The LA Times has a good article on how aid money to treat diseases with sophisticated medical care ends up hitting the reality of lack of an infrastructure.

Been there, done that….

However, the headline “Unintended victims of Gates Foundation generosity” is misleading.

The implication is that the Gates foundation is making things worse. It is not. But like most limited programs, it isn’t able to cure all of the problems faced by those with malaria or HIV.

Problem one: lack of infrastructure, and a dependency mindset made worse by colonialism and by NGO’s. ..but that’s another discussion for another essay.

Problem two: doctors and nurses are human. It’s not the fault of the Gates foundation that doctors and nurses prefer to work at a good paying job where they can use their training.

It’s a myth that if they didn’t work at these higher paying jobs they could work at rural clinics. The dirty little secret is that most of them would just leave to work in the UK. Most have large extended families that they support, and view work as a way to help their families.

If you want to keep highly trained doctors and nurses working in rural areas, there are two ways to do it:

One: Hire altruistic types. Missionaries, especially nuns, who essentially leave family to serve the Lord. Many missionaries are now local people who stay to serve their own people, or go to nearby countries to work. Similarly, many young graduates and retired doctors will give a year or two to serve. (Peace Corps, Mercy Corps, Doctors without Borders).

An alternative is to pay a decent salary, and guarantee that the doctors and nurses will not be overworked.

There is a third way: To force newly trained doctors and nurses to “give” one or two years to work at such clinics. This can be universal, or in exchange for payment of school fees. This is how the US manned the Indian Health Service clinics: Originally, doctors could chose working on a reservation to their military commitment under the draft laws; later, government scholarships required “payback”.

Such schemes have limitations: Some doctors and nurses when supervised don’t do the work, and there are cultural differences between city trained medical personnel and the locals. And of course, most leave as soon as the contract is finished.

So when I read:

The Global Fund pays for salary increases for clinicians who provide antiretroviral drug therapy, known as ART, for HIV/AIDS patients. Doctors and nurses move into AIDS care to receive these raises, creating a brain drain….

Wrong. A lot of these same people wouldn’t be working long hours for a small salary at understaffed, poorly equipped government clinics if the Global Fund wasn’t around…they’d be emigrating…

Because of the brain drain, responsibilities for education, triage and low-level nursing pass down to lay people, particularly in rural areas that rarely if ever see a clinician. In much of Africa, task-shifting is the key response to staff shortages.

Yes, you “task shift”. That means recruiting and training low level workers. They have fewer job opportunities, so might stay in place.  And unlike the (mainly) city born and bred doctors, they understand the local culture, and communicate better with the locals.
Yes, they aren’t doctors, but you don’t need doctors for 95% of these illnesses.

The dirty little secret is that most of the deaths can be treated with cheap things, like vaccines, clean water (digging wells), DDT spray (less toxic and cheaper than other malaria prevention) and WHO rehydration solution for diarrhea, a major cause of death in children.

The nurses and nurses aides could be (and probably are) supervised by the highly paid doctors.

That’s how things are done. Sorry about that.

As for the rest of the story: it comes down to you can only do so much.

You make a priority, and then work on that. Hopefully someone else would work at another priority.

To point at the Gates foundation and blame it for the lack of infrastructure, the lack of supplies, the lack of food, and the corruption of government officials is a red herring.

The real problem is development, jobs, and building an infrastructure. Ironically, those problems might better be solved by small loans to local entrepeneurs than by funding governments. Once people have jobs, they can fund their own health care, and tend to eat better.

Yet with HIV decimating the educated, you have to start somewhere.

Another dirty little secret is that African HIV has hit the educated the most, because in African tradition, those with money/prestige would have more wives, but now they have more girlfriends.

You treat HIV, and save the educated. The educated feel well on HIV treatment and can work. They run businesses, teach in schools, and run hospitals. Without the money from Gate’s Global fund, they’d be dead.

As for the infant that the article claims died for lack of a 35 dollar valve: remember, a lot of people live on one dollar a day.

I’ve seen children die of lack of a ten cent vaccine, or a lack of WHO Rehydration fluid (10 cents) given to them by a local village aid worker (ten dollars a month for a part time job).

As for the comment: “The clinics don’t have what we need: Food”…that’s a bunch of bull too.

Blame the NGO’s from stopping the use of high yield GM food, and blame governments for not putting a priority into selling high yield seeds and fertilizer to farmers. Blame warlords for causing chaos so people can’t plant food. And blame the Portuguese from introducing maize 400 years ago, since maize destroys crop land without fertilizer.

But stop blaming those trying to help.


Nancy Reyes is a retired physician living in the rural Philippines. Her website is Finest Kind Clinic and Fishmarket, and she writes medical essays at HeyDoc Xanga Blog. 

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