HIV/AIDS: Obama's easy win, Alan Ingram Kris Peterson

A small portrait of the translator

November 26, 2008 @ 19:28 UTC

Written by

Barack Obama
Government & Politics, Health Care

Amid international financial
meltdown and recession, the challenge of withdrawal from Iraq and the
growing crisis in Afghanistan, there will be few "quick wins" available
to President Obama. But fixing the US response to HIV/AIDS is one way
he can do a lot of good relatively quickly and begin the move towards
a new standard for international engagement. As the world prepares to reflect on its response to the pandemic,
it is worth asking what Obama might achieve by World AIDS Day 2009.

will inherit President Bush's Emergency Plan for AIDS Relief (the PEPFAR programme), which has helped to place hundreds
of thousands of people on life-saving medication. PEPFAR was launched
in 2003, and has spent some $19 billion so far with another $48 billion (including
$9 billion for tuberculosis and malaria) pencilled in for 2009-2013.
But while it is often cited as the only positive foreign policy accomplishment
of the outgoing administration, it is also deeply
The programme has been undermined by the US culture wars,
the Republican assault on science and a unilateral and privatised approach
to foreign policy. So what must Obama do about it?

There are a number of
things that could be done quickly. First, he should cancel the Mexico City
was introduced by Reagan, repealed by Clinton and reintroduced by Bush)
that denies US funds to foreign NGOs that even mention abortion in counselling
or referrals, undermining the provision of comprehensive health services.
Although Bush signed an order exempting PEPFAR from the policy, it still
applies to all US family planning funding and should be repealed.

social conservative positions on abortion have also led to HIV/AIDS-related
programming becoming separated from reproductive health and family planning
services. Reintegration would help to protect women and girls and boost maternal health.

the first version of PEPFAR  mandated that one-third of all money
spent on preventing the transmission of HIV be focused on ineffective "abstinence-only" interventions rather than the comprehensive prevention
strategies supported by the vast majority of experts and international
opinion. The second phase (authorized by the Tom Lantos
and Henry J. Hyde United States Global Leadership Against HIV/AIDS,
Tuberculosis, and Malaria Reauthorization Act of 2008
) removes this "hard earmark"
but replaces it with a requirement for all country programs to report
to Congress if they spend less than fifty percent on "abstinence-only" programs.
This should be removed.

PEPFAR II requires "at least half" of all funding to be spent on
treatment and care. But many experts believe that with new HIV infections
running faster than the roll out of treatment, the focus in stopping
the pandemic must be on prevention, and that, in any case, the decision
on what interventions to adopt should be decided in-country
and not in Washington DC.

PEPFAR II retains requirements for partner organisations to denounce
prostitution and sex trafficking. While this might sound reasonable
on the surface, it makes it impossible to reach groups who are vulnerable
to HIV but also often oppressed by law enforcement agencies. It should
be scrapped.

PEPFAR II still allows partner organizations to opt out of best-practice,
comprehensive programming if they don't like any aspects of it (the
‘conscience clause'). This too should go. Finally, the new legislation
contains a clause that should make travel to the US easier for people
living with HIV. This needs to be fully implemented. 

Overall, too much of the
programme has been influenced by earmarks and provisions that are geared
to domestic political and economic constituencies rather than international
best practice and assessments of need. At the same time, global HIV/AIDS
policy raises larger questions about how the US engages with the world
that the new President will also have to confront.

has been very closely linked to other aspects of US foreign policy, echoing their problems. In 2007 the US
Institute of Medicine

identified a lack of transparency and accountability to partners and
recipients within the programme. The vast majority of PEPFAR funding
is channelled bilaterally via US embassies and focuses on selected countries.
This contrasts with the multilateral Global
Fund to Fight HIV/AIDS, Tuberculosis and Malaria
, which is by no means perfect
but aims to support all countries with viable action plans and is guided
by scientific criteria. However, it remains underfunded. Meanwhile,
the Bush administration has placed the fight against HIV/AIDS on the
agenda of the Pentagon's new Africa
, which
has been hastily assembled and has proven deeply unpopular. A substantial
shift towards a dialogue-based and partnership-driven approach is therefore
required in global health and foreign policy alike. Other countries
are well ahead of the US in setting
themselves standards

for the relationship between health
and foreign policy
Though there is a long way to go in holding them to account, this does
provide new openings for social movements to articulate their visions
of global health.

should be remembered that the biggest challenge in global health right
now is not HIV/AIDS, tuberculosis, malaria, pandemic influenza or any
individual disease. It is the chronic weakness or complete absence of
health systems in the world's poorest countries, compounded by deep
inequality and an overall lack of public health infrastructure. While
PEPFAR has delivered life-saving drugs to hundreds of thousands of people,
there is widespread concern that the international drive to focus on
individual diseases is weakening health systems rather than strengthening
them, a problem compounded by the Bush administration's preference
for the contracting-out of foreign policy to private actors and its
scepticism towards public bodies. Health system strengthening, increasingly
a focus within global health, must be placed at the fore of US policy under
Obama, but to achieve real progress a deeper rethinking of the political
and economic forces shaping health and health systems
is also required.

Ultimately, this calls
for a new global health paradigm that confronts the deeply asymmetric
nature of global economic interdependence and pervasive deficits of
accountability and responsibility in the conduct of foreign policy.
It must also reflect the balance of need rather than the balance of
power. Developing such a paradigm can only be a collective endeavour.



is Lecturer in Geography at University College London. He researches
relationships between global health, foreign policy and security and
is a contributor to Global
Health Watch


is Assistant Professor of Anthropology at UC Irvine and co-chair of
the Association
of Concerned Africa Scholars

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