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USA/Africa: AIDS - No We Can't?
AfricaFocus Bulletin
Dec 6, 2009 (091206)
(Reposted from sources cited below)
Editor's Note
"It was ordinary people, people living with AIDS and those who
loved them, who spoke up, demanded action. Activists in Brazil,
Thailand, South Africa, Uganda and elsewhere shamed their
countries, the world into action. [international AIDS programs
... were swept into place by the force of the voices crying out for
justice only a few years ago. It is almost 10 years later and we're
in danger of losing everything we've achieved on AIDS this decade."
- Greg Gonsalves
This AfricaFocus Bulletin contains the transcript of a talk by
veteran AIDS activist Greg Gonsalves, warning of the danger of
pitting funding on AIDS against other health expenditures, instead
of mustering the political commitment to do both. It also contains
a related opinion piece by Dr. Steven Gloyd and Rep. Jim McDermott.
Both were posted on the Healthgap listserv.
Also posted today on the AfricaFocus web site, but not sent out by
e-mail, are two related Bulletins. One is a press conference by
U.S. Global AIDS Coordinator Dr. Eric Goosby, in which he presents
the transition of U.S. international AIDS programs from "emergency"
to a more "sustainable" phase, and tries to answer questions from
journalist seeking a response to critics of administration plan
for funding levels.
See:
USA/Africa: AIDS - Yes, We Can? (web-only)
http://www.africafocus.org/docs09/hiv0912b.php
The other contains several updates, a summary report on the new
UNAIDS annaul report, a joint press release by PEFPAR and the
Global Fund, and the AIDS day speech by South African President
Jacob Zuma.
See
Africa: HIV/AIDS 2009 Update (web-only)
http://www.africafocus.org/docs09/hiv0912c.php
More details on proposed budget numbers and an evaluation by
activist groups of the first-year record of the Obama
administration are availed at:
http://www.africaaction.org/resources/docs/WADreportcard.pdf
The groups rate the administration's first-year record as very
disappointing, with a grade of D+ on a scale from A (best) to F
(failure). But they stress that one year is a short time and there
is still much opportunity to improve if there is political will to
do so from both the administration and Congress.
For a new policy brief and chartpack, from the Kaiser Family
Foundation, provide a detailed breakdown of the U.S. budget for the
global health programs in President Obama’s new Global Health
Initiative, announced in May 2009, see
http://www.kff.org/globalhealth/8009.cfm
The brief provides an overview of the projected budget for the
Global Health Initiative, including the $8.6 billion proposed by
the Administration in its pending fiscal year 2010 request and the
$8.4 billion approved in fiscal year 2009. It examines the
different U.S. programs that would fall under the Global Health
Initiative over time, tracking data back to fiscal year 2001. The
supplemental chartpack includes additional breakouts and budget
trends over time.
For previous AfricaFocus Bulletins on AIDS and other health issues,
visit http://www.africafocus.org/healthexp.php
++++++++++++++++++++++end editor's note+++++++++++++++++++++++
No, We Can't: Barack Obama's New Global AIDS Strategy
Remarks by Gregg Gonsalves, International Treatment Preparedness
Coalition at the symposium on HIV Scale-Up and Global Health
Systems
hosted by Columbia University's International Center for AIDS Care
and Treatment Programs
1 December 2009 New York, NY
Greg Gonsalves
Email: gregg.gonsalves@gmail.com or gregg.gonsalves@yale.edu
Mobile: 1-203-606-9149
Posted on Healthgap listserv:
http://www.healthgap.org
http://critpath.org/mailman/listinfo/healthgap
For those of you who know me, I am about to say something shocking.
I miss George W. Bush. Well, not really. He was a terrible
President in so many ways. However, he was exceptional in one.
The President/s Emergency Plan for AIDS Relief, despite its flaws,
saved millions of lives around the world.
People seem to forget what the world was like before PEPFAR and its
multi-lateral sister effort, the Global Fund to Fight AIDS,
Tuberculosis and Malaria, arrived on the scene. Before the turn of
this decade, the fight against AIDS in the developing world was a
joke. Great leaders like Nelson Mandela failed to understand and
react to the gravity of what was emerging in his newly free
republic. President Clinton for all his heralded work since he left
office did absolutely nothing when he was in office to stem the
rising tide of death and new infections across the globe. Even the
World Health Organization ignored the epidemic ravaging dozens of
countries wholesale in Africa, exploding in specific populations in
other nations on other continents.
It was ordinary people, people living with AIDS and those who loved
them, who spoke up, demanded action. Activists in Brazil, Thailand,
South Africa, Uganda and elsewhere shamed their countries, the
world into action. The establishment of the Global Fund, the
World Health Organization's effort called 3x5 to get 3 million
people on AIDS treatment by 2005, were all swept into place by the
force of the voices crying out for justice only a few years ago.
It is almost 10 years later and we're in danger of losing
everything we've achieved on AIDS this decade. For the past two
years, there has been a pernicious and false rhetoric rising up in
academic journals, in think-tanks, and now in governments and
international agencies that goes something like this: the fight
against AIDS has misdirected our energies towards broader goals in
health and development; the provision of antiretroviral therapy is
a folly, it's too expensive and isn't worth the money to continue
its expansion; efforts against AIDS are destroying health systems
and promoting unnecessary deaths from other simpler-to-treat
diseases and conditions such as childhood diarrhea. One of the
most vocal proponents of these ideas sits in the White House
advising the President: Ezekiel Emanuel, a doctor and bioethicist,
whose November 2008 paper in the Journal of the American Medical
Association has become a key document in what I call the "AIDS
backlash." But there are others, such as Bill Easterly at NYU, and
a mysterious fellow named Roger England who seems to be quite the
favorite of the editor of the British Medical Journal. Even
Newsweek gets into the act this week, with their call to scale-back
PEPFAR.
Many of the people making these charges of course are the people
who did little to stem the tide of AIDS and TB in the 1990s. They
posit that the fight against AIDS has been a malevolent force in
public health and development, while ignoring the fact that before
AIDS supposedly came along to suck all the air out of the room,
other areas of health - for instance, maternal health and childhood
immunization in Africa - languished terribly under their watch.
They conveniently refuse to acknowledge that chronic
underinvestment in health, structural adjustment policies that
crippled the public sector in many developing countries, corruption
at the highest levels and other factors decimated health systems
across the world. AIDS has become the new bogeyman - deflecting
attention from the culpability of national governments in the North
and South for the long-standing crisis in health and development
around the world.
We've made great strides in fighting AIDS, but now as a recent
report by the Nobel Prizing winning organization, Doctors without
Borders has suggested, the world is about to punish success. Some
are now calling for a redistribution of funds, to cut up the
current pie of global health money, so that other illnesses and
conditions profit from the largesse lavished on AIDS. The problem
is that the pie of current funding for AIDS still represents a
fraction of what is needed to combat the epidemic - asking for a
redistribution of funds is akin to starting a fight for crumbs from
the table of our national leaders. The true scandal is that in the
age of bank bailouts, fiscal stimulus packages and multi-million
dollar bonuses, it isn't AIDS that is overfunded, it's the fact
that the USA and other donor nations have systematically
underfunded health and development overall for decades. Justice
isn't cutting up a too small pie into more evenly distributed
smaller pieces, but is putting more money on the table for global
health and development.
We need to spend more on health and development, promote stronger
health systems and work towards a comprehensive package of health
interventions for all conditions in developing countries. However,
accomplishing this won't happen by essentially weakening the AIDS
response, but by building on its tangible successes. Have we done
everything right in AIDS? Of course not. But we've done the
impossible in 10 years time - when the experts said treating people
with AIDS wasn't going to work because "fricans can't tell time" or
because it wasn't cost-effective or sustainable, we showed that it
was. We've brought a yes-we-can attitude and higher aspirations to
global health and development than the field has had in decades.
The choice right now is between building on the successes of AIDS
to strike out against other diseases and conditions or to go back
to the future, to the golden days of the 80s and 90s, which were
not so golden at all. What is being proposed right now from many
quarters is a return to sector-wide approaches in health or SWAPs
as they are known, in which governments will get a fixed sum from
donors for health and program it to ostensibly strengthen their
health sectors overall. It all sounds so good. Rather than having
all these different pots of money at the national level, it will
all be rationalized and coordinated through ministries of health,
and all directed towards a set of coherent national policies.
SWAPs were the darling of development agencies and the UN
throughout the 1990s. They are theoretically appealing to those
who work in the field and who have devoted their lives to building
health systems, but often what looks good on paper doesn't work in
the real world. There is scant data on the effectiveness of SWAPs
on health, with even strong proponents saying it would take 10 or
more years of investment in this approach to see tangible impacts
on real outcomes. In the worst cases, such as health sector
reform in Zambia in the late 1990s, SWAPs destroyed the country/s
TB program and it had to be built up from scratch. SWAPs are
based on the idea that vertical programs, disease-specific
programming are essentially destructive, when the truth is that
health systems need breadth and focus, strong structural
foundations but also targeted efforts on the major killers of in
their midst.
Almost directly after the Alma-Ata Declaration thirty years ago and
which launched a progressive movement for health for all, the
critics arose to say that it couldn't be done. That is, health for
all, is a utopian fantasy, and that we need to be satisfied with
doing small bits of good with small pots of money for a small
amount of people. The post-Alma Ata consensus is a Malthusian one,
and finds its real rationale in a late 70s/early 80s conservative
notion of the role of the state, which were ably promoted by
Margaret Thatcher and Ronald Reagan in the 80s: the less government
the better, the less governments do the better. Those who survive
on the largesse of government are welfare queens undeserving of our
support. This is all a far cry from the progressive politics that
gave rise to the British National Health Service or the
Medicaid/Medicare programs in the USA up until then. The big idea
since 1980 is that we are not our brothers or sisters keepers at
home or abroad.
The fight right now is for the soul of global health, and the lives
of millions of people around the world. It's not just about AIDS.
It's about a return to the 1990s, a post-Reagan consensus on social
services and foreign aid, the stagnation in public health that
stood for progress in so many areas. It's about a failure to
remember what it was like back only a short time ago. These people
had the keys to the car back then and made a wreck of things. Now
they want to be back in charge and nowhere is this more apparent
than in the debates happening in the White House, where the Obama
Administration risks turning its back on a decade of real progress
against HIV/AIDS, turning back the clock to failed or untested
approaches to health and development because the "experts" like
Zeke Emanuel or Bill Easterly say this is the right thing to do.
Get beyond their complaints about AIDS or AIDS treatment and their
vision for the future is bleak.
Perhaps it is old-fashioned to think that there can be real
progress for poor people, for the most despised of us on the
planet. Perhaps it's quaint to believe that the provision of
national health care in most of the developed world, Social
Security and Medicaid in the USA in the last century were not
aberrations in human history but some of our finest achievements
over adversity. The fight against AIDS is part of those earlier
struggles for social justice and equality and is part of the
struggle for health for all. We won't fight among ourselves for
crumbs from our leaders' tables. We won't be told that care and
treatment for AIDS or any other disease is unsustainable or not
cost-effective, when that calculus changes for your own family once
you become an elected official sitting in an office in the capital.
The President has a choice. He can stand with all of us fighting
for social justice and health care for people around the world or
he can join the ranks of the new Malthusians, who say let's do the
least for the least number of people with the least amount of
money. In the current health care debate in the USA where the
President has shown very little stomach for pushing through a
robust set of reforms in deference to conservative Democrats and
moderate Republicans, the outcome of his choices will mean an
open-ended postponement of key changes in the American health care
landscape. However, if the President takes the advice of the
current crop of noisy critics of AIDS, he risks making things worse
and setting us back a decade or more, not just on HIV but on
progress in global health overall.
Let's pledge a dime for global health
By Steve Gloyd and Jim McDermott
Dr. Steve Gloyd, left, is executive director of Seattle-based
Health Alliance International and a professor in the University of
Washington's Department of Global Health. U.S. Rep. Jim McDermott
represents Washington's 7th District and recently co-sponsored a
congressional briefing on global health.
Seattle Times, November 30, 2009
Ten cents out of every $100 would get the job done.
According to acclaimed economist Jeffrey Sachs, if the United
States, European countries and Japan made a commitment to donate
just 10 cents on every $100 generated by our economies, we could
help save 6 to 8 million lives each year.
The global community would have enough resources to address the
AIDS epidemic, prevent children from dying of diseases that are
easy to prevent and treat and ensure that mothers have safe
deliveries throughout the world's most under-resourced areas.
The challenge is not in whether the funds exist, but whether we
have the vision and the will to mobilize them.
We should look to the global response to HIV/AIDS to inspire us.
Four million people are alive today who otherwise would not be
because they are on lifesaving AIDS treatment. In Mozambique, a
woman named Florencia learned she was HIV-positive in 2002. She
was one of the lucky few at the time to start on antiretroviral
medications, and seven years later is thriving, working and
sending her daughter to medical school. Florencia's story is
multiplied by more than 160,000 times today - that's the number of
HIV-positive Mozambicans currently on antiretrovirals provided for
free through government clinics.
These results are a testament to the AIDS activists who refused to
accept that treatment for all was "unaffordable," and gave us a
new vision of what is possible. Poverty, whether in the U.S. or
Mozambique, is no longer a tolerable justification for denying
treatment to those who are clinically eligible.
President Obama announced a new Global Health Initiative earlier
this year, proposing $63 billion over six years. The announcement
heralded a more comprehensive approach to global health by also
prioritizing maternal and child health, neglected tropical
diseases and training and support of health workers in addition to
combating infectious disease.
This expanded initiative is laudable, but we cannot make advances
in some areas at the expense of people living with HIV. We must
fulfill our promises to those whose lives and futures depend on
daily antiretrovirals. This means carrying through with the
authorizations Congress made last year to fight AIDS, as well as
tuberculosis and malaria.
And we must not merely stand still - it is time to take our
commitment to a new level. In addition to working to equip labs
and clinics and train a work force to treat and care for those
living with HIV, we must work to strengthen primary health care
across the board, ensuring that all people have the care they
need, whether for HIV, or prenatal care, or pneumonia. AIDS
funding has contributed to health-system improvements and better
health outcomes for other diseases, but more is necessary.
U.S. advocacy and funding for HIV/AIDS have inspired the world to
act. Americans are also notably generous in the face of human
suffering; a recent survey [http://www.kff.org/globalhealth/posr111209pkg.cfm] found that
most Americans want the U.S. to contribute significantly to global
health.
A coalition of organizations has called on the administration to
think boldly and increase the total commitment over the next six
years from $63 billion to $95 billion. Their report, called "The
Future of Global Health," [http://www.theglobalhealthinitiative.org/] outlines a set of
targets to make real progress on HIV, tuberculosis, malaria,
maternal and child health, tropical diseases and the health
workers and systems that underpin all of these efforts.
This momentous contribution would hardly require belt-tightening
in our tough economic times. Ten cents out of every $100 would get
the job done.
AfricaFocus Bulletin is an independent electronic publication
providing reposted commentary and analysis on African issues, with
a particular focus on U.S. and international policies. AfricaFocus
Bulletin is edited by William Minter.
AfricaFocus Bulletin can be reached at africafocus@igc.org. Please
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or to suggest material for inclusion. For more information about
reposted material, please contact directly the original source
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