The Other War

Published: Wall Street Journal
Date: December 29, 2006; Page A8

Stories about AIDS and malaria don't typically carry good news, but 2006 was a year of progress on both fronts thanks to some new thinking about how foreign aid can best be spent.

The White House held a malaria summit this month, and the message was one of accountability, not just spending more money. The U.S. malaria initiative targets 15 of the hardest hit countries in Africa with the goal of cutting mortality rates in half. The plan is to spend $1.2 billion over five years on indoor insecticide spraying, bed nets and medicines to combat a preventable disease that kills a million people in the Third World each year. An additional goal is to work with the private sector; the Gates Foundation and ExxonMobil are among those taking the lead.

"Transparency" and "accountability" are not terms heard often today in discussions of global health; the focus usually is on how much money is being spent. "We are insisting on measuring," President Bush said at the summit. "We can determine whether or not nets are being distributed or medicine is being provided. But more important, we can measure whether or not we're saving lives."

This emphasis may seem obvious. Yet it's long been neglected by aid organizations -- including the U.S. Agency for International Development -- and has led to such travesties as the conscious distribution of ineffective anti-malarial drugs. Another problem has been an unwillingness among global health groups to pursue such politically incorrect measures as indoor spraying of the insecticide DDT, the cheapest and most effective weapon against malaria. Admiral Tim Ziemer, the U.S. malaria coordinator, says the U.S. will promote DDT spraying to fight the disease.

This malaria effort builds on successes in dealing with AIDS, particularly in light of new evidence that malaria tends to increase the HIV viral load that causes AIDS. Since Mr. Bush launched his $15 billion plan for AIDS relief in 2003, the U.S. has provided life-saving antiretroviral drugs for 822,000 people -- a number growing by 50,000 a month -- while providing care for another 4.5 million people such as AIDS orphans. That's still only a fraction of the 39 million HIV infections world-wide, 62% of them in sub-Saharan Africa. But as U.S. AIDS relief coordinator Mark Dybul says, this is "as much as all other developed countries combined."

Here too, the work has been distinguished by a focus on what Dr. Dybul calls "a culture of accountability." The U.S. global AIDS bureaucracy, previously divided along country and bureaucratic lines, now has a uniform funding and administrative approach. The U.S. has also insisted on regular reporting requirements from its overseas partners, 80% of which are private or non-governmental organizations.

At the HIV clinic of South Africa's McCord Hospital, for instance, a computer-based monitoring and evaluation system allowed doctors to notice abnormal fatality rates among overweight, middle-aged female patients on the antiretroviral Stavudine. The drug was discontinued, the problem was eliminated and the rest of the hospital adopted the reporting system. As a result of such efforts focused on behavior modification, at least some African countries are beginning to see sustained reductions in HIV infection rates: 10% in Botswana, 23% in Zimbabwe, 30% in Kenya.

That won't be close to enough to save every HIV-infected person, and matters haven't been helped by the fashionable demonization of the drug industry, which has led to resistance to antiretrovirals in places like South Africa. But what the Bush Administration is showing with AIDS and malaria is that a well managed effort can save millions from an early grave.

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