Tag: AIDS

It’s Not Just Big Data: Data Granularity and Aid Targeting

Earlier this spring, I had a chance to talk to Mark Dybul, the head of the Global Fund to Fight AIDS, TB, and Malaria and former administrator of PEPFAR, the U.S. bilateral AIDS program. At the time, he expressed optimism about using geo-referenced data on HIV/AIDS prevalence to better to target AIDS foreign assistance. In advance of the recent AIDS conference in Australia, researchers (which include Dybul) released a new study in The Lancet ($) that modeled that potential in Kenya by focusing on the hot spots of high HIV/AIDS prevalence (see above East Africa map, purple represent high prevalence levels). Dybul’s comments were music to my ears. For the past year, I’ve been part of the AidData Research Consortium’s project (ARC) to develop sub-national foreign assistance data. Already that project has worked to help geo-reference World Bank, African Development Bank and Asian Development Bank projects as well as foreign assistance from all donors in a number of countries. As many of you know, I’ve been part of climate vulnerability mapping for the better part of five years through my work on Africa through the Minerva Initiative and the CCAPS program at the Strauss Center. This fall we will embark on a new Minerva project to look at disaster vulnerability and complex emergencies in South and Southeast Asia. In this post, let me say a few more words on the importance of data granularity and aid targeting. Continue reading

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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

 

Continue reading

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How to Survive a Plague

I am putting the finishing touches on a new book manuscript on social movements and market transformations with my co-author Ethan Kapstein. In the process of researching that book which focuses on the global AIDS treatment advocacy movement, we tried to get our hands on any relevant material. We became aware of two important documentaries that have just been released, one is David France’s How to Survive a Plague which captures ACT UP’s mobilization for AIDS treatment in the United States in the 1980s and 1990s. The other is Dylan Mohan Gray’s Fire in the Blood, which covers the global movement for AIDS treatment access of the early 2000s. I had an opportunity to screen both films, and here is my review of How to Survive a Plague.

ACT UP (AIDS Coalition to Unleash Power) emerged on the scene in the 1980s at the height of the AIDS crisis in the United States and other rich countries. ACT UP embraced an anti-establishment ethos, staging occupations of governments offices, hospitals, drug companies, even church services with aggressive in your face tactics that drew in the media and brought gay rights and the AIDS epidemic front and center to the nation’s attention. But as much as ACT UP relied on shock tactics, they also took it upon themselves to learn the biology of the virus and how the process of drug testing and development worked.

At the time, the gay community, one of those most affected by this disease, was deeply stigmatized and faced widespread discrimination. Partners of those living with and dying of HIV and AIDS lacked visitation rights at hospitals and often were kicked out of housing if their lover died. Until the realization in the mid 1980s that AZT, a drug once meant to fight cancer, could slow the progress of the disease, HIV was a death sentence accompanied by a variety of horrific opportunistic infections as the disease moved inexorably forward to its bitter end, with lesions and cancers that would gradually rob the body of its mass and vigor as those afflicted with it wasted away to skeletal figures.

Peter Staley
In the face of this trauma that would kill hundreds of thousands, a shell-shocked gay community and supporters mobilized with the movement that began in New York, spreading to other cities and internationally. “Act Up Fight Back” became the movement’s rallying cry and helped provide purpose for those fighting the AIDS epidemic as they sought greater attention, resources, and swifter delivery of drugs to treat the disease.

How to Survive a Plague vividly captures a period in American history just long enough ago that people in their early forties and younger might not have an appreciation for what it was like for a community to face both systemic discrimination and a devastating disease. I was struck by how self-aware the community of activists who fought the AIDS crisis were in documenting their struggle through video. Many if not all actions were accompanied by videographers, whether it be Catholic church services where activists disrupted Mass or the wrapping of Senator Jesse Helms’ Washington house with a gigantic condom.

The director David France’s achievement is to make that material, collected over the past two decades, accessible to an audience too young or unaware to have known the scene. For those who lived through it and know the players or the wider arc of the disease, the film surely has a different poignant resonance as they look back on lost loves and their own past (Andrew Sullivan’s remembrance is one of my favorites).

Beyond the archive material of public protest, there are private moments and footage of a number of key figures in ACT UP like Peter Staley, Marc Harrington, Ray Navarro, David Barr, Jim Eigo, Bob Rafsky, Ann Northrop, many of whom have gone on to do other things and others who are now dead. For those who do not know at the outset who is still alive today, the film purposefully builds a dramatic narrative, holding back contemporary interviews with a number of players in the back half of the film, revealing their disparate fates. That reveal is cathartic both for the viewer and those interviewed.

When we first see these men and women, the architects of ACT UP, most of them are in their twenties and thirties with the flush of youthful good looks and energy about them. By the time we arrive at the end of the film, we have witnessed in some cases footage of the physical and psychological toll the disease has taken. Or we see the activists now middle aged, craggy with the enormity of what they experienced visible in their demeanor. In those interviews, the activists have a chance to look back on their past, and the weight of memory is profound for them and us as audience.

ACT UP by the early to mid 1990s began to come apart amidst internal conflict over its direction. The film does not shy away from this moment and shows some of the footage of meetings in which these tensions are manifest. Larry Kramer, the playwright and ACT UP founder, witnessing this conflict is aghast and shouts down the back and forth in a meeting, “We are in the middle of a fucking plague.” “Until we get our act together we are as good as dead.”

The nature of the disputes that rent ACT UP have much to do with the mainstreaming and taming of the movement as it grappled with a system initially deemed hostile to it but ultimately one that could gradually accommodate them. The Centers for Disease Control (CDC), the National Institutes of Health (NIH), and to some extent drug companies like Merck became more willing partners to move the scientific process of drug discovery and testing along to get therapies available faster as ACT UP demanded.

This increasing coziness of some in the movement, especially the T&D Committee (or Treatment and Data), to government and business ultimately became a strong enough rift for some of them to break off and form their own organization, the Treatment Action Group (TAG). Other divisions, that perhaps get less coverage here than they have in academic circles, is the fault line between those HIV positive, many of them white gay men, and allies, some of them lesbians, who tried to bring attention to wider sets of social issues facing the community of those living with HIV. For those living with HIV, the emphasis was largely on getting drugs into bodies. For others, issues like discrimination, both gender and racial, demanded more attention.

The film, with its focus on those who sought an accommodation with CDC and NIH, perhaps implicitly sides with that group and they are an incredibly sympathetic bunch. That said, there are important stories to be told about how advocacy for women also brought attention to how both the science and the movement focused on the needs of men, until women helped bring attention to a variety of symptoms and ailments that were AIDS-related but were not initially classified as such.

I was struck by the change in activists’ tactics as those who had been among the most vigorous supporters of swift roll-out and clinical trials of drugs began, after initial failures of some early drugs like ddI, to encourage more caution and time as the drugs that would ultimately offer a breakthrough, protease inhibitors, started to be developed. I still wonder what the activists think now about their early efforts and whether they were useful, looking back on that earlier period.

The opponents of action like arch-conservative Senator Jesse Helms of North Carolina are captured in all their vitriol. Helms is observed decrying those suffering from AIDS from having brought the disease upon themselves for engaging in unnatural acts. While this early ugly legacy is there, Helms’ later embrace of AIDS treatment globally is not, given the emphasis on the American epidemic. 

The footage in this film is understandably largely New York-centric, and there were other cities with vibrant ACT UP scenes, both in the United States and abroad. The ACT UP Oral Archive has interviews with many other figures from the scene, and another film on the subject, United in Anger, is also set to be released this fall.

These minor reservations aside, I found How to Survive a Plague emotionally resonant and evocative. I was in my early teens at the time, living in Texas, scarcely aware of ACT UP and the wider AIDS crisis. My interest in the subject came about in the late 1990s, just as the global scope of the AIDS crisis became apparent. While I had heard of ACT UP, the film makes you feel present in the vibrancy and sorrow of the period that only a video medium can. The film is going in to wider release this fall, and I encourage you to see it.

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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.

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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.
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Part II on the AIDS Crisis and Learning from History: Lessons from South Africa


In my last post, I profiled the Origins of AIDS, Jacques Pépin’s masterful study of how the virus that causes AIDS in humans originated in chimps and then jumped to humans and later took off as a result of a complex series of events involving local populations uprooted from traditional practices, the spread of prostitution, and widespread use of injections to fight infectious diseases, among other factors (see Donald McNeil’s compact summary review in the Times).
If Pépin’s book is of a scholar/detective sifting and sorting evidence to advance an argument, Geffen’s book represents the history if somewhat impersonal memoir of the experienced social pugilist. His efforts remind the world of the achievements of the Treatment Action Campaign (TAC), the South African AIDS advocacy campaign that challenged the government of Thabo Mbeki to provide antiretroviral  (ARV) therapy to those suffering from AIDS.

Geffen is one of TAC’s longtime leaders, and this book chronicles TAC’s clashes with both the South African government and a series of quacks and denialists who sought to promote anti-scientific remedies that likely contributed to the deaths of thousands of those suffering from HIV.

Geffen casts Mbeki (and his health minister) as villains in the struggle to extend treatment to those with HIV. For those familiar with the work of Nicoli Nattrass, William Forbath, the political cartoons of Zapiro, and others, Mbeki’s indulgence of AIDS denialism rings both true and familiar. 
Alongside retellings of the legal wrangling by TAC with the Mbeki government and the quacks and hucksters, Geffen peppers the narrative with stories of people who took the their advice rather than the guidance of the medical community. The examples of failed and ultimately fatal vitamin and garlic treatments are sober reminders of the price paid by so many. 
Geffen’s last chapter seeks to understand how it was possible that the African National Congress government, the movement of liberation from apartheid, could sully its legacy by embracing AIDS denialism. Here, Geffen engages a debate taken up in Evan Lieberman’s important book Boundaries of Contagion: “Why have some governments responded to AIDS more quickly and more broadly than others?” Geffen’s asks a slightly different question: “Why did Mbeki’s views on AIDS prevail for a while?”
Geffen writes: 

As president of the ANC and by far its most powerful member, Mbeki was able to impress his personal positions on the organisation. Despite an essentially democratic structure – branches and sectors elect their leaders, who in turn elect the organisation’s leadership at provincial and national level – the ANC has much within its culture that is anti-democratic and renders it vulnerable to and easily manipulated by the personal views of its strongest leaders (p. 193).

This argument, essentially about Mbeki’s leadership, is contingent upon the ANC exercising significant, largely unchecked, power over the country’s direction. As Geffen describes, the ANC possessed such status:

 The ANC together with its allies liberated South Africa from apartheid. It is recognized and admired as the liberator by about two-thirds of the voting population. This enables it to exert a powerful hegemony over South African society (p. 194). 

By appeals to African nationalism, Mbeki and his allies were able to stave off vigorous contestation from AIDS advocates for several years. Though TAC was ultimately able through the court system to push the South African government to change direction, the damage was done with at least two studies estimating that 330,000 plus deaths could have been averted with different policy.
This explanation – emphasizing the leadership role of Mbeki himself and the dominance of the ANC – fits my own understanding of the South African case as well as the Ugandan case where President Museveni took a much more aggressive stance in addressing the AIDS crisis.
Here, Geffen’s book intersects with the Lieberman book mentioned above. The recent issue of Perspectives on Politics features three (!) reviews on Lieberman’s book by Macartan Humphries, Eduardo Gomez, and Daniel Posner. While Geffen’s book is obviously limited to a single case and represents the work of an activist rather than academic, I found his answer more persuasive than the account, at least of the South African case, featured in Lieberman’s book. 
Through mixed methods including sophisticated econometric analysis, Lieberman attempts to show that the fluidity of ethnic boundaries explains the reason why some countries addressed AIDS more than others. Where boundaries are rigid, groups less affected fail to support policies to help out others, as they see themselves less at risk and those communities disproportionately affected by the AIDS crisis fail to mobilize, given their marginalized status. Where ethnic boundaries are weaker, there is a greater sense of shared fates.
Here, I share with Humphries and Gomez some of the concerns about Lieberman’s treatment of key cases and rival explanations. Humphries writes:

But South Africa remains puzzling. One would expect that if there were any place where the effects Lieberman describes would not be determinative, it would be in a case in which the affected group was both a large majority and in control of policymaking (pp. 875-876).

Gomez echoes this view: 

While he provides evidence showing that state capacity and the presence of NGOs is insufficient for predicting policy responses, it is hard to say the same for political leadership. The dismissal of AIDS leadership fell on President Nelson Mandela’s avoidance of the issue in South Africa, Thabo Mbeki’s interest in AIDS prior to election, and then his avoidance of it once in office, notwithstanding ongoing political support. In Brazil, Lieberman claims that aggressive policies predated Presidents Fernando Henrique Cardoso’s and Luiz Inácio Lula da Silva’s political leadership. Yet this is factually incorrect. Prior to Cardoso’s and the World Bank’s loans in 1993, there was no aggressive AIDS program. Thus, leadership under Cardoso, at the presidential and bureaucratic level, was important for reform (p. 878). 

In Lieberman’s view, leadership is unsatisfying because: “The relationship between cause and effect is so close that they are almost indistinguishable” (p. 19). However, one can identify differences in state structures where personal rule is possible. As Robert Jackson and Carl Rosberg argued in their classic article “Personal Rule: Theory and Practice in Africa,” many newly independent African states lacked institutionalized checks on individual leaders. While that portrait has started to change, it is still a recognizable feature in many African countries. Though South Africa possesses more of the societal and institutional checks than the rest of the continent – an independent judiciary, a free press, and a vigorous civil society – the ANC’s legacy as liberator and Mbeki’s privileged position within the party gave him significant scope to pursue an idiosyncratic agenda for several years.
While social scientists tend to dislike individual level explanations in favor of more domestic structural and international systems level explanations, one cannot understand critical cases like South Africa without bringing in agency and leadership. For that matter, we can’t understand PEPFAR without acknowledging the role of President Bush and his personal interest in the problem. Here, I’m reminded of the piece by Dan Byman and Ken Pollack in a 2001 issue of International Security, “‘Let us now praise great men: bringing the statesmen back in.” The challenge is to recognize the conditions under which leaders may exercise agency. The structural impediments  to action vary by country and circumstance. Sadly, in these tough economic times, the scope for more aggressive efforts to address the AIDS crisis appears much more circumscribed than it was just a few years ago.
Leaving this more theoretical social science question aside, Geffen’s book supports the notion that the Mbeki government did the wrong thing when it could and should have done something different. It is heartening that the Jacob Zuma government did an about-face on AIDS and has dramatically changed course to extend ARV therapy, support male circumcision, and enacted a host of other measures to treat and contain the epidemic.
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Learning from Histories of the AIDS Crisis

What can we learn from histories of the AIDS crisis? Jacques Pépin’s The Origins of AIDS and Nathan Geffen’s Debunking Delusions: The Inside Story of the Treatment Action Campaign are two important contributions to our understanding of a disease that has now claimed nearly thirty million lives.

In different ways, both books raise interesting questions about what we can learn from history about causal mechanisms and wider sets of issues. In this two-part blog post, I’ll talk about each book and a recent set of review essays in Perspectives on Politics on Evan Lieberman’s important 2009 book Boundaries of Contagion: How Ethnic Politics Have Shaped Government Responses to AIDS.

Pépin, a Canadian medical doctor with a specialty in African sleeping sickness, has written a compact yet magisterial book that traces how the virus that causes AIDS leapt from chimpanzees to humans and then became a generalized epidemic in Africa that radiated around the world.

Pépin asks and answers a number of important questions in the book to weave a complex narrative of the worst health crisis since the Black Death. Could animals other than chimpanzees been the cause of transmission of HIV? (No. A hunter likely came in contact with chimp blood and picked up the disease and passed it on.) When and where, to the best of our knowledge did HIV originate? (Much earlier than we thought, perhaps as early as the 1920s and probably in central Africa in or near present day DRC). What role did colonial governments play in dislocating rural African societies and fostering the growth of male-dominated urban centers susceptible to prostitution? (By creating towns where only African men could legally live or by uprooting men to work on the railroads or the mines, the colonial powers disrupted rural populations and left large numbers of men without families and more likely to procure the services of the “oldest trade”). How did colonial era medical interventions to protect against other diseases like yaws and syphilis likely engender the spread of HIV? (Injectable drugs helped reduce the burden of infectious disease but poorly cleaned equipment likely helped spread HIV more widely). How did AIDS likely spread from Africa to and throughout the Americas? (One of 4,500 Haitian teachers in the Congo likely acquired the virus and brought it home where it became amplified through sexual tourism from the United States and the trade in blood which both spread the virus to hemophiliacs but also back to blood donors through efforts to separate out plasma).

As a political scientist, I found it fascinating how Pépin explicitly addressed alternative explanations for different facets of the argument. Even as Pépin sought to answer questions about AIDS, I learned a great deal about colonial era health practices, key protagonists in the fights against yaws and sleeping sickness, among other diseases. At each step, Pépin sought to engage rival explanations, “Could it have been this?”

At the same time, he consistently assembled a variety of evidence including colonial era statistics on trends in treatment of infectious diseases to sophisticated genetic evidence dating the origins of particular varieties of HIV with a margin of error.

In terms of policy and the present day, I was especially troubled how even well intended interventions to deal with other public health problems likely helped set the stage for the spread of HIV. This observation made me wonder how modern practices intended to enhance health and save lives (like the widespread use of antibiotics in animal feed) may create unanticipated consequences of grave proportions later on (such as drug resistance).

Even as AIDS continues to cast a large shadow over global health efforts, I wonder about our readiness for the next crisis and the leap of infection from animals to humans that proves both especially transmissible and deadly (or in light of the reports of manmade bird flu, from the lab to humans). Just this week, the Washington Post ran a story on the CDC’s efforts to test confiscated African bush meat for potentially lethal pathogens. The budget of this program: $59,740.

While I can’t say whether or not this amount of money is enough, I am worried that health agencies are being called upon to do more with less, in some cases much less. With the WHO having experienced unprecedented budget cuts in 2011 (nearly $1bn or almost 20% of its biennial budget) and the CDC having significant cuts of its own ($740mn or nearly 11% of its budget was cut between FY2010 and FY2011, are we becoming less capable in this time of economic crisis, even as our global health needs have grown?

In the next post, I’ll focus more on Geffen’s book and understanding the role of leadership in national efforts to address HIV/AIDS.
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An AIDS-Free Generation?

Three weeks ago, Hillary Clinton gave a speech at the National Institutes of Health suggesting that because of recent advances in scientific understanding we could finally envision an AIDS-free generation. Wow, fantastic, the beginning of the end! Could it be?

A week ago, the Global Fund to Fight AIDS, TB, and Malaria announced that because of insufficient donor funding, it was canceling its next funding round for new projects and that it would likely struggle to maintain some of its existing commitments. On the Huffington Post, Jeffrey Sachs groused that President Obama hadn’t done enough to defend the Global Fund’s budget.*

Two nights ago, an optimistic Bono was on the Daily Show talking up the idea of an AIDS-Free Generation. With media accounts of the Global Fund in trouble, something does not compute. What is going on?

Yesterday, December 1, was World AIDS Day, and if you tuned in to the live webcast of the ONE Campaign event on YouTube like I did, you witnessed not one but three U.S. presidents – Obama, Bush the younger, and Clinton (plus Bono, Alicia Keys, and Sanjay Gupta!) take part in an event meant to celebrate and defend the role of the United States in the incredible scale-up of AIDS treatment services over the last eight years. President Bush was beamed in by telecast from Tanzania where he and the Tanzanian President made the case that PEPFAR, President Bush’s signature AIDS program (and the single most important positive legacy of his campaign), was a remarkable success.

President Bush had a terse warning for those considering gutting foreign aid spending:.


I understand that we are in tight economic times. The wealthy nations are going through budgetary struggles… There is nothing more effective than PEPFAR…. The number of people who live today as a result of PEPFAR is staggering. There is no greater priority. And this is something our American citizens must understand. And  our government must understand. There is no greater priority than living out the admonition to whom much is given much is required. We are blessed nation the United States of America. And I believe we are required to support effective programs that save lives.

President Obama followed his remarks by pledging to increase the number of people on treatment in the developing world from the existing target of 4 million to 6 million by 2013. Again, he talked about how we can finally envision an AIDS-free generation, that the combined efforts to employ male circumcision, prevention of mother to child transmission of AIDS, and early detection and treatment of AIDS could, along with other policies, ensure that the next generation is AIDS-free.

Now, at this point, the audience is hooting and clapping, as any dutiful audience is bound to when President Obama at his oratorical best. But, in my classroom where we were streaming the event live, there were a few titters and grumblings. Where is the money going to come from?

We know that the Obama budget for foreign aid has many detractors in Congress, and while global health spending is only subject to a modest trim in the House version, it would go down nonetheless. How do you propose to put 2 million more people on treatment when money is going down?

It was this kind of mismatch between rhetoric and reality that got health policy journalist-think tanker Laurie Garrett worked up in a pointed blog post:

It is time that everybody engaged in this ill-defined mission we call “global health” – including advocates for expanded access to HIV treatment – wake up to reality and cast off the old course entirely. The time is overdue for fundamentally new ways of thinking about what is meant by the phrase “global health,” how HIV fits into that picture, and most urgently how the overall mission is to be financed at proper scale, equity and sufficiently ensured for the long haul.

The UNAIDS Zero Campaign and Secretary Hillary Clinton’s AIDS-Free Generation calls are excellent goals. But reality dictates that the strategies used to attain those goals, and the tactics deployed both in the field and directed to donors must change radically and immediately.

Now, I’ve not had a chance to do the detailed analysis of the President’s plan, but on NPR on the way to the airport, the basic story that I heard was the President aims to do this through existing funds and extracting efficiencies in the program, by lowering drug costs further and by cutting the full costs of treatment, from procurement to delivery. Here, I want to be sympathetic to what the President is trying to do, but at this point, I’m not keen on the man overpromising and then not being able to extract the necessary resources from Congress.

I take it this event was a marker to try to defend the Administration’s spending on AIDS, by bringing the full political heft of three presidents, including a Republican, to bear. However, the times being as they are, speeches that talk about preventing the oceans from rising or talking about an AIDS-free generation just don’t quite do it for me any more. The devil is in the details and the politics.

* (As an aside, I tweeted back and forth with Sachs as Obama’s budget for 2012 is actually larger than the one that was requested last year. The real trouble is that the U.S. had a temporary lull in disbursements last year to the Global Fund due to new Congressional rules and the fact that countries like Spain and Italy are delinquent with their pledges or no longer contributing. In terms of Global Fund finances, the news about canceling the next commitment period may be a little over the top. To be fair, the Global Fund still plans to disburse $10 billion between 2011-2013.)

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