DURBAN, South Africa – Dr. Carlos del Rio, chairman of the HIV Medicine Association, chairman of the Department of Global Health at the Rollins School of Public Health, has a pair of maps he shows medical students entering the field of infectious diseases.
One shows the countries of the world sized according to the numbers of adults living with HIV in each. The other shows the countries of the world sized according to the number of physicians living in each. On the first, sub-Saharan Africa balloons out, its distended countries dwarfing other continents. On the other, the balloon is deflated, Africa a sliver of its actual size, let alone the size representing HIV burden. With 24 percent of the world’s disease burden, Dr. del Rio tells his students, and told an audience here, Africa has 3 percent of the world’s workforce, and less than 1 percent of the world’s financial resources.
He was saying this Monday at a pre-conference event examining factors that will influence whether 2020 goals set to end the impact of HIV by 2030 will be met. Those factors include political will to adopt guidelines, to supply resources and to target them appropriately. Dr. del Rio was there to discuss a gap adding to the challenges of each of those, and that will take decades to fill: The people to design, deliver and sustain the needed medical responses. It is a crisis, he showed, that continues to be in danger of worsening. Sub-Saharan Africa, for example, home to an average of 18 physicians per 100,000 potential patients, is no longer home to the 20 percent of the 65,000 African born physicians who have moved — or been recruited — to high income countries in the last five years. At the same time about a third of medical faculty posts remain vacant.
Making medical practice in low resource environments safer — “We know what happened with Ebola,” Dr. del Rio noted — is one immediate need, but, he added, other answers face new challenges. “Task shifting,” a frequently offered answer is one. “Task-shifting to who?” Dr. del Rio asked, pointing to a need for increased training for nurses. Reliance on community health workers he said, is another answer that deserves more critical examination. A favorite illustration, he said is a start. “The lone health-worker,” he calls it, shows a woman balancing the weight of a community’s health and social services needs on her head, with miles to walk, scores of homes to visit.
Expecting anyone to take on a community’s ills is unrealistic, he noted. Expecting people to do it for free is wrong, he added. “They need to be paid,” he said, to an outbreak of applause. “We need to pay them for what they do. It needs to be a job, not just volunteer service.”
Donors have been more generous with surplus — and too often useless — equipment, he said, illustrating that point with a picture of a room filled with it. Sending people — to train medical students and nurses — would be more valuable, he said.
Dr. del Rio who heads a program at Emory that sends about a dozen residents annually to Ethiopia for a one month clinical trainings supported by the Medical Education Partnership Initiative, highlighted that initiative’s role in sustainable responses. A partnership of the President’s Emergency Plan for AIDS Relief, the National Institutes of Health and the Health Resources Services Administration, currently offers support to medical schools in 11 African countries to build capacities that will improve not just care, but in country research, he said.