A neighbor shaved Matsepang Nyoba's head with an antiquated razor. Blood beaded on her scalp. Tears trickled down her cheeks, but not because of the pain. She was in mourning, and this was a ritual.
Two days earlier, her newborn baby girl had died in the roach-infested maternity ward of Queen Elizabeth II, a crumbling sprawl that is the largest hospital in Lesotho, a mountainous nation of 2.1 million people surrounded by South Africa.
Nyoba, 30, whose given name means "mother, have hope," has AIDS. But that is not what killed her baby daughter, Mankuebe.
Nyoba owes her own life to the Bill & Melinda Gates Foundation, which has given $8.5 billion to global health causes. Through its grantees, including the Global Fund to Fight AIDS, Tuberculosis and Malaria, the foundation underwrites, inspires or directs major efforts to prevent, cure or treat those diseases. The fund pays for Nyoba's costly AIDS medicine.
But when she gave birth on a recent Sunday morning, her baby was suffering from a different kind of distress. The infant was limp and barely breathing. A nurse rushed her to the nursery, packed with sick babies, some two to a crib. Jury-rigged stethoscope tubes let six of the babies share lifesaving oxygen from a single valve.
There was no oxygen tube for Mankuebe. She asphyxiated for lack of a second valve. It would have cost $35.
The hospital, with no staff to move Mankuebe's remains to the morgue, placed her body on a shelf near the delivery room while her father arranged for burial. The tiny corpse was swaddled in a baby blanket. A handwritten death notice was stuck to the blanket with a used hypodermic needle.
The Gates Foundation, endowed by the personal fortunes of the Microsoft Corp. chairman, his wife and Berkshire Hathaway Inc. Chairman Warren E. Buffett, has given $650 million to the Global Fund. But the oxygen valve fell outside the priorities of the fund's grants to Lesotho.
Every day, nurses say, one or two babies at the hospital die as Mankuebe did -- bypassed in a place where AIDS overshadows other concerns.
The Gates Foundation has targeted AIDS, TB and malaria because of their devastating health and economic effects in sub-Saharan Africa. But a Times investigation has found that programs the foundation has funded, including those of the Global Fund and the GAVI Alliance, which finances vaccines, have had mixed influences on key measures of societal health:
* By pouring most contributions into the fight against such high-profile killers as AIDS, Gates grantees have increased the demand for specially trained, higher-paid clinicians, diverting staff from basic care. The resulting staff shortages have abandoned many children of AIDS survivors to more common killers: birth sepsis, diarrhea and asphyxia.
* The focus on a few diseases has shortchanged basic needs such as nutrition and transportation, undermining the effectiveness of the foundation's grants. Many AIDS patients have so little food that they vomit their free AIDS pills. For lack of bus fare, others cannot get to clinics that offer lifesaving treatment.
* Gates-funded vaccination programs have instructed caregivers to ignore -- even discourage patients from discussing -- ailments that the vaccinations cannot prevent. This is especially harmful in outposts where a visit to a clinic for a shot is the only contact some villagers have with healthcare providers for years.
The Gates Foundation's largest grants for healthcare in Africa go to two organizations: the Global Fund and Geneva-based GAVI. The foundation formed GAVI and has given it $1.5 billion of more than $1.8 billion it has donated for vaccination programs. The Gates Foundation holds a seat on each group's board of directors and helps determine their policies and priorities.
Because of the generosity of the foundation and other donors, millions of children have been protected against scourges such as malaria and measles -- and AIDS deaths in much of Africa are finally leveling off. Dr. Mphu K. Ramatlapeng, Lesotho's health minister, echoed health authorities worldwide when she said this would have been impossible "if it were not for the money from Bill Gates."
But because of the overwhelming nature of AIDS, wartime disruptions and poor governance in some nations -- and because of the priorities of global health groups, including GAVI and the Global Fund -- key measures of societal health have stalled at appalling levels or worsened.
Dr. Peter Poore, a pediatrician who has worked in Africa for three decades, is a former Global Fund board member and consultant to GAVI (formerly the Global Alliance for Vaccines and Immunization). He says they and other donors provide crucial help but overstate the impact of their programs. "They can also do dangerous things," he said. "They can be very disruptive to health systems -- the very things they claim they are trying to improve."
In a recent editorial on the Global Fund, the British medical journal the Lancet Infectious Diseases wrote: "Many believe that its tight remit is increasingly becoming a strait jacket."
Joe McCannon, vice president of the Institute for Healthcare Improvement, a U.S.-based nongovernmental aid organization, or NGO, with operations in Africa, said, "You have to ask: 'Net, are we having a positive effect?' It's a haunting question."
The Global Fund, GAVI and the Gates Foundation say that pockets of success in several African nations have shown that their approaches are sound and that in time overall health across the continent will improve.
"The Global Fund is very young," having started in 2002, said its director, Dr. Michel Kazatchkine, a French physician who formerly led France's National Agency for AIDS Research. To see decades of neglect reversed, "wait for two or three more years," he said.
Bill and Melinda Gates referred questions to Dr. Tadataka Yamada, president of the Gates Foundation's global health program. Yamada, a leading gastroenterologist and former research director at the drug company GlaxoSmithKline, said African nations themselves must do more to improve public health. They should spend less on weapons and more on doctors before they demand increased assistance, he said.
"We're a catalyzer. What we can't do is fill the gaps in government budgets," Yamada said. "It's not sustainable."
During Mankuebe Nyoba's short life, no doctor was available in the maternity ward at "Queen II." That was normal. Fifteen babies were born overnight. Those babies, 110 mothers and other infants were cared for by three nurse-midwives. That was normal.
One woman, Limpho Jobo, 24, lay on a bed screaming as the harried midwives cared for others. Suddenly, Jobo slid off the bed onto the bare floor. At that moment, her baby was born. Jobo's eyes rolled back.
Somehow, she and the baby survived.
After so frantic a night, no one at the hospital told Matsepang Nyoba or her husband why their baby had died. Suspicions were etched on Peo Nyoba's face. "When we first arrived . . . . [Matsepang] was already in labor, but it took a long time before we were served . . . ," he said. "It is not quite clear what really happened afterward. The way I see it, [the death] could have been avoided."
Sub-Saharan African nations face desperate shortages of doctors and nurses. Some clinicians, including nurses and doctors, have died of AIDS -- in some cases caused when they were accidentally stuck with used needles. More than a dozen nurses interviewed throughout Lesotho said they would leave as soon as possible for safer, better-paying jobs in South Africa or Europe.
The narrow approach of the Global Fund and other aid groups compounds the problem, according to global health experts and African officials.
Ramatlapeng, the health minister, said her nation faced a conundrum. Donors won't help finance higher salaries for basic health workers. Yet the same groups refuse requests for other types of aid, citing concern that funds would not be spent effectively because of a dearth of staff.
The Global Fund pays for salary increases for clinicians who provide antiretroviral drug therapy, known as ART, for HIV/AIDS patients. Doctors and nurses move into AIDS care to receive these raises, creating a brain drain.
"All over the country, people are furious about incentives for ART staff," said Rachel M. Cohen, mission chief in Lesotho for Doctors Without Borders, which operates health facilities in partnership with the government.
Because of the brain drain, responsibilities for education, triage and low-level nursing pass down to lay people, particularly in rural areas that rarely if ever see a clinician. In much of Africa, task-shifting is the key response to staff shortages.
"But there are limits," Cohen said. "Some things shouldn't be done by lay people."
The situation is as bad or worse elsewhere in Africa.
In Rwanda, nurses often earn $50 to $100 a month if paid from a clinic's standard budget. They work beside Global Fund-supported nurses who earn $175 to $200 a month.
Florence Mukakabano, head nurse at the Central Hospital of Kigali, the capital of Rwanda, said she loses many of her staff nurses to United Nations agencies, NGOs and the hospital's own Global Fund-supported AIDS program.
The health personnel shortage in Africa could cost billions of dollars to fix. But in a small country such as Lesotho, major changes could be made for a fraction of the $59 million already committed by the Global Fund, Ramatlapeng said. With $7 million annually, she could raise the pay of every government health professional by two-thirds, sufficient to retain most of them.
In some cases, salary increases targeted to certain types of care "may have had a distorting effect," Kazatchkine acknowledged. But the AIDS crisis justifies such dislocations, he said. "We are a global fund for AIDS, TB and malaria. We are not a global fund that funds local health."
He emphasized a key principle of the Global Fund: If the group took over from weak or inept governments, the result would be worse, because African countries would never develop their own expertise.
Botswana offers an example of how a special Gates initiative, narrowly applied to a specific disease, may have disrupted other healthcare.
In 2000, the Gates Foundation joined with the drug firm Merck & Co. and chose Botswana as a test case for a $100-million effort to prove that mass AIDS treatment and prevention could succeed in Africa.
Botswana is a well-governed, stable democracy with a small population and a relatively high living standard, but one of the highest HIV infection rates in the world.
By 2005, health expenditures per capita in Botswana, boosted by the Gates donations, were six times the average for Africa and 21 times the amount spent in Rwanda.
Deaths from AIDS fell sharply.
But AIDS prevention largely failed. HIV continued to spread at an alarming pace. A quarter of all adults were infected in 2003, and the rate was still that high in 2005, according to the U.N. Program on HIV/AIDS. In a 2005 survey, just one in 10 adults could say how to prevent sexual transmission of HIV, despite education programs.
Meanwhile, the rate of pregnancy-related maternal deaths nearly quadrupled and the child mortality rate rose dramatically. Despite improvements in AIDS treatment, life expectancy in Botswana rose just marginally, from 41.1 years in 2000 to 41.5 years in 2005.
Dean Jamison, a health economist who was editor of Disease Control Priorities in Developing Countries, a Gates Foundation-funded reference book, blamed the pressing needs of Botswana's AIDS patients. But he added that the Gates Foundation effort, with its tight focus on the epidemic, may have contributed to the broader health crisis by drawing the nation's top clinicians away from primary care and child health.
"They have an opportunity to double or triple their salaries by working on AIDS," Jamison said. "Maybe the health ministry replaces them, maybe not.
"But if so, it is usually with less competent people."
Yamada, the Gates Foundation official, said research was needed to determine whether "vertical" aid, such as the foundation's Botswana program, had contributed to brain drain and higher mortality.
To bolster basic healthcare in Africa, he proposed that universities in rich nations help found medical schools on the continent. And he challenged African nations to spend at least 15% of gross domestic product on health.
As of 2004, only 13 countries worldwide spent as much as 10%, and only one African country, Malawi, is among them.
Yamada said the foundation had asked Botswana to focus more on AIDS prevention -- including circumcision, which can reduce susceptibility to HIV.
"I don't know what to do there, frankly," to reduce unsafe sex, short of "changing the hearts and minds of the people," he said.
Issues of food and health
Malerotholi moleko says her problem is not AIDS. Thanks to the Global Fund, she gets medicine.
Her problems are transportation to a clinic to get her free AIDS pills, and hunger, which makes many patients vomit them.
"After I've taken the pills, my appetite becomes bigger, and I don't have the food," Moleko said, hoisting her niece's baby on her back in a colorful blanket. It is the way women in the mountains of Lesotho carry their children and stay warm.
Moleko, 41, whose husband died of TB in 2004, supports eight children by doing laundry for neighbors. Four are hers, and four are from a niece who died of AIDS. For her own AIDS treatment, Moleko travels to Maseru from her home village of Sefikeng, about a 30-minute ride. The bus costs $3.25 -- more than the average daily wage for domestic servants.
After a recent trip to the clinic, Moleko walked home from the bus stop through steep, rugged pastures. In parts of Lesotho and Rwanda, patients must walk for as long as nine hours to reach the nearest clinics. Sometimes, Moleko said, she barely makes it. Many don't make it at all.
On most days Moleko's family eats only pappa, cornmeal mush. When possible, she adds a few wild greens from the rocky soil. Pellagra, a nutritional disease that can lead to dementia and death, is common here.
The Global Fund has used Gates Foundation money and other support to finance AIDS treatment for 1.1 million people and TB treatment for 2.8 million, mostly in sub-Saharan Africa.
"The clinics," Moleko said, "don't have what we need: food."
Eyes brimming with tears of frustration, Majubilee Mathibeli, the nurse at Queen II hospital who gives Moleko her pills, said four out of five of her patients ate fewer than three meals a day.
"Most of them," she said, "are dying of hunger."
In recent interviews in Lesotho and Rwanda, many patients described hunger so brutal that nausea prevented them from keeping their anti-AIDS pills down.
Mathibeli is grateful to the Global Fund for its AIDS grants but said the fund was out of touch. "They have their computers in nice offices and are comfortable," she said, nervous about speaking bluntly. But "they are not coming down to our level. We've got to tell the truth so something will be done."
The Global Fund provides food for AIDS patients and their families, but only for a few months. When the food runs out, the hunger returns.
At that point, said Epiphanie Nizane, a lay counselor in Rwinkwavu, a village in eastern Rwanda, many women with AIDS turn to prostitution.
"The Haitians have a saying: Giving a patient medicine without food is like washing your hands and drying them in the dirt," said Dr. Jennifer Furin, the Lesotho director for Partners in Health, a Boston-based NGO. "You're consigning that person to death because they are poor."
Partners in Health gives 10 months' worth of food to AIDS patients, their families and others who need it. The practice has put the group at odds with government officials who fear an endless cycle of dependence.
The imbalance between needs and Global Fund priorities is even more pronounced in Rwanda, where the AIDS problem is far less severe than in Lesotho or Botswana.
In Rwanda, only about 3% of adults are infected. But Dr. Innocent Nyaruhirira, minister of state for HIV/AIDS, said more than 50% of Rwanda's health budget, mostly from the Global Fund and other international sources, was designated for AIDS.
From 2000 to 2005, Rwanda's health budget increased dramatically due to foreign donations -- and deaths from AIDS and AIDS-linked TB dropped.
But despite the aid and strong national leadership, measures of health most dependent on the strength of the nation's overall system of clinics, hospitals and clinicians showed less encouraging results.
TB overall, and TB deaths among patients without HIV, rose dramatically. Child mortality -- mostly from diarrhea, sepsis and other killers rather than from AIDS, stalled at about one death in every five or six live births. Maternal mortality fell slightly, but remained at one of the highest rates in the world.
"Health delivery systems in Africa are now weaker and more fragmented than they were 10 years ago," said a 2006 report commissioned by the Global Fund and the World Bank. The weakening has been "exacerbated as the Global Fund and other programs now promote universal access to [AIDS] treatment."
To turn this around, the report concluded, the Global Fund needs help from the World Bank to "provide the human support needed to balance the massive financial contribution."
Using the most authoritative available data, maternal and child mortality and life expectancy show no statistical relationship -- for better or worse -- to Global Fund grants or to overall Gates Foundation spending in Africa.
Key health measures in countries that received less money per capita have been just as likely to improve or decline as in countries that received more money, according to data from the World Health Organization, World Bank and UNICEF.
Mosilo Motene, the chief nurse at Queen II, expressed frustration with the Global Fund and other donors whose grants don't supply basic needs such as oxygen valves or 3-cent gloves to protect nurses from the AIDS virus. "Conditions are going from bad to worse," she said, "despite what is given."
Pregnancy-related deaths often have been the highest in nations where most aid has gone to treat AIDS, TB and malaria, said Dr. Francis Omaswa, special advisor for human resources at the WHO. "People find it easier to talk about AIDS, about malaria."
Donations "could be five times more beneficial," Omaswa said, if they better supported health systems.
"Who chose the human right of universal treatment of AIDS over other human rights?" asked economist William Easterly, co-director of the New York University Development Research Institute, in his book "The White Man's Burden." He added: "A nonutopian approach would make the tough choices to spend foreign aid resources in a way that reached the most people with their most urgent needs."
The Global Fund has given 1% of its funds to strengthening overall health systems directly and says that almost half of its AIDS money goes for training, monitoring and evaluation, and administration -- indirectly strengthening basic healthcare.
In Rwanda, the Global Fund money has added buildings, refrigerators and power to rural clinics, supported universal health insurance and subsidized cellphones for lay health workers. In addition, some HIV/AIDS nurses whose salaries are paid for by the fund provide care for other ailments as well.
But benefits take time to trickle down. "Everyone agrees to subscribe to fairy tales about how investments in this or that top-down mandate will lead to collateral benefits elsewhere," said Robert Steinglass, a 30-year global health veteran and now technical director of Immunizationbasics, a U.S.-funded project that operates in three African nations.
"But much of the rhetoric is bogus," he said.
Should the Global Fund underwrite essentials such as food, exam gloves and oxygen valves? "Yes, yes, yes," Kazatchkine, the director, said. "Should, could, will,"
Last month, the fund invited new proposals for health systems support.
But the support had to directly attack AIDS, TB or malaria. In general, Kazatchkine said, health systems and food must be each government's responsibility, with the fund playing "a catalytic role." The Global Fund "cannot resolve all the problems of all the people."
Yamada at the Gates Foundation called sustainable food supplies central to the foundation's strategy. It has a large research and development program to improve agriculture in Africa and has donated $70 million to the Global Alliance for Improved Nutrition, which uses market-based approaches to feed developing nations, including seven in sub-Saharan Africa. It also plans to boost research and development for early-childhood nutrition.
"We want to have something that has a lasting impact," he said, "for the countries to be able to support themselves."
Unintended consequences also are a problem in vaccination drives.
Mamoraturoa Polaki trekked for hours down rocky paths to the mountain village of Semongkong, near the center of Lesotho, to get her son Huku, 2, a measles shot.
The boy was small, frail.
His shot was part of a vaccination drive that included vitamin A and deworming medicine. It was supported by the GAVI Alliance and managed by UNICEF, which has received $68 million from the Gates Foundation.
Thanks to such support, measles deaths in Africa have fallen about 90% since 2000. Indeed, measles was not Polaki's main concern. She was worried about Huku's frailty. Was it a sign of malnutrition?
Or was it something worse? Her husband has AIDS. She had tested negative for HIV. But what about the boy? Polaki could not get any answers. Nor did the clinic offer AIDS tests.
Most nurses would not talk about such things. Visitors were admonished not to discuss ailments other than measles. It might scare patients away.
At the very least, UNICEF said, such talk could slow down vaccination lines.
Polaki, however, was joined by many in her concerns. All of the six mothers and six nurses interviewed by a Times reporter volunteered deep worry about hunger, TB or AIDS.
The lack of AIDS tests seemed perverse given that free AIDS testing and treatment are widely available in Lesotho thanks largely to the Gates Foundation.
One nurse, Nthekelong Motsoane, mindful that mountain trails become impassible in winter or during bad weather, had tried to get authorities to piggyback other services onto the vaccination drive.
She was unsuccessful.
After their vaccinations, some patients left with their worst diseases unaddressed.
The GAVI vaccination day at Semongkong typified the narrow, paternalistic health programs seen throughout Africa, said Furin, the Lesotho director for Partners in Health. "These [patients] are people who haven't seen a doctor in five years. Should they be satisfied with just a vaccination? I wouldn't be for my kids.
"When powerful organizations like UNICEF say, 'Keep it simple or the people will run screaming from the room,' what do you think the ministry of health will say?" Furin said. "They are completely dependent on the big international agencies."
As successful as vaccination drives have been in curbing targeted diseases, 2006 data, the most recent available, show a paradoxical relationship between GAVI funding in Africa and child mortality. Overall, child mortality improved more often in nations that received smaller than average GAVI grants per capita. In seven nations that received greater than average funding, child mortality rates worsened.
To be sure, malaria, wartime disruption and the relentlessness of AIDS play a big role. Restrictive health programs are to blame, as well, where they turn a blind eye to malnutrition and largely neglected diseases, such as diarrhea and pneumonia.
UNICEF supports health systems but discourages general screening during immunization drives, said Dr. Peter Salama, chief of the agency's health section. "There is a risk of health workers raising expectations and [not] being able to deliver" and of "overburdening the campaign and getting poorer [vaccine] coverage."
Dr. Julian Lob-Levyt, chief executive of GAVI, said his group disagreed with that approach and was committed to integrating general maternal-child health into vaccine drives. "Some of these campaigns are so focused on their own results," he said, "that maybe they don't see the bigger picture."
Lob-Levyt predicted that UNICEF and other aid groups would move rapidly in the direction of more integrated efforts. "We should be spending in all areas, in treatment and prevention," he said. "It isn't . . . a zero-sum game."
Eleven months ago, in response to demands by recipient governments, GAVI created a $500-million fund to expand its approach by improving general health delivery and training, as well as immunization services.
The program is designed for "broader, integrated child survival," Lob-Levyt said. "We're learning as we go."
But he defended GAVI's vaccine emphasis, saying that research had shown that preventing one disease improved overall survival.
Vaccinations, widely seen as cost-effective, numbered more than 15 million in five years against measles, diphtheria, tetanus and pertussis, and 99 million against hepatitis B, yellow fever and hemophilus influenza B, which causes meningitis.
Bill Gates told CNBC earlier this year that GAVI vaccinations had "saved several million lives."
But experts in global vaccination programs said such claims were hard to validate because so many children in developing nations die of conditions for which no vaccine exists.
According to GAVI's website, most of the vaccinations were for prevention of hepatitis B, which can cause cancer and liver failure.
The vaccine was widely used, Lob-Levyt said, because it could be offered rapidly at reasonable cost. Hepatitis B, however, rarely kills children, and many African children die of other ailments long before the vaccine could have saved them.
"You can't say any life was saved until they are older," said William Muraskin, a professor of urban studies at the City University of New York and author of a book about GAVI.
Citing a recent study in the Lancet, Yamada agreed that rates of child mortality in much of Africa had been flat to worse due to such problems as diarrhea, malaria and pneumonia.
"We can't rest on our laurels," he said. "The low-hanging fruit didn't necessarily have the outcome that we would have hoped."
The foundation is supporting research on vaccines against pneumonia and diarrheal illnesses. If these become available, he said, "you'll start to see an impact on child mortality that may be the next phase of GAVI's success story."
The failure to support basic care as comprehensively as vaccines and research is a blind spot for the Gates Foundation, said Paul Farmer, recipient of a John D. and Catherine T. MacArthur Foundation fellowship, and founder of Partners in Health, which has received Gates Foundation funds for research and training.
"It doesn't surprise me that as someone who has made his fortune on developing a novel technology, Bill Gates would look for magic bullets" in vaccines and medicines, Farmer said. "But if we don't have a solid delivery system, this work will be thwarted.
"That's something that's going to be hard for the big foundations," he said. "They treat tuberculosis. They don't treat poverty."
Still, Farmer, who knows the Gateses, said they had a deep personal commitment to understanding and addressing the needs of developing countries. He said he expected the Gates Foundation to increase its support for health delivery systems.
Yamada called delivery of care "a key strategic issue for us." The foundation will not provide care, he said, but has begun to study regulation, financing and how markets can improve delivery.
"What we do is we catalyze" -- develop tools to help governments improve, he said. "We are not replacement mothers."
Piller reported from Lesotho, Rwanda, Switzerland and Seattle; Smith reported from Los Angeles. Times staff writer Edmund Sanders, staff photographer Francine Orr, data analyst Sandra Poindexter and researcher Maloy Moore contributed to this report.Copyright © 2014, Los Angeles Times