- Email: [email protected]
Controlling humanitarian aid cowboys in Afghanistan
CORRESPONDENCE
4
5
Zuck TF, Preston MS. Evidence suggesting that immune globulin preparations do not transmit AIDS. In: Petricciani JC, Gust ID, Hoppe PA, Krinjen HW, eds. AIDS the safety of blood and blood products. London: John Wiley, 1987: 93–101. Yu MYW, Mason BL, Tankersley DL. Detection and characterization of hepatitis C virus RNA in immune globulins. Transfusion 1994; 34: 596–602.
Taking HIV to court Sir—Internationally, the South Africa government stands accused of severe ineptitude in its handling of the AIDS epidemic, as you note in your Sept 1 editorial.1,2 Locally, the government did not respond positively to the detailed report compiled by the Medical Research Council under Malegapuru Makgoba, which clearly states that AIDS is now the major cause of death in young South Africans. Thus, South Africa is way behind in its views and actions, especially for victims of rape and children born to mothers who are HIV-1 positive. The government seems reluctant to implement a national programme to prevent mother-to-child transmission of HIV-1, citing affordability as the main reason. However, much research shows that such a programme is cost effective and would absorb less than 3% of the health budget.3 According to one estimate, it costs the government substantially more to treat the symptomatic illnesses of HIV-1-positive children than it would to finance a national programme to reduce motherto-child transmission.4 irrespective of whether nevirapine or zidovudine is used, and whether the mother continues to breastfeed or is provided with formula. As you point out, The Treatment Action Campaign (a non-governmental organisation working in the AIDS arena) has taken legal action against the government to force it to provide a national programme to prevent motherto-child transmission of HIV-1. Research shows that provision of one dose of nevirapine to mothers during labour and to neonates immediately after birth can lower mother-to-child transmission by more than a third. At present, this service is provided only in a few sites, and by the western Cape provincial government (which has been controlled by the opposition Democratic Alliance, and not the ruling African National Congress). The position of raped women is also dire. A voluntary counselling drugprovision programme in one of the provinces (Mpumalanga) was closed by an eviction order served by the provincial minister of health. This decision is especially inexplicable
2002
because that province has one of the highest rates of rape. Therefore, unless a raped woman is rich enough to afford medical aid and private practice medication, or unless she lives in the western Cape, she not only experiences the psychological trauma of the rape but also the hazards of HIV and AIDS. As you say, had this happened under apartheid governments, they would have been horrified. *Lionel Opie, Nicoli Nattrass Cape Heart Centre, and School of Economics, University of Cape Town, Observatory 7925, South Africa (e-mail: [email protected]) 1 2 3
4
Editorial. Taking HIV to court. Lancet 2001; 358: 681. Mbeki and AIDS. International Herald Tribune 2001; June 28. Farley T, Buyse D, Gaillard P, Perriens J. Efficacy of antiretroviral regimens for prevention of mother to child transmission of HIV and some programmatic issues. http://www.who.int/reproductivehealth/rtis/MTCT/mtct_consultation_october _2000/consultation_documents/efficacy_of_ar v_regimens/efficacy_of_antiretroviral_regimen s.en.html (accessed Nov 9, 2001). Skordis J, Nattrass N. What is affordable: the political-economy of policy on the transmission of HIV/AIDS from mother to child in South Africa. AIDS in Context Conference, University of the Witwatersrand, April, 2001.
Controlling humanitarian aid cowboys in Afghanistan Sir—Afghanistan’s basic health indicators have been invariably low throughout the 23-year conflict, and have not changed now. Throughout the 1990s, donor fatigue struck. Now, suddenly, the miserable humanitarian condition is back on the agenda. True, Afghanistan had a 3-year drought, sinking water tables, and repeated crop failures in addition to low scale conflict in the north, with thousands of people stranded internally. Probably, international attention was attracted for these events, but certainly not on the present scale. Private and public monies flow as never before. As a side-effect, there are lots of meetings and lots of new nongovernmental organisations (NGOs). International health bodies have been jerked into life. The ad-hoc meetings are seemingly uncoordinated between organisations, with apparently overlapping agendas, although most agendas are unclear. What is clear, however, is that international health bodies are ready to take on the horrendous health indicators, even if they have to fight among themselves to reach that target. They are very short of field-related information for fundraising, which NGOs are supposed to supply.
North Afghanistan is awash with NGOs—established NGOs who have been there for years, scaling up their operations, ones that have worked there previously, and newcomers. The surrounding countries contain more, waiting to move in. There is space and work for everyone, but the problem remains of what to do and where. The NGOs fight for a slice of free land to work on to avoid duplication of aid. Therefore, information is shared cautiously, so others do not move in first. Once established, NGOs have to ignore other actors nearby. Every organisation has to find a justification for being there, to which a competent and professional neighbour is a threat. Having come in with their own monies and investing them, each NGO must play up their own performance and importance, and down-play that of competitors to qualify for private fund raising from home—“we were the first there and nobody else is there to help the suffering Afghans”. Newcomers endanger the incumbent’s position. The offer of doubled salaries attracts staff from other agencies, making it much easier to perpetuate the myth of a limping underperforming NGO neighbour. The result of such land grabbing is that, despite attempts by other international bodies to coordinate aid, these attempts generally fail to direct the aid to where needs are highest. Control needs to be addressed. First, international health bodies need to be controlled by another international body that specialises in coordination and information sharing. Second, when convening meetings, timely information on the venue and agenda must be made available so that NGOs’ partners can come prepared. Third, binding procedures need to be formulated for new NGOs arriving to work in complex emergencies. Disregard for these procedures needs to be sanctioned (eg, exclusion from funding through all major international donors). Fourth, international controlling bodies must be empowered to exact common practice for NGOs working in their attention area, such as agreement on salary scales for local staff. Fifth, priority of funding should be given to established quality NGOs in the country to enable them to scale up their operations, instead of diversifying to stakeholders who still need to establish themselves. I am the senior Health Advisor for the Swedish Committee for Afghanistan, which employs about a third of all employed national staff by all agencies (UN and NGOs) combined.
Gyuri Fritsche Swedish Committee for Afghanistan, GPO Box 689, Peshawar, Pakistan (e-mail: [email protected])
THE LANCET • Vol 358 • December 8, 2001
For personal use. Only reproduce with permission from The Lancet Publishing Group.
4
5
Zuck TF, Preston MS. Evidence suggesting that immune globulin preparations do not transmit AIDS. In: Petricciani JC, Gust ID, Hoppe PA, Krinjen HW, eds. AIDS the safety of blood and blood products. London: John Wiley, 1987: 93–101. Yu MYW, Mason BL, Tankersley DL. Detection and characterization of hepatitis C virus RNA in immune globulins. Transfusion 1994; 34: 596–602.
Taking HIV to court Sir—Internationally, the South Africa government stands accused of severe ineptitude in its handling of the AIDS epidemic, as you note in your Sept 1 editorial.1,2 Locally, the government did not respond positively to the detailed report compiled by the Medical Research Council under Malegapuru Makgoba, which clearly states that AIDS is now the major cause of death in young South Africans. Thus, South Africa is way behind in its views and actions, especially for victims of rape and children born to mothers who are HIV-1 positive. The government seems reluctant to implement a national programme to prevent mother-to-child transmission of HIV-1, citing affordability as the main reason. However, much research shows that such a programme is cost effective and would absorb less than 3% of the health budget.3 According to one estimate, it costs the government substantially more to treat the symptomatic illnesses of HIV-1-positive children than it would to finance a national programme to reduce motherto-child transmission.4 irrespective of whether nevirapine or zidovudine is used, and whether the mother continues to breastfeed or is provided with formula. As you point out, The Treatment Action Campaign (a non-governmental organisation working in the AIDS arena) has taken legal action against the government to force it to provide a national programme to prevent motherto-child transmission of HIV-1. Research shows that provision of one dose of nevirapine to mothers during labour and to neonates immediately after birth can lower mother-to-child transmission by more than a third. At present, this service is provided only in a few sites, and by the western Cape provincial government (which has been controlled by the opposition Democratic Alliance, and not the ruling African National Congress). The position of raped women is also dire. A voluntary counselling drugprovision programme in one of the provinces (Mpumalanga) was closed by an eviction order served by the provincial minister of health. This decision is especially inexplicable
2002
because that province has one of the highest rates of rape. Therefore, unless a raped woman is rich enough to afford medical aid and private practice medication, or unless she lives in the western Cape, she not only experiences the psychological trauma of the rape but also the hazards of HIV and AIDS. As you say, had this happened under apartheid governments, they would have been horrified. *Lionel Opie, Nicoli Nattrass Cape Heart Centre, and School of Economics, University of Cape Town, Observatory 7925, South Africa (e-mail: [email protected]) 1 2 3
4
Editorial. Taking HIV to court. Lancet 2001; 358: 681. Mbeki and AIDS. International Herald Tribune 2001; June 28. Farley T, Buyse D, Gaillard P, Perriens J. Efficacy of antiretroviral regimens for prevention of mother to child transmission of HIV and some programmatic issues. http://www.who.int/reproductivehealth/rtis/MTCT/mtct_consultation_october _2000/consultation_documents/efficacy_of_ar v_regimens/efficacy_of_antiretroviral_regimen s.en.html (accessed Nov 9, 2001). Skordis J, Nattrass N. What is affordable: the political-economy of policy on the transmission of HIV/AIDS from mother to child in South Africa. AIDS in Context Conference, University of the Witwatersrand, April, 2001.
Controlling humanitarian aid cowboys in Afghanistan Sir—Afghanistan’s basic health indicators have been invariably low throughout the 23-year conflict, and have not changed now. Throughout the 1990s, donor fatigue struck. Now, suddenly, the miserable humanitarian condition is back on the agenda. True, Afghanistan had a 3-year drought, sinking water tables, and repeated crop failures in addition to low scale conflict in the north, with thousands of people stranded internally. Probably, international attention was attracted for these events, but certainly not on the present scale. Private and public monies flow as never before. As a side-effect, there are lots of meetings and lots of new nongovernmental organisations (NGOs). International health bodies have been jerked into life. The ad-hoc meetings are seemingly uncoordinated between organisations, with apparently overlapping agendas, although most agendas are unclear. What is clear, however, is that international health bodies are ready to take on the horrendous health indicators, even if they have to fight among themselves to reach that target. They are very short of field-related information for fundraising, which NGOs are supposed to supply.
North Afghanistan is awash with NGOs—established NGOs who have been there for years, scaling up their operations, ones that have worked there previously, and newcomers. The surrounding countries contain more, waiting to move in. There is space and work for everyone, but the problem remains of what to do and where. The NGOs fight for a slice of free land to work on to avoid duplication of aid. Therefore, information is shared cautiously, so others do not move in first. Once established, NGOs have to ignore other actors nearby. Every organisation has to find a justification for being there, to which a competent and professional neighbour is a threat. Having come in with their own monies and investing them, each NGO must play up their own performance and importance, and down-play that of competitors to qualify for private fund raising from home—“we were the first there and nobody else is there to help the suffering Afghans”. Newcomers endanger the incumbent’s position. The offer of doubled salaries attracts staff from other agencies, making it much easier to perpetuate the myth of a limping underperforming NGO neighbour. The result of such land grabbing is that, despite attempts by other international bodies to coordinate aid, these attempts generally fail to direct the aid to where needs are highest. Control needs to be addressed. First, international health bodies need to be controlled by another international body that specialises in coordination and information sharing. Second, when convening meetings, timely information on the venue and agenda must be made available so that NGOs’ partners can come prepared. Third, binding procedures need to be formulated for new NGOs arriving to work in complex emergencies. Disregard for these procedures needs to be sanctioned (eg, exclusion from funding through all major international donors). Fourth, international controlling bodies must be empowered to exact common practice for NGOs working in their attention area, such as agreement on salary scales for local staff. Fifth, priority of funding should be given to established quality NGOs in the country to enable them to scale up their operations, instead of diversifying to stakeholders who still need to establish themselves. I am the senior Health Advisor for the Swedish Committee for Afghanistan, which employs about a third of all employed national staff by all agencies (UN and NGOs) combined.
Gyuri Fritsche Swedish Committee for Afghanistan, GPO Box 689, Peshawar, Pakistan (e-mail: [email protected])
THE LANCET • Vol 358 • December 8, 2001
For personal use. Only reproduce with permission from The Lancet Publishing Group.