Hospital Visit and Research Topics

I visited St. Mary’s private-public hospital outside of Durban today; it was wonderful! St. Mary’s was founded in 1927 and allegedly (although not likely) serves a population of 1 million people with 200 hospital beds. The hospital is relatively comprehensive with casualty units, obstetrics, surgery/theatre, medical, and outpatient and tuberculosis units. I found the politics of the hospital and the tuberculosis unit the most interesting.

As a private-public hospital, St. Mary’s has funding form the South African government and private funders. The private funding was previously dominated by PEPFAR (the Presidents Emergency Plan for AIDS  Relief)– the African HIV/AIDS funding provided by the US government during the Bush administration). However, PEPFAR was not supposed to last forever and has been steadily decreasing in funding. As a Catholic hospital, St. Mary’s does not want to become a fully public hospital and solely exist on government funds because it would have to give up on some of its Catholic values, namely abortion and family planning. This was interesting to me because apparently the hospital could receive much more funding from the government if it became fully private, however because of religious affiliation, they are reluctant to do so.

The PEPFAR funding also provides a really interesting discussion. PEPFAR is considered one of the most successful aspects of the Bush administration, however it has been critiqued for it’s earmarked funding (funding that can only be used for certain purposes). Before Obama came to office, 2/3 of PEPFAR funding could only be used for pro-abstinence programs; none of the PEPFAR funding could promote safe sexual practices or contraceptives to prevent HIV transmission. Obama overturned this, but it does provide an interesting example of the complexities surrounding foreign aid. If this is interesting to you, check out Dead Aid by Dambisa Moyo; she provides a fascinating synopsis of the complexity surrounding foreign aid and provides a critical analysis of its effectiveness.

The topic of my consolidation paper is Tuberculosis in South Africa, focusing on the DOTS programme. Our consolidation has to be on a health promotion policy in South Africa and I chose Tuberculosis as the heath problem because it is a truly interesting disease: Tuberculosis is truly a disease of the poor. As I have previously discussed, HIV is a disease that effects approximately 30% of South African youth. HIV itself does not usually cause mortality; it weakens the immune system, making the person susceptible to opportunistic infections such has Tuberculosis. Tuberculosis is an airborne disease and is most commonly transmitted through sneezing. It is most commonly found in areas of high density, inadequate housing (dark and damp areas) and in people with poor diets. Therefore, poverty exacerbates tuberculosis while tuberculosis exacerbates poverty- talk about the pervasive cycle of poverty and disease!

To matters more complicated, despite being curable, TB requires a rather extensive treatment plan that involves a six-month antibiotic course. The BCG vaccination against Tuberculosis is effectively useless, especially in adults. There are four epidemiologic patters of TB: 1) in persons with HIV in developing countries 2) in immigrants in developed countries (the Southern US has high TB rates) 3) in areas with economic decline, poor TB control and substandard health 4) Globally, Sub-Saharan Africa is disproportionately effected by TB. TB used to be a disease of young men, however with the HIV co-infection (women are more susceptible to HIV), TB in sub-Saharan Africa is now becoming a disease of women. This is even more interesting because it is attributed to societal/gender norms, namely intergenerational sex. Women are typically seven years younger than men and men typically have multiple and irregular sexual partners and often engage in high-risk sexual behaviour. You can really see how HIV and TB go hand-in-hand. A quote from our visiting professor exemplifies this: “Nothing in the history of the world predisposes people to TB like HIV”.

Now, I get nerdy and into my favourite global health figure: Paul Farmer. This is an example from Mountains Beyond Mountains by Tracy Kidder. Globally, the WHO initiated the DOTS programme: Direct Observational Therapy. This policy was tried and tested in a central African country before being recommended by the WHO as a worldwide solution for TB. This programme dealt with people who were not recovering from TB, despite allegedly taking the drugs. However, the study found that due to inherent conflict and displacement in the experimental community, patients were not completely adhering to their drug regimes. They countered this by giving more drugs to the patients and directly observing them to ensure that they took the drugs. When this policy was implemented globally, Partners in Health in Lima, Peru found a problem. Despite adhering to DOTS principles, patients were getting worse and worse as they continually adhered to the programme. Finally, Paul Farmer and his colleagues found that the DOTS programme worked in the Central African context specifically because people were defaulting on their drugs. However, in Peru, people were taking the drugs and were still getting sicker. The problem was that the TB patients in Peru had a different strain of TB. Pumping the patients with more drugs that weren’t really working effectively served to create multi-drug resistant tuberculosis (MDR-TB), which has now evolved into XDR-TB (an even worse version of multi-drug resistant TB that is almost universally fatal).

For my consolidation paper, I am excited to explore the effectiveness of DOTS in South Africa. South Africa provides such a unique perspective for diseases like TB, especially because of their social determinants and vast social inequality following Apartheid.

I figure I should also clue you into my ISP project as of now. I am still planning on exploring the impact of donor funding in HIV non-governmental organizations. As I discussed above with the PEPFAR reference, donor funding can have a profound impact on an organization’s behaviour and successes. The Global Health arena is dominated by six main agencies: The Global Fund to Fight AIDS, Tuberculosis and Malaria, The Bill & Melinda Gates Foundation, PEPFAR, the World Health Organization, the International Monetary Fund and the World Bank. All of these organizations are Western and Northern based and mostly work in the Eastern and Southern hemispheres. I have pasted a passage from my electronic journal that discusses my proposed topic:

HIV/AIDS In KwaZulu Natal

According to the SANAC KwaZulu Natal Provincial AIDS Spending Assessment Brief, the prevalence of HIV/AIDS is the highest in Durban of all the provinces in South Africa, with prevalence at 37.4% in 2011 and a population of 1,576,025 people in KZN living with HIV/AIDS in 2011(SANAC 2013).

As elicited in Reimagining Global Health, biosocial approaches to health dictate that “biologic and clinical processes are inflected by society, political economy, history and culture and are thus best understood as interactions of biological and social processes (Farmer et al, p.735, 2013). Thus, HIV/AIDS is a disease that is social in nature and as such is complex with many factors influencing its prevalence and incidence.

Shifts in Funding

The onset of the HIV epidemic and the establishment of NGOs were relatively synonymous. According to Jeffery Sachs and Amir Attaran (2001) from 1996 – 1998 the donor funding for HIV programs was US$170 million (US$69 million went to Sub-Saharan Africa (SSA). Since 2001, donor funding for HIV programs has drastically increased, with total resources for AIDS rising from US$1.6 billion in 2001 to US$8.9 billion in 2006 (Attaran and Sachs 2001).

The epidemic coincided-with and lead-to further increases in funding for global health programs. It is estimated that “development assistance for health from private and public institutions rose from US$8.65 billion in 1998 to US$21.79 billion in 2007” (Farmer et al, p2518, 2013). The Gates Foundation, a primary donor of global health programs has donated over US$10 billion to global health programmes (Farmer et al, p2567, 2013). In a period of less than ten years, an unparalleled level of massive global health programmes were initiated: the Global Fund to Fight AIDS, Tuberculosis and Malaria, the U.S. President’s Emergency Plan for AIDS Relief, UNAIDS, and programs by the WHO, IMF, and World Bank. Development funding for health increased from US$5.6 billion in 1990 to US$9.8 billion in 1999 and even more to US$21.8 billion in 2007 (Farmer et al, p. 2567, 2013). This increase was not only unprecedented, but astronomical.

This incredible influx of international funding for global health programs, especially for HIV/AIDS programs lead many African countries into dependency, relying on foreign and seeing their “health budgets dwarfed by foreign aid and health policies determined by donor organizations” (Johnson, p. 496, 2008) South Africa has attempted to avoid dependency and now has the world’s largest public sector antiretroviral treatment (ART) programme, which is 95% funded by South Africa and not by outside donors (Johnson, p.496, 2008). Despite this, as Krista Johnson states, South Africa still has a long history of tension between the government and the donors, namely perpetrated by “western paternalism and South Africa’s determination to avoid dependency” (Johnson, p.496, 2008). The increases in donor funding have been drastic and in some cases even overtake government budgets. “In Uganda and Zambia external donors exceeded public health expenditures by almost 185%” (Johnson, p. 498, 2008). A donor representative told Johnson that the “tepid relationship between the [South African] government and USAID/PEPFAR in part stems from US support for the apartheid regime” (Johnson, p.502, 2008).

Despite the less-than-ideal relationships between the South African government and the United States (USA) and other donors, the USA provided US$584 million through PEPFAR to South Africa. Furthermore, the Global Fund had provided over US$88 million for AIDS and TB (Johnson, p.506, 2008). Johnson also found that significant amounts of donor funds are being refunded to the donors because they are earmarked for specific objectives or programs (507, 2008). A key point in Johnson’s article is:

“According to Ndlovu, ‘Although earmarked funding is beneficial in ensuring that new and critical projects are funded, donor funds may hinder or clash with national government priorities, leading to decreased flexibility for implementers when spending on vital local priorities.’ In addition, spending donor funds is hindered by weak provincial health systems and insufficient capacity of government to commit the money to augmenting key programmes. In recognition of this, several donors, the European Union and the United Nations in particular, have targeted capacity building within the public sector”

(Johnson, p.507, 2008).

There are several key points to be made. As shown above, a lack of sustainability, balance and even distribution of HIV/AIDS funding threaten its success and lasting influence. As Johnson states, a vast civil society influence is necessary but will not happen without funding. Given the unpredictability of funding, it is difficult to adequately plan and implement programs (498).

I will need to undertake further research on how these funds are spent and within the private sector, where they come from and which programs they fund. I also hope to look at Global Fund and Gates Foundation presence in South African HIV/AIDS programs and how much influence they have over which programs run. However, I am slightly concerned that I will hit a ‘dead-end’, as South Africa has clearly gone to extreme lengths to avoid the dependency trap that many other African nations have fallen into with foreign aid.

Donor Influence: Significance

Donor funding is important to address because it has many underlying implications. When donor funding exceeds government budgets or is substantial enough to compete with government budgets, macroeconomic stability and fiscal management are threatened and even potentially undermined (Johnson, p.498, 2008). Donor funding can also undermine the public sector simply by bypassing it; if the government does not have the stability or resources to properly utilize the donor funds or direct them, the funds can subvert institutional capacity and exacerbate government problems (Johnson, p.498, 2008).

PEPFAR provided over US$584 million in 2008 for HIV/AIDS programmes in South Africa and worked with over 300 NGOs. None of the money went to the South African government, but the United States Agency for International Development (USAID) does work with national and provincial departments in South Africa. This is significant because PEPFAR is the largest donor that does not give funds to the South African government; other large donor organizations such as the European Union and the Global Fund provide funds to the South African government. At a 2006 PEPFAR conference in Durban, the South African Health Minister stated that “PEPFAR in South Africa ‘started off on the wrong foot. We were not consulted’” (Johnson, p.507-508, 2008)

This touches upon the significance of donor influence. As stated by Johnson, undermining the government and directly funding NGOs and local programmes “creates a coordination problem” (p.508, 2008).

As seen in Haiti and described by Dr. Paul Farmer: “It wasn’t a good idea to funnel foreign assistance exclusively through NGOs and private contractors. Without real and sustained commitments to strengthening the public sector-including its capacity to monitor and coordinate services offered by NGOs- who would make sure development funds were used effectively?” (Farmer, p.1097, 2011).

Donor influence in health organizations is an important area to study, especially as the world is increasingly dominated by a few select organizations. As discussed above, the main organizations dominating global HIV program funding are the Bill & Melinda Gates Foundation, PEPFAR, the Global Fund to Fight AIDS, Tuberculosis and Malaria, the World Bank, the IMF and the World Health Organization (Farmer et al, p2567, 2013). It will be important to explore and begin to understand whether these organizations are funnelling their funding through the South African government or directly to NGOs and programs.

On the other hand, Johnson identifies further potential implications of donor influence. U.S. Secretary of State Condoleezza Rice implemented a plan for “transformational diplomacy” where the aid will go to governments and not to NGOs. This not only divides up funding for disease specific programs (ie by overriding the Global Fund), but also increases the likelihood for aid to reflect U.S. strategic interests in a more overt manner (Johnson, p508-509, 2008).

Another area of complication of PEPFAR funding is pharmaceuticals. PEPFAR funding for ARVs can only be used for US Food and Drug Administration (FDA) approved ARVs- AKA brand-name drugs that are extremely expensive as opposed to generic brands that are exactly the same, just cheaper (Johnson, p.509, 2008). This is yet another example of U.S. big business interests trumping cost-effective alternatives to pharmaceuticals.

As you can probably see and as Dr. Paul Farmer states in Haiti After the Earthquake, “Doing good is never simple”. I hope to address some of the complexity surrounding global health and development programmes through my independent study project.

I am enjoying my time in South Africa and am relatively busy with schoolwork. I haven’t found much of the work to be challenging, just lengthy, which is a bit frustrating. I am still enjoying the group, despite the lack of adventure-ness. I am certainly having a socially – relaxing semester compared to my Franklin semesters. It makes me recognize how unique Franklin students are and makes me miss always having someone to call upon for an “adventure”. At Franklin and travelling with Frankliners, we almost universally consider going out a vital part of visiting a new place and consider our travels unsuccessful if we don’t meet locals. It’s interesting being around so many Americans who actually enjoy being considered Americans; this is totally new territory for me.