Ernest Darkoh has been at the forefront of what has been called the most important public health experiment on the African continent today, leading the charge to fight AIDS in the African nation of Botswana — and building a nationwide health system from the ground up in the process.
Born in the U.S.A. to Ghanaian parents who were completing their graduate studies, Darkoh grew up in Kenya and Tanzania. There, pervasive poverty and the absence of effective government services made a deep impression on him. Encouraged by his parents, he returned to America as a young adult, first to triple-major in chemistry, biochemistry and molecular biology, then to attend Harvard Medical School. He then added a master’s degree in public health followed by an MBA, after which he took a job at McKinsey & Co., one of America’s leading management consulting firms.
His medical and public health studies taught him what might be accomplished, but Darkoh credits his business experience with teaching him how to get things done. As he once told Chicago Tribune reporter Laurie Goering, “In business you succeed or go out of business. There’s no fluffy ‘I help humanity’ in the middle. Business forces you to do things well and show results.”
In 2001, the government of Botswana hired McKinsey & Co. to develop a strategy for implementing a large scale AIDS treatment program, and Darkoh suddenly found himself in a position to apply everything he had learned.
A nation of 1.7 million people with a large migrant population, Botswana had a reputation as a stable, safe, and democratic country with substantial mineral wealth, but its adult HIV infection rate, then estimated at 35.4 percent, was among the highest in the world. Facing catastrophic social collapse, Botswana formed a partnership with the Merck Company Foundation and the Bill & Melinda Gates Foundation. These two philanthropic organizations had become convinced that the only way to effectively tackle the AIDS pandemic in Southern Africa was through comprehensive national programs featuring both prevention and treatment. The hope was that a successful program in Botswana might serve as a model that could be applied in other African nations. (note: both The Merck Company Foundation and the Bill & Melinda Gates Foundation are funders of the Rx for Survival project.)
With the Harvard AIDS Institute providing key expertise, Botswana and the two foundations launched the African Comprehensive HIV/AIDS Partnerships (ACHAP) —a public-private collaboration backed by a pledge from Gates and Merck to provide $100M in cash and drugs to be delivered over a five-year period.
With the strategic plan in place, Darkoh signed on to set up Masa, Africa’s first national antiretroviral (ARV) Program. “It became clear this project was going to redefine HIV issues on the continent,” Darkoh recalls. “If we could pull this off and create a successful treatment model, it would change things for Africa. And if we failed it would be fuel for all the naysayers who, to this point, had said there should be no treatment for Africa. We knew it had to work.”
The goal for Masa was not only to provide anti-retroviral drugs but also to expand HIV/AIDS education and prevention all across Botswana. For the treatment program to succeed, the massive stigma associated with the disease would have to be overcome, a stigma so intense that most Botswanans preferred to forgo treatment rather than admit that they were suffering from AIDS.
Darkoh found that a great deal of the challenge involved creating a new health infrastructure in a culture that often seemed set in its ways. “It was very tough at the beginning,” he says. “I was the head of the program, and I didn’t even have a landline; I had to use my cell phone.” An even more serious problem in a country without a medical school was recruiting and training staff. Darkoh had to import doctors and nurses from other countries, ultimately signing them on for multiple-year contracts. His to-do list included securing computers, refrigerators, and clinic space; purchasing and managing drug supplies; developing educational outreach materials; and figuring out how to track patient records.
“No one knew whether the program would work,” Darkoh recalls. “But barely three years later we had the largest program in Africa, and over 40 percent of those eligible for therapy are on treatment. It shows what can be done. But you have to be in it for the long haul. It’s a marathon; it’s not going to be a sprint.”
By spring of 2005, 40,000 people had enrolled in the Masa program, and 36,400 were in treatment, with 2,000 new people coming in each month. Overall, 75,000 people had agreed to be tested. To support the growing willingness of the populace to participate, the Masa program created 32 clinics and 17 counseling centers, trained more than 2,200 health workers, and helped outfit labs to treat some 20,000 patients per year.
Equally crucial to the success of the testing program has been the government’s promise that ARV drugs will eventually be available to all those who test positive. Thus, although a third of those tested to date have proved to be infected with the disease, such a diagnosis is no longer seen as a death sentence.
Darkoh credits President Festus Mogae with helping to turn things around. “There was exceptional political commitment; the president of Botswana is personally very involved.” Mogae had himself publicly tested for HIV, and recently moved to make HIV testing a routine procedure with every medical visit nationwide. “Most importantly,” says Darkoh, “the country took a leading role in saying that we’re going to fight for our lives and we’re going to do this.”
Darkoh finds the results satisfying: “The program is scrambling now to keep up with demand, but I believe it can. There were a lot of doubters when we started, and I think we’re proving them wrong.” He also thinks that other developing countries can learn from Botswana. “The issues on the ground at an operational level are the same,” says Darkoh, “You have to wake up and say you are going to do it. It may take 20 years, but you are going to do it. Similar antiretroviral treatment programs are now being set up almost from scratch in Tanzania, Kenya, Mozambique, Rwanda, and South Africa.
With the Botswana-Gates-Merck ACHAP alliance now offering important lessons and a ray of hope to other nations struggling with the AIDS pandemic, Darkoh has established a new company, BroadReach Healthcare, specializing in anti-retroviral treatment and offering expertise in program design, implementation, monitoring, and evaluation to other countries around the world.
Through BroadReach Darkoh is already deeply involved in expanding public access to antiretroviral drugs in South Africa, the nation with the world’s highest number of HIV-positive citizens. While South Africa currently has one of the developing world’s biggest antiretroviral programs, almost all of it is administered by private companies offering treatment to their workers through private doctors. Darkoh is working to tap excess capacity in this private system to treat public patients too. That means devising a medically sound yet affordable way to manage the treatment of individuals far beyond the direct reach of these specialists.
Working with private treatment partners like South African-based Aid for AIDS, and Netcare, and with financing from the USA’s PEPFAR fund and the UN’s Global Fund for AIDS, Tuberculosis and Malaria, Darkoh’s team has set up a network of private physicians who are willing to take on public patients. They have also trained groups of non-expert activists who can go into remote communities to identify uninsured people who appear to be HIV-positive and need treatment. Once these individuals are identified, BroadReach then sends in frontline health-care workers to supply the missing link. “The reality is, you don’t need a doctor to regularly see every single person who’s HIV-positive,” Darkoh asserts. Training local health-care workers to consult with urban specialists is cheaper and can also create new jobs in rural areas.
In a country where antiretroviral drugs now reach only 26,000 out of the more than 610,000 who actually need them, Darkoh believes this new program can bring 100,000 to 300,000 people into treatment within a couple of years.
Yet the world wide count of those infected with HIV is so much higher that Darkoh is sometimes asked how he can remain hopeful. His reply is simple. “What we have found is that it can be done. Solutions can be developed that match the scale at which these problems exist. There are ways of designing programs to treat 40 million people.”