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AidmAfrka

AYANGE, RWANDA IS ONE OF THE POOREST

towns in one of the poorest conntries onearth. This dusty settlement of25,000 farm-ers in the center of Africa has no rnnningwater or electricity.It got its first paved roadthis summer. Mnch of the popnlation was

mped out during Rwanda's 1994 genocide, and many currentresidents resettled here from elsewhere after the war. Some peoplehere don't see as much as $50 in cash in a whole year.

Until a ye", ago it was not uncommon in a single week tohave the funerals of three young kids. Many of them died in theirhomes because their parents couldn't afford the town's 18-bedclinic, which was often out of drugs anyway. "I am used to theidea of death;' says 82-year-old Rosalia Kabera, who has lived inthe town her whole life. "I have seen women die, young girls dieand babies die during delivery:' Her I-year-old grandson, Daniel,died of malaria in 2006. His parents, who live in a nearby town,didn't seek treatment nntil it was too late because they conldn'tafford a 30-cent co-payment.

But this year is different. Only 28 children nnder the age of 5have died, down from over 100. The difference is that the villagenow has a functioning health center. It is staffed by nurses, notdoctors, and has little high-tech equipment other than a fewmicroscopes. But it provides basic services like generic anti-biotics, rehydration fluids for diarrhea, malaria medicines, insec-ticide-treated bed nets and, beginning soon, AIDSdrugs. A littleover a year ago the clinic was seeing 5 to 10 patients a day.Nowit sees 200, and the biggest problem is overcrowding.

The changes are possible because of a Columbia Universityprogram that has pumped $145,000 into the health center,money used to hire and train more nurses and install an ordersystem so drugs don't rnn out. The program is run by JoshuaRuxin, a Columbia professor of public health. "We are trying totake health systems that have declined and bring them into the21st century:' says Ruxin, who hopes to bring sintilar iroprove-ments to 32 other clinics in Rwanda. "In IS years people aregoing to say stuff happened here. It wasn't iropossible:'

THERWANDACUREWestern do-gooders are pouring billions of dollars into controlling

malaria,AIDS and other killers ravaging the world's poorest continent.Nowcomes the hard part I ByRobert lc~mgreth

142 FORBES OCTOBER 29. 2007

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Of the 9.7 million annual deaths world-wide of kids under 5, at least 6 million couldbe averted with existing technologies, a 2003study found. The million malaria deathscould be dramatically reduced with $5 bednets. Oral rehydration fluids, at 25 cents pertreatment, can prevent many of another 1.6 million deaths fromsevere diarrhea. And $1 generic antibiotics can cure the 1.8 mil-

" lion who die every year from bacterial pneumonia. Measles still~ kills 390,000 a year; the vaccine to stop fbat was invented in 1963.~ Some of what sub-Saharan Africa needs is new technology,~ like a malaria vaccine. But what's needed most, particularly in<" Africa, is better logistics. Much of Africas population lives in~ rural villages and farms miles from the nearest clinic. Many~ countries have one doctor or less for every 10,000 residents. It's

AWebcam workswonders in

signing up poorvillagers for

health coveragein rural Rwanda.

OCTOBER 29. 2007 FORBES 143

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.not uncommon for rural folks to die at home without ever seeinga doctor or nurse.

"The hardest truth for people to come to terms with is that'the practical solutions are already out there, but they are notbeing applied;' says Ruxin, who leads the effort in Mayange. (It ispart of a larger Columbia University/United Nations undertakingcalled Millennium Villages, which focuses on making broadimprovements in 12 clusters of poor villages across Africa.) AddsFred N. Binka, a public health expert at the University of Ghana:"Donors always want to do something new. The simple thingsaren't so glamorous:'

Economists debate whether the $600 billion (in today'sdollars) spent on foreign aid to Africa in the last 46 years hasdone any good. But health spending has delivered visible results.Smallpox was eliminated in 1980 after a 20-year effort. Merck's

.,.

20-year-program to donate its antiparasitic ivermectin hashelped treat 530million cases of onchocerciasis (river blindness),spread by black flies in some parts of Africa; it has prevented40,000 cases of blindness per year. Cases of Guinea worm, a par-asite that slowlyburns through the skin, are down from 3.5 mil-lion in 1986 to 25,000 last year, thanks to efforts of the CarterCenter and others.

Yet, until the last fewyears, the industrialized world neglectedmany developing-world diseases, even as malaria and AIDSspi-raled out of control in Africa. "When I went to medical school,global health was almost a nontopic; recalls Tadataka Yamada,62, the former GlaxoSmithkline executive who now leads theGates Foundation health efforts. Rich countries spent $100 mil-lion on malaria control in 2000, according to one study-20 centsper case. They spent $69 million annually on AIDSin Africa,according to a 2001 Lancet study.

The pessimists said it was simply impractical to bring compli-cated drug regimens into poor regions with little infrastructure.

144 FORBES OCTOBER 29, 2007

A Bush Administration aid official told the Boston Globe in June200I that bringing more AIDSdrugs to Africa wouldn't workbecause many residents "don't know what Western time is:'

One of the first to prove otherwise was H.rvard MedicalSchool physician Paul Farmer, In 1985 he started a clinic in oneof the most godforsaken parts of Haiti, among the poorest coun-tries in the Western Hemisphere; it soon expanded into a hospi-tal. For years skeptics told him his programs were too complex orexpensive to work in dirt-poor settings. But by 2003 the centershad treated 1,050 patients with AIDSdrugs. The Haitian patientsturned out to be more reliable than low-income patients inBoston at adhering to their regimens.

Celebrity economist Jeffrey Sachs, then at Harvard and nowdirector of Columbia University's Earth Institute, started think-ing about health care after a business trip to Zambia in 1995. "I

Joshua Ruxin (left) aims to make Rwanda into ahealth care success story by improvingmanagement practices in isolated dinics; herehe is with patients at one rural center. Above.a nu..e consults with a mother at Mayange.

had never seen people dying before my eyes. Itwas the most shocking thing:' he says."I had noidea that people died of the most extreme lack

of access to the most simple things;Sachs at first presumed that rich countries must be helping

as much as they could, but the more he looked the more he real-ized how little was being done despite the rhetoric. He beganexposing the meager response of the developed world. He alsoexamined the relationship between malaria and poverty,concluding that a severe malaria problem reduced a country'seconomic growth by 1.3 percentage points a year, even after 0other factors such as geography and governance were taken into ~accpunt. Youdidn't need a humanitarian motive to stop malaria. ~It made economic sense. ~

In 2000 Sachs started pushing in speeches and journal arti- ~

cles for a worldwide fund for treating poor-country plagues. ~Instead of having to negotiate with dozens of donors, African;countries could set their own plans and apply for grants to buy ~AIDSor malaria treatrnents:The grants would be evaluated on ~

technicalmerit, just like medical grants at the Nationallnsti- ~tutesof Health. ~

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In 2002 the Group of Eight countries and others created theGlobal Fund to Fight AIDS,Tuberculosis and Malaria, muchalong the lines Sachs had advocated. It has distributed $8.6 billionso.far, half to Africa; it includes two-thirds of all worldwide fund-ing for malaria and tuberculosis. It tries to hold countriesaccountable by using accounting firms to audit results. Out of450 grants, only 9 have been canceled so far for poor perform-ance; another 3 have been suspended for corruption.

Others also stepped up. Last year the Bill & Melinda GatesFoundation spent $360.5 million delivering health interventionto poor countries; in fiscal 2007 the Bush Administration spent$4.7billion on treating AIDSand other diseases in poor countries.Novartis sold 62 million courses of its malaria drug, Coartem, atcost to poor African countries.

Bythe end of 2006, 1.3 million Africans were on HIV treat-

AidJoAfrkaothers. When they started, there was not one doctor in thisimpoverished region of 425,000 people near the Tanzanian bor-der, 7 miles from the nearest paved road. The drug storeroom wasnearly bare. Partners in Health quintupled the nursing staff andbrought in six Rwandan doctors and the first AIDSdrugs to theregion It hired hundreds of part -time workers to visitpatients andmake sure they were taking their drugs. The Rwinlcwavu'Hospitaihas treated 1,995patients with illY drugs-and kept 96%of themalive. It delivers 100babies a month, versus 5 a month in 2005.

Jennifer Uwimana was a living skeleton when she arrived atRwinkwavu in January 2006. She was vomiting, had bad diar-rhea and weighed just over 8 pounds, 40% the normal weightfor a I-year-old. She had AIDS and tuberculosis,an.especiallylethal combination that has killed millions across Africa. With-out treatment she wonld have died within weeks. But doctors

ment, up from 100,000in 2003. "When it comesto Africa, the belief isthat not much can bedone. My goal is to

prove otherwise; says Abdirahman Mohamed, a Somali-bornAmerican doctor who leads a Gates-funded program to distributeinsectidde-treated bed nets and control malaria in Zambia. In JuneanHIV"implementers" conference brought 1,500doctors and pub-lic health experts to Rwanda to discuss how to get AIDSdrugs toAfrica. "This is all brand new. It is astounding;' says Harvard'sFarmer. "Afewyears ago there were no implementers:'

~ Rwanda has 899 doctors fora nation of9.9 million, bntonly 185E are in rural areas,wheremost of thepopnlation lives.Per capitahealth~ spending is $14 a year,versus $6,000 in the U.S.But the Rwandan~ government is stable,the cellphones work and the economyisgrow-~ ing-notwithstanding a low scoreon the Heritage Foundation/Walli Street Journal index of economic freedom. "The level of vision for; what the country will do with the average health center is far more~ ambitious than I have seen anywhere else" in Africa, says Colum-~ biaSRuxin, who has also worked in Kenya,Ethiopia and Nigeria.<~ In 2005 Farmer's Partners in Health charity renovated a~ decrepit, barely functioning public hospital in rural Rwanda, with~ $2 million in funding from the William J. Clinton Foundation and

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Jennifer Uwimana, at left. with Mom.was weeks from death bef"", aremarkable recovery- Above, Ruxin'scolleague Blaise Karibushi. At right,a community health worker inMayango.

were able to treat her with a cocktail ofTB medicines, antibioticsand generic AIDSdrugs.

Jennifer's HIYis now under control, her tubercnlosis is curedand her cheeks are chubby. At 2112she cruises around the hospi-tal malnutrition ward (where her mother now works), boldlystarting a game of peek-a-boo with a stranger and grabbing hiscamera to see the display. Her mom, Olive llibagiza, sometimeslooks at her child, amazed at the turn of events. "Where I camefrom and where I am now, it is unbelievable;' she says.

Ruxin became fixated on Africa after the big Ethiopian famineof 1984.While still in high school he founded a student charity toraise money for hungry children; by his senior year it had chaptersnationwide. But after gening a Ph.D. in the history of medicine, heconcluded that charitable groups didrit have the answers and wentto wor!<:in the private sector as a consnltant to developingcountries.His work eventually led him to croSSpaths with Sachs,who hiredhim. He now supervises a staff of 85 aid workers in Rwanda.

When Ruxin visited Mayange in 2005, there were no nurses

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OCTOBER 29. 2007 145FORBES

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AidJoAfrkapresent even though it was the middle of a workday. The healthcenter had such a bad reputation that locals would walk miles toavoid going there, saysRanvn-Dhillon, an American medical stu-.dent who helped out in Mayange for 18 months. When hestarted, the village was in the midst of a drought, and malnutri-tion was so prevalent that Dhillon would shove 16 skinny kidsinto the project's SUVto drive them to a hospital where food wasavailable. For the first few months so many people were dyingthat Dhillon spent much of his workweek delivering bodies backto grieving families and organizing and attending fimerals.

A few radio ads brought in dozens of unemployed nursesfrom nearby; 11 were hired to bring the staff up to 15. Thishelped the clinic stay open all night to deliver babies; previously-most momshad deliveredin their homeswithout professionalhelp. Now 80% of births take place at the center.

The health center was only a few hundredyards from electric transmission lines, butnobody had ever bothered to connect it. Ruxinpersuaded the government to do that. AlisonHager, a Pfizer finance official who volunteered in Rwanda forsix months, got her company to donate 100 used laptops forMayange and other nearby clinics, for use in tracking druginventories. One. problem was getting people to come to thehealth center. Rwanda requires citizens to pay a $2 annualpremium for health coverage and get a photo !D,but the neareststore with a camera was a 7-mile walk from Mayange. The solu-tion: a $35 Webcam attached to the laptop.

Vumumlriya Mugorewase, 47, lives in Mayange with her sixchildren. She makes $8 per month braiding hair. In the past sheused traditional African healers, even though their medicinesdidn't work, because she couldn't afford the national health plan.Her 16-year-old daughter, Madeline, nearly died from malaria inJune 2006. She survived only because Mugorewase ran intoDhillon on the street one evening a week after Madeline haddeveloped a fever. They took turns carrying the nearly comatosechild to a car to got her to a hospital in the nick of time.

In the fall of 2006 Mugorewase was able to sign up for thehealth plan at a reduced rate (subsidized by the MillenniumVillages project) via the Webcam. Since then she has used the

146 FORB'S OCTOBER 29, 2007

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health center for everything from various fevers to her kids' nightterrors. "1have never had proper care like this before;' she says.

Can the progress at Mayange (or Rwinkwavu) be dupli-cated elsewhere? New York University econ,omist WilliamEasterly is what you might call a compassionate skeptic. Hesays: "People like Jeffrey Sachs and Bill Gates see themselves asmessiah-like figures who are going to change the world. In thereal world money and technology is 5% of the solution; 95% isimplementation. Youneed a functioning public I)ealth system,and that is exactly what is missing in most of Africa. ... If onlywe had good Latin names for diseases like 'missing healthworker' or 'stolen drugs' -those should be the diseases thatdonors should treat:' .

Easterly says efforts to help places like May,mge are "liketrying to create a miniature utopia in the middle of a dysfunc-

Weighing babies at the Mayangehealth center (left). Rosalia Kabera,82, has watched many people diefrom treatable diseases. Kids play in atypical Mayange street (right).

tional society you cannot fix. Theycannot be replicated, they cannot bescaled up;' (Sachs dismisses his crit-

ics as "professional complainers. If they want to do somethingsome other way, do it. If all they want to do is complain, stay outof the way:')

Mayange is snccessful in part because the MillenniumVillagesproject pays the salaries of 14of the 17nurses now there.The Rwandan government is supposed to eventually take overmore nurse salaries. The typical rural clinic in Rwanda is a lotfarther than Mayange's from the electric grid.

With funding from the Glaser Progress Foundation, Ruxinand his Rwandan colleague Blaise Karibushi are trying to help32 isolated clinics better manage the limited resources theyhave. Laptops, for example, help nurses keep track of who hasbeen treated for what, so clinics can qualify for governmentbonuses. But where does the electricity come from? Oneforlorn clinic in Mareba, miles down a hilly dirt road from ~0Mayange, has two laptops to track drug inventory and ~expenses. The clinic's solar-powered batteries are able to ~

run only one at a time, along with some dim fluorescent ~bulbs. Ruxin doesn't have enough money to put in a better ~

solar energy system. F ~