J. Stephen Morrison
Senior Vice President, CSIS & Director, Global Health Policy Center at CSIS
This coming Sunday, July 22, the International AIDS Conference --'AIDS 2012' -- opens in Washington, DC. This marks the return to U.S. soil of this biannual global gathering after a 22 year hiatus. There will be loud protests, lively debate, an excess of panels and abstracts, and sore feet among the more than 20,000 participants. Organizers will argue an end game is in sight – the conference’s theme is “Turning the Tide Together” -- and focus much discussion on creating an “AIDS-free generation.” It is a choice opportunity in the midst of our bitter electoral season to tell the good news of the extraordinary achievements, at home and abroad, in both science and delivery of effective treatment, care, and prevention to people living with HIV or at risk of infection. It is a moment to be proud of U.S. leadership in attaining these achievements. It is also a moment to address key obstacles to future progress. The U.S. global health strategy is in disarray and there is no realistic possibility of a Congressional reauthorization in 2013. Aggregate resources available for global health are contracting. And an “AIDS-free generation” remains more a mantra than set of clear policies and programs.
For the President's Emergency Plan for AIDS Relief (PEPFAR), the massive U.S. effort launched by President Bush in 2003, the narrative is dramatic and profound: more than 4 million persons around the world today receive life-sustaining treatment, millions more receive prevention and care, through an effective investment that now totals over $40 billion. The crucial political factors that undergird success: sustained White House leadership and enduring bipartisan Congressional support; the shared vision for policy and programs embodied in legislative authorizations successfully passed by Congress in 2003 and subsequently updated and renewed in 2008. Advocates, the faith community, foundations, scientists, public health experts, celebrities and the business sector have all been vital to building an unprecedented coalition supporting expanded US engagement in combating HIV/AIDS globally.
From President Obama, Secretary Clinton and others, we will hear at AIDS 2012 a hopeful vision: that the United States, in partnership with others, can raise the numbers on effective AIDS treatment from 4 to 6 million by 2013, using existing resources, while moving towards an 'AIDS-free generation' that makes aggressive use of new scientific gains--e.g. using treatment and male circumcision to prevent transmission of HIV, as well as expansion of programs to prevent mother-to-child transmission.
We can and should also use this week to focus realistically and candidly on the tough challenges that lay ahead in the present era of austerity, uncertainty and worsened political divisions.
An 'AIDS-free generation' at present remains a hopeful mantra, a call to action, an unproven grand proposition. To move beyond rhetoric and the hope arising from recent scientific research, we need a feasible and concrete strategy for implementation that is within our means. Prevention of HIV, we have learned in the past three decades, is complicated and often quite elusive. We need to guard against excess hubris and focus on how to test recent scientific gains and verify progress, using evidence to guide programs.
We need also to address the reality that resources available globally to combat HIV/AIDS and address other global health priorities peaked a few years ago at roughly $27 billion per annum, and are contracting. Aggregate US funding has been stable these recent tough years, thankfully, but is not likely to grow. The Global Fund to Fight AIDS, Tuberculosis and Malaria, the critical but fragile financial instrument created in 2002, is undergoing major internal reorganization but it is not clear when the Fund will see renewed adequate resources flows, despite very strong US financial commitments ($1.3 billion this fiscal year). The ongoing Euro zone crisis threatens to continue eroding the will and capacity of European donors to meet their obligations. Emerging powers such as China, India and Brazil have much to contribute internally and globally in advancing the health of poor, vulnerable populations, but they are not going to come to the rescue of the Fund any time soon or move much beyond their existing modest direct assistance programs. As we look to the future, it will be essential that African and other developing country partners be able to do much more and own a larger share of the fiscal responsibility.
We have to address the reality that the US global health strategy itself is in disarray. There are intensified pulls in multiple directions -- HIV/AIDS, maternal health, including family planning and child survival -- without clear prioritization. Programs remain fragmented across different competing agencies -- the Office of the Global AIDS Coordinator (responsible for PEPFAR), the US Agency for International Development, the Centers for Disease Control and Prevention, the National Institute of Health, and the State Department (now responsible for the U.S. Global Health Initiative, GHI). Overall there is no cohesive well-led vision.
In 2009, the Obama administration launched GHI, intended to bring about stronger leadership and oversight across programs, more integrated, efficient and unitary efforts, a new priority in maternal and child health programs, elevated attention to gender and accountability, and a strengthened role for our ambassadors in key overseas missions. That effort, grounded in very worthy principles and objectives, suffered weak leadership and never really got off the ground. It was burdened further by persistent confusion and contestation about the overall future of US development assistance. Recently, the Obama administration quietly announced that GHI was to be phased out. A period of uneasy pause and reflection within the U.S. government has now begun.
An updated vision for US global health is essential to explain to the American public and our partners what we seek to achieve and thereby sustain support in a period of budgetary stress and political division. Where might that come from? In the short term, it will not again be achieved through a legislative reauthorization: current divisions in Congress, especially in the House of Representatives, are simply too forbidding. It is not likely to come soon from the Obama administration, given fatigue over the GHI process and the demands of re-election. Advocates, key congressional offices, foundations, the faith community, and think tanks can be expected to bring forward many fresh ideas and frameworks for action. Ultimately, though, responsibility for renewing and updating the course for US global health leadership will rest with the next administration. We should work actively now to raise the expectation that the next administration will indeed choose to take up that challenge as an early priority.
As always, I welcome your questions and comments. Please leave any thoughts you have below.