To the surprise of no one who attended the recent “Penn Summit on Global Issues in Women’s Health: Safe Womanhood in an Unsafe World,” the most critical issue in women’s health care today is HIV/AIDS. Indeed, in some parts of Africa, 60% of those testing positive for HIV are women, and the fastest-growing rate of new infections in sub-Saharan Africa occurs among young women. These two statistics alone have led UNAIDS – the coordinating body organizing all United Nations AIDS-related activity — to announce that HIV/AIDS “has a female face.”
Yet participants at the conference may also have been surprised by Christopher Murray’s slides showing causes of mortality and morbidity for women globally. Although these slides did not contradict the overwhelming concern over HIV/AIDS, they told a different, perhaps more expanded, story of women’s health. Formerly an executive director of the World Health Organization (WHO) and now director of Harvard University’s Global Health Initiative, Murray discussed the important role of epidemiology in health policy. “Good decision making requires good information, and part of the good information in health care decision making is knowing the size of different problems and keeping track of that over time,” he stated.
Not until recently did we begin to systematically look at mortality and other dimensions of ill health across parts of the world, Murray noted. “The Global Burden of Disease Study, when it first came out in the early 1990s, was certainly the first such effort,” he said, referring to a study originated by WHO. By focusing not just on causes of death but also charting the costs of living with a disease or disability, the study revealed the magnitude of other health issues, such as mental illness and childhood sexual abuse. In fact, current statistics show that depression ranks just slightly lower than HIV/AIDS when looking at the burden of disease among women globally. The two diseases that cause the biggest burden to the health care system are lower respiratory infections and perinatal conditions.
One of the benefits of having these kinds of statistics, Murray told audience members, is the ability to separate advocacy from epidemiology. “There is a great tendency … to focus on certain problems that are seizing the limelight and to forget about the magnitude of other things,” he said. “It’s not to say that the topics getting more attention are unimportant. It’s just that there’s a natural human tendency to forget about all the other [needs] that are out there. And if there isn’t an advocate or champion for something, then often it doesn’t get into people’s consciousness.”
As governments, policy makers, and organizations look to spend their precious resources, they also focus on matters they can actually do something about. This, too, plays into decisions about how and when to tackle health concerns. Said Murray: “Something may be a very big problem, but there may be very little we can do about it with our current technology.” Consequently, it’s important to know which problems to tackle, what the costs of different strategies are, who the beneficiaries will be and so forth, he added.
“Failing Billions of People”
One trend in recent years sees big business stepping into roles formerly reserved for ministers of health. The Bill and Melinda Gates Foundation, which focuses primarily on children’s health and vaccines, is one obvious example. When Gates addressed the World Health Assembly in Geneva on May 16, he expressed his alarm at the state of world health. “In my view,” he said, “and there is no diplomatic way to put this, the world is failing billions of people.” He suggested that numerous groups were to blame for the global health crisis: rich governments who are not fighting some of the world’s deadliest diseases because they don’t occur in their own back yards; the private sector, which is not developing vaccines and medications for the diseases because poor countries can’t afford to pay for them; and developing nations themselves, many of whom are not doing nearly enough to improve the health of their people.
Harvard’s Murray believes that “business has a huge role, both as an employer — giving health care to their employees — and as an enormous engine of innovation for health care technology and for health service delivery.” He cited Coca-Cola, ChevronTexaco, and Heineken as examples of companies creating and implementing HIV/AIDS programs for their employees and surrounding communities. As Heineken notes in its HIV/AIDS policy on its website: “We believe that public health is primarily the responsibility of national governments. But in so far as national governments fail to assume their primary public health duties, and if this failure affects employee performance, the company will accept a supplementary role in the organization of health care.”
Indeed, so many companies are stepping into this new role that three years ago the Global Business Coalition (GBC) on HIV/AIDS was created to serve as a central hub for businesses wanting to make a difference. Headed by Richard Holbrook, U.S. Ambassador to the United Nations under the Clinton administration, the GBC acts as a clearinghouse for best practices, provides technical expertise and encourages shared learning among its member companies, which now number 200, up from an initial 17.
The Ripple Effects of AIDS
In its promotional materials, the GBC states that it is clearly good business sense for companies to respond to the epidemic. “Increased costs, loss of productivity and overall threats to the foundations of the economies in which [these companies] operate threaten the bottom line,” it notes. “The workforce is placed at increasing risk, with the epidemic disproportionately affecting people during their most productive years.” Indeed, the workforce as a “victim” hits companies hard. With young people at greatest risk of infection, firms with workforces in regions with high rates of HIV must be concerned with profitability. As employees fall sick with HIV/AIDS, for example, companies are faced with paying for more expensive health insurance, sick leave and funeral benefits. Productivity is also affected, including higher absenteeism due to sickness or caring for a sick family member, and skill and knowledge loss due to high turnover.
The AIDS crisis has an enormous impact on a macroeconomic level as well. WHO projects that for every 20% of adults infected in African countries, Africa will experience a 1% decrease in gross domestic production. National budgets are also hit hard, with the increased demand for health care straining public sector capacity. And from a purely market perspective, the pandemic is wreaking havoc on household spending, with families losing pace due to the loss of an income earner or because of financial burdens due to taking care of extended family members affected by the disease. This is playing out even in relatively richer countries like Botswana, which has the highest per capital GDP in Africa. WHO and UNAIDS predict that in the next 10 years in Botswana, “AIDS will slice 20% off the government budget, erode development gains and bring about a 13% reduction in the income of the poorest households.”
Setting aside the moral imperatives, the business imperatives are clear for a company like Coca-Cola, the largest private-sector employer in Africa. In 2001, the company launched the Coca-Cola African Foundation to concentrate resources on health care, education and the environment. In its 2004 report, the company stated that “HIV/AIDS is now the biggest threat facing Africa’s development and future,” concluding that there are “moral and business imperatives” to addressing the pandemic. The company has an enormous stake in the health of the continent. In 2003, Coca-Cola’s African business generated $827 million in net operating revenues, a 21% increase from the prior year. This momentum, however, “is threatened by the HIV/AIDS pandemic,” warned the Foundation’s chairperson, Alexander Cummings, in a 2004 report.
Books and Billboards
With 1,500 direct employees and their families, and 60,000 bottling employees and their families, Coca-Cola Africa comprises a community of some 300,000 people. Its program is particularly comprehensive, focusing on awareness and prevention programs, community involvement and treatment, and care and support for all employees and their families. The company is not going it alone, however. It has partnered with organizations like UNAIDS, the International Labour Organization, and UNICEF for technical assistance. In addition to financial resources — the company expects to spend $30 million on HIV/AIDS programs between now and the end of the decade — Coca-Cola is exploiting any means possible to address the AIDS crisis. It is using its bottlers, for example, to deliver educational books and materials developed by organizations like UNAIDS, donating billboards for educational purposes, and asking its advertising and marketing partners to donate their time and expertise to developing communications programs.
While Coca-Cola’s interventions are focused primarily on their employees and employee families, other companies have taken different approaches. ChevronTexaco, for example, is looking at ways to address the root causes of the disease. Since 1992, the company has worked to improve blood banks and blood services in Angola, with the goal of decreasing the risk of contamination through blood transfusions. In its report on African activities, the company states that since the intervention, new HIV cases due to blood transfusions have fallen from 24% to 1%.
This kind of hard data helps companies evaluate the effectiveness of their programs, or whether to develop programs at all. Heineken had an HIV prevention program in place for 10 years in Central Africa before deciding to expand its services. Its initial program was primarily educational in nature, providing information to employees, condoms, counseling and short-term courses of antiretroviral medications to prevent transmission from mother to child. But in 2001, the company expanded its involvement to include access to care, support and treatment for employees and their families. The decision was based in part on a study conducted to assess the cost-effectiveness of introducing highly active antiretroviral therapy (HAART) to HIV-positive employees. The study analyzed the risks of providing HAART and of not providing the service, and the likely impact on Heineken’s role as a community leader and humanitarian employer. Conducted at three production locations in Africa and Asia, the study showed that risk factors associated with HAART are not limited to the cost of drug therapy itself. “Although AIDS is a significant cost to the company, indirect costs of not providing antiretroviral therapy may outweigh direct costs,” the study concluded.
As Murray noted, “There is a lot of scope to improve the quality and delivery of health care in low and middle income countries, and lots of scope for business to help provide solutions to those problems.”
Yet while business-led action is making a difference in the global fight against HIV/AIDS, business alone cannot solve the crisis, notes the GBC. The organization proposes that rather than replacing the leadership needed by governments and political leaders, “the business community can support and pressure governments to act through examples of good practice and by demonstrating that prevention, testing and treatment services can be provided effectively.”