As I describe in my Foreign Affairs article “The Challenge of Global Health” (January/February 2007), we find ourselves in a paradoxically perilous moment. Health philanthropy that just five years ago witnessed “large” donations in the tens of millions now routinely hears of awards exceeding $200 million, targeting single projects. A sense of urgency, both genuinely driven by expanding pandemics and politically propelled by a wealthy-nation public that demands immediate results, is pushing money into the coffers of poor nations’ ministries of health and a vast array of nongovernmental and faith-based humanitarian organizations. But on the ground, where the health needs are the greatest, decades of neglect have rendered hospitals, clinics, laboratories, medical schools, and the pool of health talent dangerously deficient. As a result, this Age of Generosity could, with equally likelihood, usher a time of spectacular improvements in the health of billions of people, or push societies into even deeper trouble.
To witness the untoward, and unintended, effects of health generosity Americans need go no further than a 45 minute plane flight from Miami, to Haiti. This country with the highest HIV infection rate in the Americas is managing one of the best AIDS treatment programs seen in any poor country in the world, thanks in part to U.S. government support. But as Haiti pushes down its HIV rates and treats people with AIDS, all its other health markers deteriorate.
More than 5,000 Haitians now get daily medicines to control their HIV infections, and the prevalence of HIV has plummeted from a 2002 high of six percent in the general population to today’s 3 percent. For a war-torn, impoverished nation in which 80 percent of the population lives on less than $2 a day these are grand achievements. But Haiti has gone backwards since 1985 in every health indicator except AIDS. When civil turmoil commenced in 1986, ushering in economic collapse, Haiti’s medical and public health systems fell to pieces. Surveys showed that Haitians were dying younger—life expectancy for men is now merely 51 years. More women were dying in childbirth, with a national maternal mortality rate that is the highest in the Western world. Today Haiti needs 5,000 nurses and 2,000 doctors. Expatriate physicians, mostly working in New York and Florida, keep the hospitals of Haiti alive with their remittances, Bijou says. But you can only do so much with charity.
Haiti reflects the paramount problem facing global health leaders worldwide today: There is money on the global health table, thousands of nongovernmental and humanitarian groups vie to spend that cash on the ground, and a profound sense of charity is pervasive in the wealthy world. Some NGOs have shown real success in treating AIDS and slowing spread of HIV in poor countries. But it takes a state, a health system and an infrastructure to raise all boats in a murky sea of health needs.
Tackling the diseases of global poverty has over the last six years become a key feature of the foreign policies of European, North American and some wealthy Asian nations. For some of the G-8 nations—which have committed to spending $50 billion a year on global health and poverty alleviation by 2010—stopping the spread of HIV, tuberculosis, drug-resistant malaria and other major killers is a pivotal form of public diplomacy. The United Kingdom’s Gordon Brown has framed the fight against disease in epic proportions, calling for a $300 billion war chest to execute a penultimate moral and diplomatic battle against poverty and premature death. For some G-8 players, spending copiously to diminish the global burden of disease is as much about self-interest as altruism: Spreading microbes know no borders.
If the global community, and in particular the U.S. foreign aid establishment and WHO leadership, do not handle this historic moment with great care, the end result of this Age of Generosity may well be an increase in mortality in key poor countries.
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