BEIRA—The pediatric ward is on the second floor of the central hospital here in Mozambique's second-largest city. The tile floors are cracked, the fluorescent lights flicker, and there is a rotten stench of urine and waste. The many beds in the doorless rooms are full of silent children and their parents. When tuberculosis and malaria are at their worst, the doctors say they have to put seven children in each bed. There is one pediatric nurse for 40 patients, and nearly one in five children does not leave the hospital alive. About three-quarters of those deaths are AIDS-related. Trash lies uncollected everywhere, and rats and roaches scurry through broken windows. Dr. Eduardo Matediane sighs as he looks at the building, which houses maternity wards, operating rooms, and other departments in addition to pediatrics. "They should just tear the whole thing down," he says.
Over his shoulder sits a freshly painted two-story building where Matediane has spent a huge amount of time over the past two years. It, too, is crowded. But relatively speaking, it is bright, clean, and efficient. It is the hospital's AIDS clinic, which is run by Health Alliance International, a Seattle-based group working to fight the disease in this sprawling southern African country. Here, HAI provides free counseling, treatment, and life-extending anti-retroviral drugs (ARVs).
HAI's funding for the clinic comes in large part from President Bush's Emergency Plan for AIDS Relief, for which he has pledged $15 billion through 2008. Mozambique got $27 million in 2004 and will get $48 million this year. It's a huge amount of money, and most observers credit the administration for taking action. But most of the money goes to independent groups like HAI, not through the central government. The idea is that these groups have the expertise to jump in and get the job done quickly without the bureaucratic delays or corruption that plague many developing nations. But in a country as poor as Mozambique, which ranks 171 out of 177 countries on the U.N. human development index, even some of the groups getting U.S. money say the country needs to develop if it ever hopes to stand on its own two feet in the battle against AIDS. A gleaming new clinic does little if the infrastructure around it is falling apart.
Beira is a port city at one end of a transportation corridor that takes goods through Mozambique to Zimbabwe, Malawi, and other landlocked parts of Africa. Truckers and migrant workers traveling these roads help spread the disease, making Beira one of the most infected parts of the country. The AIDS clinic lies within the sprawling campus of the central hospital, across the road from the Indian Ocean. The clinic opened in February of 2003 and now sees more than 2,200 people a month. As of mid-March, about 550 patients there were on ARVs. HAI's job description is to provide technical support, but in fact they run the clinic from top to bottom and pay the salaries of the Mozambican doctors, nurses, and counselors.
AIDS presents a series of challenges to Mozambique's health system. Unlike most other diseases, it never goes away, even for people on ARVs. Patients must take the drugs for the rest of their lives, so the strain on the infrastructure is always increasing. That's why doctors are urging an expansion of services that is both fast and sustainable. The central government limits the number of people who can start ARVs in a given month based on the availability of medical staff to monitor them, not just on the availability of drugs. That means severe limits on drugs in a country that has about 600 native doctors for 19 million people, 1.4 million of whom are HIV-positive.
HAI's success and the success of the clinic are closely intertwined, but that's a virtue of HAI's philosophy, not the U.S. strategy. U.S. treatment methods stand at odds with many practices in Mozambique and, increasingly, in other developing countries. For example, Bush's global AIDS plan requires FDA approval for generic ARV drugs made in countries such as India and South Africa, despite the existence of a parallel World Health Organization screening system. So far, only one generic has been approved, which leaves FDA-approved drugs made in the United States, where they lack generic counterparts. [Update June 1: The FDA approved a second drug, from Indian company Ranbaxy, on May 31.] Brand-name drug regimens can cost two to four times as much as generics and thus reduce the number of people who can be treated, according to a January report from the U.S. Government Accountability Office. The Mozambican government, with the help of the William J. Clinton Foundation, had already worked out a deal to buy cheap drugs from India. When the Mozambicans suggested the United States take its money elsewhere if it wanted to insist on brand-name drugs, Washington backed down. That's why HAI's drugs are generics from the government of Mozambique.
The U.S. funding mechanism is also unusual. Nearly all the other countries that send money to fight AIDS in Mozambique pool their contributions in a common fund that the group manages with the Mozambican government. The government is attempting to implement its detailed, five-year national plan to fight AIDS. The U.S. initiative does not allow donations to go directly to foreign governments, so the money goes to groups such as HAI, which in turn works with the government under the guidelines of the national plan.
HAI officials say they're in Mozambique to develop the government's health system, not undermine it. So, it's ironic that they have joined with the U.S. plan, which can't invest in the government or its long-term needs. "As a general philosophy, it would be better if the United States would coordinate its funding with other donors and do it in a way that's responsive to what the governments in these countries want and need in terms of building local infrastructure," says Wendy Johnson, HAI's Mozambique field director.
The problem, U.S. officials say, is that that approach is far too slow. The spread of AIDS in Africa presents a grave emergency, and NGOs that parachute in with expertise and money can attack the problem faster. Groups like HAI have a long record of service in the country and close ties to many local organizations. Thomas Hardy of Columbia University's Mailman School of Public Health, which is setting up clinics across Mozambique, says that the funding mechanism is not important so long as the money shows up and goes to backing local groups, providing expertise, and working through the national plan. "As a practical matter, the quickest way to get kicked out of a country is to ignore what the country wants you to do," he says. Ideally, Hardy adds, you can build infrastructure and fight disease at the same time. In practice, it's not so easy. Often it depends on the priorities of the aid recipients, not the philosophy of the United States.
In the hospital, AIDS often shows up in tuberculosis patients and pregnant women. Some doctors say 60 percent of tuberculosis patients in Beira are HIV-positive, but the TB and maternity wards are not equipped to diagnose and treat HIV. Patients could be picked up from the main hospital, deposited in the AIDS clinic, and started on treatment, but in most areas there are few links between different departments to ensure that happens, and there's nothing in the U.S. plan to see that it does. At HAI, there is talk of training people who work with TB patients to spot AIDS, but it's not been done yet. HIV-testing facilities remain separate, though HAI also runs services to counsel and test pregnant women and tries to prevent them from passing the disease to their children.
Washington is concerned about numbers: How many people are on ARVs; how many people have been tested; and how many people got care. This results-based approach is an effort to keep close track of how money is spent, but many say the drive for efficiency is misplaced. "When you're so indicator-focused and that drives everything that the organization is doing, you lose the reasons why you're doing it," Wendy Prosser, one of HAI's AIDS program managers, says. There are no indicators for doctors trained, buildings built, or nurses hired. Meanwhile, the United States budgeted $4 million of its 2004 spending in Mozambique for management costs, compared with $2.6 million for testing and $1.1 million for clinical care. Still, you can't lay the blame on the U.S. government or on that of Mozambique. The fact is that this is extremely difficult work in extremely poor countries and doing it requires climbing an immensely steep learning curve.
The week after I visited Beira, HAI hosted a meeting to announce the opening of a clinic in the small city of Nhamatanda. The ceremony began with singing, dancing, and drumming. About 40 activists from religious and community groups listened to speeches from HAI and Mozambican officials then filed through the brand new building. As in Beira, this clinic operates on the grounds of a larger hospital, whose rooms overflow with patients wasting away from AIDS-related illnesses. On the day of the meeting, the hospital had no running water. Rubber gloves and needles were being boiled for reuse. In one room, a man with a broken leg lay in a traction device, his casted limb elevated. The weight holding his leg in the air was a plastic bag filled with rocks.
After the activists left, the HAI staff worked into the night.