drawing all the healthcare worker talent out of the Ministry of Health of that government because PEPFAR can pay people so much more.

Now, Congress has a law saying no -- what’s called topping off, meaning we’re not supposed to go in and essentially bribe people away from their government jobs to come work for a U.S.-funded program by directly competing on a salary level.  So what we do is we offer them to pay for their children’s education, buy them a car, offer college education subsidies for their older children.  For many of these people it’s the first time anyone has offered them a pension plan.  And we could go on and on.  So that there are a host of ways that in fact we make their real life and real income, you know, phenomenally wealthy compared to what they were dealing with in their ministry job. 

So DeWaal’s right, there’s a social responsibility on the part and, I would argue, a sort of larger political and even national security responsibility to do it right.  And we’re not exercising that right now. 

And I think Farmer is right, that when you get on the ground, the implementers are thinking too narrow.  I’ve been heartened to see just in the last three weeks that the Gates Foundation has sent out some signals that they’re trying to think in a broader term.  They recently issued grants requesting that people figure out how to tackle multiple infectious diseases in a single effort.  But unfortunately, they’re all what used to be called the “neglected diseases” -- they’re not the dominate big kickers like HIV and tuberculosis.  They’re mostly parasitic diseases isolated to specific regions.  I’m looking forward to a much bolder big picture view from them. 

And finally, on the American Enterprise Institute’s claim that the local governments are at fault, that they don’t spend enough and they don’t care enough, that is woefully out of date.  That claim would have been quite accurate five years ago.  But thanks to pressure from the United Nations AIDS Program, in particular, and additionally from WHO, and from the wealthy donors, including the United States, the whole discussion of health has elevated in most of the targeted poor countries to the level of the minister of finance.  And we’ve seen real growth in how much the local governments are spending themselves on health from their own budgets, not just from external donor budgets.  And we’re seeing real commitments to try and elevate the import, particularly in countries like Swaziland, Malawi, Lesotho, Botswana, where AIDS in particular is claiming in excess of 20 percent of the adult population.

ROSE:  Okay.  I think that’s an absolutely true point, the last point about the amount of aid that’s going.  If you had someone like a Bill Easterly here, they might phrase that larger point about local capacity not so much in just that they’re not trying hard enough or giving enough money, but the fundamental problem on the other side is not just a lack of will, but a lack of institutional capacity; that a public health system is a subset of a broader ability to have effective governance, and politics, and general management of your society and country, and that those countries suffer from this in every area, not just public health.  And so it’s utopian, some of those types might say, to imagine that we can get an effective public health system up and running in a country where everything else is disastrous. 

What would your response be to something like that?

GARRETT:  Well, Bill Easterly wrote an important book called, “White Man’s Burden,” in which he attacks almost every aspect of foreign aid.  I don’t entirely agree with his arguments.  I would frame it a little differently. 

Here’s what I think is the key problem -- and I think it’s racist, really.  The key problem is that we, for reasons that really go back to the earliest days of colonialism in Africa and Latin America, and to a lesser degree in Asia, we view -- we, the wealthy world -- view global health, meaning the health of people in poor countries, as a charity. 

You know, it was originally framed in the context of missionary hospitals and networks of Catholic hospitals, Lutheran, and so on.  And, you know, the whole idea was that it’s okay for every aspect of health to be a profit center in the wealthy world, even to the point of excess, one would easily argue, here in the United States.  And it’s okay.  It’s moral.  We go along with it that they guy who makes eye glasses makes money off of making eye glasses, and then the guy who sells the eye glasses makes money off of selling eye glasses. 

But when we go to the poor world, somehow the whole moral universe is different.  Somehow in the poor world no one is allowed to turn a profit. No one is allowed to earn a decent living.  The whole darn thing is a giant charity operation, and it will be so in perpetuity.  Therefore, number one, it’s not sustainable, because if you don’t have any capacity to really build the program as a permanent structure on the ground operated by, run by and profited by local people through legitimate, honest profit as opposed to corruption, then it will just be endlessly sticking your palm out and begging to the rich world:  “Here, we the brown-skinned and black-skinned peoples of the world hold our hands out to you, the white-skinned peoples of the world, and beg that you send us little dribbles of money every year so that we can deal with these diseases that are killing our populations.”

And I just think that is utterly abhorrent, and that we can’t -- now that we have billions on the table, we have the capacity to think with real, permanent, business models that could fundamentally change the picture on the ground.  The only way right now that most doctors, nurses and, more importantly, the folks that deliver supplies in the health system -- the drivers, the folks that operate the hospitals and the clinics -- none of them earn enough in their direct Ministry of Health salaries to make a living, so there is built-in corruption every step of the way.  Everybody is plucking off the system.  And nobody has a way of making an honest additional income.  All they have is ways to milk the system.

ROSE:  I think that’s a fascinating set of comments.  I want to get everybody in here.  I just want to ask one last question myself, which picks up on something you just mentioned, but it also addresses this question of business attitudes and charity attitudes.

We have seen or we are witnessing the emergence of far and away the most dominant player in this arena that anybody has ever seen or is likely to see, which is Gates, now with Gates-plus-Buffett money.  Is this a situation now in which, as I understand it, what the Gates Foundation can do is going to -- and will do -- will dwarf what particularly everybody else, including governments, will do?  And does that mean that we now actually have an opportunity here in which the decisions of a fairly small set of people disbursing all this money can actually make changes more quickly and hopefully with greater technocratic sense and efficiency than might be true of other organizations?  Can you speak to the role of the Gates Foundation in this new global health arena going forward?

GARRETT:  Yeah, the Gates Foundation is really the giant elephant in the room.  And worse yet, it’s a giant elephant that’s given money to every single aspect of academic public health all over the world.  So all of academic public health is talking about the room as if the elephant wasn’t in it, because nobody wants to lose the money they’re getting from the Gates Foundation.  So we’ve actually reached a point where it’s difficult to get objective critique.  And I think that’s hard for the Gates foundation.  They don’t like that.  They want to be able to have critique and analysis of how they’re moving this.  You know, it’s a very, very young foundation.  It’s only really been giving on any mega-scale the last five, six years.  And the real scale of giving is about to start next year when the Buffett money kicks in and is required to be given away as received.  It cannot go into the equity funds of the foundation.  And there, you know, one can just imagine enormous mistakes being made.

I think already two, maybe even three years ago, the Gates Foundation had become the dominant policy force, because it’s agile.  It can move very quickly.  It doesn’t have to convene a meeting, as WHO does, of 193 member states and lobby everybody and then try to get a vote passed.  The Gates Foundation can hold a meeting of we don’t even know who, utterly opaque, there’s no transparency here, in a closed-door and change direction radically overnight.  And as a result, they’re in, on the one hand, a marvelous position to react to events on the ground, to see oncoming potential hazards, such as pandemic influenza, and shift funds very, very quickly.  But on the downside, it makes it almost impossible to have any kind of accountability, feedback is difficult.  And as a result, I think it’s hard, whether you’re inside the foundation, to feel comfortable that all the decisions are correct, and it’s hard when you’re on the outside of the foundation to have any idea how and why those decisions were made. 

ROSE:  Well, thank you very much.  Let us now turn it over to our distinguished media participants and have you guys join the discussion. 

OPERATOR:  Okay, at this time, we will open the floor for questions.  If you would like to ask a question, please press the star key, followed by the one key, on your touchtone phone now.  Questions will be taken in the order in which they are received. 

And our first question today comes from Jim Landers from Dallas Morning News. 

QUESTIONER:  Thank you.  I wanted to ask you about the U.S. responsibility in the health care worker segment of this debate.  We’ve seen recommendations for things like a U.S. global health service, to send volunteers over to supplement the health care force that’s on the ground.  But we’ve also got, you know, an acute nursing shortage here that’s being fed by migration that is at least in part due to the fact that none of our nursing schools has the faculty to absorb the applicants that are pounding on the door.  What do we need to do to look at this labor aspect holistically? 

GARRETT:  Great question. 

You know, in Texas you can walk through the halls of hospitals and hear Tagalog being spoken in all the nurses’ stations because you have so many nurses that have been brought in from the Philippines.  Similarly, you can walk through the halls of the National Health Service in the U.K. and hear Zulu and Xhosa being spoken at all the nurses’ stations because they’re sucking the nurses away from South Africa.  And South Africa, in return, is sucking the nurses away from Botswana, Lesotho, Zambia, and Zimbabwe.  And you know, you end up hitting a point where there ain’t no nurses as you get further and further upstream. 

It is a huge problem, and I think part of the reason it’s proven so difficult to solve, from our U.S. point of view, is that even at the level of Congress, the committees responsible for the different pieces of the pie have never spoken to each other and never held joint hearings.  And when you get into the federal bureaucracy, the various subcomponents responsible for, you know, say, immigration procedures for foreign nurse exceptions in our immigration acts, versus those responsible for nursing training domestically, have no connection to each other.  So we have no, sort of, common universal policy. 

The U.K. has gone far ahead of us on this, because they still have this thing that’s sort of an antique of the past called the Commonwealth.  And the Commonwealth meets, and at various Commonwealth meetings, the poorer Commonwealth countries have made it very clear to the U.K. that they’re sick of the U.K. sucking nurses away from Jamaica and South Africa and Zimbabwe and so on.  So they have really looked at how to link their own training inside the U.K. and, you know, what they’re looking for -- ethical policies for recruiting health staff from poor countries inside the Commonwealth. 

But there is no kind of global policy in all this, and we don’t have any policy at all, because in the United States, of course, we don’t have a national health system, so we wouldn’t have any ways to really enforce a policy.  Every hospital that wants to recruit staff can do it pretty much as they please under their local state guidelines, as long as the office of Homeland Security is willing to grant the visas.  So we desperately need to have Congress take a look at this in a way that brings the expertise from the various germane committees into the same room, to have a discussion that links foreign policy and domestic policy, to really come up with solutions. 

And you’re right to pinpoint the question of nursing training.  We are turning away tens of thousands of nurse applicants every single year and frankly, increasingly physician applicants, as well -- medical technician applicants, radiology assistants, dental, everything, because we don’t have enough faculty, and we don’t have enough support structure for direct patient access training.  All of this requires federal support.  The states largely support the universities to execute these vocational training programs -- (audio break) -- the states are all in budget crunches.  Without some federal underwriting, forgiven loan structure in exchange for service, something of that nature, we’re not going to solve the problem. 

And I would just point out we used to have a whole infrastructure for this in the 1960s, and one of the reasons we created such a massive boom in physicians -- domestically trained physicians and nurses and all foremost professionals in public health and so on is because during the Vietnam War it was possible to avoid the draft by going into these services and then to get your cost forgiven for all of your training if you agreed to do a certain amount of time service in things like American Indian reservations, in some of the poor, underserved innercity communities and so on so that -- or in the Peace Corps.  And Ronald Reagan’s administration eliminated all those programs, and we have not reinstituted or revisited any of that structure since.

ROSE:  Why hasn’t the market stepped in -- this is Gideon, Laurie -- why hasn’t the market stepped in to full this deed?  I mean, there are these -- you see the late-night commercials for DeVry or you used to have these ones for APEC Tech and, you know, vocational -- private sector vocational training schools.  Why couldn’t -- if there is this great demand for nurses or vocational training in health care, why wouldn’t the private sector emerge to fill that need?

GARRETT:  The bottom line is -- well, first of all, thankfully nursing and physician training is highly regulated.  So something like DeVry would never have the expertise to train people to fulfill the regulatory status and pass their examinations, their state certifications.  But beyond that, the real problem is that any given physician or nurse can make more money continuing to practice as a physician or nurse than they ever could make as faculty.  And so you literally have a situation where you can’t accept in more students to your nursing school because there aren’t enough faculty to teach the required course curriculum in a timely fashion.

I was in Michigan when -- been several visits to Michigan looking at the nursing schools there because, as the auto industry has collapsed, many of the employees -- former employees have been encouraged to look at nursing as a new profession.  And there are nurses who are -- it’s taking them six, seven, eight years to get through nursing school because they’re waiting for a faculty member to teach them this one required course and this one required course.

OPERATOR:  Okay.  Thank you.  Our next question comes from Betsy McKay  from The Wall Street Journal.

QUESTIONER:  Hi, Laurie.  I really enjoyed your piece.  I had a couple of questions.  One is just logistics.  You all were referring to a discussion on your website about the article.  I was wondering if you could tell us where that was.

ROSE:  Www.foreignaffairs.org -- O-R-G, not .com, that’s a porno site.  So don’t go there.

QUESTIONER:  Okay.

ROSE:  Foreignaffairs.org.  (Laughter.)

QUESTIONER:  And within that is it obvious -- (laughter) -- I guess I was up --

ROSE:  Don’t check it at work.  (Laughs.)

QUESTIONER:  (Laughs.)  No.  Okay, I’ll find it.  What I would link to directly was Laurie’s article, so maybe -- and there wasn’t -- I didn’t see a link from there, but I’ll --

ROSE:  It just -- it literally just went up, so -- yesterday, so.

QUESTIONER:  Okay.  I’ll find it.  Secondly, Laurie, going back to the Gates Foundation and the -- you know, the big donors.  I mean, there’s potentially an opportunity there, but I’m wondering if the problem could actually -- the problem that you’re describing could actually be getting worse or, you know, in the future get worse because control over public health could or is becoming more centralized in a few hands.  And you know, I’m wondering if you can just talk a little bit more about that.  I mean, is Gates -- the Gates-Buffet money making WHO increasingly irrelevant and that’s going to have, you know, that’s going to funnel more of the money into academia, less into -- even less into building infrastructure on the ground.

GARRETT:  Very good, very important question.  First of all, we already can very clearly see and it’s easy to document that the -- as the Gates Foundation has grown, and the astounding speed with which it can move money around has been breathtaking.  All the older foundations are walking away from the health field, and they’re certainly decreasing their portfolios.  There was just quite a brouhaha over the last nine months about the new leadership at the Rockefeller Foundation, which originally came in and said, “You know what?  Even though we were created to be a global health foundation by John D. Rockefeller 100 years ago, we’re going to walk away from this whole health arena because we can’t possibly compete with the Gates Foundation.”  And some of the board members freaked out, and just in the last couple of weeks there seems to be some retrenchment in the position at the Rockefeller Foundation.

But you look across the gamut of the major foundations and you can see that they don’t figure -- they can’t see where the fiscal space is for them.  How can they, you know, give -- through their much slower, much more ponderous process -- give monies on a smaller scale that make a significant difference and that, of course, they would have bragging rights over, because why -- that’s what they all want, when the Gates Foundation is just so, you know, massive?  So that’s one piece of the problem that I think is very significant.

ROSE:  Hold on a second.  Let me just take a point of order there. Are you saying that it’s not that they couldn’t give money effectively and well for serious things -- either research or programs -- but that it would be hard to get the kind of credit and publicity and so forth for it and so they’re not as interested in doing that?  Right?

GARRETT:  Well, you know, I hate to be blunt about it, but that’s -- you know, donors like to be able to say to their boards, to their -- you know, their whole constituency, “Look, thanks to the John Brown Foundation, these 40,000 children have been vaccinated.” 

And, you know, what we’ve actually seen, sadly, with the whole foundation world is an increased pressure for empirical results, which, you know, you get to the ground and it’s almost laughable.  Sometimes I’ve been in countries where people are saying, “You know what?  They’re already demanding our first results report, and the money hasn’t even cleared for the program, hasn’t even cleared the banks yet.”  So, you know, it’s a crazy-quilt situation.

But, you know, let me go the next step, which was that Betsy asked about WHO.  Let’s face it, you know, this is a new world for WHO.  We have a new leader.  It’s too early to know how Margaret Chan is going to fit in that job.  The initial signals, her initial set of appointments and her staff and so on are all very promising.  But what we really need is to recognize that WHO will never have enough money.  Its core budget is less than half of the annual budget of the City Health Department of New York.  It has a supplemental budget, but that is all earmarked by the donors.  So here’s X amount just for tobacco prevention or what have you. 

And so, you know, Margaret Chan’s hands are tied.  There’s only so much she can do with the budget she has and with the structure she’s saddled with; that is, the original charter of WHO plus these amazing power centers that are the regional health commands of WHO.  And the leaders of those are so powerful that she literally has to beg them to attend meetings, you know?  So what can she do effectively?

I think that in the end -- and this is a key place where I disagree with the American Enterprise Institute colleagues -- I think the key role for WHO is the sort of bully pulpit, the high ground of leadership.  And when you think about this huge range of donors, from DFID in the U.K., to USAID, from the Gates Foundation to the Global Fund to Fight AIDS, Tuberculosis and Malaria, the World Bank, you name it, and then the vast array of recipients, somebody needs to corral all these forces and say, you know:  Number one, we need ethical guidelines.  We’re to allowed to poach each other’s staff.  We’re not allowed to run around badmouthing each other’s programs to the various ministries of health in a direct, competitive and undermining fashion.  We can’t build programs for one disease that rob from programs for another disease, therefore literally saving one set of lives at the cost of another set of lives.

I think there’s never been a more crucial moment for WHO to flex its muscles and stand up and say, “We are the only organization that eery nation in the world is a voting member of; therefore, we -- like us or don’t like us, yell at us all you want, but we’re the only organization that actually represents the health interests of the people of the entire world.  So we’re going to play that card for all its worth and corral all the various forces to come together and behave each other, have real conversations, create joint strategies and execute them in ways that actually result in sustainable health systems instead of this plethora of scaled-up cottage industry NGO operations.”

OPERATOR:  Okay.  Thank you.

Our next question today comes from Jim Landers from Dallas Morning News.

QUESTIONER:  Hello again.  I’m wondering about how to regard the Healers Abroad, the Institute of Medicine report that recommended the formation of a U.S. Global Health Service to try to tackle some of these emergency situations.  I mean, on the one hand, it perpetuates the sort of model you were talking about of, you know, a charity role.  But on the other hand, I mean, to figure out a way to beef up the labor force in the health care sector in these countries is going to take years.  And is there a way to do this by, say, you know, forgiving student loans for medical personnel to work overseas for a couple of years and whatnot?  I mean, is that a practical way to approach this?

GARRETT:  Yeah, here I think we have two things going on.  The first is the sort of Bill Frist approach, which was, you know, let’s all have the wealthy world doctors donate in a charitable manner some finite amount of their time every year and fly into countries they don’t know, where people speak a language they don’t know and have a culture they don’t know, and, quote-unquote, “practice medicine” for two weeks.

I think that the data clearly shows that with a handful of very narrow exceptions, such as cataract surgery, this is not a workable approach.  It’s the most blatant example of a charity-minded approach.  And you know, frankly, in Africa they call it safari science and look upon it with disdain. 

You know, I think -- just think about all the doctors who are practicing medicine in Los Angeles who deal with immigrant patients who are in labor, who have come to Los Angeles and San Diego to give birth in order to have American citizen babies, and the combination of the cultural issues and language issues mean that it’s incredibly difficult to understand what this woman’s going through when she’s going through labor.

So -- then imagine that instead of it being right there on their home turf, that doctor is suddenly airlifted to the middle of Guatemala to deal with a Kekchi-speaking population set and in two weeks figure out how to do something useful.  That’s just crazy.

But there’s a very, very different issue when you’re talking about emergency response with high-level expertise.

You know, the first responder to make it in real serious force to Aceh after the tsunami was not, you know, the Indonesian government, was certainly not any of the NGOs anybody’s been talking about.  It was the United States Navy, and with a massive response, which by January, mid-January, after the tsunami, entailed more U.S. military personnel than we had at that time in Afghanistan.  And it was a response that meant that we were on the ground with physicians, doctors, logistics/supply personnel.  We had people on the ground remapping the entire coastline of the newly reconstructed and devastated portion of Indonesia.  And that -- and it was absolutely a spectacular display of the best of what our armed forces can do and the best of what, you know, emergency technical response entails.

And I’ve been in, you know, ebola epidemics and pneumonic plague epidemics.  And you name it, I’ve been there.  And certainly everybody on the ground appreciates the arrival of the CDC scientists in a crisis like that.

So I don’t think anybody disputes that there will continue to be a great need for that sort of highly technical emergency response capacity.  And there, you know, we have our Epidemic Intelligence Service inside the CDC.  I would argue it needs to be beefed up and that part of being in the EIS should indeed be some level of debt forgiveness for your medical and scientific training.

OPERATOR:  Just a reminder:  If you would like to ask a question, please press the star key, followed by the 1 key on your touch-tone phone now. 

GARRETT:  While people are thinking of questions, the one thing I would just sort of point out, by virtue of news peg time, the Davos meeting is under way, and it’s quite interesting that perhaps the complexities of this global health area are beginning to resonate in that community, because this year there’s a real -- so far a real tendency to avoid the whole discussion of -- that previously has dominated Davos, of the individuals who stand up and say, “Here’s my check for $10 million for malaria control.”  And other than Bono, there are virtually none of the classic celebrities we’ve become accustomed to seeing, who basically are preaching the Jeff Sachs line that it’s just about the money.

I think that there’s becoming a wider and wider recognition within the G-8 and within a lot of the big donor community that this game is much more complicated and that it needs more sophisticated solutions than simply throwing money down a pipeline.

OPERATOR:  Okay.  We do have a couple of questions lined up, and our first one comes from Rosanne Skirble from the Voice of America.

QUESTIONER:  Hi, Laurie.  Thank you very much for the article and for this discussion this morning.

I just want you, if you could -- you’ve talked about some solutions to some of the issues, but could you sum up some of the solutions that you’re thinking of that -- beside the restructuring of -- or the refocusing of WHO?

GARRETT:  Absolutely.  Thank you.  (Chuckles.)

Yeah, Rosanne, I do get into a little bit of this in the piece, but I think that some of it got missed by my critics.  They didn’t understand what I was getting at.

You know, if I were a CEO of a large corporation and you walked in and said, “Here’s $15 billion of new capital.  Now, here’s our target.  We’re going to decrease the life expectancy gap between the longest-lived and shortest-lived societies in the world, and we’re going to increase the numbers of women that survive pregnancy and decrease the numbers of children who die before age 5.  So you take that $15 billion and figure out, you know, how to exercise it.”  Trust me, no CEO would take the 15 billion (dollars) and find a whole bunch of tiny, cottage-industry NGOs and do-gooder groups and say, “Here, you take this little piece and you take that little piece.”  (Chuckles.)  But that’s how we’re doing it, and it’s irrational.

You know, there’s a lot of complaining going on about patents and how the patent agreements hold drug pricing too high, make developments in innovations in drugs and diagnostics at prices affordable to poor countries lack any kind of incentive.  But the problem is we’re not thinking on a global scale.  So if we were thinking globally, we would have a centralized drug procurement, medical supplies procurement and diagnostics procurement center that’s bulk purchasing on such a scale that the per unit profit level could be quite, quite low, could be in the pennies, and still greatly satisfy the stockholders of the major pharmaceutical companies, the major biotech firms and the major medical supply companies.

But right now we’re operating on a system in the developing world that is mirroring inefficiencies that we have here in the United States so that, you know, the reward to the company is in high per unit pricing on everything, whether it’s a pair of Latex gloves, it’s a diagnostic kit for tuberculosis or it’s, you know, a fancy cancer drug like Gleevec.

We desperately need a much larger superstructure that, you know, looks at the long-standing, essential drugs list that WHO has had promulgated for years now and the essential medical supply list.  And so, you know, how can we create a rational global system of ordering, you know, procurement, warehousing and delivery?

The other piece of that is and when you start to think about it on that kind of scale, you can very quickly imagine how to decrease the amount of graft and corruption at the delivery end, because you would get out of these picky-uny, little orders that go through to a small dock and some guy is, you know, carving out a chunk of the boxes and taking them straight to the black market.  So you want to increase the level of honesty in the system and efficiency in the system and the scale and volume of ordering so that the per unit prices can come down.  That’s just one example.

If you go -- another example is to think in far more rational ways about how to use that meager pool of skilled health talent more efficiently.  So, why, for example, do we have to have an RN get in a beat-up, old Land Rover and drive a bunch of dirt roads out to the middle of nowhere to do vaccination campaign twice a year for children?  A lot of that can be done by a community health worker; it doesn’t require a RN.  More importantly, it’s for that very skilled RN to be supervising a pool of well-trained community health workers.  In some places, we’re already seeing real breakthroughs with that kind of approach, but that requires a systems think, and it requires building in efficiencies in the whole health model that are just far beyond anything we currently have.

And you get on the ground in most poor countries and you’ll see that wherever the largest hospital is, that’s where the former colonial power put the largest hospital a hundred years ago.  And it hasn’t changed not too much in a hundred years.  And the whole system of health delivery is built around people having to walk vast distances and find buses or pay for transport to come vast distances into centralized hub facilities.

What we need is a global-scale rethink that envisions large-scale massive training of community-based health workers that are linked in real supervised systems that ensure quality and ongoing training with that finite pool of skilled doctors and nurses busy doing the right things, the things that really require their skill set, rather than wasting enormous amounts of time, and becoming demoralized in the process, and considering moving to a rich country to get away from it, by the current way that we operate.

OPERATOR:  Thank you.  Our next question comes from Jim Moody from the Council on Foreign Relations.

(Pause.)

GARRETT:  Jim?  (No response.)

Maybe not! 

OPERATOR:  Okay, well our next question comes from Elizabeth Lapotto (ph) from the Bloomberg News.

GARRETT:  Hi, Elizabeth.

QUESTIONER:  Hi.  How are you doing today?

GARRETT:  Okay.

QUESTIONER:  Look, I was wondering what you felt the role of things like the Latin America School of Medicine might be in training things like nurses.  I mean, it is a program that essentially allows people to go to school for free, as long as they practice for free -- I think it’s two years -- wherever it is they came from.  Do you think something like that on a larger scale, maybe funded by the Gates Foundation, could potentially provide some relief for the nurse shortages that are going on in these countries?

GARRETT:  Well, right now, Latin America is an interesting example because the biggest provider of doctors and nurses, you know, exported to deal with poor areas, of course is not the United States, it’s Cuba.  We just had a situation in Jamaica where malaria reemerged for the first time in, I think, five decades in Jamaica was directly imperiling the entire tourist industry of Jamaica.  My understanding is that the Jamaicans were requesting assistance from the United States, but ultimately it was a whole vast team of Cuban doctors and nurses that went in and helped shut down their malaria problem.

So we have an interesting public diplomacy piece of this going on, you know, all across Latin America right now. 

But let me step back and put this in the bigger picture.  For example, we have a program under way operated by Cornell University, Pfizer Corporation, Cornell Weill University, and so on, doing doctor training in Tanzania.  There are similar efforts under way for funding nursing schools in different parts of the world.  The problem with all of that -- and by no means do I think those efforts should stop.  But the problem with all of them is that we don’t have enough time to create a pool of doctors and nurses on the ground to offset the drainage rate, both the drainage in brain drain to other countries, and the drainage literally in deaths and demoralization. 

You know, we have surgeons, trained surgeons from Nigeria, from Ghana, from Zimbabwe, who are driving taxi cabs in London today, and probably here in New York.  And they’re driving taxi cabs because they’re so demoralized by the situation in their home countries, and so underpaid in their home countries, that they’re willing to actually give up their entire professional training just to live someplace that feels, you know, like a more comfortable place to live, even if it means something like driving a taxi cab.  And this is ridiculous, this is just horrible.

So I don’t think that increasing the rate of training alone, particularly for the higher skilled nurses and physicians, is going to come close to solving the problem.  It’s going to be a small Bandaid.  And I do think, though, that the U.S. government, in our Pax Americana backyard, should take a good hard look at the lessons to be learned from how Cuba is operating in the region and how Cuba has used the whole issue of health as its number one drive for external diplomacy and friendship in the region.

ROSE:  Laurie, have you seen the movie, “Dirty Pretty Things”?

GARRETT:  I don’t think so.

ROSE:  It was a 2002 movie, and it was quite good.  And the reason I bring it up is because it focused on exactly that situation.  The lead character is a doctor from Nigeria who is an illegal immigrant in London working as a driver and a hotel superintendent, and so forth.  And it illustrates exactly the kind of stuff you’re talking about, which is, you know, you can be a major figure in your local country in health care and still do better by being a minor figure in a non-healthcare profession here.

GARRETT:  Absolutely.  And it’s tragic.  You know, I really, really -- if I could urge the new Congress to examine some key issues, there are many pieces of all of this that really require attention, that have gone utterly ignored or without solution for far too long.  I already mentioned in response to Jim’s questions some pieces of that.  But, you know, another piece is to ask:  What is the relationship?  What is public diplomacy?  Do we believe in it?  Well, this administration did not until relatively recently when Karen Hughes, who had been in the White House, was made a special roving ambassador in charge of a kind of public diplomacy, but it’s a tiny, tiny effort.

When you think back to the days of John F. Kennedy and the foundation of the Peace Corps, the whole idea was that we were creating some way of taking American can-do mentality and expertise and making that expertise available where needed in the poor world, and doing so not just in a charitable fashion, but also in a fashion that was meant to win over hearts and minds around the world.

We really need to be thinking about that in this new world where we’re battling over the hearts and minds on a whole different scale.  It’s sad but true that a lot of the programs that would have been, such as our responding to malaria in Jamaica before the Cubans did, a lot of those programs were stronger during the Cold War when we were battling, you know, the Communists, and it was the capitalist world versus the Communist world, and we’ll use every tool possible to convince the world in between that our side’s the better side.

With the collapse of the Cold War -- the end of the Cold War, the collapse of Communism, we’ve seen most of those efforts deteriorate.  And I think we really need to reexamine the entire arena of public diplomacy.  And I would argue that very few things win over hearts and minds better than saving a child’s life and having a forever-grateful mother who says, “I saw that it was an American, English-speaking doctor or nurse, or a medical supplies that said `From America’ that saved my child’s life.”

ROSE:  Well, on that note, one of our traditions here at the Council on Foreign Affairs is to keep things on time, and so we are going to wrap it up.  I want to thank Laurie very much for participating.  As always, it’s a pleasure to work with her and allow her to reach her audiences.

Thank you all for participating, and we’ll see you next time.

GARRETT:  Thanks to all of you.

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