By Liz Borkowski 

Last week, Revere at Effect Measure used extremely drug-resistant tuberculosis (XDR TB) as an example of why the world needs a resilient and robust public health infrastructure (and just a few days later, an article on an XDR outbreak in South Africa made it to the New York Times’ list of the 10 most e-mailed articles). Earlier this month, Laurie Garrett, a senior fellow for global health at the Council on Foreign Relations, published an article in Foreign Affairs (subscription only) in which she listed TB as one of the diseases that’s been getting more money and attention recently – and warned that new resources might not improve health if infrastructure isn’t strengthened.

Not everyone who gets infected with the TB bacilli becomes sick, but those with weakened immune systems are most likely to fall ill. The treatment process is extensive, and drug-resistant TB strains tend to emerge in areas where drug supplies are unreliable, health workers prescribe the wrong treatment, or patients don’t complete the full treatment course. (The WHO has more details.)

XDR TB is practically untreatable. It exists in Russia and China, but its presence in South Africa is particularly alarming because of that area’s high rate of HIV. TB is a major cause of death among people living with HIV/AIDS, and the spread of XDR TB could threaten millions of lives throughout Sub-Saharan Africa. It could also become a health crisis on the global level – in fact, Revere reports that cases of XDR TB have already turned up in North America.

The Hurdles: Training, Illness, and Emigration
One of the challenges that Garrett highlights in her article is a shortage of trained healthcare workers in the countries suffering from high rates of AIDS, TB, and malaria. She cites the experience of Botswana, where a program launched collaboratively by the Gates Foundation, Merck, Bristol-Myers Squibb, the Harvard AIDS Initiative, and the country’s government aimed to get anti-retrovirals (ARVs) to all its infected citizens.

With its relatively low rate of unemployment (compared to its neighbors) and sound general infrastructure, Botswana seemed primed for success in this venture. Garrett explains that the program ran into unanticipated problems, though, because Botswana lacked sufficient healthcare workers – it had no medical school, and it lost 60% of the nurses it trained to emigration. Healthcare infrastructure was also a problem, with labs and clinics in short supply. The program needed additional aid and preparation before it was able to commence in 2005.

Botswana is far from alone in its health worker shortage. According to the WHO, 57 countries – 36 of them in sub-Saharan Africa – have severe shortages of healthcare workers, and it’ll take more than 4 million additional doctors, nurses, midwives, managers, and public health workers to fill the gap. Last year, the WHO announced the launch of The Global Health Workforce Alliance, which will work to achieve a rapid increase in the number of qualified health workers in countries experiencing shortages.

It’s important to train more health workers, and to provide ARVs to those who are HIV positive. (According to the International Labor Organization, 18 – 41 % of the healthcare labor force in Africa is infected with HIV.) Garrett emphasizes, though, that the health worker shortage can’t be solved until NGOs and developed countries stop poaching local talent to staff their narrowly targeted programs or overseas hospitals. She offers some examples given by health officials in the affected countries: 604 of 871 medical officers trained in Ghana between 1993 and 2002 now practice overseas; only 360 of the 1,200 doctors trained in Zimbabwe remain in the country today; and Kenya has lost 1,670 physicians and 3,900 nurses to emigration over the last ten years.

The lack of appropriate supplies and equipment hurts morale among healthcare workers – Garrett reports that some feel more like hospice and mortuary workers than healers – and can make them more likely to emigrate or take a job with a wealthy NGO. It’s unlikely that the drain would be so severe, though, if developed-world NGOs and hospitals would put more effort into training new healthcare workers and less into active recruitment of those already trained by countries that need them.

The U.S. Nurse Situation
Garrett says that OECD nations “should offer enough support for their domestic healthcare training programs to ensure that their countries’ future medical needs can be filled with indigenous personnel.” A report published last year by the Institute for Women’s Policy Research gives some more insight into how the U.S. might increase its supply of nurses without relying on immigrants to fill the growing demand. (The U.S. Department of Labor projected that 1.2 million nurses will be needed to fill new and vacated nurse slots between 2004 and 2014.)

First, the report notes that hospitals haven’t tended to respond to the growing demand for nurses by increasing nurses’ pay, which they could do by raising starting salaries and also by making it possible for nurses with additional training or experience to earn more (nursing salaries plateau at around $47,000, according to one study). Instead, they’ve been scheduling too few nurses for the predicted workload, extending nurses’ work schedules, and hiring temporary or contract nurses. These strategies compromise patient care by increasing the likelihood of errors and adverse events.

Poor job conditions – which include stress from overwork, low pay, and a lack of career ladders – drive many nurses out of hospital jobs and toward settings such as physicians’ offices. Meanwhile, it’s hard to get enough new nurses trained because salaries for nursing instructors are unattractively low.

The study found that nurse unionization increases wages for nurses in the cities with greatest levels of unionization, and cites research showing that heart attack mortality rates are lower in unionized hospitals. Some research suggests that unions may improve quality of care by increasing nurse staffing levels; the report’s authors suggest that the presence of unions may also have a positive effect on patient care because it improves morale, job stability, and collegial relationships.

The report offers several policy recommendations, including increasing wages and salaries for nurses and nursing educators, providing legal protection for union organizing, and requiring hospitals to pledge not to collude with one another to set nurse wages. It notes that a 10 percent increase in hospital nurses’ wages would cause total healthcare spending to rise only one percent – and some of that increased spending might be offset by resulting improvements in the quality of patient care.

So, perhaps some of the organizations that are working to stop the spread of AIDS and TB in developing countries should also start calling for improved working conditions for U.S. nurses. Slowing the drain of nurses from the countries that already face acute health worker shortages would give those countries’ health programs a much better chance at success.

Liz Borkowski works for the Project on Scientific Knowledge and Public Policy (SKAPP).