How can one country fight an epidemic?

Q: Could you give us some background on Zambia and the public health issues in the country?

Zambia’s population is projected to be about 12 million. It’s a relatively diverse country in that there are 70 different ethnic groups, each with its own language, with English as the official language. They have never had a war on Zambian soil. Independence was a peaceful transition. We’ve had several years now of effective multi-party democracies with three presidents each elected according to a democratic process since 1992.

In terms of the health status, Zambia has had pretty poor indicators. Maternal mortality, for instance, which is 11 per 100,000 live births in the U.S., was 729 in Zambia, which is among the worst in the world. But we did a demographic and health survey this last year and the indicators have almost all improved. Maternal mortality is now down to 449 per 100,000 live births, which is a huge accomplishment.

HIV prevalence is 14.3%, according to the most recent population-based survey. In the world that’s extremely high. Europe is around 0.3%. The US is 0.6%. In West Africa, most countries are below 5%. Uganda, which people always looked at as having really high prevalence, is only 5.4%. Kenya is 7 or 8%. However, South Africa is 18%; Botswana is 23% percent, so in the region Zambia is doing pretty well.

About three years ago, Zambia introduced free treatment for anyone who needs it. This was made possible largely thanks to George Bush’s President’s Emergency Plan for AIDS Relief [PEPFAR]. That initiative dispensed 15 billion dollars in 5 years. PEPFAR focused their investment in 15 countries. Zambia was one of them and has benefitted greatly.

Three years ago, we had 3,000 people on treatment. Between PEPFAR and the Global Fund we are now able to provide treatment to over 170,000 people.

Prior to that, it sounds crass, but people were dying all the time. I kept track until the list of people that I knew personally who had died in a six month period grew to over 100. It was so depressing. Anytime you drove by the cemetery there would be five or six funerals going on. Now it’s more of the exception. I can think of one person that I know who died of AIDS in the last six months. That’s a huge, huge difference.

We are now working in a much more upbeat environment. A lot of focus has been put on getting access to treatment and I wouldn’t say we are done with that, but we also have to reinvigorate efforts on prevention.

Q: What are the management challenges in your work?

Getting our council, our governing body, to be effective was one challenge. When I came in with my current project in 2004, the National AIDS Council was largely dysfunctional and the secretariat to the council was understaffed. The initial council was appointed to a five-year term without anyone knowing quite what they were supposed to do. It’s a 15 person board; five of the members had died and five moved to other countries. There were no replacement appointments and the remaining five were not engaged. We tried to work with that council but it was difficult.

The buzzwords in this field are harmonization and alignment: making sure all the donors have harmonized and aligned their support and the best way to do that is by having a national strategy and a plan of action and to have that costed. Then many donors are willing to give their money to the government to implement that plan. There was a lot of talk about this years ago and not much action. Now there’s action, and it’s starting to work.

We have something called a joint financing arrangement which is all those “likeminded” donors who want to give money directly to government can direct it through this mechanism, and one of the stipulations is that there’s an effective council in place. The donors lobbied the health minister to say, look, you are not going to get any more money until you do this. A new council was put in place with a chairman who is active and engaged. They have been providing really satisfying, and necessary, leadership.

Q: How much role do you have in making sure there is money coming in from donors?

I do get involved in negotiating behind the scenes and making sure that, especially on the donor side, they feel confident that what the National AIDS Council is doing and what the government, as a whole, is doing, is working and is effective. I try to make sure that the data and the information that they need is there, but at the end of the day, it really is the responsibility of the Zambians in permanent positions at the National AIDS Council because when I leave they need to still be able to do that themselves.

When I took on this project, the message was come in to develop the administrative systems, the human resource systems, the financial systems, help hire the staff, help us make it work. There were just four people on staff. Now most of the full complement of 121 staff, including the district and provincial offices, has been hired.

Q: How much of your role is, in a sense, to make yourself unnecessary by the end of the project?

Well, I think completely.

Q: What sort of work do you do with the broader Zambian community?

In the area of HIV and AIDS we often talk about mainstreaming. The idea is that in a context like Zambia, HIV should be everybody’s business, on everybody’s mind. Everybody should be involved in doing whatever they can to prevent HIV, to provide treatment, care, and support for people with HIV, and to mitigate the impact of HIV whether it is the issue of orphans or families made vulnerable by HIV.

There’s internal mainstreaming and external mainstreaming. Internal mainstreaming is: “I have a company or I have some organization that I work with and I need to make sure I have an HIV policy in place; I need to make sure that my staff all have the support that they need to take care of themselves and their families.”

External mainstreaming is more: “How can we use our business to address issues of HIV and AIDS?” For example, we’re working with the Bank of Zambia to see how they could use some kind of incentive for people to get an HIV test when applying to get a mortgage. It is not that anybody needs to know the results because in the age of treatment the important thing is you know your status. If you are positive you can get on treatment and you can still live a long and healthy life. So it is in the interest of a bank giving a mortgage that the person they are giving the mortgage to knows their own status.

We are trying to work out ways in which the Bank of Zambia can authorize or even mandate all the banks to provide some kind of an incentive like half a percent reduction in the interest rate for people to know their HIV status.

Q: What’s the big picture of the healthcare issues in Zambia?

The biggest issue is the human resources crisis. We do not have enough clinical staff to meet the needs of the population. Partly that’s because a lot of people have died, partly it’s due to emigration. Zambian nurses get the same training as nurses in the UK, so it is relatively easy for them to get jobs in the UK, especially because they are often willing to accept a lower wage and do more menial work, than the UK resident nurses.

The issue is particularly bad with nurses but really there are chronic shortages of all health service providers, including lab technicians, pharmacists, and doctors too.

Beyond that we are going to have a very big problem putting more people on treatment for HIV. We don’t have funding to put more than the current 170,000 people. We’re meeting about 50% of our need right now and the need is going to continue to grow, so even if we maintain 170,000 people on treatment what is 50% coverage today may be 30% coverage next year as more and more people with HIV progress to the stage where they need treatment. The UN and others are defining universal access as meeting 80% of the need but without even greater external financial resources to do it, we can’t.

The UN readily acknowledges that they initially underestimated when they projected we were going to need something like $10 billion a year globally to combat HIV/AIDS. The reality is actually closer to $18 billion a year. The donors came up with the $10 billion or something close to it, but now they are being told “Actually, we were wrong. We need almost twice that.”

I know this is high on the agenda of the UN General Assembly. Certainly the U.S. government is looking at what it can do.

Interview conducted and edited by Ted O’Callahan.