Los Angeles Times - December 16, 2007
Charles Piller, Doug Smith

Two days earlier, her newborn baby girl had died in the roach-infested maternity ward of Queen Elizabeth II, a crumbling sprawl that is the largest hospital in Lesotho, a mountainous nation of 2.1 million people surrounded by South Africa.

Nyoba, 30, whose given name means "mother, have hope," has AIDS. But that is not what killed her daughter, Mankuebe.

Nyoba owes her own life to the Bill & Melinda Gates Foundation, which has given $8.5 billion to global health causes. Through its grantees, including the Global Fund to Fight AIDS, Tuberculosis and Malaria, the foundation underwrites, inspires or directs major efforts to prevent, cure or treat those diseases. The fund pays for Nyoba's costly AIDS medicine.

But when she gave birth on a recent Sunday morning, her baby was suffering from a different kind of distress. The infant was limp and barely breathing. A nurse rushed her to the nursery, packed with sick babies, some two to a crib. Jury-rigged stethoscope tubes enabled six of the babies to share lifesaving oxygen from a single valve.

There was no oxygen tube for Mankuebe. She asphyxiated for lack of a second valve. It would have cost $35.

The hospital, with no staff to move Mankuebe's remains to the morgue, placed her body on a shelf near the delivery room while her father arranged for burial. The tiny corpse was swaddled in a baby blanket. A handwritten death notice was stuck to the blanket with a used hypodermic needle.

The Gates Foundation, endowed by the personal fortunes of the Microsoft Corp. chairman, his wife and Berkshire Hathaway Inc. Chairman Warren Buffett, has given $650 million to the Global Fund. But the oxygen valve fell outside the priorities of the fund's grants to Lesotho.

Every day, nurses say, one or two babies at the hospital die as Mankuebe did - bypassed in a place where AIDS overshadows other concerns.

The Gates Foundation has targeted AIDS, TB and malaria because of their devastating health and economic effects in sub-Saharan Africa. But a Los Angeles Times investigation has found that programs the foundation has funded, including those of the Global Fund and the GAVI Alliance, which finances vaccines, have had mixed influences on key measures of societal health:

-- By pouring most contributions into the fight against high-profile killers such as AIDS, Gates grantees have increased the demand for specially trained, higher-paid clinicians, diverting staff from basic care. The resulting staff shortages have abandoned many children of AIDS survivors to more common killers: birth sepsis, diarrhea and asphyxia.

-- The focus on a few diseases has shortchanged basic needs such as nutrition and transportation, undermining the effectiveness of the foundation's grants. Many AIDS patients have so little food that they vomit their free AIDS pills. For lack of bus fare, others cannot get to clinics that offer lifesaving treatment.

-- Gates-funded vaccination programs have instructed caregivers to ignore - even discourage patients from discussing - ailments that the vaccinations cannot prevent. This is especially harmful in outposts where a visit to a clinic for a shot is the only contact some villagers have with health care providers for years.

The Gates Foundation's largest grants for health care in Africa go to two organizations: the Global Fund and GAVI (formerly the Global Alliance for Vaccines and Immunization). The foundation formed GAVI, based in Geneva, and has given it $1.5 billion of more than $1.8 billion it has donated for vaccination programs. The Gates Foundation holds a seat on each group's board of directors and helps determine their policies and priorities.

Because of the generosity of the foundation and other donors, millions of children have been protected against scourges such as malaria and measles - and AIDS deaths in much of Africa are leveling off. Dr. Mphu Ramatlapeng, Lesotho's health minister, echoed health authorities worldwide when she said this would have been impossible "if it were not for the money from Bill Gates."

But because of the overwhelming nature of AIDS, wartime disruptions and poor governance in some nations - and because of the priorities of global health groups, including GAVI and the Global Fund - key measures of societal health have stalled at appalling levels or worsened.

Dr. Peter Poore, a pediatrician who has worked in Africa for three decades, is a former Global Fund board member and consultant to GAVI. He says they and other donors provide crucial help but overstate the effect of their programs. "They can also do dangerous things," he said. "They can be very disruptive to health systems - the very things they claim they are trying to improve."

In a recent editorial on the Global Fund, the British medical journal the Lancet Infectious Diseases wrote: "Many believe that its tight remit is increasingly becoming a straitjacket."

Joe McCannon, vice president of the Institute for Healthcare Improvement, a U.S. nongovernmental aid organization with operations in Africa, said, "You have to ask: 'Net, are we having a positive effect?' It's a haunting question."

The Global Fund, GAVI and the Gates Foundation say that pockets of success in several African nations have shown that their approaches are sound and that in time overall health across the continent will improve.

Having started in 2002, "the Global Fund is very young," said its director, Dr. Michel Kazatchkine, a French physician who formerly led France's National Agency for AIDS Research. To see decades of neglect reversed, "Wait for two or three more years," he said.

Bill and Melinda Gates referred questions to Dr. Tadataka Yamada, president of the Gates Foundation's global health program. Yamada, a leading gastroenterologist and former research director at the drug company GlaxoSmithKline, said African nations themselves must do more to improve public health. They should spend less on weapons and more on doctors before they demand increased assistance, he said.

"We're a catalyzer. What we can't do is fill the gaps in government budgets," Yamada said. "It's not sustainable."

Sub-Saharan African nations face desperate shortages of doctors and nurses. Some clinicians, including nurses and doctors, have died of AIDS - in some cases caused when they were accidentally stuck with used needles. More than a dozen nurses interviewed throughout Lesotho said they would leave as soon as possible for safer, better-paying jobs in South Africa or Europe.

The narrow approach of the Global Fund and other aid groups compounds the problem, according to global health experts and African officials.

Ramatlapeng, the health minister, said her nation faced a conundrum. Donors won't help finance higher salaries for basic health workers. Yet the same groups refuse requests for other types of aid, citing concern that funds would not be spent effectively because of a dearth of staff.

The Global Fund pays for salary increases for clinicians who provide antiretroviral drug therapy, known as ART, for HIV/AIDS patients. Doctors and nurses move into AIDS care to receive these raises, creating a brain drain.

"All over the country, people are furious about incentives for ART staff," said Rachel Cohen, mission chief in Lesotho for Doctors Without Borders, which operates health facilities in partnership with the government.

Because of the brain drain, responsibilities for education, triage and low-level nursing pass down to lay people, particularly in rural areas that rarely if ever see a clinician. In much of Africa, task-shifting is the key response to staff shortages.

"But there are limits," Cohen said. "Some things shouldn't be done by lay people."

The situation is as bad or worse elsewhere in Africa.

In Rwanda, nurses often earn $50 to $100 a month if paid from a clinic's standard budget. They work beside Global Fund-supported nurses who earn $175 to $200 a month.

Florence Mukakabano, head nurse at the Central Hospital of Kigali, the capital of Rwanda, said she loses many of her staff nurses to U.N. agencies, nongovernmental organizations and the hospital's own Global Fund-supported AIDS program.

The health personnel shortage in Africa could cost billions of dollars to fix. But in a small country such as Lesotho, major changes could be made for a fraction of the $59 million already committed by the Global Fund, Ramatlapeng said. With $7 million annually, she could raise the pay of every government health professional by two-thirds, sufficient to retain most of them.

In some cases, salary increases targeted to certain types of care "may have had a distorting effect," Kazatchkine acknowledged. But the AIDS crisis justifies such dislocations, he said. "We are a global fund for AIDS, TB and malaria. We are not a global fund that funds local health."

He emphasized a key principle of the Global Fund: If the group took over from weak or inept governments, the result would be worse, because African countries would never develop their own expertise.

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