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."