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A global health fund: heeding Koch's caution
EDITORIAL
THE LANCET Volume 358, Number 9275
A global health fund: heeding Koch’s caution Last week, a UN Special Session in New York City released an unprecedented “Declaration of Commitment” against HIV/AIDS. This document emphasises the devastation caused by HIV/AIDS in developing nations, where 90% of the 36 million people with infection live, 75% in sub-Saharan Africa alone. Not since the commitment made 40 years ago to eradicate malaria has the world united to challenge such a serious health threat. Indeed, the eventual failure of that malaria-eradication programme raises important questions and concerns about this latest and much heralded agreement. The UN statement rightly underlines the connection between poverty and HIV/AIDS, together with the corrosive influence of underdevelopment, war, and debt on efforts to contain the pandemic. And it points to access to medicines as “one of the fundamental elements” in tackling the infection. The teeth, such as they can be in a document marked by the politics of compromise as much as commitment, come in a series of prevention goals—eg, to cut HIV prevalence globally by 25% by 2010. But the headline pledge—paragraph 80 of the declaration—is to “reach an overall target of annual expenditure on the epidemic of between US$7 billion and US$10 billion in low and middle-income countries”. The significance of this special session is both political and economic. Politically, after a halfcentury of neglect, Africa is now a priority for the world’s richer nations. This sea-change in attitude owes a great deal to African leaders themselves. The shift in the centre of gravity of political responsibility from North to South is a cause for optimism. Economically, the UN declaration is a victory for a new generation of development theorists, such as Jeffrey Sachs. Together with Amir Attaran, Sachs argued in The Lancet earlier this year that lack of finance was the primary constraint on progress against HIV/AIDS and that grants, not loans, were the answer to this funding vacuum. A crucial part of this campaign against HIV/AIDS is to widen access to antiretroviral drugs. Politicians, economists, advocacy groups, and international health leaders have all supported this goal. The call comes as part of a justifiable critique of the pharmaceutical industry, which is charged with profiting from drugs that it refuses to make available to those THE LANCET • Vol 358 • July 7, 2001
people who most need and can least afford them. Yet the reality of Africa is that there is no working primary health-care infrastructure for large parts of the continent. In Ethiopia, for example, Addis Ababa has several large hospitals and a reasonably wide network of well-staffed health clinics that could successfully distribute antiretroviral drugs. But over three-quarters of the population live in rural communities. In these rural areas, there are few clinics, and what facilities do exist are presently unable to cope with even the most basic health needs of the people they serve. The village life of rural Africa is one typically without safe water supplies, sanitation, and food security. Is provision of antiretroviral agents an answer to the health problems many Africans face? Certainly, it is part of the answer. But far more crucial are the elements of a sustainable primary-health-care system. These are given only passing acknowledgment in the UN declaration and in the speeches that surrounded it. Such fundamental services are not an eye-catching platform for politicians and policymakers. Yet they remain desperately needed—for without them, any effort to distribute medicines will fail. Such services should be at the centre of a strategy to combat AIDS and other diseases with a global health fund. Here is the lesson of the failed malaria-eradication programme of the 1960s, a programme that relied too heavily on one instrument—DDT—to solve a complex health problem. 100 years ago, on July 23, 1901, Robert Koch addressed the British Congress on Tuberculosis. He supported wider provision of TB treatment services—in his day, sanatoria—and he called on governments and private benefactors to give generously to an ambitious treatment programme. But Koch also wanted the “root of the evil” of TB to be addressed—namely, the overcrowded living conditions of the poor. “The sanatoria will never render the other measures I have mentioned superfluous”, he said. Substitute drugs for sanatoria, and primary health-care services for “other measures”, and Koch’s caution remains true to this day. Sustainable primary care must be the first ambition of any global fund for health. The Lancet 1
For personal use. Only reproduce with permission from The Lancet Publishing Group.
THE LANCET Volume 358, Number 9275
A global health fund: heeding Koch’s caution Last week, a UN Special Session in New York City released an unprecedented “Declaration of Commitment” against HIV/AIDS. This document emphasises the devastation caused by HIV/AIDS in developing nations, where 90% of the 36 million people with infection live, 75% in sub-Saharan Africa alone. Not since the commitment made 40 years ago to eradicate malaria has the world united to challenge such a serious health threat. Indeed, the eventual failure of that malaria-eradication programme raises important questions and concerns about this latest and much heralded agreement. The UN statement rightly underlines the connection between poverty and HIV/AIDS, together with the corrosive influence of underdevelopment, war, and debt on efforts to contain the pandemic. And it points to access to medicines as “one of the fundamental elements” in tackling the infection. The teeth, such as they can be in a document marked by the politics of compromise as much as commitment, come in a series of prevention goals—eg, to cut HIV prevalence globally by 25% by 2010. But the headline pledge—paragraph 80 of the declaration—is to “reach an overall target of annual expenditure on the epidemic of between US$7 billion and US$10 billion in low and middle-income countries”. The significance of this special session is both political and economic. Politically, after a halfcentury of neglect, Africa is now a priority for the world’s richer nations. This sea-change in attitude owes a great deal to African leaders themselves. The shift in the centre of gravity of political responsibility from North to South is a cause for optimism. Economically, the UN declaration is a victory for a new generation of development theorists, such as Jeffrey Sachs. Together with Amir Attaran, Sachs argued in The Lancet earlier this year that lack of finance was the primary constraint on progress against HIV/AIDS and that grants, not loans, were the answer to this funding vacuum. A crucial part of this campaign against HIV/AIDS is to widen access to antiretroviral drugs. Politicians, economists, advocacy groups, and international health leaders have all supported this goal. The call comes as part of a justifiable critique of the pharmaceutical industry, which is charged with profiting from drugs that it refuses to make available to those THE LANCET • Vol 358 • July 7, 2001
people who most need and can least afford them. Yet the reality of Africa is that there is no working primary health-care infrastructure for large parts of the continent. In Ethiopia, for example, Addis Ababa has several large hospitals and a reasonably wide network of well-staffed health clinics that could successfully distribute antiretroviral drugs. But over three-quarters of the population live in rural communities. In these rural areas, there are few clinics, and what facilities do exist are presently unable to cope with even the most basic health needs of the people they serve. The village life of rural Africa is one typically without safe water supplies, sanitation, and food security. Is provision of antiretroviral agents an answer to the health problems many Africans face? Certainly, it is part of the answer. But far more crucial are the elements of a sustainable primary-health-care system. These are given only passing acknowledgment in the UN declaration and in the speeches that surrounded it. Such fundamental services are not an eye-catching platform for politicians and policymakers. Yet they remain desperately needed—for without them, any effort to distribute medicines will fail. Such services should be at the centre of a strategy to combat AIDS and other diseases with a global health fund. Here is the lesson of the failed malaria-eradication programme of the 1960s, a programme that relied too heavily on one instrument—DDT—to solve a complex health problem. 100 years ago, on July 23, 1901, Robert Koch addressed the British Congress on Tuberculosis. He supported wider provision of TB treatment services—in his day, sanatoria—and he called on governments and private benefactors to give generously to an ambitious treatment programme. But Koch also wanted the “root of the evil” of TB to be addressed—namely, the overcrowded living conditions of the poor. “The sanatoria will never render the other measures I have mentioned superfluous”, he said. Substitute drugs for sanatoria, and primary health-care services for “other measures”, and Koch’s caution remains true to this day. Sustainable primary care must be the first ambition of any global fund for health. The Lancet 1
For personal use. Only reproduce with permission from The Lancet Publishing Group.