Sunday, August 31, 2003

Five-year-old Hassan Bukenya, from a poor neighborhood outside Uganda’s capital city of Kampala, faced certain death without surgery at Children’s National Medical Center in Washington to repair the hole in his heart.

A few days after a 24-hour journey from Uganda, Hassan — whose family survives on a few hundred dollars a year — was in one of the world’s finest operating rooms last month for a procedure that typically costs up to $35,000.

Hassan’s operation was a success. The dilemma facing doctors and public health officials is that millions of other children in poor nations are dying. And not for want of an expensive operation, but for lack of pennies to buy rehydration salts, vaccinations, antibiotics or daily vitamins.

Amid huge need, resources are limited. Someone decides where money will be spent and thereby chooses who lives and who dies.

“The hardest part is deciding who can come,” says Dr. Craig Sable, a heart surgeon who went to Uganda and picked Hassan from among 90 children who required extensive medical treatment. “It’s not a decision I enjoy making.”

The World Health Organization (WHO) says nearly 11 million children under age 5 die each year from easily preventable and cheaply cured diseases — including pneumonia, diarrhea, malaria and complications during the first year of life.

It costs just 2 cents for a six-month supply of vitamin A supplement, 15 cents for a five-day course of antibiotics to treat pneumonia and $15 to immunize a child against the six main childhood diseases, according to the U.S. Coalition for Child Survival.

A bed net, treated to kill and repel malarial mosquitoes, costs less than $10.

“The bottom line is that we do have to have priorities,” says Dr. William H. Foege, former director of the Centers for Disease Control and Prevention (CDC) in Atlanta and currently senior adviser to the Bill and Melinda Gates Foundation for Global Health. “I don’t see any way around the fact that we have to do basic treatments first.”

In January, President Bush promised to increase spending on HIV/AIDS, mainly in Africa and the Caribbean, to $15 billion over the next five years.

Public health specialists fear the plan, while urgently needed for HIV/AIDS, might wind up siphoning money away from other public health crises.

“I’d put my money on the [funds] for child survival before the [funds] for AIDS,” Dr. Foege says, referring to U.S. spending on global health.

By all accounts, the United States already outspends other rich countries on global health in terms of total aid delivered, although not necessarily on a per-capita basis.

The United States spent $1.7 billion on global health, education and population programs in 2001, according to rough calculations based on figures from the Organization for Economic Cooperation and Development. France was the second-biggest spender, with $1.1 billion in aid, followed by Germany at $1 billion and Japan at nearly $800 million.

In the same year, the United States was the biggest contributor to UNICEF with about $110 million, followed by Norway, the Netherlands, Sweden, Japan, Britain and Denmark, which each contributed between $35 million and $20 million.

A call for change

No one argues that Hassan should have been sacrificed because his heart condition was too expensive to treat.

But with limited budgets, doctors struggle to save as many children as possible.

“If you have to take from a single pot, much more consideration should be given to conditions like diarrhea and pneumonia, since they are larger and the interventions are rather cheaper,” says Gareth Jones, director of technical research at the U.N.’s Children’s Fund, commonly referred to as UNICEF.

The British medical journal Lancet published a five-part study this summer raising the question of whether the commitment to fighting HIV/AIDS was taking attention and money away from basic diseases and conditions.

“The child survival effort has lost its focus,” the Lancet article said, with “levels of attention and effort directed at preventing the small proportion of child deaths due to AIDS with a new, complex and expensive intervention … outstripping the efforts to save millions of children every year with a few cents’ worth [of basic treatments]. This must change.”

The World Health Organization reports that AIDS causes about 3 percent of child deaths. Deaths related to complications during the first month of life — often malnutrition — account for 23 percent, respiratory diseases (largely pneumonia) for 19 percent, diarrhea 13 percent and malaria 9 percent.

Health specialists say they are trapped. Most say they would prefer spending more money on both AIDS and more common childhood killers.

Dr. Foege, the former CDC director, says that spending on global health is “such a small amount of money, we should be embarrassed.”

But given Mr. Bush’s $15 billion plan to fight AIDS over five years — $10 billion in new money announced in the State of the Union message — specialists are asking whether that money will save the most lives, because basic health spending would help more children.

The Lancet study concluded: “Twice as many children die from any cause as adults from AIDS, tuberculosis or malaria.”

However, health officials say that tomorrow the balance might be different. An estimated 40 million people already are infected with the AIDS-causing HIV virus, 3 million die yearly from the disease, 5 million new HIV infections occur per year and up to 40 million children will be orphaned because of AIDS by 2010.

Political interference

The Lancet study makes its position clear.

“HIV/AIDS is a new epidemiological challenge, an epidemic that is costly to prevent among young children,” the study says. “However, other diseases and underlying conditions that can be treated easily and inexpensively cause almost 19 in 20 preventable child deaths.”

“If you’re only dealing with one disease, you tend to put blinders on the easily preventable deaths,” says Nicholas Eberstadt, a health and population specialist at the American Enterprise Institute.

Tripling or quadrupling current spending levels would save many more children.

But, says Nils Daulaire, president of the Global Health Council, “We have to live in the real world,” where politics and budgetary decisions often trump public health concerns.

Officials at the U.S. Agency for International Development (USAID), the main agency for distributing American foreign aid, say they try to help as many children as possible. But they too acknowledge a gap between where the agency would like to invest and where Congress and the president allocate much of the agency’s annual budget.

“We hold our own,” says Joyce Holfeld, acting deputy assistant administrator for global health.

She calls the Lancet study’s findings “legitimate and honest,” but declines to say whether USAID would prefer to spend more of next year’s budget on basic health programs.

“We fully support the need for child survival programs,” Ms. Holfeld says.

The 2004 budget request to Congress, the first to reflect the president’s AIDS initiative, leaves global health spending about the same at $2.9 billion, excluding an additional $500 million in AIDS funding.

About $1.9 billion will be spent explicitly on AIDS programs and about $470 million on child health programs. Congress is expected to finish the budget after summer recess.

Forced choices

The AIDS plan will focus on the 14 worst-hit countries and on preventing HIV transmission from mother to child.

“People worry that the overemphasis on HIV/AIDS makes some forget that in developing countries, even in ones heavily affected by HIV/AIDS, mothers and children can easily die of basic diseases,” says Dr. Eric van Praag, care and treatment director at the HIV/AIDS Institute of Family Health International, which received $97 million last year from the U.S. government.

But the chief of UNICEF’s AIDS section argues that public health officials should not have to pick and choose.

“If you want to limit yourself, you’re going to come to no satisfactory outcome,” UNICEF’s Mark Stirling says. “Increasingly, among [basic health] deaths, AIDS is a contributing factor, directly or indirectly.”

Indeed, AIDS causes more than half of child deaths in Botswana and Zimbabwe, and specialists in the field say the new AIDS money will enhance overall health care systems in nations where it is spent.

AIDS funding “has helped overall health functions,” Dr. van Praag says. “What we do is strengthen the antenatal and labor practices in general, so that the HIV interventions can be fully integrated and strengthen mother and child health services at the same time.”

Others agree.

“The way we would like to think about it is to find ways to build up the primary care system, to increase the investment in the general infrastructure of health services,” Dr. Fareed Abdullah, director of health services in West Cape, South Africa, says in a telephone interview.

A year’s worth of drugs to suppress HIV-infection, known as antiretrovirals, costs about $350 in poor countries, a sum that can go up significantly depending on treatment.

It costs about $100 or less to block HIV transmission from mother to child with a single dose of drugs. Preventative treatments, including testing, counseling or reproductive health care, can fall into the $10 range and begin to rival basic health costs.

Publicity game

Health specialists describe a common problem in getting the most funding for the biggest killers: Health care solutions often are driven by publicity, rather than clinical need.

“So much of what is done internationally is done for promotional purposes, for the human desire to give back,” says Dr. Jordan S. Kassalow, an international health specialist at the Council on Foreign Relations. Heart surgery is “sexier than handing out vitamin A pills or giving a shot for diphtheria.”

“There was never the political activism” to get as much support for basic conditions as for AIDS, Dr. van Praag says.

Dr. Sable, whose operation on Hassan was paid for by private charities, acknowledges the considerable cost of the surgery. He defends it, saying he picked Hassan based on urgency and the probability of a complete cure.

“You have the ethical problems between heart surgery for this child and for that child two villages down,” says Susan Raymond, research director at the philanthropy management firm Changing Our World Inc.

“The question becomes: Is there any way to resolve the dilemma, short of having infinite resources?”

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