I was fortunate enough to study abroad this past spring in Botswana—often referred to as one of Africa’s success stories. With a per capita income of $14,100 (as of 2008), the standard of living is well above many other countries on the continent. And the country is far enough south that it has mostly escaped some of Africa’s most devastating climate-related health problems. Malaria is only found in the sparsely populated north, and is not a significant health problem, unlike in Botswana’s much poorer neighbor to the north, Zambia.

However, Botswana has not escaped perhaps the worst health problem in Africa, HIV/AIDS. While I commend GHF’s emphasis on malaria and other tropical diseases that receive scant attention in much of the developed world despite their pernicious effects on the poorest people throughout much of sub-Saharan Africa, after visiting Botswana the attention surrounding HIV/AIDS certainly seems quite justified. Although HIV is a problem in every country around the world, it is most prevalent in Africa, and particularly in Southern Africa. South Africa has the largest population of HIV+ individuals of any country in the world—over 5 million, and Swaziland, Botswana, and Lesotho lead the world in proportion of their populations with HIV (in the case of Botswana, roughly 25% is HIV+).

As a matter of background, let me expound on HIV just a bit (courtesy of AVERT). Because far from being a homogenous virus, HIV has mutated into a number of different, related viruses. HIV comes in two types, the most common and more lethal type being Type 1. Within Type 1, there are four groups (labeled M-P), with M being the most common. Under Group M, there are currently nine viral subtypes, with subtype C being the most common worldwide and in Southern Africa. It is also considered an especially lethal subtype, meaning that it tends to develop into AIDS and kill more quickly than some of the other subtypes. Thus not only does Southern Africa suffer from a high prevalence of HIV, but those in the region who have HIV suffer from a particularly bad strain.

Botswana recognizes this problem, and has worked hard to solve it. The country has done a much better job than many others in the region at spreading prevention messages, increasing access to confidential testing and counseling services, and providing treatment and support to those who need it. It has received tremendous sums from PEPFAR, which have in turn helped fund some of the much needed HIV-prevention and testing services with very good results. And Botswana continues to work with organizations such as the Harvard-Botswana HIV Partnership, which conducts a great deal of research on HIV in the lab and in the field throughout the country. Two of my fellow exchange students worked at the Harvard lab in Gaborone, alongside newly-minted Harvard PhDs who were engaged in large-scale studies regarding transmission and mutations. Increasingly, the problem in Botswana is multiple concurrent partners. Despite a gazillion public health messages, many funded directly by our tax dollars, many Batswana, especially men, continue to have unprotected sex with several partners without telling their other partners. As you can imagine, the virus easily gets transmitted through this chain, and the result is quite devastating. Moreover, as the country’s public infrastructure continues to be overtaxed, and donors become stingier, it will become harder for HIV patients and their families to get the services and resources they need, potentially exacerbating the problem further.

I want to relate my own experience with the health system in Southern Africa because it wends its way in with Botswana’s continuing HIV challenges. This past March, on a 12-hour overnight bus ride between Gaborone (Botswana’s capital) and Victoria Falls in Zambia, I foolishly slept with my contact lenses in. I had slept with my contacts in before, and nothing bad had come of it, but this time was different. When I awoke at the Kazungula border, I couldn’t see out of my left eye. Though I had also left the contact in my right eye as well, it was only my left one that was infected. My left eye started to swell, and though I was able to get some eye ointment, I hoped that as with many eye irritations, this one would go away after a day or so. Sadly that was not the case. So much of the weekend I spent in Zambia was not too fun (especially the all-day bus ride coming back to Gaborone). I did, however, manage to bungee jump with one usable eye (the Victoria Falls bungee is the ninth-highest in the world, with a drop of over 350 feet!).

On Monday in Gaborone, I saw an ophthalmologist who said I needed to be immediately admitted to the hospital. It was determined that I had a corneal ulcer caused by bacteria. I was able to go to a newly-built private hospital on the outskirts of Gaborone, and get treatment equivalent to what I would receive in the States for a fraction of the price. The ophthalmologist in the hospital was from the Philippines, and many of the other doctors in the hospital were originally from the United States or Europe, but wanted to come to Botswana for a new challenge. Several days later, I went to South Africa for additional treatment and prescription eye drops that are not yet licensed in Botswana. Despite the experience being somewhat of an ordeal, I was able to get the best treatment possible for my eye without having to go home to the States, but at a price. Right now, although the ulcer has healed I still can’t see well out of my left eye due to a layer of scar tissue. I will get a corneal transplant in Philadelphia in late August, soon before school starts, after which my vision should come back to something resembling normal six to twelve months after the surgery (meaning I am hoping to get the graduation present of restored vision—one of the best gifts I could receive).

But the reason I tell this story is not to present a long diatribe of my medical problems, but to illustrate an important trend that is occurring in Botswana, and throughout much of the developing world. The rich have increasing access to first-world medical care in private hospitals surrounded by guards to keep out the riff-raff (that was the case in Botswana, at least, where the private hospital I went to had guards all over the place). Public healthcare systems, on the other hand, are increasingly losing the little funding they’ve received. Had I gone to the public hospital, I would have been served in overcrowded wards with overworked nurses and where supplies run out frequently. Obviously, the staff does the best job they can given the circumstances, and many of the nurses receive advanced training in South Africa. However, educated staff can only do so much when they lack the resources to do their jobs properly, and unfortunately Botswana’s public healthcare system is simply insufficiently funded to meet everyone’s needs.

The work of charities and research institutes to find cures for diseases that plague Africa is extremely important. And in no way do I want to downplay the significance of their efforts because it is not hyperbole to say that their work saves millions of lives each year. But my concern is that this work, and the efforts by governments to help distribute these treatments has a crowding out effect on the rest of the health infrastructure. There is little question that Botswana needs help finding and paying for solutions to its HIV epidemic. But Botswana’s government is now paying almost 80% of the cost of antiretroviral drugs that can prolong patients’ lives. Yet by paying for these treatments, it has the effect of crowding out spending for other healthcare needs, including for public hospitals.

And unfortunately, limited resources combined with heavy spending on treatments for diseases such as HIV affect how others in Botswana live healthy lives. For instance, is it worth extending the life of an AIDS patient for three months with antiretroviral therapy instead of paying for treatment to prevent the sufferer of an ocular infection from permanently going blind? Nobody wants to make that choice, and yet I fear that is the choice being made all too often in Botswana and other developing countries.

This is an argument for prevention, and illustrates why distributing condoms or bednets not only keeps people healthy, but reduces healthcare spending in the long run by reducing the number of ethical decisions that must be made about treatment. And to be fair, while Botswana’s government has made attempts to prevent certain types of conditions, such as HIV, it has done a less effective job at preventing others. For instance, at the government-controlled University of Botswana where I studied, none of the soap dispensers in the student restrooms were filled. That very simple and inexpensive step to improve public health has the potential to improve academic performance as well as reduce health spending, but hadn’t been taken by staff who were preoccupied with more pressing matters. Moreover, the government has done little to promote healthy diet and exercise, despite the fact that the country is increasingly urbanized. Most Batswana used to live out in villages and work in the fields all day, so if they ate their traditional diet of meat and starch (usually maize meal or sorghum meal), with few vegetables, they stayed relatively healthy. Now, people continue to eat their old diets, but work in office parks all day, and you don’t need the intelligence of a Swattie to predict the result.

My fear of visible diseases such as AIDS crowding out other health spending was confirmed in a lecture given to my exchange student group by former health minister (and current UB professor), Sheila Tlou. Ms. Tlou made wonderful strides in combating HIV throughout the country, for instance reducing the maternal-child transmission rate from 40% to 3% during her four years in office. Yet when I asked whether tradeoffs in health spending had occurred because of the emphasis on HIV, she replied in the affirmative, but said that it was an inevitable consequence of living in a country where a quarter of the population suffers from an incurable fatal disease. Still, though, I wonder whether even small changes can be made in how health dollars are spent that would improve the health of the other 75%, without materially making the HIV-sufferers worse off.

But despite the best efforts of our organization and other well-meaning governments and NGOs worldwide, people will still succumb to illness in spite of preventative efforts. We can try to prevent the necessity of tradeoffs having to be made, but all too often, regardless of the amount of dollars pushed into prevention; those tradeoffs will still have to be made, and nobody wants to make them.

I wholeheartedly stand by the statement I made above, that the work GHF does regarding malaria awareness and prevention is incredibly important. But we cannot forget, nor can we let the wider public and NGO community that we work with forget that Africa is a continent where people suffer from tropical diseases like malaria and deadly retroviruses such as HIV in addition to the full spectrum of health problems that human beings encounter throughout their lives. This may seem obvious or trite, but it is a point that seems to be underemphasized in discussions about improving health in the developing world. We must work to apply the best available methods in combating all illnesses in the continent, not merely those that command attention because of their uniqueness to Africa or their widespread effects on vulnerable groups such as infants.

Charisma has much to do with the popularity of a health problem. People often donate to the World Wildlife Fund because they see a picture of a charismatic megafauna (eg. a sad-looking panda bear) and ask themselves what they can do to help the poor defenseless pandas. In fact, the plight of the pandas is a problem, but it is only one of many facing the animal kingdom. If WWF gave all its money to support pandas, each one could in theory eat many tons of bamboo for the rest of their lives and be plump and jolly. Yet the other animals in the ecosystem which help support the panda’s plentiful bamboo supply would obviously face real challenges and this in turn could hurt the panda.

A similar analogy can be made in healthcare delivery. People in Botswana still get eye infections, they get cancer, they have heart attacks, they break bones, etc. And all these health problems that we in the West may be more familiar with can still have very devastating consequences for the quality of life of those living in Botswana. Westerners are more familiar with these problems arguably because we don’t have to deal with widespread and deadly conditions such as malaria and HIV on an everyday basis. But the presence of HIV and malaria doesn’t make the other deadly health problems that people experience in the developing world any less real or any less prevalent. In fact, I suspect that for some conditions, such as cancers and broken bones, the incidence in the developing world is higher due to lax laws about product, worker, and road safety. (Don’t get me started on the problems with DUI in Botswana…)

I would argue that such a holistic approach starts with institution and capacity-building—ensuring that systems of public health delivery are equipped with the technical knowledge and resources to solve Africa’s health challenges. Locals obviously need to be trained, and NGOs need to provide funding to address a wider spectrum of health problems than simply one disease. This is why the Global Fund has started emphasizing the importance of developing entire healthcare systems (see points 9 & 10) instead of targeting resources only to specific diseases.

Systemic healthcare can ideally address health problems from people who don’t have much of a voice. The plight of the disabled in the developing world is often horrific, yet their cries for help get drowned out along with many others. The plight of women who need access to birth control or protection from abusive husbands, or of girls who need access to sanitary pads which allow them to stay in school after menarchy continue to be ignored all too often by a male-dominated health establishment. Even countries such as Botswana which publically promote equality of sexes continue to marginalize them through the healthcare system.

Integrated and systemic healthcare delivery has the capability to empower caregivers, mostly women, who are often burdened with the long-term care of an HIV patient or an aging relative. Providing some sort of training and support to these individuals has the potential to improve health care outcomes as well as improve the quality of life for those shouldered with this responsibility. Protecting the physical health of one individual should not come at the expense of the mental health of the caregiver. Perhaps some form of hospice or other community-based care where the burdens are shared among many is a way of easing the challenge of care. It is often the most marginalized individuals who must access care outside the traditional hospital or clinic setting due to lack of transport, payment, or an inability to get to the care facility due to ill health. Thinking about care that takes place outside these formal settings necessarily means thinking about those who are most socially marginalized as well as those who are not receiving care but providing it to a loved one.

A systemic approach to healthcare in the developing world also considers many means of healing that are often-marginalized from discussions about global health. One is the role of local or traditional medicine. Traditional healers are still popular in Southern Africa and becoming more so, as they can be more affordable than going to a formally-trained doctor. Some of what they practice is nonsense, or even dangerous. For instance, one healer my exchange group got the chance to visit promised that if caught early, his herbs could cure someone of HIV. Obviously, this raises a whole host of complications and dangers that I don’t want to elaborate on, but must be addressed if traditional healers are more closely integrated into mainstream healthcare systems.

Yet at the same time, there are aspects to traditional medicine that can be backed by Western science. Some herbs or other plant parts used in such medicine do contain antioxidants or other compounds which have demonstrated healing effects. Moreover, even if the plant contains few healing properties, it does have the power of the placebo effect, and the psychosocial experience of healing as opposed to pill-popping may be just as powerful for some conditions as taking drugs. Traditional healers are often distinct from the formal healthcare delivery system in Botswana, but I would argue that by integrating the two in a responsible manner, it has the power to enable developing countries to provide healthcare more independently of western donors and their medicine while delivering similar or better health outcomes.

My plea for integrated systems of healthcare should not in any way suggest that we should not take care of the problems that are most deadly and pernicious in the developing world, and that includes malaria and HIV. But for better or worse, we live in a world with lots of health challenges. To give someone a bed net and protect them from malaria is a wonderful act. But if that person dies a year later because of a mild flu, I don’t know whether we’ve really done our job.

As students, we face innumerable barriers to action and while I present a vision for examining problems systemically, it’s one that is obviously difficult for a student group such as GHF to carry out. But that doesn’t mean we can’t do anything. In looking towards the future this year at GHF, it may be advisable to see whether we can look at ways the NGO sector can supplement public health spending through efforts which include marginalized individuals and problems into the discussion about healthcare spending and delivery. What can we do to support caregivers and family members? How do we get people to make better decisions about their own health, and that of their family members? Is an issue such as domestic violence one that we should examine as a group promoting better global health? (And can we even do anything about that issue?) Does providing insurance or some form of community-based support, as in Rwanda, create a moral hazard problem, or provide an important safety net?

To conclude, I must apologize if this piece seemed like a rant. I was in a situation where I had to be treated for a serious but non-lethal health problem in an environment where others in my situation very well may have lost vision in one eye because most of the health dollars are going towards spending on a very serious, very lethal health problem, but one affecting a minority of the population. This experience has impressed upon me the importance of viewing global health challenges holistically, not merely through the lens of specific (albeit serious and widespread) diseases. You are free to disagree with my conclusion. But I hope that this essay generates discussion about what it really means to promote global health, and whether it should be part of the prerogative of NGOs or donors to use funds for systemic healthcare delivery that addresses more routine health matters which often continue to be serious problems in donor countries themselves.

- Sam Sellers