Tag: global health

Patient Zero and Global Health

With any luck, the myth of Patient Zero being responsible for HIV/AIDS in the US will finally be completely put to rest.

Gaétan Dugas may not be a household name for most, but he’s the man who has largely been blamed for HIV/AIDS in the United States. Dugas was a gay French-Canadian airline steward who worked for Air Canada in the 1970s and 1980s. Because his work involved a significant amount of travel and because of the number of his sexual contacts, a 1984 study linked him to some other early cases (though it could not necessarily prove a direct line of infection).

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An Ebola Marshall Plan?: How to Stop Ebola and Salvage the Health System in Sierra Leone

This is a guest post by Dehunge Shiaka, a gender expert in Sierra Leone. This is post #3 of a series he has written on the impacts of Ebola in Sierra Leone (post 1, post 2).

How can we ensure that when Ebola ends, Sierra Leone’s medical infrastructure and economy doesn’t disintegrate with it? Yesterday Oxfam called for an Ebola Marshall Plan to help countries like Sierra Leone, which have been seriously impacted by the deadly virus. This would involve economic interventions in health, education, and sanitation- amongst other areas. But given the slow and late response to the Ebola crisis- is this realistic? Continue reading

WHO is responsible for the failure on Ebola?

Nathan Paxton has a provocative post on The Monkey Cage where he suggests, among other things that the World Health Organization (WHO) is not to blame for the Ebola crisis. Rather, he lays the blame squarely on donor countries.

He rightly notes that the WHO’s budget and staff was cut after the financial crisis, but I think he lets WHO off too lightly. With many ideas circulating about the future of the WHO in advance of the upcoming WHO Executive Board meeting beginning January 26th, understanding the various factors that contributed to the failed response to Ebola is all the more critical.  Continue reading

Ebola is Not Over

The Ebola crisis isn’t over. In the absence of new infections in the United States, Americans have moved on to other preoccupations (Ferguson anyone?), but the problem hasn’t gone away even if Google searches have plunged. There has been some positive news out of Liberia with a decline in the rate of new infections from 80 new cases per day to about 20 to 30, but the news from Sierra Leone suggests the problem is far from under control, with the end of the rainy season potentially making transit easier and facilitating the spread of the virus further. More troubling still is the new hot spot of infections coming out of Mali, eight confirmed cases in all, 7 of them related to a single Guinean imam who died in diagnosed in Mali and whose body was not handled properly as one would a deceased Ebola patient. Continue reading

Thursday Ebola Linkage

Well, this has been a very difficult period to watch as we see the unfolding tragedy of the Ebola outbreak in West Africa. We have seen dire warnings for the region, with a dramatic uptick in reported infections and some heartbreaking (and problematic) images from hospitals. There have been credible projections that left unchecked Ebola could have as many 1.4 million infections by early 2015 in Liberia and Sierra Leone, which would amount to more than 10% of the population of those two countries. With President Obama’s announcement of $500 million (perhaps up to $1 billion) and the deployment of 3000 soldiers, help may be arriving and more on the way, but it is unclear if this belated scale-up of attention and resources will arrive to stave off the worst in Liberia and Sierra Leone. Fortunately, the spread in neighboring Nigeria seems very well-contained.

We have also seen the first diagnosed Ebola patient outside the continent, in my own state of Texas, by a Liberian who travelled here and became symptomatic upon arrival. The situation appears to be under control but questions remain, as the patient was initially sent home after his first visit to the hospital. Here are some news and comments from around the web. I had some exchanges with WSJ and NYT reporters about airport fever monitoring as well as the ethics of the images the NYT had of suffering children on their pages. Read on for more. Continue reading

Thursday Morning Linkage: Ebola Edition

The death total of the Ebola viral outbreak in West Africa now exceeds 900, leading the World Health Organization to declare it a “global health emergency.” Urbanization and weak states in the region, coupled with rural practices of bush meat consumption, appear to be some of the problematic drivers of the epidemic. Local populations skepticism of health workers and attachment to traditional practices of care and burial are making the situation worse. The army is being deployed in Liberia to contain the spread and be able to enforce quarantine policies. The potential spread to Nigeria by a Liberia American official is especially worrisome.

Ebola spreads only through bodily fluids (i.e. saliva, urine, blood) and appears to have a low transmission rate (1 to 1.5 people per infected person on average) but high lethality (killing about 70% of those it infects). At present, there is no vaccine or treatment, other than palliative care, though there are some promising possible therapies. Two American aid workers who were infected received an experimental treatment and appear to be on the mend. They are now back in the United States for continued care, which has spurred a spate of public and media interest and irrational fear. In the midst of this crisis, the weakness of the international community, the World Health Organization in particular, loom large. It’s unclear if the topic will be added to the margins of the agenda of the on-going African leaders summit in Washington. Links below.

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Polio and the International Politics of Eradication: CIA Vaccination Ruse, Vaccine Trust, and DNA as a Tool of War

[Please note: this is a guest post by Alison Howell, Rutgers University- Newark]

The recent WHO designation of polio as a ‘global public health emergency’ has reignited debate as to whether the spread of polio is the result of reduced vaccine trust due to the CIA vaccination ruse in Pakistan. The vaccination ruse in Pakistan was part of the CIA’s apparent aim to get Osama bin Laden’s family DNA. In 2011 the Guardian first reported on the ruse and global health experts began to express concern that this would lead to vaccine refusals in Pakistan. There, major efforts were underway as part of the Global Polio Eradication Initiative, which was launched in 1988 and inspired by the success of the eradication of smallpox (a campaign very much tied up with Cold War politics, but that’s another story…). The Taliban opportunistically seized on the moment to ban polio vaccinations until the US stopped its drone strikes, and in 2013 at least 26 polio workers were killed.

With the WHO’s report of a rise in polio, the worst fears of a link between the CIA ruse and polio seemed to be confirmed. Yet, as reported in the BMJ, the WHO previously asserted that it did not expect the ruse to have a major impact on polio eradication. Despite the inconsistency, some media outlets have made a direct link between the CIA activities and this rise in polio. These arguments are understandable not only because they draw our attention to the serious and growing problem of the spread of polio, but also because they seem to point us to yet another major cost of the post- 9/11 wars. This is a tempting association, but there are at least three problems with it:

First- It is unclear that the issues at stake best captured by the frame of ‘vaccine trust.’ Continue reading

World AIDS Day and the Global Fund Replenishment

Sunday, December 1st was World AIDS Day, the annual reminder of the state of the epidemic, a way to focus attention on a problem that is perhaps less visible than it was two or three years but not defeated, not by a long shot. To that end, this week, the Global Fund to Fight AIDS, TB, and Malaria will be convening its fourth replenishment conference in Washington, DC, where it is seeking $15 billion for the next three years.

Recall, in 2011 , the Global Fund canceled its 11th funding round in the midst of the global economic crisis and concerns about some millions of the Global Fund’s multi-billion dollar portfolio having been misappropriated by recipients.  Its then leader Michel Kazatchine resigned in 2012 in the face of board contestation over his role. Since then, the Global Fund has undergone a major reorganization, and Dr. Mark Dybul, the former head of PEPFAR, was appointed in late 2012 as the new executive director of the Global Fund. Both the disease and the Fund have maintained something of a low profile, at least compared to heady days of the mid-2000s at the height of public and political awareness of the cause. So, where do things stand with the epidemic, and will the Global Fund likely have a successful replenishment conference this week?

The State of the Epidemic 

Forty years ago, Anthony Downs documented how issues go up and down the attention cycle, that public attention to domestic problems is ephemeral, issues come and go in the public consciousness even before they are ever fully addressed. That is also true of the international arena. Stories

The global AIDS epidemic has peaked as a news story, but the problem has not gone away. There is no vaccine for AIDS, though there are some tantalizing approaches like the early deployment of AIDS treatment drugs to break the chain of transmission that advocates hope will help reduce the number of new infections dramatically.

While issue attention has slipped like a lot of other issues that come and go, AIDS benefits from a set of institutional and financial commitments that were established in the 2000s that did not go away even during the dark days of the global financial crisis.

slide-1-1024World AIDS Day is a time to take stock of the state of the epidemic, and UNAIDS and the Global Fund usually use the occasion to put their best foot forward, to highlight the successes of their organizations in the effort to address the pandemic but to also remind the public and the policy community that the work is far from done. This year is no different.

UNAIDS put out an infographic that seeks to document the story of expanded access to treatment, declining numbers of new infections (more than 30% since 2001) , particularly among  children (down more than 50% since 2001), and a 30% decline in mortality worldwide since 2004. From 1.3 million with access to treatment in 2005, UNAIDS estimates that some 9.7 million people in low- and middle-income countries had access in 2012.infographic

The Global Fund, as one of the main providers of finance for treatment, is highlighting its own role in expanded access that has continued despite largely level funding:

The results show that 6.1 million people living with HIV were receiving antiretroviral therapy under programs supported by the Global Fund by the end of 2013, up from 5.3 million six months ago and from 4.2 million at the end of 2012.

Good News?

While these results are encouraging and on some level an incredible accomplishment, given how few people received access to treatment more than a decade ago, that coverage is far from complete. UNAIDS estimated that there are still some 28 million people needing treating worldwide, that coverage only extends to 34% of the people who need it. Some 70% of those living with HIV are concentrated in Africa.

Moreover, the declining number of new infections and mortality still means that the ranks of those needing life-long treatment continue to swell. 2.3 million new infections and 1.6 million deaths are too many on both accounts.

The prevention agenda, which has been bolstered by an embrace of male circumcision and other techniques in recent years, is not succeeding nearly fast enough. Dybul for his part is optimistic that new techniques in geospatial mapping of disease will be able to isolate the pockets within countries that need attention:

A critical mass of epidemiological intelligence is revolutionizing our understanding of HIV, providing the global health community with an opportunity to laser-guide the right health interventions to the right populations. Geographical and epidemiological mapping is suggesting that HIV is being pushed into concentrated pockets amid a sea of much lower levels of infection….Using this data, ministers of health and finance, heads of state, development partners and civil society leaders are working in close partnership to structure interventions around the foci of transmission to maximize health investments.

There is some evidence to suggest that about a dozen countries in Africa have reached the tipping point where treatment access is expanding faster than the number of new infections, but whether those advances will continue depend on donors staying the course on treatment and doing better on prevention going forward.

AVAC

Will the Global Fund Get its $15 Billion?

Whether the Global Fund gets the resources its has asked for depends in part on the leadership on display this week in Washington.

The Obama Administration is hosting this replenishment meeting, and an American now sits at the helm of the organization. So, whatever the problems in U.S. appropriations, I feel pretty confident that the U.S. government will try to make a good showing this week.

By law, the U.S. government is constrained in contributing more than 1/3 of the resources to the Global Fund. That would mean a $5 billion contribution by the United States. The FY 2014 budget request from the Obama Administration was for $1.65 billion, a 27% increase of $350 million over FY 2012 levels. If fully funded and sustained over three years, that would be just shy of the $5 billion contribution.

The Senate and House appropriated the president’s full request, suggesting that the Global Fund continues to enjoy bipartisan support despite strong budget cutting pressures in Washington. Other donors like the UK have also followed suit with generous commitments to the Global Fund:

The UK has committed to give £1 billion to the Global Fund over the next 3 years so long as others join us in ensuring it meets its target of $15 billion and our contribution is 10% of the total replenishment.

So, chances are that the replenishment meeting will be a success this week and net the organization considerable new funds (though one reminder of the 2011 troubles was the report that two leading makers of anti-malarial bednets were suspended for contracts from the Global Fund for kickbacks to the Cambodian government for contracts).

Whether those new resources are ultimately translated into successful programs on the ground will be the great test of Dybul’s leadership in the years to come.

World AIDS Day 2012: A Moment for Optimism?

Today is World AIDS Day, an annual opportunity to take stock of the state of the epidemic. Despite a decade of incredible mobilization of finance for and visibility of the AIDS pandemic, UNAIDS estimated that the number of new infections last year 2.5 million still far outstripped the 1.4 million people who received treatment for the first time.

There has been some good news. 8 million of the 15 million people thought sick enough to need treatment now have it, up from 200,000 in the early 2000s. New infections of HIV and deaths from AIDS have dropped significantly in a number of countries. Some like Botswana have even crossed the “tipping point” when those starting treatment exceeds those dying from AIDS. Moreover, the financial crisis notwithstanding, the level of funding to support AIDS treatment remained at high levels. There was a dip in disbursements in 2010 but the drop off was not as steep as some feared.

With new studies that suggest early treatment of AIDS can disrupt the chain of transmission, activists have renewed optimism that an “AIDS free generation,” indeed the “end of AIDS” itself, is possible . They have been emboldened in part because the policy community, after some wavering amidst the financial crisis, has embraced this perspective, as evinced by Secretary Clinton’s World AIDS Day event in which she rolled out the Obama administration’s new PEPFAR Blueprint. Still, I worry that something is amiss, and it’s been a little hard to put my finger on.

2012 PEPFAR Blueprint

 

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An AIDS-Free Generation? HIV Is Not A Fad

The International AIDS Society conference began Sunday in DC, the first time the conference has been held in the United States since 1990 because of the now-lifted travel ban on HIV+ people coming to the U.S. That means that 25,000 activists, researchers and clinicians have converged on DC and what seems like a fanciful goal – an AIDS-free generation. Given that donor foreign assistance budgets are increasingly constrained around the world, what gives advocates such hope that a renewed push against AIDS will be successful? For a disease that lacks a cure, does an AIDS-free generation means an “end” to AIDS?

I’ll elaborate below, but let me preface this post by saying that the turn to treatment over the past decade has been a tremendously amazing representation of global collective action and moral generosity. However, the
storm clouds of the economic downturn and some portents in pharmaceuticals markets have me worried that these gains could be upended by spendthrift donors and new development fads. (On another note, this is the second IAS conference running where my paper was rejected. What does a scholar have to do to get on the agenda? Seriously. Harder than APSA.)

Seizing upon recent studies that suggest that antiretroviral treatment can help prevent the transmission of HIV (one study found a 96% reduction in transmission risk),  activists are encouraging a scaling up of treatment as prevention. What this means programmatically is a little unclear, though advocates have identified the goal of putting 15 million people on treatment by 2015. Today, July 24th, activists will be doing their part to put this front and center on the agenda of the policy community through a major protest action.

The Good News

Lazarus Effect: Before and After ARVs

If funding were not constrained, that might be doable. UNAIDS estimates that more than 8 million people are now on treatment in low and middle income countries, up from just 400,000 in 2003. 6.2 million of them are in Africa which has experienced an incredible scale-up of therapy such 56% of those estimated to be sick enough to need treatment now have access to it.

(These estimates may be somewhat problematic as the proportion of people “lost to follow-up” can be shockingly high a year or two after people are put on the treatment rolls, perhaps as much as 70% in some projects but certainly not that high for all).

UNAIDS also announced that last year the world community spent $16.8 billion on AIDS in low and middle income countries and that half (!) of that money is coming from affected countries themselves. South Africa, the country with the largest number of HIV positive people, has assumed 80% of the costs of treating its citizens since Jacob Zuma took office and reversed the denialism that had previously undermined the country’s AIDS policy under Thabo Mbeki. 

And, in other good news, CHAI, the Clinton Health Access Initiative, released a study that found that average cost of treating a patient in low and middle-income countries for a year has fallen to $200. This isn’t just about driving drug prices down (which has happened thanks to CHAI even for newer, second-line ARVs) but it’s also due to efficiencies in supply chain management of getting the drugs to the clinics and in task-shifting so that trained local health care workers can carry out some essential duties.

The U.S. Contribution
As Tom Hart of the ONE campaign reminded us, the United States has led the way:

Thanks largely to support from Americans of all stripes – Democrats, Republicans, religious leaders, college students, public health officials and the business community – 8 million HIV-positive people around the world now have access to life-saving treatment.

The United States is the largest international donor to global AIDS efforts, and for this, the American people should be proud. George W. Bush, whatever his flaws as president (and there were many), deserves enormous credit. Indeed, the former president is spending his energies these days taking on other global health challenges like cervical cancer.

Take a look at the data for last year. In 2011, if you look at al international donor disbursements, the United States contributed an astounding 59.2% in 2011. With that money, PEPFAR says it is supporting 4.5 million on treatment and is poised to support 6 million on treatment by the end of 2013. 

(Note: When the USG says support, it does not mean that PEPFAR supports 100% of the treatment costs. Activist Brooke Baker suggested it was actually about 50%. 
Looking at this PEPFAR study, it really varies by country. For example, in middle income countries, PEPFAR only paid $139 of the $1017 in per patient treatment costs. For first-line therapies, the estimated average PEPFAR contribution was $305 of the $708 in annual treatment costs.)
The Not So Good News
The not so good news is that there were still an estimated 2.5 million infections last year. And, though that is down by 20% since 2001 and there are lots of countries where the rate of new infections has fallen even faster, the prevention agenda has to be much more front and center.

And, notably, donor funding for HIV/AIDS remained flat at 2008 levels. If this goal of 15 million by 2015 is to be met, an additional $2-3bn in resources would be needed per year to reach $22bn by 2015. This also comes at a time when the United States may be facing a huge budget fight over sequestration that could lead to across the board cuts for major programs. Obama’s proposed 2013 PEPFAR budget was already 3% lower than the previous year, the House and Senate topped it up a little bit. If the politics play out wrong, AIDS funding and treatment goals could suffer.

Moreover, the economic crisis in Europe has already had some effect on European donations for global AIDS efforts, particularly in Germany and the Netherlands which have seen their contributions slump since 2009. Countries like Italy have never really given much. Outside of Europe, Japan is another rich country that has been miserly on AIDS (though maybe given Fukushima we can cut them a little slack).

AIDS-Free Generation
So, what’s all this talk about an AIDS-free generation? Basically, I think activists are excited to think that with a combination of early treatment, other prevention strategies like male circumcision and universal mother to child therapy, that the next generation will be AIDS-free.

Secretary Clinton affirmed these ideas in a speech on Monday where she promised an additional $150 mn for targeted interventions alone these lines. She said:

It is a time when, first of all, virtually no child anywhere will be born with the virus. Secondly, as children and teenagers become adults, they will be at significantly lower risk of ever becoming infected than they would be today no matter where they are living. And third, if someone does acquire HIV, they will have access to treatment that helps prevent them from developing AIDS and passing the virus on to others.

I think what the USG and other donors are hoping is that with rising efficiencies in service delivery and increasing middle income country assumption of the costs of treatment that you can get more for less. However, even with improved efficiencies in the supply chain, I fear that drug prices (at least for first line older drugs) don’t have that much more to fall. Without some infusion of new money, you don’t get much more for little or no new money. You may get less than you want with less than you need.

Should We Spend More Money on AIDS? Yes.
Last night, the World Bank hosted a vigorous debate that had UNAIDS’ Michel Sidibe and Columbia’s Jeff Sachs in support of more funding for AIDS and CGD’s Mead Over and Roger England taking the opposing position.

Over’s position was basically similar to the one Bjorn Lomborg has adopted on climate change, that there are lots of other problems that are equally deserving of attention and where money would go further in saving lives. Now, I know Over has a nuanced position about the need to focus on prevention (which I’m all for), but I fear that economists are a little tone deaf to both the politics and the nature of the disease itself. It’s not as if there is a pot of $25 bn for a bunch of different health interventions and we can choose which ones make most sense.

People mobilized on AIDS because millions were dying, overflowing hospitals and treatments existed that could keep them alive. Other diseases don’t have as capable political boosters. And many other health issues like malaria and TB, even primary health, have ridden AIDS’ coattails.

Moreover, as Laurie Garrett noted on twitter, for communicable pandemic diseases, you do need specialized funds. You can’t partially address this challenge and then let the situation revert to larger and larger numbers of new infections.

And for those 8 million people on treatment (or however many it actually is), we have made a commitment to treat them for the remainder of their lives. If donors and governments renege on such a promise, that is a death sentence and morally unconscionable. However, just treating the people who have it now and doing nothing for those who need it or little more on prevention is not sustainable.

While all of the rhetoric about treatment as prevention is compelling, there are some huge logistical and financial challenges. Putting people on treatment early offers immense promise to break transmission but my understanding is that you have to catch it early when people still have high viral load levels and have a higher risk of passing on the virus to their partners.  The current approach basically forces people to wait until people they already have had the virus for a while and are sick enough to meet certain thresholds. If you only have a limited amount of money, you would want to get the healthier HIV+ people on treatment early for prevention purposes, but morality dictates that you treat those who are really sick. I don’t have answer other than more money for that.

All of this does mean that going forward we have to think strategically about how best to achieve the desired ends given that we have millions on treatment and too many millions of new infections. I still have yet to see what the realistic plan is to break the back of AIDS in a generation, but that’s where we have to go.

Peter Piot’s Memoir on Infectious Disease

I just finished reading Peter Piot’s lively memoir No Time to Lose of his time as an epidemiologist helping identify the Ebola virus in the 1970s through to his service as the first director of UNAIDS. It is an engaging read not least because Piot conveys a profound empathy for those affected by disease. Piot also projects additional warmth and humanity, from his appreciation for Congolese music to good beer.

More substantively, Piot has a proportionate sense of the outrageousness of bureaucratic politics in the UN system, while recognizing the need to navigate in those shark-filled waters.

Unlike many memoirs, there is some bite here, with some choice words for donors who talk a big game but don’t provide much money (here, France and Italy were named) to mid-level careerists who put turf before those they are meant to serve, as well as some for campaigners whose occasional “extreme” demands or tactics can backfire (his account of an AIDS activist calling France a shit-hole on a live fundraising telethon was on point here).

One aspect of the book made me rethink what I thought I knew about transnational advocacy movements, and his epilogue made me question what scope there is for coordination not only in the UN system but also within the interagency process in the U.S. government.

Who Are the Advocates? 

When we think of transnational advocacy movements, our paradigmatic actors are activists, the charismatic leaders of groups leading protests and petitions like Greenpeace, Oxfam, ACT UP, and Doctors Without Borders. However, if you go back to Keck and Sikkink’s foundational book Activists Beyond Borders, you will find that the advocacy networks in their view may also include state actors and representatives of intergovernmental organizations (pg. 9).  However, these are the final items six and seven in their list, and in the ten years plus since Keck and Sikkink came out, NGO activists captured the lion’s share of scholarly attention in the literature (This is not a systematic finding but my sense as a reader of that literature). 

But when you read Piot’s account of his efforts to help cobble together a broad coalition to fight AIDS, you realize that Piot was an advocate and that those change agents inside governments and international organizations deserve more attention as central figures in transnational campaigns. Piot captured some of the breadth of this movement:

But by the turn of the of the millennium our “brilliant coalition” was taking shape in its diversity and apparent chaos. What could the South African Chamber of Mines, Anglican Church, Community Party, and trades unions have in common with the Treatment Action Campaign, Medecins Sans Frontieres, and UNAIDS? A common goal: defeating the AIDS epidemic and caring for its victims. A powerful joint desire to be a force for change.

The Piots of this world need to take center stage in our analysis, not least because every activist campaign needs countless Piots inside to have their ideas become policy. 
Can Organizations Work Together?
In a sense, this book is a coming of age story, of Piot’s transition from medical professional to skilled political operator. So much of what passes for politics in this book is the jostling for position among mid-level careerists in intergovernmental organizations and within countries. UNDP and UNICEF jockey for turf internationally with similar dynamics at play inside countries with the CDC and the NIH having difficulty at times playing nice within the U.S. government. 
Among these, Piot comes across as an adult, and for such petty games, Piot has little patience. Nonetheless, he became sufficiently attuned to their inherent part of the game. To survive in this business, he describes his persona as chameleonic (something in common with his UNAIDS successor Michel Sidibe). In an obsessive desire to help those suffering, Piot adopted a healthy, ethical pragmatism and flexibility, of a willingness to work with whoever was needed to get the job the done. 
But, his epilogue to the book, leaves me uneasy about the scope and capacity for coordinated action. Even if the financial crisis were not leading to more miserly patterns of foreign aid, the collective response of the international system may be largely unmanageable. Here, Piot wrote of his sense that UNAIDS, the “most advanced” attempt to coordinate various UN agencies to “deliver as one” was fraught:

Over the years I became increasingly skeptical as to whether the current UN coordination governance could ever by effective operationally, despite the goodwill of many, if not most, staff. The two main obstacles for delivering as one UN were the institutional interests of individual agencies — careers, political influence, budgets–and the incoherence and volatility of its member states, which not only had different, sometimes mutually exclusive, interests, but which also lacked internal coherence…

This resonated strongly with me as this week the Obama Administration issued an enigmatic statement suggesting that the much ballyhooed interagency Global Health Initiative would be reconceived/mothballed, leading analysts like Laurie Garrett and Amanda Glassman to parse what went wrong in this grandiose effort to conduct a “whole of government” response.

Here, Piot’s conclusions are ones we should take to heart when we think about global and national governance of development, health, and foreign policy writ large:

My conclusion on UN coordination was that it was a collective failure, and that the international community goes for some bold mergers and acquisitions as the current plethora of organizations is too expensive, or that it accepts that pluralism is a strength, as long as only effective and well-managed institutions are supported and others closed down.

Interestingly, he suggests that setting up institutions outside of the UN system like the Global Fund is “not a solution” as much as he tried to make it a success. Frankly, I’m not sure what to do with that.

Any Regrets?

Aside from the time away from family, Piot’s main regret is whether or not he could have done more   to save lives earlier and faster. Here, I’m struck by the other quasi-memoir on HIV/AIDS that also came out this year Tinderbox by journalist Craig Timberg and public health professional David Halperin. In that book, they charge Piot with late attention to male circumcision, a powerful AIDS prevention technology that took too long to gain currency. 

Piot at one point, in what might be a veiled reference to the duo, dimisses efforts to identify what prevention strategy worked in Uganda to stem the tide of new infections – was it A (abstinence), was it B (be faithful), or was it C (condoms), writing: “However, some scientists and journalists continue to fuel the debate in a fairly obsessive search for the magic bullet in HIV in prevention…” And to be fair, Halperin has long been obsessive about male circumcision, but as I wrote in a piece for CSIS in 2008, perhaps rightfully so. 

Was Piot slow to the uptake on the promise of male circumcision? He praises it as one strategy among many that have taken center stage of late on prevention, but I don’t know the internal history well enough to judge. In general though, I agree with those like Mead Over who see the prevention agenda to have largely been a failure amidst this incredible and important turn to treatment access over the last decade. 
But, I would be wary of blaming Piot for that. While one can quibble on the margins with aspects of his service (I think some campaigners would say he was too accommodating of the branded pharmaceuticals companies), Peter Piot clearly has been on the right side of history on HIV/AIDS with remarkable skill, poise, grace, and pragmatism.

Global Implications of the Contraception Kerfuffle

Our readers are surely aware of the contraception kerfuffle, the outpouring of criticism and controversy engendered by the Obama’s administration’s efforts to ensure that more American women have access to contraception as part of their health plans. With the insurance schemes of religious-affiliated universities and hospitals often not covering contraception services for women, the Obama administration sought to use the new health care law to extend access to contraception. (It took John Stewart to point out that many of these same plans cover Viagra for men but not contraception for women). The ensuing political melee was almost comic, with the president’s detractors, mostly on the right, seeking to make hay about the extent to which this move was an affront to religious liberty.

In the process, by putting forward only men as interlocutors to speak for women, critics of the President’s plan likely further alienated both women and younger voters. Polling and analysis suggest this that may prove to be a winning issue for the president in the fall election (nearly all American women, including Catholics, use birth control). That said, given a divided Congress, U.S. advocates of family planning and reproductive health face deeper obstacles of mobilizing U.S. government resources to support their cause internationally. I thought I’d use this post to explore some of the global health implications of U.S. domestic politics.

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Family Planning and Reproductive Health as Political Football

While global health issues have frequently enjoyed bipartisan support, the same cannot be said of family planning and reproductive health which have unfortunately often become casualties of America’s culture wars. A constant battle has been waged between successive Democratic and Republican administrations mostly about abortion but with important consequences for more consensus issues like birth control.

In 1984, Ronald Reagan initiated the Mexico City policy, what critics call the Global Gag Rule. The policy forbids NGOs that receive U.S. government money from performing or promoting abortion services. NGOs that refused to adopt policies satisfactory to the policy are ineligible for funding.  The International Planned Parenthood Federation was one such organization and lost 20% of its funding. While there were exemptions for rape, incest, and life-threatening conditions, the policy was seen by critics as overly restrictive, sometimes at odds with national laws (which in some cases mandated providing information on all options), and ultimately making it more difficult for women to get family planning services and information.

The policy has since become a political football between U.S. presidential administrations; it was rescinded under President Clinton, reinstated under George W. Bush and rescinded again under President Obama.

Congressional opponents of abortion have also extended their concerns to the United Nations Population Fund (UNFPA), again out of concern that the organization was supporting abortions and helping China implement its one child policy. From 2002 to 2008, the United States suspended contributions to UNFPA, an organization that has increasingly shifted its mission from population management to women’s empowerment (As an aside: the Center for Global Development issued an important working group report last year that encouraged UNFPA to streamline its mission and activities to focus more centrally on family planning). 

In 2011, supporters of reproductive health fought off aggressive efforts to cut $150 million in funding for international programs and efforts to prohibit U.S. support for the United Nations Population Fund as well as proposals to reinstall the Global Gag Rule.

In an election year in which the GOP primary candidates have largely focused on the domestic agenda, global health issues have not surprisingly been largely invisible across 20 GOP primary debates and on the campaign trail.  That said, this year’s Republican presidential candidates have pledged to resinstate the Mexico City/Global Gag policy should they win. Romney, in his January 2012 speech to CPAC (the Conservative Political Action Conference), sought to win over conservatives who questioned his bonafides on abortion:

On day one, I will reinstate the Mexico City policy. I will cut off funding for the United Nations Population Fund, which supports China’s barbaric One Child Policy.\

Michelle Goldberg for one warns that the consequences of such pledges could be quite significant for women around the world:

If Romney is willing to scrap the only federal program to provide birth control to low-income women in the United States, programs to do the same thing abroad certainly aren’t safe. We already know that, like every Republican since Ronald Reagan, he’ll impose the global gag rule, preventing any American money from going to organizations that perform or even counsel about abortions. He will likely follow George W. Bush in withholding money from the United Nations Population Fund, or UNFPA, an agency that promotes reproductive health worldwide, on the demonstrably false grounds that it supports coerced abortion in China.

It would be convenient to suggest that the Republicans are wholly opposed to women’s health issues, but this assertion would forget that the incredible rise in global health spending happened on President George W. Bush’s watch, not President’s Clinton nor President Obama who has merely continued what his predecessor started. Indeed, his 2013 budget looks like it may be something of a step back from the boom years of the Bush administration.

Bush’s Other Surge: Funding for Global Health

In the midst of recent criticism of Republicans for the stance on contraception here at home, former Senator Rick Santorum and his supporters have received the bulk of the criticism for their socially conservative views. But, it should be remembered that Santorum was one of the leading supporters of Bush’s other surge: funding for global health.


Throughout the early 2000’s, U.S. funding for global health expanded dramatically from less than $2 billion a year to nearly $9 billion by the time George W. Bush left office. While most of the Republican candidates have fallen over themselves to talk about reducing and even zeroing out foreign aid altogether, only Rick Santorum has offered a vigorous defense of PEPFAR and the Global Fund in the November 2011 national security debate. As David Fidler noted, Rick Santorum is the one GOP candidate who has a track record of supporting HIV/AIDS programs that have had a tremendous impact on saving the lives of women and children.

It is true that even as U.S. funding for global health increased in the Bush years, U.S. funds for reproductive health and family planning remained largely flat by comparison (as these tables from the Kaiser Family Foundation reveal). This left disappointed proponents of family planning grousing that disease like AIDS were diverting attention and resources from other problems that in their view accounted for a larger share of deaths in some countries.

This always struck me as a little bit of sour grapes from groups hoping to capitalize on the success of the AIDS treatment advocacy movement. It is not as if those funds were fungible. The President and Congress were moved by the compelling story of millions needlessly dying of AIDS while treatment was possible. Activists from these other causes needed to make a stronger case that their issues were worth supporting.

Indeed, the Global Health Initiative from the Obama Administration did widen the aperture of issues that received attention from the U.S. government, including reproductive health. President Obama just released his proposed 2013 budget which, according to Population Action International, includes modest increases for international family planning and reproductive health after two years of cuts. Most of the money is dedicated to bilateral programs administered by USAID but also includes the U.S. contribution to the UNFPA.

Source: Population Action International
However, these are just proposals and with Republicans controlling the House, it is anybody’s guess as to what level of support these programs will ultimately receive. Obama’s total request of $8.5 billion for the Global Health Initiative is 3.4% lower than than FY 2012 levels.

Given that poor women overseas have no voice in the U.S. political system, it is easy enough to see how their concerns, however trivial a part of the federal budget, will not get much attention in an election year.

Of course, the same was once said of global health writ large. AIDS activists dogged Al Gore on the campaign trail in 2000 and the ONE campaign (which appears to be pretty silent this primary season) vigorously engaged the candidates on international development and global health in 2008. Even as advocates celebrate the planned extension of contraception services here at home and the modest proposed increase in funding, they should seek ways to engage the candidates and the broader political class about the value of providing reproductive health services.

Given our two party system, one party’s ownership of this piece of global health is ultimately bad for women’s access to family planning. Perhaps it is impossible to disassociate contraception from abortion, but this episode may provide an opening for advocates to appeal to women and particularly younger voters across the political spectrum about the benefits for families both at home and abroad of being able to decide when is the right time to have children (As a new father, that is something I completely understand).

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