Wall Street Journal - April 20, 2005
Marilyn Chase, marilyn.chase@wsj.com

Access to cheap generic AIDS drugs has exploded in recent years, but a critical shortage of health-care workers has stymied the progress of many treatment programs.

The Institute of Medicine, an affiliate of the National Academy of Sciences in Washington, D.C., proposed launching what it calls the U.S. Global Health Service in its report "Healers Abroad: Americans Responding to the Human Resources Crisis in HIV/AIDS."

Fitzhugh Mullen, professor of pediatrics and public health at George Washington University and the report's author, said the Global Health Service eventually could reach more countries and treat more than just AIDS . "The Global Health Service is a vehicle of American compassion that's long overdue," he said. It also is "a strategically important way to use our health care sector."

Envisioned under the proposal is a select corps of 150 AIDS physicians and other specialists, who would give two years of service as federal employees in exchange for $225,000 in salary and benefits for the period. Additional fellowships, perhaps 100 to start with, would be available to early and midcareer professionals, paying $35,000 in exchange for a year of service. And a debt-for-service plan would offer an initial 100 graduates of medical school and other health-care training loan repayments of as much as $25,000 a year for two years of service. "Twinning" partnerships would send U.S. professionals to fill in for local health-care workers who receive training outside their native country.

The State Department's Office of the Global AIDS Coordinator requested the report. Certain aspects, such as loan repayment, would require legislation, Dr. Mullen said, but legislation probably wouldn't be needed to send health workers overseas. "If the administration took this seriously, within a year or two you could have a substantial part of this in the field," he said.

A spokeswoman for the Global AIDS Coordinator Randall Tobias said officials were poring over the IOM report and it was premature to give a timetable for action. "Since we requested this report and on a short timeframe, we certainly will waste no time reviewing its findings," she said.

In a separate move yesterday, Senate Majority Leader Bill Frist, a Tennessee Republican, introduced a bill to mobilize U.S. doctors, nurses and other health professionals abroad. The Global Health Corps Act of 2005 would similarly deploy a mix of both doctors as federal employees, plus private-sector health-care professionals as volunteers. His program, which wouldn't be limited to AIDS treatment, would fall under the Department of Health and Human Services.

The IOM proposal, at least at first, would focus on the 15 countries receiving the lion's share of aid available under the President's Emergency Program for AIDS Relief, or Pepfar, a State Department program. Some international health workers, while calling the proposal a positive step, expressed concern that the program would be limited to those countries and not available more widely. The 15 Pepfar countries that the Global Health Service would initially target are Botswana, Ivory Coast, Ethiopia, Guyana, Haiti, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, Vietnam and Zambia.

Peter Piot, director of the Joint United Nations Programme on HIV/AIDS, known as UNAIDS, called the proposal "welcome and timely" but urged that the volunteers work in teams led locally. He said the corps should be linked to broader policy objectives, for example to ensure health-care workers in poor countries get decent wages.

The recruitment of the developing world's doctors to better-paying jobs in North America and Europe contributes to the brain drain in the developing world. "Isn't it a bit absurd," Dr. Piot said, "that we then send nurses and doctors to fill slots in Africa that have been emptied by our recruitment policies?"

Nancy Padian, associate director of the Global Health Sciences Program at the University of California San Francisco, said Pepfar itself could exacerbate the drain of medical personnel in some countries hit hard by AIDS .

"Zimbabwe is training nurses, doctors and other health-care workers," she said, and the newly minted workers migrate next door to Zambia and Botswana, lured by Pepfar funds and programs they lack at home.

Implementing the report's proposals would cost about $100 million a year for the first year, or about 3% of Pepfar's budget. About $35 million of this would go toward funding the elite corps. In subsequent years, if the number of fellowship and tuition-repayment recipients rose to, say, 1,000 from 100, the cost could rise to $140 million a year, the report's authors said.

Among the report's other findings: Few African nations have more than one general doctor for every 5,000 people. Ramping up AIDS treatment stretches their already-thin human resources. Rwanda has one physician for every 53,374 people; Mozambique has one for 41,060.

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