Smart generals study history. The lessons of battles past provide valuable clues about how to win in the future. In the war against AIDS in the developing world we need to study how major successes have been achieved in health programs and how to apply those lessons today.
As we are sure to be reminded on World AIDS Day, this Wednesday, the disease has killed 22 million people since 1980, most of them in the prime of their lives. Forty million people around the world are living with AIDS; 70 percent live in sub-Saharan Africa. Last year alone, 5 million more people in developing countries became infected, and 3 million died.
Without a major improvement in prevention efforts, within 10 years 45 to 50 million more people will become infected. This is the contour of a war in which winning now looks impossible but losing is unthinkable.
Success is possible against AIDS, tuberculosis, malaria and the many other diseases of poor countries. Major battles against devastating diseases have been resoundingly won — even in the world's most underdeveloped and remote regions, in the face of grinding poverty and weak health care systems. For example:
- Children in seven southern African nations no longer die in large numbers from measles, because of focused immunization efforts.
— Across 11 countries in West Africa, a major public health program lasting 28 years and run almost exclusively by African professionals has prevented hundreds of thousands of cases of blindness.
— A national campaign in Egypt that promoted a simple treatment for dehydration helped reduce the number of infant deaths from diarrhea by 82 percent over a six-year period.
— In Thailand, a government program that required sex workers to use condoms led to 80 percent fewer cases of HIV among high-risk groups in 2001 than a decade earlier, preventing nearly 200,000 new cases.
— Starting in 1985, governments in Latin America and the Caribbean made a major effort to vaccinate virtually every child against polio. Today, polio is no longer a threat in the Western Hemisphere.
These experiences offer strategies and inspiration for those dealing with today's great global health challenges. So do the dozen others that a panel of experts in international health, public policy and economics has studied to find clues to success.
There are findings here that challenge popular notions about the expense and futility of trying to make dramatic gains in health in poor countries.
One surprise is that donor funding can work; it's not "money down a rathole" — the popular image of the foreign aid business. In Egypt, for example, it was a USAID-funded program, supported by technical expertise from the World Health Organization, that contributed to the prevention of 300,000 child deaths from diarrheal disease between 1982 and 1989.
Public health programs turn out to be remarkably good investments, in fact. The costs are dwarfed by the social and economic benefits of eliminating, treating or controlling diseases. For example, a tuberculosis program in China treated more than 1.5 million patients over 10 years, preventing 30,000 deaths each year at a cost of just $15-$20 for each additional healthy year of life. The economic returns were enormous: Each dollar invested in the program generated $60 in the form of savings on treatment costs and increased earning power of healthy people.
Experience also shows that national governments can get the job done — a finding that contrasts with the view that governments in poor countries are inefficient at best and corrupt at worst. The public sector was integral to the successful delivery of services in most of the cases. In the southern cone of Latin America, for example, ministries of health collaborating across borders greatly diminished the threat of Chagas disease, an often deadly parasitic disease spread through insect bites. In Sri Lanka, a 60-year commitment to provide key public health services dramatically reduced the number of deaths during pregnancy and delivery.
Not only can national governments do the job, so can the alphabet soup of international agencies often dismissed as wasteful bureaucracies. They can do the job if they work together and — in at least some instances — with private industry.
The guinea-worm eradication campaign illustrates the point. Twenty African and Asian countries reduced the number of cases of this devastating disease from 3.5 million to less than 35,000 in 17 years. To do this required collaboration between each of the 20 governments and a veritable army of agencies and organizations: the Centers for Disease Control and Prevention, UNICEF, WHO, the Carter Center, the Bill & Melinda Gates Foundation, the World Bank, the United Nations Development Programme, nongovernmental organizations, more than 14 donor countries and private companies.
Public health programs, too, can change behaviors — something that is particularly good news for the fight against AIDS.
In Bangladesh, mothers learned — and now teach their grown daughters — how to mix clean water with a simple salt-and-sugar solution to prevent childhood deaths from dehydrating diarrheal disease. And in Poland, a country that had the highest cigarette consumption in the world before 1990, smoking rates have plummeted because of a combination of legal measures, taxation and communication programs.
A look at past successes also shows that there's no time to lose in marshalling appropriate resources. The best known global health success — the eradication of smallpox in 1977 — probably could have been achieved nearly a decade earlier had enough money and political will been put to the service of public health. The delays cost lives, money and the credibility of international institutions.
Reaching success in current health battles will not be easy, but it can be achieved. Closing the gaps may require new and longer funding commitments, a bigger push to get and use information, an effort to create a genuine consensus about what needs to be done and even more hard work. These actions take energy, brains and money, but they are far simpler and less costly than the loss of lives and livelihoods that failure will bring.
That's how to win the public-health war — a war in which the face of victory is productive workers, safe mothers and thriving children.
Ruth Levine is a senior fellow and director of programs at the Center for Global Development and head of the center's Global Health Policy and Policy Research Network.