Bill Frist, MD
Masaka Health Clinic, outside Kigali, serves a community of about 27,000. The American taxpayer through PEPFAR provides over half of its budget. Children’s deaths have been cut by a third, thousands are alive today because of treatment with ARVs for HIV, and the malaria death rate has been cut by a third. Capacity is being demonstrated that spills over to upgrade all health care in Rwanda. Healthy people become productive people.
Today we are focusing on Health issues. An unhealthy society cannot be productive no matter how much money is spent or how much aid is given—by the U.S. or any other nation for that matter. Health is fundamental. It is a precondition to prosperity.
In order to address the issues of a growing economy and poverty with sustainable growth, we MUST establish good health. And if we are going to invest in societies through developmental assistance, we also have to invest in that societies’ good health. Otherwise, we might as well be throwing the money away. For instance, where HIV is hollowing out the most productive segment of a society (i.e. teachers, military, civil servants) and malaria is sacrificing the very young (Note: malaria hits hardest those under five years of age), our health programs should focus on HIV and malaria. That being said, we should not be limited to single diseases in a “stovepipe” fashion because health for productive and fulfilling lives requires much, much more. Think about it: lack of clean water kills more children than anything else. So we have to be smart with health aid. In addition, health and medicine can be used as a currency for peace by building trust and understanding in a community, society, and a nation.
HIV testing at Masaka: 8 years ago this test would take a week and cost $20; today it takes 10 minutes and cost $1.
Fifteen months ago, my wife Karyn and I visited the Masaka Health Center, just outside Kigali, which has been heavily supported (to the tune of about 50% of its budget) by PEPFAR, the President’s Emergency Program for AIDS Relief, that spent about $19 billion globally fighting HIV predominantly as well as malaria and tuberculosis over its first five years. The Masaka Clinic demonstrates a wonderful success story. I wish all Americans could join our delegation to see how wisely their contributions have been spent, and with accountability. We witnessed increased numbers obtaining antiretroviral treatments for HIV. We also saw the demonstration of successful community-wide programs combating malaria with insecticide-treated bednets, indoor home anti-mosquito spraying (each lasts about 6 months) and early malaria treatment, all of which have resulted in remarkable, measurable results. For example, malaria has fallen by 2/3 over the past two years (remember malaria kills a million people a year, most children in Africa); overall neonatal mortality has fallen by a third; and childhood mortality has fallen a third.
This little girl came to clinic dying of malnutrition. A year later she is healthy and energetic. The importance of proper eating is taught at the clinic. The boy furthest away from me has a swollen eye – form an orbital tumor. He will be referred to Uganda for radiation!
But what impressed me most in this current visit, which I did not see last year, was the advanced use of “low tech” technology to get state of the art results. Raul, the chief of medical technology for Rwanda, demonstrated to us how over 50 health centers around the country file weekly reports on the result of diagnosis and treatment for diseases like HIV and malaria. They do so over the telephone (solar powered if necessary) to a centralized, fully-automated, voice answering system, complete with computerized voice prompting to collect data. A central computer analyzes and aggregates the telephone produced information and reports back the collective results. It also gives center vs. center comparisons that are used for ongoing quality improvement. Wow! We don’t even to that among doctors’ offices back in the states. And here we are, in one of the poorest countries of the world, that only 14 years ago had its heart torn out with the genocide. Therein lies the magic in a country like Rwanda. Rwanda shows how American taxpayer money can be used wisely and has an effect that goes far beyond what has been traditionally regarded as humanitarian aid.
Our tour of the facility was led by the Minster of Health and Dr. Agnes Binagwaho, executive director of the National Commission on HIV/AIDS. I also met with Cornelia Van Zyl of the Elizabeth Glaser Foundation, which is doing a tremendous job on the ground there (as they do around the world). We reviewed the prenatal counseling in action and had the opportunity to talk with some of the “soon to be” fathers, observed the laboratories, and witnessed the bed-net distribution activities. With these future dads and moms (about 30 were gathered in a room for a weekly prenatal counseling session), we learned that about 80 percent of women know their HIV status by the time of birth. There is not compulsory testing, but all receive voluntary counseling and testing is encouraged.
The mother-to-child transmission program is active, and you should know, is the most cost-effective of all programs. A mother-to-be is tested and counseled. If she is found to be HIV positive, she is giving a dose of niverapine (a drug that cost less than a dollar) at about 26 weeks. The dose is then repeated when she is in labor, and a dose is given to the baby after birth. The baby is tested with a simple test 6 weeks after delivery for the presence of HIV viral load. If negative, the baby is followed; if positive, the baby is treated. When I told the groups during this presentation that this very cheap protocol cut the incidence of HIV infection by a remarkable 80% (what it was when I was last here), Dr. Agnes jumped up and corrected me, politely and with pride, “No, Dr. Frist, we have cut HIV in these babies by 95%!”
Though we give Rwanda a lot of money to fight HIV and the programs demonstrate measurable success, you have to ask yourself, should we be channeling some of this money to other public health needs which affect a lot more people? Should most of the money we give Rwanda be used for just one disease? It can be debated, but what we give works. Only 3.1% of the population is HIV positive. About 160,000 children have been orphaned by HIV. Malaria is the overall leading cause of mortality and morbidity in Rwanda, accounting for at least half of all the outpatient costs in Rwanda.
So what are you the American taxpayer doing about all this? A lot! From 2004-2007, under PEPFAR you invested $298 million to fight HIV. The President's Malaria Initiative spent $17million here just last year. And HIV spending through PEPFAR will be $123 million in 2008. (This is more than half of all U.S. aid and development funding given to Rwanda. The U.S. also strongly supports community-based in-home programs around the hospital.)
The Masaka Health clinic is probably the best example I’ve ever witnessed that implements an HIV program that really works in the developing world. Remember though, we are not winning this battle. For every person that we put on treatment with antiretroviral agents (and treatment is for a lifetime), there are four new infections coming through the door at the same time. You cannot treat your way out of this infection.
We have more to do. Science and education will provide the answer.