It can be hard for people with HIV to get to their doctors. When you're poor, with no car, and not feeling well, you'll be looking for quarters and wondering if you have the energy for a long trip on a crowded bus. If you live in an area of a city underserved by public transit, if you live in the poor section of a suburban town with no bus service, or especially if you live in a rural community, you may find it hard to travel to your doctor's office, to testing centers, or to the pharmacy. And in some parts of the country, HIV docs are hard to find outside of major urban areas.

But even if you are poor, the U.S. has enough doctors, nurses, and technicians specializing in HIV care. If you live in rural KwaZula Natal province in South Africa, though, or if you live a little further north in Limpopo, you're in trouble -- real trouble -- if you have HIV and need life-saving care. The paradox of recent successes in lowering the cost of medicines and increasing global AIDS spending tenfold is that we now confront a new crisis -- low numbers and misdistribution of health workers and tattered health systems that provide almost no access to care for rural communities in Africa.

I traveled to South Africa this past summer and visited a rural school in the Valley of a Thousand Hills, 20 miles from Durban. As my wife and I descended a windy hillside in the late afternoon, we saw lines of schoolchildren beginning their five-mile walk home. Teachers told us that this school had many children whose parents had died of AIDS and who now lived in child-headed households. In fact, the valley was full of people living with AIDS -- the adult HIV infection rate in the region is over 35%. And those PWAs were a long walk, a steep hill, and many bus rides away from the closest hospital and a doctor who could prescribe antiretrovirals.

When we went even further into the countryside, to a tented game park in rural Limpopo Province, we met a wildlife tracker who told us about a fellow tracker, Vincent, who had died of AIDS just a month earlier. This man worked from 5:30 a.m. to 9:30 p.m. every day for six weeks in a row before finally getting a week off. The game park had a nurse who administered first aid, but little else. The nearest health facility that could prescribe medicines was over 40 miles away. This is in a province in which 20% of new mothers are HIV-positive.

Health systems in poor and middle-income countries are unable to respond to the AIDS pandemic and other persistent health care needs like tuberculosis, malaria, and the increasing burden of chronic diseases like diabetes and heart disease. Developing countries have 84% of the world's people, 90% of global disease burden, but only 20% of global GDP and only 12% of global health expenditures. Africa is particularly under-resourced -- it bears 24% of the global burden of disease, with 3% of the world's health workforce, paid with less than 1% of global health expenditures. High-income countries spend 30 times more on health care than low-income countries. North America has one health workers for every 25 people, whereas Africa has one for every 500.

A History of Neglect

Even after developing countries tried to reverse a century of colonial neglect in health services for indigenous populations, the debt and oil crisis of the late 1970s and early 1980s gave the World Bank and the International Monetary Fund leverage to impose draconian policies that reversed two decades of increased investment in health system strengthening. The resulting disinvestment in health and education, reductions in the public workforce, stagnant wages, and eroding support systems left developing countries with fewer and fewer options for responding to escalating public health care needs.

As health budgets shrank, health service provision focused on the urban core and local elites -- rural, township, and urban informal settlements were left to traditional healers and substandard medicines. As working conditions and pay deteriorated, low- and middle-income countries hemorrhaged skilled doctors, nurses, and pharmacists to rich countries, creating a perverse brain drain whereby developed countries' health care training costs are subsidized by some of the poorest countries in the world. Several countries, including Ghana, have more doctors working overseas than in their own health care systems. Zimbabwe has retained only 360 out of 1,200 physicians trained since 1990.

Even as health systems were crumbling, international financial institutions imposed cost-recovery measures that required governments to charge fees for services that poor people could not afford to pay. As a result, clinic visits for sexually transmitted diseases and child health decreased, out-of-pocket expenses for medicines soared, and the most basic health needs of poor people went unmet. By the time patients finally sought medical care they were often seriously ill, and tapped-out health facilities could offer little hope.

International donors and multilateral institutions responded to this burgeoning crisis with indifference. There were occasional initiatives focused on specific diseases -- smallpox and polio eradication, childhood immunization, and tuberculosis. But even these initiatives were often shortchanged and highly dependent on international charities and volunteer or short-term contract labor at the local level. Paradoxically, these initiatives sometimes drain human resources from the public and local sectors, offering higher pay and better working conditions for more highly trained health care workers.

Responding to the Crisis

After two decades of decay, the global community was forced to confront the burgeoning and long-neglected AIDS crisis in Africa. This crisis was further buffeting the already depleted health care sector with increased demand for medical services -- 75% of hospital admissions in some facilities are HIV-related. At the same time, AIDS was killing health care workers by the thousands. For example, nearly a quarter of Malawi's health care workforce is expected to die from AIDS within the next five years. The few health workers left behind have become increasingly demoralized as they watch people die or simply send them home.

In response, African activists and their international allies demanded that existing medical capacity be used to roll out comprehensive prevention, treatment, and care. They demanded that new investments be made to increase capacity to treat first millions and then tens of millions living with HIV. These same activists recognized that responses to AIDS could not be implemented through a fatally flawed and disabled public health care sector. As a result, global attention turned belatedly to evaluating the human resource needs not only for AIDS but also for pediatric and maternal health, for infectious disease control, and for community-centered primary health care.

Once rigorous human resource assessments began, they were brutal. The Joint Learning Initiative (JLI) did one of the earliest and most comprehensive studies of human resource needs and found that developing countries required more than four million additional doctors, nurses, and skilled birth attendants for the minimal purposes of achieving medically safe births. Africa needed to more than double its existing professional level workforce -- over a million new doctors, nurses, and birth attendants were required. The World Health Organization (WHO) confirmed the health workforce shortfall found by JLI and outlined the costs of health system strengthening:

• Education & training costs (doctors, nurses, midwives): $7.7 billion/year for 10 years.

• Incremental operating costs for hiring new HCWs: $17.7 billion/year.

• Incremental costs for doubling salaries: $53 billion/year.

Additional unknown costs include: building health education facilities and health infrastructure; hiring, training, and paying community health workers; strengthening procurement and supply systems, health management, and improving working conditions.

In making these calculations, WHO built on its earlier Commission on Macroeconomics and Health, which concluded that donors should provide $22 billion more per year by 2007 and $31 billion more per year by 2015. Needless to say, nothing close to close to this amount is being provided by rich countries. Likewise, developing countries were not committing the billions of dollars they needed to provide, mainly because of constrained tax revenues, crushing debt burdens, and warped internal policies. For example, the African Union promised in Abuja in 2001 to spend a minimum of 15% of national budgets on health care. So far, the scorecard is abysmal. Only Botswana spends 15%, and Zimbabwe comes in a surprising second at 14.5%. Tanzania and Uganda are spending 13% and 12% respectively. All other AU members are spending between 7% and 12%, with Kenya at the bottom, spending only 76 cents per capita on AIDS but $12.92 per capita on debt payments.

Funding and lack of commitment are not the only problems. Doctors take more than six years to train, nurses more than three, and birth attendants two or more. Building human resources for health is not just a function of time -- it is also a function of education and training capacity. Unfortunately, Africa and many other developing regions lack sufficient facilities and medical educators to double the workforce in the near future.

Community Health Workers

A partial solution to the immediate crisis is to implement a community health worker (CHW) program. Such a program would train both HIV-positive and negative community members to be proactive agents of public health initiatives and to be a link between struggling communities and a strengthened health care system. The bare outline of such a proposal is relatively straightforward. Training would include HIV-specific interventions such as HIV prevention, treatment literacy and preparedness, counseling and testing, treatment adherence, psychosocial support and peer group activities. It would also include basic elements of health such as clean water and sanitation, good nutrition, and child and maternal health.

CHWs can provide respite and support to primary caregivers in the home and help strengthen social and material support for orphans and vulnerable children. But they will not be able to perform their functions reliably unless they are supported by a system that is responsive to their needs and limitations. And CHWs must have direct access to systems of referral for medical, social service, and child-well-being services.

International Efforts: Help or Hindrance?

A major barrier to cost-intensive efforts to expand human resources for health and to strengthen health systems at the community level is the economic policies of the International Monetary Fund (IMF). These policies prevent poor countries from devoting additional resources to AIDS programming and health system strengthening. Paradoxically, these same policies may prevent countries from spending money from the U.S. PEPFAR initiative or the Global Fund to Fight AIDS, TB, and Malaria.

For the IMF, ensuring economic stability means ensuring the ability to repay international creditors and imposing "structural adjustment" policies, which include low inflation and low deficits. This leads to public spending caps for health and education that restrict countries' ability to invest either domestic or donor funds in comprehensive HIV prevention, treatment, and care. Likewise, they restrict the investment needed to rehabilitate weak health systems and to hire sufficient numbers of health care workers. Instead of encouraging investment in health care, the IMF preserves an economic order that has resulted in low growth, greater inequality, and a raging AIDS pandemic in Africa and elsewhere.

Similarly, the U.S. and other donors are reluctant to pay for recurrent costs like public sector salaries. Instead, the U.S., particularly Senator Frist, hopes to rely on international volunteers and a relatively small contingent of short-term, high-cost health consultants. Although the U.S. will pay consultants $140,000 a year to work in a country receiving PEPFAR funds, it will not hire a hundred CHWs for that same amount of money. Likewise, it will occasionally hire and place contract workers in public sector positions for a period of time, but it will not support funding approaches that would allow a developing country to institutionalize human capacity in needed areas. These policies must change before developing countries can sustain the human resources needed to stengthen health systems.

An Urgent Call

Activists and public health analysts have launched an international campaign to mobilize commitment, resources, and expertise to treat, train, and retain an expanded corps of health care workers for Africa and other developing countries. In the U.S., activists have launched the demand below. People with HIV in the U.S. and their allies have increased their solidarity with those living with the disease around the world. They have supported campaigns to lower drug costs, increase global funding, and prioritize access to treatment. At this point, treatment rollout is hitting the wall -- the outer limits of existing health care capacity. Once again people concerned about the global AIDS pandemic must raise their voices, and ask "Where are the doctors? Where are the nurses? Where are the billions of dollars?" If they succeed, the deaths of millions can be averted. If not, relatives will continue to bring dying loved ones to distant facilities in wheelbarrow ambulances. Once there, they will find patient wards overflowing and doctors and nurses few and far between.

My hope is that when I return to the Valley of a Thousand Hills there will be clinics dispensing medicines and a vibrant network of community health workers building an AIDS-resistant community. When I return to Limpopo, I hope mobile clinics can reach distant rural communities and worksites to promote access to care.

But these hopes will not be realized in South Africa or anywhere else in the region unless well-conceived strategies are undertaken on a massive scale to treat, train, and retain a greatly expanded and more diverse corps of health care workers at the community level. Stingy donors must commit predictable and sustainable resources; developing countries must implement bold human resource and health system strengthening plans; and the IMF must take its foot off the fiscal brake so that scaled-up resources can be invested wisely. Anything less is medical apartheid.

Brook K. Baker is a Professor at the Northeastern University School of Law and a policy analyst for Health GAP (Global Access Project).