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An essay from my NS3321 US Foreign Policy in Africa class at NPS
In evaluating the design and execution of U.S. foreign policy in Africa with regard to HIV/AIDS, one must consider the United States’ own history that served as the initial motivating factor and which shaped (and continues to shape) the scope of our involvement. HIV/AIDS erupted and ripped through the United States beginning in the 1980s. With infections most vocally felt within the urban gay community, an HIV-positive diagnosis equaled a death sentence during the early years. David France’s documentary “How to Survive a Plague” tells the story the herculean efforts by dedicated activists members of the AIDS Coalition to Unleash Power (ACTUP) and the Treatment Action Group (TAG) who waged a guerilla campaign of protests and stunts over a decade and a half that forced the U.S. government to acknowledge and address the problem. The pharmaceutical industry was also a primary target and activists’ lobbying efforts forced the industry to innovate and streamline testing and development processes, as well as pricing. These men and women (many of them HIV-positive and slowly dying themselves) were directly responsible for the 1996 antiretroviral therapy drugs (ARV) breakthrough that represented a turning point for the pandemic in the United States (Schneider, 7).
These lobbying efforts reaped incredible dividends for the United States—a developed nation with a modern health care system—curbing new HIV infections and enabling near universal treatment for those living with AIDS by the late 90’s. For most nations in Sub-Saharan Africa (SSA), however, new infections continued to skyrocket and the majority of those living with HIV/AIDS were unable to get needed treatment. Of the 33 million HIV infections globally, two-thirds are in SSA (Lyman, 74-5). What are the mechanisms and agencies responsible for U.S. HIV/AIDS policy? What were the initial policies and goals? How have these changed since their inception? In this essay I argue that while morally well intentioned, the U.S. HIV/AIDS policy has been doomed from the start due to mirror-imaging and an ignorance of the reality on the ground in most Africa nations. I begin by outlining the central actors and their initial policies and goals. Then I analyze the effectiveness of the design of the myriad programs themselves. Next, I evaluate the manner in which the U.S. has executed its programs and policies. Finally, I address the local realities of most African states that stymie the prospect for fiscal independence.
The global effort to fight HIV/AIDS is a dizzying array of agencies, countries, individuals and organizations. With regard to U.S. policy there are also a plethora of players but the thrust of the American international effort began with President George W. Bush’s Emergency Plan for AIDS Relief (PEPFAR) in 2003. The year prior, the National Security Strategy (NSS) took into account new societal indicators from increasingly accurate and far-reaching data collection agencies and placed an increased emphasis on global health (especially infectious diseases) as a stabilizing factor for partner nations (CFR, 65). In a marked departure from a U.S. policy that had previously focused on HIV/AIDS prevention since the early 1990’s, 1993’s bipartisan PEPFAR expanded the policy to focus on treatment through a bilateral approach (CFR, 65, 68). Its immediate focus was to prevent further deaths; in 2004 2.3 million people in SSA died as a result of AIDS (CFR, 66). Congress originally approved its design as a $15 billion five-year long program that would focus on 23 African states and 3 others outside the continent. PEPFAR’s stated goal was to deliver ARV treatment to two million people (this was 55% of its budget), prevent the infection of seven million more and provide orphan care for 10 million children (CFR, 64-5). These treatment efforts were helped by former president Clinton’s foundation that negotiated with various pharmaceutical companies to garner agreements to produce generic ARV drugs. These efforts drove down prices for first-line ARV drugs to just $86 per patient per year (Schneider, 10). Since its beginning, PEPFAR has greatly expanded. From 2005 to 2008, the U.S. spent $25 billion, an increase in keeping with a $6 billion increase of U.S. assistance to Africa between 2001 and 2009 (Lyman, 73). By 2009, PEPFAR had provided treatment for half of the four million who received treatment that year—this still left, however, another six million unable to get any ARV treatment (Lyman, 74-5).
Six year later, President Obama’s administration passed PEPFAR II which
authorized $48 billion to be spent from the fall of 2009 through the fall of 2014 (Schneider, 2014). While this is a staggering sum, its efficacy has been stymied in part due to the allocation process, where decisions on its use and implementation are made not by healthcare professionals and scientists but by politicians (i.e., congressmen). In concert with PEPFAR II, the president established the Global Health Initiative (GHI) that same year in an expansive attempt to tackle the problem of global health. While PEPFAR falls under its umbrella, GHI’s official purpose is to build up foreign health-care infrastructures and systems so that nations are able to develop their own capacity to provide and care for their populace (Lyman, 77). Central to this task is eliminating redundancies and ensuring a maximal return for U.S. effort and investment. It aims to accomplish this through a “whole of government” approach that uses a principals committee composed of the USAID Administrator, the U.S. Global AIDS Coordinator (who reports directly to the Secretary of State) and the Director of the Centers for Disease Control and Prevention (CDC). Through this triad, they further consolidate the efforts of NGOs, IGOs and the DoD.
The Office of the U.S. Global AIDS Coordinator (OGAC) was created as part of PEPFAR and is today headed by Ambassador Eric Goosby. He oversees the implementation of PEPFAR and coordinates the U.S. government interaction with the Global Fund to Fight AIDS, Tuberculosis and Malaria. This position also leads the newly created Office of Global Health Diplomacy that supports the goals of the GHI as well as coordination of diplomatic-health efforts at the country team level.
Outside of the direct purview of the U.S. government are two other key players in the effort against HIV/AIDS: the Joint United Nations Program on HIV/AIDS (UNAIDS) and the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund). While neither of these are direct instruments of U.S. foreign policy, their funding and efforts are deeply enmeshed with Washington’s. UNAIDS developed out of the World Health Organization and was created in 1996 to synchronize the global UN efforts against AIDS. It also aggregates global HIV/AIDS data and assists developing states in implementing sound AIDS policy and strategies (Schneider, 7). The Global Fund is an international organization launched in 2002 to independently and multilaterally finance the battle against the three aforementioned diseases (CFR, 63-4). Originally setting out to close the gap in funding needed to effectively combat the three diseases, its function was never that of an implementer but rather a collector and distributer of funding received by states and private donors (Schneider, 8). In 2005, over half of its funding went to Africa and more than half of those funds were appropriated for HIV/AIDS (CFR, 72). The Fund’s efforts and fundraising are complicated, though, by large principal donors such as the United States (who contributed $1.05 billion in 2010) who must balance its own contributions with its principle bilateral PEPFAR efforts.
The impetus and arc of American policy today largely stems from the 2005 G-8 Summit’s pledge to enable “as close as possible to universal access to treatment for all those who need it by 2010” (Lyman, 80-81). While this promise by eight of the world’s wealthiest
countries was a morally laudable one, its design also reflected a clear ignorance on their part as to the realities on the ground in most developing states (especially in Africa). Practically, this commitment meant funding a lifetime of treatments (typically three to four decades for the average 20 or 30 year old Africa AIDS patient). Ultimately, this idea of universal access may be discarded as impractical with a greater proportion of a finite amount of funding dedicated to prevention (Lyman, 80-81).
For wealthy nations like the U.S., there was a mirror-imaging assumption that simply pouring more money into SSA could solve the problem as it had done in the U.S. This was further complicated by a lack of understanding of HIV/AIDS as a disease—this was due to both its recent emergence and to how relatively quickly it was slowed in the United States. The reality on the ground in SSA was that Africa was not one country but 49 states with separate needs and problems. In SSA, there were not 49 effective and modern national health care systems. There were not 49 effective CDCs. There were not 49 nations with modern transportation systems capable of connecting the country. There were not 49 states with the medical staff needed to implement and treat millions of AIDS patients. There were not 49 African presidents who all recognized the importance of preventing and treating HIV/AIDS. There were not even 23 states (the initial PEPFAR focus) that possessed any of these prerequisites. This oversight partially came from a lack of any corporate memory within the U.S. of what it takes to perform tasks such as building a national health care system or a CDC—or what its like to live in a state without them. This same could be said for America’s initial misunderstanding of malaria treatment in Africa. Malaria was highly prevalent throughout the southern United States up until the first half of the 20th century. American only eradicated malaria in 1949 because as a nation it had industrialized and possessed the government infrastructure necessary to implement a massive three-year DDT campaign through the South. There are very few fully industrialized nations with similar modern infrastructures in SSA today.
As expected with a morally admirable but structurally flawed design, the execution of U.S. HIV/AIDS policy in Africa has had its peaks and valleys. A high point came in 2004, when the U.S., the UK and UNAIDS agreed to work with NGOs and donors to synthesize their efforts through “The Three Ones” policy: one common action framework, one National HIV/AIDS Coordinating Authority and one country-level monitoring and evaluation system (M&E) (CFR, 74). While this policy and moment is much touted within the websites and documents of most health organizations, it has yet to materialize practically more than eight years later. A large hurdle to it lies in the capacity of the countries themselves. A country level M&E system means that there needs to be an effective national AIDS council which can act as a synchronizer for the myriad organizations and bodies within a state. For many states in Africa this is still an un-scalable hurdle. Furthermore, there is scant evidence of implementation for the other two principles.
Today there is a common lamentation that decries the deleterious effect of U.S. humanitarian assistance in Africa thus far as an expenditure that has provided little to no political leverage for its investment (Lyman, 75-7). These critics largely miss the point of the nature of the U.S. commitment. When poorly understood moral imperatives are intertwined into policy decisions, one cannot expect positive results (Lyman, 83). Disdain for the inability of the State Department to influence political change in Uganda, Zimbabwe and Ethiopia miss the mark from a logical standpoint. The U.S. commitment to fighting HIV/AIDS in Africa did not begin as a political effort to promote western democratization. How then can it be evaluated in the same vein? Furthermore, these
critics ignore longtime U.S. support for other African dictators, such as those in Morocco, Tunisia and Egypt. The point is that one loses credibility when one cherry picks which countries “need” democratization. Ultimately, those inside the Beltway need to be dissuaded of their assumptions that aid necessarily buys influence, especially aid dedicated to food and medical assistance (i.e., between 80% and 90% of U.S assistance in Africa) (Lyman, 76,83).
Aside from this perceived lack of return on investment, as a public relations campaign PEPFAR has created a lasting tide of U.S. popularity in Africa (the elite-excepted). The price of this popularity, however, is likely to be costly (Lyman, 81-82). In the long-term, if the U.S. (even in concert with the G-8) was able to ensure universal treatment, the practical output of that achievement would mean a century-long fiscal commitment to fund the treatment (Lyman, 82). Strategies to broaden the number of countries that support programs may certainly lighten the U.S. load but do little to correct a misguided arc. Strategies and funding must instead focus on health infrastructure development (a central, if underfunded, GHI objective) and reducing redundancies of effort. This seems unlikely, though, with $51 of the $61 billion GHI budget going toward PEPFAR in 2010 (Lyman, 79). The entire international community involvement must be invited and encouraged under the auspices of an international organization such as the Global Fund to Fight AIDS (Lyman, 84). A thoughtful and gradual departure from using HIV/AIDS assistance as a hopeful political tool could free valuable U.S. budget dollars to the Global Fund and other endeavors and help break the cycle of aid dependence so prevalent in most African states.
A large detractor of much of the U.S. progress is that these stated financial aid commitments require a lasting fidelity and longevity over the course of numerous electoral and budgetary cycles—a monumental if not impossible task. One example of this is President Obama’s pledge to honor the U.S. commitment to bring the number of those receiving ARV treatment in Africa up to four million by 2014. Such a goal requires yearly increases in budget allocation—increases that weren’t met in 2011 (Lyman, 78). Practically these inconsistencies damage progress made by organizations on the ground and have trickle down effects on those receiving treatment. These patients sometimes share their medication with infected family members who are unable to enroll in underfunded local ARV treatment programs (Lyman 78-9). While morally laudable, these patchwork strategies by infected local citizens only weaken the ARV treatment’s efficacy and put more people at risk for infection (Lyman, 79).
In countries where U.S. policy has been successful, there have been two key contributing factors: leadership buy-in and government capacity (especially within its health care ministry). The leadership buy-in needs to occur at both the U.S. Embassy level (i.e., from DOS/USAID down to the Ambassador) and within the country’s political leadership itself (CFR, 66-67). In South Africa, the missing element for a number of years was the leadership buy-in. It wasn’t until Jacob Zuma took the reins that the government recognized the importance of taking decisive steps to combat new infections and to treat existing ones (Lyman, 79-80). In most Africa states, however, the enthusiasm of its leaders cannot overcome dilapidated or non-existent health care systems. These efforts are further hampered by personnel shortages in the health care system that are driven by shortfalls in both retention and recruitment (CFR, 70).
Overall, the execution of American HIV/AIDS policy is becoming an increasingly precarious balancing act. Each year an increasing portion of the PEPFAR budget is allocated towards treatment which means that less goes to combatting new infections (Lyman, 79)—this is a trend likely to only increase as lifetime patients develop immune resistance to first-line ARV drugs. This problem is exacerbated by the inability of African states to pay for HIV/AIDS treatment within their borders. Despite the promises of the 2001 Abuja Declaration, the goal of
15% of national budgets being dedicated to building capacity within the health sector remain a distant dream for nearly every SSA nation (Schneider, 8).
From a practical perspective, the prospect of the average citizen in an Africa country being able to afford their own treatment in the foreseeable future is highly unlikely. In 2011, the GDP Purchasing Power Parity per capita (PPP) of every state in Africa was less than $25,000 with more than 85% of countries coming in below $10,000. This means that even a yearly treatment cost of $86 (the price in 2007 for the most common ARV combination) is well outside the average family budget (Schneider, 10). Couple this poverty with a widespread economic disparity (i.e., GINI index rating for the few African states that have a rating) and the likelihood that most Africans living with AIDS will ever be able to afford their own treatment is nil.
Even in a relatively wealthy country such as South Africa, 50% of its HIV/AIDS funding is externally sourced (Lyman, 79-80). As countries like South Africa make steps broaden access to treatment, they are forced to cut or freeze funding for other health initiatives. The commentary of a trio of South African bioethicists carries applicability beyond the borders of their nation: “It would be medically, politically and morally—and probably—legally—unacceptable for expanded treatment of the HIV population to come at an unacceptable cost to patients who bear the burden of other chronic diseases and health conditions . . .” (Lyman, 80). The call for universal access as a moral imperative is a slippery slope. While few would make the emotional argument that a poor man in Senegal does not deserve access to the same second-line ARV as a wealthy one in Chicago—the follow-on reasoning then assumes the same should be said for cancer treatment and costly organ transplants, etc. (Schneider, 4). Meanwhile, the overwhelming apportionment of humanitarian assistance toward HIV/AIDS the past decade amounts to wealthy states playing God as they decide which diseases and social conditions are the most important.
Today, HIV/AIDS certainly no longer carries a death sentence for those with access to and the means to pay for ARV treatment. Without a vaccine or cure, however, much is still unknown about the long-term path and associated costs of the disease. With no official U.S. policy (i.e., funding) focused on finding a cure or vaccine, that “no major viral epidemic [was ever] defeated without a vaccine” must serve as a stark warning for those trying to determine the future of U.S. fiscal support (Lyman, 84). Even if a vaccine were to be discovered in the near future, the infrastructure does not exist in most Africa states (or the U.S.) to immunize hundreds of millions of adults (Schneider, 2). In the meantime, with aging patients increasingly requiring second and third-line ARV treatment it is difficult to predict what the coming century will hold. It is clear, however, that the U.S. must depart from a short-sighted policy that fails to focus on treating both the cause (i.e., prevention and poverty) and the cure (i.e., health care infrastructure). If the United States does not devise a strategy by which it can withdraw from bilateral commitments that will become increasingly unaffordable in the future, AIDS may end up spelling a death sentence for the nation’s influence and prestige around the globe.
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