To the Editor:

As head of an organization that has struggled for over two decades with the challenges Laurie Garrett raises ("The Challenge of Global Health," January/ February 2007), I know that making a lasting impact on the health of the world's poor is fraught with difficulties. No issue is more pressing than the work-force crisis in local health sectors, because it ultimately erodes the very same local structures that are essential for sustainable progress.

But the health worker shortage can be addressed, even in environments previously thought to be too poor, too remote, and too unstable. Focusing simply on increasing the volume of assistance, however, does not ensure quality.

At International Medical Corps, we have found that the best way forward is to train midlevel health workers -- particularly nurses, midwives, and lay health workers -- within the context of their societies and communities. Especially in countries with weak institutions and low state capacity, these midlevel providers have a direct and immediate impact on the health of people who often have previously been denied access to any form of primary health care. Trained health workers witness the value of their work and how it improves their own communities. This, in turn, leads to more immunizations for more children and cleaner and safer deliveries for pregnant women.

Close collaboration with local nongovernmental organizations, health authorities, and village health committees is also essential for any approach in which the transfer of skills to local people is the main goal.

The key to preventing the windfall of money for global health from making things worse lies in strengthening the very same communities that desperately need help. And here we agree with Garrett: the millions who needlessly die from preventable and treatable diseases deserve not only quantity but quality.

Nancy Aossey

President and CEO, International Medical Corps