Year 25+

"Rights are not something handed down from above, but are fought for from below." 

I did a thought experiment the other day, imagining I had 100 million dollars to spend on development in Zambia. While there has been much recent criticism of aid from the West to developing countries (some of it well taken- see William Easterly's 'White Man's Burden') there is good data that certain forms of aid do work. Health projects (where outcomes- like deaths and disease rates- are relatively easy to measure) are one area with good data. So as part of my experiment, I tried to conceive of ways to give 100 million dollars directly to health care in Zambia. It's not easy to donate well. For example, giving directly to the Zambian government runs into problems with fungibility, where 100 million dollars donated to health might mean the government spends 100 million dollars less on health, with no net gain. Donating to local community projects has its own problems. The Bamako Initiative, which is a community managed health program piloted in Benin, Guinea and Mali, had success in those countries, allowing local communities to use donations to purchase drugs directly, and empowered to hire their own staff for health clinics. But the success of this type of program hasn't translated to countries like Zambia, where human resource limitations mean no real choice for communities. This lack of 'soft' infrastructure is a major hurdle to donating well in the health sector.

The following is from a paper I'm currently working on. I apologize if it is dry in places, but it does make a few key points about the whole idea of "AIDS Exceptionalism."Final3.25Paper.doc

A few developments in the past few years have come to light in the world of HIV/AIDS. One is that people on anti-retroviral therapy for a decade or so- which we're beginning to see now in the United States- develop chronic conditions like cardiovascular disease, kidney disease, diabetes and cancer at a premature age. This wave of chronic disease is just beginning to hit the developed world, and it will be a tremendous challenge to Africa and the rest of the developing world in the near future. The other development, which is an offshoot of the AIDS activist movement from the early days of the AIDS pandemic, is the shaping of AIDS policies and the creation of HIV care systems by people living with HIV. While those with HIV have always been the midwives of HIV care, the remarkably rapid expansion of HIV care in Africa over the past few years is a unique testament to this movement. Furthermore, when people are both patients and providers in a health care system, in their own communities, they are a powerful engine for transparent, accountable health care systems built from the ground-up. The future will tell whether the systems they've helped build can broaden to manage the new face of AIDS- which really means whether these systems can provide comprehensive care for all health, given the multiple dimensions of chronic HIV infection.

About this time last year I was sitting in the office of Dr. Cassius Banda, the spokesperson for the Zambian Ministry of Health. While the purpose of my visit was to obtain a letter of permission for filming at government-run clinics, the conversation inevitably turned to the American presidential campaign that played on TVs broadcasting CNN throughout the building. Dr. Banda spoke of the great psychological impact of Barack Obama as president, and how much that would mean throughout the world- especially in Africa. I have not spoken to Dr. Banda since our meeting, but I'm sure he's very happy, like much of the world.

President Obama speaks of "the fierce urgency of now" and no more is that true than in a part of the world where people die by the thousands every day for very treatable medical conditions. The work of CIDRZ (Center for Infectious Disease Research in Zambia) as portrayed in our film is all about that urgency. A recent case study of their work at the Harvard School of Public Health remarked on how fast they are increasing the numbers of patients receiving effective anti-retroviral therapy. Really fast- from zero to nearly a 100,000 patients in a matter of a few years. And the numbers keep increasing day by day. Yet they are still treating less than a half of the people who need treatment in Zambia (although not due to a lack of effort); and Zambia is only one country in sub-Saharan Africa. [It is hard to imagine the suffering in places like Zimbabwe or the Congo, where political instability makes health care delivery nearly impossible.] As CIDRZ deputy director Iris Mwanza describes her work and that of her colleagues, some days they can pat themselves on the back, and other days they realize how much more needs to be done.

Some have written and spoken of AIDS exceptionalism, and there may be some truth to that, when children die of diarrhea while others receive cutting edge HIV care. But no one can deny the suffering from AIDS, and PEPFAR and other money being spent is a fact. It's happened. There is so much to learn about health care delivery from what has been accomplished in Zambia, and so much potential use for that knowledge. Urgently, and now.

The great thing about World AIDS Day is the way that the press and governments focus on this critical health and human rights issue. The bad thing is that it's only one day. A great number of wonderful and dedicated people have devoted their lives to dealing with the AIDS crisis, but there is always a concern that the rest of the world will develop a fatal complacency. Things are much better, but we all know there is still a long way to go. Even if there was a halt to new infections from this moment, there are millions already infected that need care for decades to come. But new infections still do occur. And AIDS is a long wave event. Inertia is a mighty force, and the job of filmmakers, artists, journalists, doctors, nurses and all those who fight this scourge is to also fight the inertia and complacency that can settle in so easily.

In the 1980s, two trains collided in Africa. One was carrying the AIDS pandemic, the other, a broken health care system. Africa has been suffering from that train wreck ever since. The film "Year 25+: Healing Africa" returns to the scene twenty-five years later.
The AIDS pandemic strained an already strained health care system. Doctors and nurses fled abroad, or succumbed to the disease themselves. Fewer doctors meant little care for AIDS patients, let alone all the other ills of Arica, from TB to malaria. This worsening disease burden led to a vicious cycle- a greater patient load for doctors, more brain drain, more disease, more poverty.
To understand the enormity of this crisis in human resources, you need to understand the humans behind it- the providers. And to understand possible solutions, you need to understand what once seemed impossible. Not only has a network of AIDS care providers arisen in parts of Africa, but this network is now at the vanguard of health provision.
This story looks at the three acts in this drama- the haunting past of millions of deaths, the promising present of AIDS care, and the challenging future to deliver this promise to not only AIDS patients, but to the child with malaria in a rural village, or the shantytown barber with multi-drug resistant TB. The film personalizes the drama by telling it through the eyes of six compelling characters at the frontlines of health care. It is a vital story, not just for Africa, but for health care everywhere in the developing world.