Debate: Should funds go directly to support the cause or strengthen governmental infrastructure?

Ashlee Metcalf, MD and Natasha Ang, MD

The Case for Direct Allocation of Funds:

The comparison between the rebuilding efforts after the earthquake that devastated Haiti in 2011 and the tsumnami that destroyed Indonesia in 2004 is a great example of why foreign aide should be focuse on the community.  The picture of Haiti in 2014 is only mildly different than the picture of Haiti post earthquake in 2011.  Why is this you may ask? Based on UN estimates, donors chaneled $6 billion in funding to Haiti from 2010 to 2012, but less than 0.6% was invested in Haiti.  Not much of the funding was given directly to the Haitian government due to concerns of disorganziation (post natural disaster), concerns of corruption, concerns of ability to mobilize material.  In times of chaos, it’s important to look at the direct needs of the community and give foreign aide directly to the community.  Take Indonesia for example… Efforts to rebuild were based on employing community development for rebuilding homes and local infrastructure to maximize the effectiveness of community recovery.  Who knows more about the needs of a community more than the people that actually live in it? There’s a sense of ownership and value in the community.  We are able to track funds more directly when we know exactly where the funds are going, instead of depending/relying on a government to disperse funds.

The Case for Strengthened Infrastructure:

80 percent of foreign aid from major donors bypasses the systems of local public institutions, going instead through US-based government contractors or numerous NGOs but there are numerous reasons we should not bypass the local government. Healthcare is not a vacuum. We need other systems in place to make it successful and when we move money through national systems, we strengthen much needed infrastructure. Think about our own US mucipal systems. Water supply, road maintenance, sanitation, regulations regarding where electrical cables can run are not privately owned for a reason. A national government may have better access to the whole nation’s resources – be it natural ones, commodities or people – to apply to a given situation. It may be able to priortize areas of need for the whole country. Paul Farmer has a great piece on this. He also discusses Haiti as an example of lack of coordination of aid and working with the national system allowed a devastating cholera outbreak to continue despite the presence of 12,000 NGOs within the nation. He also discusses how public perception of the level of corruption of foreign aid monies is vastly overestimated.

Debate: Should we allocate global health funds to treatment or prevention?

Andrew Myers, MD and Meena Hasan, MD

The Case For Treatment:

The prevention vs. treatment debate has been very contentious for years with no sign of stopping anytime soon.  For years treatment took precedence without thought to future capacity.  While the world has come around to looking to the future, we cannot sacrifice the present.  HIV is decimating sub Saharan Africa. HIV prevalence is almost 40% in some areas of sub Saharan Africa.  While abstinence, male circumcision, and condoms among many other preventative interventions are important to let a large swath of the African population suffer is inhumane. We have the ability to provide ARVs to patients for $140 per person per year. Without a healthy working ago population a country cannot improve itself.  HIV leads to many debilitating diseases and eventually death if left untreated.  Just as importantly, persons who are treated for HIV and maintain low viral levels of the disease are less likely to pass it to others.  In this case treatment IS prevention. We see this in all infectious diseases.  People cured of a disease do not pass it to other people.

Treatment is also very important in our under 5 mortality.  Diarrheal illnesses and malnutrition run rampant in many underserved parts of the world.  The main treatment for a child with diarrhea is to keep up with his fluids and electrolytes. This doesn’t involve any expensive medications, just a generic version of Gatorade to get kids through the worst parts of the diarrhea.  For malnutrition there is an equally simple solution.  Plumpy Nut is a peanut derived meal replacement for kids that supplies 500 calories per pack and costs about 50 cents to produce.  It is relatively portable and can drastically improve a child’s health which is a great indicator for their productivity later in life.  Public health and preventative measures are important, but we can’t forget the person in need standing right in front of us!

The Case for Prevention:

Forty-seven trillion dollars.  No chump change, right? Well, according to the World Economic Forum, that number is the estimated global cost of treating the five most common, non-infectious diseases including cancer, diabetes, heart disease, lung disease and mental health disorders in aggregate from now until 2030. That’s a REALLY high number and it’s NOT even factoring in other non-infectious diseases, all infectious diseases, loss of productivity and the social burden of caring for the ill. To put it bluntly, our economy will COLLAPSE if we attempt to treat all this disease one patient at a time. So what do we DO? There is only one obvious solution: A focus on prevention.

A focus on prevention means tackling disease before any chance for harm. Prevention strategies include building town infrastructure (ex roads, electricity), improving sanitation, and focusing on education, especially of girls. Improvement in these areas has been shown to improve the health of communities and has countless global benefits. It also includes strategies such as vaccination campaigns, hand washing initiatives and non-communicable disease prevention through the promotion of healthy eating and exercise. If we instead focus on treatment, we are tackling disease after the fact, allowing patients to suffer the symptoms and social isolation that results from illness before attempting to heal. Treatment is no simple task – many diseases take several years to cure, if at all, and require costly medications with side effects, numerous health visits, and systems in place to support patient care.

Our resources are limited. The burden of disease is astronomical. Our only solution for coping is to prevent. Prevention makes most CENTS.

Diabetes or Dengue? Where should we allocate our global funds?

Shelton McMullen, MD and Ashley Freeman, MD

In focusing on global health, where is our money best spent – on combatting non-communicable disease (NCD) or communicable disease (CD)?

There is, of course, no clear cut answer to such a complicated question, and sound arguments can support either camp.

The Case for Communicable Disease Funding:

1. Health leads to wealth:
Many CDs are indeed the plight of the world’s poorest individuals, who suffer tremendously from easily-treatable infection. Their position as victims demands our attention as soon as possible. Health is a precursor to wealth.

2. It’s less complicated:
CD is often far easier to treat than non-communicable diseases, which can be sometimes more chronic in nature and tied more to lifestyle, diet and other ingrained social determinants compared to many CDs. Many helminth infections can be cured with one dose of medication.

3. Kids:
The peak burden of many CDs is felt by the world’s youth. How can we choose to neglect treating these children?!

4. Treatment = Prevention:
In the case of many CDs, treatment means prevention. Simple treatment of a transmissible disease stops its spread – it’s that simple.

5. Necessity:
The global burden of tuberculosis is enormous. Regarding MDR TB, poor countries/patients cannot begin to afford the necessary treatment.

For some great information on infectious disease statistics, news and guidelines, check out the WHO’s website at (go to Infectious Diseases under the Health Topics tab).

The Case for Non-Communicable Disease Funding:

Chronic disease is no longer a problem of the rich and old.  According to the WHO, if current trends continue, non-communicable diseases (NCDs) will be the leading cause of death in Africa by the year 2030.  In fact, the number of deaths from NCDs will exceed the total number of deaths in Africa caused by infectious disease, nutritional deficiency, maternal death and perinatal deaths combined.

Consistent with the impact of health disparities on most health outcomes, the greatest burden of chronic disease falls on the poor.  Ninety percent of premature deaths (before age 60) due to NCDs occur in low-income countries.   Death at this young age preceded by years of disability drains limited resources and prevents formation of an effective workforce.

The causes of this alarming increase chronic disease are not surprising: smoking, poor diet and inactivity.  This means the vast majority of NCDs are preventable.   We have an opportunity to intervene before this global health threat cripples development in low-income countries.  This will require a coordinated commitment from global heath stakeholders, local governments and industry.  It is time to prioritize health over profit and focus on prevention efforts.

Debate: Are Medical Missions Good for Global Health

Paul Blair and Nika Safaie

The Case Against Burdensome Medical Missions

Global brigades are bad for global health. Although they may seem well intentioned it is in those misinformed intentions that poor outcomes are rooted.  These intentions shared by college or health professions students are often naive  and become dangerous when there is a component of the savior complex. The NGOs that facilitate medical missions are driven by the systemic post colonial guilt complex of global aid (see The Crisis Caravan or work by William Easterly).

A shared feeling of superiority over low income countries leads to an inflated feeling of ones abilities to help. Not only is this condescending but it is dangerous. Students practice beyond their abilities and this is often very explicit in advertising for medical brigades that participants will be able to do practice medicine in ways they couldn’t in their home country. For example, the Unite For Site organization website provides a real example of a student that saw a patient with polyuria and polydipsia and told the patient to stop drinking caffeine without follow up despite the real possibility of a deadly medical condition called DKA.  This website also highlights an anesthesia study on the Operation Smile complication rate.  Although the rate was the same intraoperatively it increased postoperatively due to lack of follow up.  There are many stories of surgeries which dump the postoperative care on the local system as highlighted by The Crisis Caravan in which a well meaning Evangelical organization provided a surgical brigade which left actively bleeding patients to be cared for by unprepared local health care workers.  The care itself is also ineffective in providing lasting health changes. There are few resources dedicated to addressing upstream factors by these organizations. Monitoring and evaluation is also rare given the intrinsic nearsightedness of short term missions.

Lastly, not only is the care ineffective at providing lasting health changes, but it is burdensome to the the local community.  Towns spend resources preparing for a medical brigade while neglecting other needs such as X-ray machines that remain in disrepair. Often wealthy local people will take advantage of free healthcare to be treated by foreigners who are viewed as highly trained taking away income from local health care workers. Often there is no community assessment of what is needed. Hospitals become full of donated worthless junk. It is also diverting translators from where they might need to be most. This diversion of precious resources turns ignorance into economic and medical harm.  Although there are notable exceptions to these major issues, they are problems that afflict medical missions across the board. We should leave global health to responsible and knowledgeable professionals that work in concert with local communities long term

A Case for Short Term Medical Missions: Bridging Disparities in Global Health Together

It is certainly no secret that with the rapid advancement of technology and communication, the world is becoming increasingly interconnected. Every day, we see more examples of how instability and injustice in any part of the world affect people everywhere, including right here at home. We can no longer afford to view the world as “us” and “them”—our vision needs to be world-embracing.

But if we believe we have a social responsibility to global neighbors as much as our local communities, how then can we work to ensure the security of all global citizens? Particularly, do short-term medical missions offer a way for clinicians to contribute to bridging global health disparities?

Although there has been a rise in the number of physicians who volunteer in these projects, many critics are asking if they are sustainable, if they are effective, or if they are in fact harmful to local populations. Do they empower local people to take ownership of their health and also their own social, intellectual and moral development? These questions spotlight some very real challenges.

But are these challenges really as insurmountable as we think? Maybe not.

Here’s one take on the issue.

One-pill wonder for HIV? Reflections from Tugela Ferry, South Africa

By Monique Duwell, MD, MPH

The South African government recently announced the roll-out of a fixed-dose combination anti-retroviral (ARV) pill  potentially reducing the pill burden for those living with HIV from three to five pills per day down to one.  The pill, which contains emtricitabine, efavirenz and tenofovir, will be offered to those newly diagnosed with HIV, HIV-positive pregnant women, as well as breast-feeding mothers.


The ARV Clinic at the Church of Scotland Hospital in Tugela Ferry, South Africa

This news prompted me to reflect on my recent medical rotation South Africa.  In Fall 2012, I traveled to Tugela Ferry, a rural town in the KwaZulu-Natal Province of South Africa.  This area has high rates of poverty and unemployment, low literacy rates and many people live without access to clean water.  I spent more than a month working in the Antiretroviral (ARV) Clinic affiliated with the Church of Scotland Hospital (COSH), a hospital serving nearly 200,000 people living in the surrounding Umsinga District.   The ARV clinic has been delivering HIV treatment to those living in this area since the national rollout of government-funded ARVs in 2004.

One of the most striking aspects of providing clinical care in this clinic is the demands on individual patients to comply with their medication regimen.  The first-line regimen for adults initiating HIV treatment includes three pills.  Many persons with HIV in this area are also co-infected with TB, so a patient may also take a combination pill for TB, along with pyridoxine.  Most patients are prescribed a multivitamin.  Many suffer from peripheral neuropathy and use amitriptyline and/or other pain medicines.  Still others require treatment for hypertension and other chronic conditions.  One can see how daily pill counts can easily reach into the double digits.

This is particularly daunting when one considers the other social and financial challenges facing many of the patients in this region.  I vividly recall a 14-year old girl who came to the ARV clinic on a Friday afternoon.  She had been diagnosed with HIV earlier that week, and referred to initiate treatment.   She was in a hurry to complete the visit, telling the nurse translator that she was concerned because she has left her baby home with her much younger brother.  In fact, her parents had both died recently, and she was the primary caregiver for both her brother and her baby.  I remember thinking, how will this young patient possible manage one more responsibility?  An array of daily pills, monthly clinic visits to pick up her medicines, and routine blood draws to monitor for complications.

Adding to these challenges, many patients in the area surrounding Tugela Ferry live in remote areas.  They face the added challenge of traversing rough terrain and walking long distances simply to obtain their medicines.

A view during a home visit in the rural area surrounding Tugela Ferry, South Africa

A view during a home visit in the rural area surrounding Tugela Ferry, South Africa

It is easy to see that initiating ARVs can be challenge for any patient, and particularly for patients in resource-poor and remote areas.  Yet, remarkably, my experience was that patients in Tugela Ferry were generally far more compliant than patients in the U.S.  My anecdotal experience is in fact supported by a 2006 meta-analysis by Mills and colleagues, which showed a higher percentage of patients were adherent to ARVs in Sub-Saharan African studies than in North American studies (77% vs. 55%).

Not surprisingly, evidence suggests that fixed-dose combination pills improve medication adherence.  In one meta-analysis, Bangalore and colleagues found that rates of non-adherence for patients with chronic diseases (e.g. hypertension, diabetes, HIV) were 26% lower among patients on fixed-dosed combinations compared to free-drug combination regimens.  Additionally, research by Airoldi et al. shows that one-pill, once-daily regimen improve not only adherence, but also quality of life for patients living with HIV.

In summary, my own experience in Tugela Ferry showed me that so many people are able to overcome enormous obstacles to obtain and adhere to HIV treatment.  Yet, particularly as the South African government continues its efforts to scale-up HIV treatment, it is critically important to support patients in their efforts to adhere to lifelong HIV treatment. The roll-out of the fixed-drug combination pill is likely to be an important step in this process.

For more information about efforts to improve care of people living with HIV and TB in Tugela Ferry, visit The Tugela Ferry Care and Research Collaboration (TF CARES) and Philanjalo websites.

The Little Emperor That Could

Chad Henson, M.D.

One of the best examples of political satire is Jonathon Swift’s “A Modest Proposal.” Written in 1729, this essay proposes a policy of selling poor Irish babies to feed the wealthy gentleman and ladies as a means to reduce economic hardship and control the population. As should be with all Juvenalism, the piece is persuasive and believable, meant to fool the reader into acceptance. Jump to the mid 1970’s and Deng Xioa Ping’s economic reform program. Proposed as a goal to prevent widespread hunger and devastation in China, the Family Planning Commission implemented a policy known today as the One-Child Policy. Already in the midst of the “late, long, few” program in which parents were encouraged to delay and space childbirth, the government mandated a restriction of one child per couple. Albeit with certain exemptions, the policy was a controversial way to maintain the population.

Like many strict population control efforts (the Holocaust, genocide), the One-Child Policy was very effective at its primary goal – to prevent hundreds of millions of birth – and even in its unstated objective – to become one of the world’s premier political powers. Even when viewing China from the perspective of the Millennium Development Goals (MDG), one cannot deny the impact of the pragmatic intervention. Infant and maternal mortality are only a fraction of their rates in 1980, and China has already met MDG1, which is to reduce extreme starvation. Women have more access to contraception, and there are reports of decreased abortion rates in the country, even when compared to the United States.

While Machiavelli might argue that the aforementioned successes are sufficient, I would challenge that the ramifications of OCP are deleterious to Chinese society and economic progress. Some of these effects are more theory than fact, such as the “Little Emperor Syndrome” of spoiled brats-turned-sociopaths and gender imbalance leading to sex trafficking and rise in HIV rates. But there are tangible consequences that have impacted the health and well being of the Chinese population, including adverse maternal and fetal outcomes from clandestine second pregnancies, sex-selective abortion (although illegal), and female infanticide. In fact, the inadequate pension policy in China has led to an unanticipated problem known as the “4:2:1” conundrum, in which every child born under OCP has two parents and four grandparents for whom he or she will be responsible in their retirement. It is akin to Full House, but without the adorable Olsen twins.

Whether OCP will stand the test of time is currently under debate, with speculation of an end to the policy as early as in 2015. The impact will inevitably remain for decades, and we as clinicians must remain cognizant of the deleterious outcomes of this policy on both health and human rights.

A New Form of OCP

Nancy Maaty, M.D.

The United Nation’s Millennium Development Goals (MDGs) are ambitious despite their good intentions. While in the past 13 of the 15 allotted years we have seen some improvement, I would argue we have not quite met our goals. Quite honestly, I find it difficult to believe that we will eradicate poverty or improve environmental sustainability in the remaining two years. But what if I told you that there is one thing that could “fix it all”?

Family Planning. Recognized by the WHO and USAID, to name a few, as an essential means to reaching (or at least getting closer) to our millennium goals. Theoretically, fewer pregnancies mean women would be less exposed to the risk and trauma of labor. This would result in a decrease in the total number of babies born that would be then subject to neonatal mortality. In the end, by avoiding an exponential increase in population size, we will preserve more resources.

Now, there is one country, which one could argue was “ahead of its time” when it proposed a radical idea in the 1970s. This idea received negative press worldwide and continues to be a topic of debate: OCP. No, not oral contraceptives, but the One-Child Policy in China. Putting aside the controversies regarding the concept and execution of the OCP, it should be noted that as of 2010, China had reached 3 of 8 MDGs, notably in eradication of hunger, universal primary education, and in child mortality. The impact on infant and maternal mortality has been drastic and out of proportion to neighboring countries. Had China maintained a birth rate of 5.9% (as reported in 1970), its limited resources would have put a strain on the country’s economic development. Previously, an International Development Association (IDA) country, China was able to graduate from this program of aide in 1999. Would this have been possible without the OCP in place?

While I may not ethically endorse the OCP as a form of family planning, I cannot ignore the likely positive impact the policy has had on China’s achievement of MDGs. Although the means by which family planning is attained in China should not be encouraged, perhaps there is still something we can all learn from China.


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• Greenland, Susan. “Science, Modernity, and the Making of China’s One-Child Policy.” Population and Development Review. 2003 June; 29(2): 163-196. <,%20Modernity,%20and%20the%20Making%20of%20China%27s%20One-Child%20Policy.pdf >