Challenging Dogma

...Using social sciences to improve the practice of public health

Friday, April 27, 2007

A Critique of the Global Fund for AIDS, TB, and Malaria for Treatment Focus in Malawi: an examination of Social and Economic factors- Lindsay Cloutier

When we come to you
Our rags are torn off us
And you listen all over our naked body.
As to the cause of our illness
One glance at our rags would
Tell you more. It is the same cause that wears out
Our bodies and our clothes.
The pain in our shoulder comes
You say, from the damp; and this is also the reason
For the stain on the wall of our flat.
So tell us:
Where does the damp come from?
Bertolt Brecht, “A Worker’s Speech to a Doctor” (1)

Malawi, a small developing country in Southern Africa, is among the poorest nations in the world with more than half of its population (55%) under the poverty line. It is no surprise that it is also among the least healthy with a life expectancy of just 41.7 years among the general population, largely due to its high prevalence of HIV/AIDS (2). Malaria and tuberculosis are also major issues in Malawi with approximately 13,00o and 7,000 deaths, respectively, in 2003 alone (3). The Global Fund for AIDS, Tuberculosis and Malaria distributes funds to developing nations to fight these three major killers around the world. The Fund has a clear mission of targeting these three diseases and has made medical treatment a major proportion of grant money donated to Malawi. There seems to be a trend in international public health to underestimate or ignore the impact of underlying social and economic factors that propagate disease. The Global Fund should broaden their efforts beyond medical interventions and should consider initiatives that affect social and economic obstacles to health; this will have a greater and overarching effect on AIDS, TB, Malaria, and many other important diseases that contribute to the high morbidity and mortality in Malawi and elsewhere.
The Issue
The Global Fund is supporting a treatment-based solution for disease in the hopes that it will also alleviate the issue of poverty in Malawi. The Fund has already pledged more than 200 million dollars in grants to Malawi with the purpose of relieving the devastation caused by the three diseases. Approximately half of the funding in grants goes directly to drugs, commodities, and products (2). Here is a perfect example of how ideological frameworks form public health intervention. If you believe that disease is the major problem, then treatment to cure disease will take care of the problem. What is not taken into account by this approach is the cyclical nature of poverty on health, and health back on poverty. It has been established by numerous studies that poverty has a major impact on health even after adjustment for other factors (4). In developing countries such as Malawi, treatment is not, and cannot be the only solution for alleviating disease. Certainly, the million people in Malawi affected by AIDS, and their lack of productivity has disturbed the workforce and devastated the economy. It also must be looked at from the opposite view, what has the socioeconomic situation of Malawi done to foster AIDS? It is paramount that before making treatment the solution of choice, that the Global Fund analyze what the macroeconomic instability of Malawi has done to foster disease and incorporate these factors into their grant proposals.
Food Security, Malnutrition, and Disease
In the past few years, Southern Africa has suffered terrible droughtwhich has created a food shortage crisis in Malawi. The country is mainly an agrarian society and has been hit both economically and nutritionally from the shortage. The Red Cross reports that Malawi has some of the highest rates of childhood malnutrition in sub-Saharan Africa with about 50% of children under the age of five suffering from chronic protein energy deficiency (5). The Red Cross, unlike the Global Fund has seen the value of distributing food rations for the purpose of alleviating the impact of AIDS (5). The Red Cross is using programs whose models are based on Maslow’s Hierarchy of Needs, which states that basic physiologic needs such as shelter, food, and drinking water must be met before Malawi can be a productive and healthy society. The on-going Fund project entitled “National Response to HIV/AIDS in Malawi,” a 73 million dollar grant, does not even mention these fundamental factors of health in any of its objectives. It has been known for years that people who are malnourished are at higher risk of developing disease. A recent study discusses how pre-existing malnutrition may exacerbate the effects of HIV due to its effects on the immune system. Malnutrition can act on the cells similarly to AIDS by decreasing CD4 T cells and provoking abnormal B-cell responses at the cellular level of the immune system (6). Studies have also shown that outcomes for HIV infected patients with insufficient micronutrient intake were poorer and the risk of death was higher than adequately nourished patients (6). If the Fund acknowledged the synergistic effects of malnutrition and poverty on HIV, they would have a more substantial impact on the health and productivity level of those suffering from HIV in Malawi. If people could be more productive than this would also alleviate some of the economic stress the country faces. Paul Farmer, a major figure in international health, has seen first hand the effects of treatment-only versus poverty conscious strategies against tuberculosis in Haiti. He and colleagues developed a small study to test the differences between patients receiving basic care versus those that also received financial aid, nutritional supplements, and money for travel among other things. Patients themselves argued that, “to give medicines without food was tantamount to…washing one’s hands and then wiping them dry in the dirt.” After a year, the group with the basic treatment plan had a cure rate that was barely half that of the more comprehensive plan (1). This example shows the importance of putting treatment in the context of the socio-economic framework of a country and how interventions that acknowledge these constraints will have greater success than those that focus solely on treatment. The Fund needs to look beyond the diseases themselves and look at the relevant socio-economic factors that influence these diseases. By alleviating economic stressors and adding a nutritional component combined with a treatment plan, the Fund will have greater success in its fight against HIV/AIDS, Tuberculosis and Malaria.
Health Workers and the Economy
The Fund has clearly defined goals for fighting AIDS, TB and Malaria in Malawi, but seems not to see the potential impact of initiatives that deal directly with socio-economic and political issues, such as low salaries for health care workers. By having such a narrow framework, the Fund has set itself up for a difficult task in the battle against these diseases. A major problem in Malawi in recent years has been the migration of health workers, especially nurses, to countries such as the UK where it is more economical to be a health professional. This medical “brain drain” not only depletes countries of much needed medical staff, but adds economic pressure due to the losing of investments made toward medical education to other countries. The health professionals that do stay have more workload, which can contribute to lower quality of care in an already strained medical setting. Malawi is inevitably losing millions of dollars due to its lack of adequate salary to health professionals (7). Round 1 of the Fund grant for “The National Response to HIV/AIDS,” which is currently in progress, grossly underestimated the value of human resources in the context of Malawi. Without the staff to administer drugs and use the products to which much of the money the Global Fund is distributing, there will still be shortages of care. Fortunately, the Fund has noticed this major issue and has since added a proposal for Round 5 of grants, which has yet to begin, for the scale up of human resources (8). The Global Fund should have acknowledged this major macroeconomic barrier to treatment before it implemented any health systems scale up. In a study published in 2006, Drager et al. describes the Global Fund’s position on how spending proposals for human resources must show that they will strengthen the health systems, and that there will be sustainability after the proposal period has ended. It has already been established in different studies that there is a direct causal link between health outcomes and the proportion of the health workforce (9). More than 90% of proposals support training for health workers but lack plans to do any follow-up or evaluation (9). Regardless of training, without first focusing attention on the issue of migration of health workers due to poor salaries, spending on training will be fruitless. In this circumstance it would be more beneficial for both the Global Fund and the government of Malawi, to work together on such large macroeconomic issues before funding treatment. By doing so, the Global Fund would have made more of a contribution to the health systems of the country than when ignoring this major economic crisis.
The contribution the Global Fund has made toward HIV/AIDS, Tuberculosis and Malaria would be more valuable to Malawi if it broadened its focus beyond treatment of the diseases and acknowledged the socioeconomic barriers to implementing programs. Socioeconomic intervention would help the baseline health of the people affected by these diseases and would be a major prevention strategy. By changing their objectives to include some of the basic physiologic needs of the people, the Fund will be able to make an even greater impact on the health of Malawi’s people beyond just AIDS, TB and Malaria. Another important consideration involves the economic stability of the country and its effect on the proportion of health workers. If the Fund had looked at the context to which they were implementing treatment and health systems scale-up they would have seen the need for a major health resources expansion. In this way they would have had more initial success, saved more lives, and done more to fix the struggling Malawian economy. Certainly treatment is an invaluable resource that must be utilized in order to lessen the burden of disease but it is imperative that the Fund and other international organizations look at how social and economic factors affect disease and the programs they implement.
1. Farmer P. Pathologies of Power: health, human rights, and the new war on the poor. Los Angeles, California: University of California Press, 2005.
2. CIA World Fact Book. Malawi. Washington, DC: CIA.
3. The Global Fund to fight AIDS, Tuberculosis, and Malaria. Country Statistics and Disease Indicators.
4. Haan M., Kaplan G., & Camacho T. Poverty and Health: prospective evidence from the Alameda county study. American Journal of Epidemiology 1987; 125, 6: 989-998.
5. The American National Red Cross. Food Crisis in Africa.Washington, DC: The American National Red Cross: Africa/030127africacrisis.html
6. Piwoz E., & Bentley M., Women’s voices, women’s choices: the challenge of nutrition and HIV/AIDS. The American Society for Nutritional Sciences 2005; 135: 933-937.
7. Muula A., Panulo B., & Maseko F. The financial losses from the migration of nurses from Malawi. BMC Nursing 2006; 5; 9.
8. The Global Fund to fight AIDS, Tuberculosis, and Malaria. Grant: HIV/AIDS Round 5. The Global Fund to Fight AIDS, Tuberculosis, and Malaria.
9. Drager S., Gedik G. & Dal Poz M. Health workforce issues and the Global Fund to Fight AIDS, Tuberculosis and Malaria: an analytical review. Human Resources for Health 2006; 4:23.

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  • At April 28, 2007 at 4:25 PM , Blogger Matthew Katz said...

    I thought this was a fantastic paper. It made a convincing argument as to the narrow-sighted intervention taking place in malawi. I particularly enjoyed the Paul Farmer reference about "washing your hands", and felt that it was followed up with strong evidence from previous studies. I realize it's outside the scope of this paper, but I wonder what's being done to address the problems mentioned. I know several countries have stop-loss programs in place to retain domestically trained health care workers. I also wonder if the Global Fund would find interventions focused on strengthening the economy a little outside their mission, even if done so in the context of decreasing disease prevalence. How broad have their efforts gone in the past? are they mostly focused on treatment at a clinical level or would they be open to the idea of an economically-based prevention intervention? Either way, I thought the content was excellent and the paper had a good flow to it. Nice work.


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