Scale Up Efforts, Or Scale Down Expectations in Global Health?
With the International AIDS Conference coming up in Vienna starting July 18th, even more attention is being focused on funding (or lack thereof) and targets related to HIV/AIDS prevention and treatment.
The World Health Organization's new director of HIV, Gottfried Hirschall, said in an interview with Reuters that he wants to continue pressure on donor countries to keep up their global health contributions, but also wants to use the AIDS conference to push dialogue on how to get more out of existing funds. "We need to shift the conversation towards asking how we can use resources that we have more efficiently and effectively."
Hirschall gives examples such as negotiating lower prices for AIDS drugs, shifting tasks from higher-paid (and scarcer) health workers like doctors to lower-level workers when they can provide the same quality of care, and simpler tests that require less lab infrastructure.
At the same time, a recent article in Foreign Affairs (No good deed goes unpunished: The unintended consequences of Washington's HIV/AIDS programs) argues that U.S. aid for AIDS, via PEPFAR, actually weakens U.S. diplomatic influence because keeping more and more people on treatment becomes an obligation we can't withdraw without backlash. In addition, an increased burden of AIDS funding could reduce the resources available for other development priorities.
Authors Princeton Lyman and Stephen Wittels suggest that the U.S. and the Obama administration need to:
- Recognize that development aid is not as influential a tool with foreign governments as some may think.
- Channel more support through the Global Fund and other international bodies, rather than continuing to expand bilateral aid.
- Continue to explore prevention efforts of all kinds so that the goal of getting everyone on treatment is eventually achievable.
Others have taken this argument -- that continued support of AIDS programs is harmful to the U.S. -- to some surprising conclusions. Mead Over's blog post on the Center for Global Development web site calls life-long treatment support "a kind of post-modern colonialism," and challenges the usefulness of the goal of universal access to treatment. He prefers instead a goal of getting just enough patients on antiretroviral therapy to "hold down AIDS mortality" while boosting prevention until the number of new AIDS cases falls below the number of AIDS deaths.
While that may be one means to shrinking the total number of people living with AIDS, it flies in the face of the ethical and moral arguments for universal treatment. Who is to decide how many patients on ART are "enough," and which people are turned away?
Rather than scaling back our goals and going back to the time when AIDS and many other diseases were a death sentence, we should increase our expectations and efforts to generate the resources needed.
On a more optimistic note, Lawrence O. Gostin has proposed that the international community adopt a "Global Plan for Justice." The plan involves countries voluntarily committing a percentage of gross national income to a Global Health Fund, to be allocated based on the health needs of developing countries. While such funding commitments are not new (and are seldom achieved, unfortunately), it's important to keep sight of the perspective on poverty and disease that Gostin articulates:
"The scale of foreign aid is both insufficient and unsustainable and fails to address the key determinants of health. As a result, the world's distribution of the 'good' of human health remains fundamentally unfair, causing enormous physical and mental suffering by those who experience the compounding disadvantages of poverty and ill health."
In light of this reality, will we find the way to do what is right and needed, or will we do what is cheaper?
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