There's an intriguing white character in your book named This is a tall order at a time when health risks abound, health costs are on the rise, and governments--especially in developing countries--are often overwhelmed by the extent of the problem and the lack of adequate resources. One of the most serious health challenges is the AIDS crisis, and institutions like the Mailman School of Public Health, along with private foundations, find themselves at the forefront of efforts to deal with the issue of HIV/AIDS.

Allan Rosenfield, M.D., came to Columbia in 1975 as founding director of the Center for Population and Family Health. Earlier in his career, following training at Harvard's Brigham and Women's Hospital (he had earned his BA at Harvard and his MD at Columbia), he had worked in Nigeria as an obstetrician. He then served as Population Council Representative and adviser to the Ministry of Public Health for family planning and maternal/child health in Thailand.

On a clear spring morning on the 14th floor of the Art Deco Building at 168th Street that houses the Mailman School of Public Health, Dr. Rosenfield joined Dr, Barry Kistnasamy, Dean of Medicine, and Dr. Noddy Jinabhai, chair of the Department of Community Health at the Nelson R. Mandela School of Medicine of the University of Natal in Durban, to discuss AIDS programs in South Africa. Some South African government representatives had recently made controversial remarks minimizing the severity of the AIDS epidemic, charging that antiretroviral drugs are poisonous and that the AIDS symptoms experienced by one in six South Africans are the result of poverty rather than infection with the HIV virus. Such statements had clouded the debate about the disease in South Africa, which has one of the highest HIV infection rates in the world.

But AIDS continues to spread, South African policy has recently changed, and the government is now approving treatment with the drug nevirapine. Drs. Kistnasamy and Jinabhai know the challenges well and say they are determined to meet them.

The AIDS statistics are staggering. There are an estimated 40,000 AIDS patients in New York City alone. In the developed world, AIDS has become a chronic illness that can be managed with intensive medical treatment. But in some developing countries as much as a quarter of the population is infected. AIDS treatment is complicated and expensive and requires constant monitoring--which makes it all the more difficult for those most devastatingly afflicted by the disease: the poor and disenfranchised, women and children. A vaccine, though a priority with researchers, is still years if not decades away, and pharmaceutical companies usually prefer to focus on more lucrative treatment priorities.

Dr. Rosenfield is leading an effort, funded by an unprecedented grouping of private foundations, to expand HIV/AIDS care in resource-poor areas in Africa, Asia and Latin America. The initiative makes use of existing mother-to-child prevention efforts run by organizations such as Unicef and the Elizabeth Glaser Pediatric AIDS Foundation.

As a member of the boards of the Kaiser Family Foundation and the Packard Foundation and a member of the advisory committees of several other national foundations, including the Dyson Foundation and George Soros¹ Open Society Institute, Dr. Rosenfield can certainly see the issue from more than one vantage point.

The initiative, called MTCT-Plus (Mother-To-Child-Transmission Plus), is intended as an additional component to the prevention of transmission of the HIV virus--the "Plus" refers to the broadening range of options in AIDS care and combines prevention with treatment and care for the mother, child and the entire family.

MTCT initiatives are not new--they go back about three years. There are already more than 120 sites in Equatorial and sub-Saharan Africa and 30 sites in South East Asia that provide MTCT services. The MTCT-Plus program is intended to build on the existing programs. It will include the training and recruitment of personnel, invest in communications strategies to overcome the barriers of HIV stigma and gender inequality, offer voluntary testing and counseling, and provide HIV negative mothers with information on how to protect themselves from infection. HIV-positive mothers will be enrolled in the MTCT-Plus program for treatment including, depending on local capacity, basic care for sexually transmitted infections, prevention and treatment of opportunistic infections, and treatment with highly active antiretrovirals (HAART).

At a staff meeting this spring to discuss the planning of the MTCT-Plus program, Dr. Rosenfield offered clarity and made suggestions on every item on the extensive agenda, managing to anticipate potential problems from the point of view of every party involved. Five separate working groups have been formed to develop and monitor clinical protocols, develop mechanisms for the procurement and distribution of drugs, put together training programs and educational materials, develop evaluation methods and assess the results of various studies.

It is anticipated that private support from the foundations in the MTCT-Plus partnership coalition will reach $100 million over five years. On April 11, Dr. Rosenfield testified with Elton John before the US Senate Committee on Health, Education, Labor and Pensions regarding the need for federal funding. The successful implementation of MTCT-Plus would not only improve the survival of mothers and children, he said. It would also result in improvements in pre-natal care for women and a general strengthening of the infrastructure for essential primary care, and would also decrease the threat of opportunistic infections and other AIDS-related complications. Family structures and livelihoods would be maintained, and the rising numbers of AIDS orphans would be reversed.

It's a daunting task. But Dr. Rosenfield has known about the perils of motherhood in developing areas since his early days as a young obstetrician in Nigeria and Thailand. And he has the clarity of purpose and unwavering determination needed to fight the good fight.

On that clear spring day, after long hours of meetings and planning, Dr. Rosenfield met with a student, a graduate in public health who was about to embark on a stint with the Peace Corps and wanted to talk about the next step in her training after her return. Dr. Rosenfield left no question unanswered. He is not losing sight of the importance of ensuring a committed succession in the field of public health.