21 February 2008
analysis
Washington, DC — As President Bush winds up his 5-day trip to Africa, the initial focus on his legacy in the fight against AIDS and malaria has been enlivened with debate on the new and highly controversial AFRICOM military command (See, for example, http://www.nytimes.com/2008/02/21/world/africa/21prexy.html), Commentators have also highlighted the contrast between Bush's itinerary (Benin, Tanzania, Rwanda, Ghana, and Liberia) and unresolved crises in Kenya and Sudan. But from AIDS to AFRICOM, coverage of the trip was also revealing for points hardly mentioned by either Bush boosters or critics.
On PEPFAR (President's Emergency Plan for AIDS Relief), the coverage has focused on how much credit President Bush should get, and secondarily on current issues such as levels of funding and abstinence-only policies. In historical perspective, however, the most striking development is the dramatic change over eight years.
In Bush's first year, USAID administrator Andrew Natsios rejected the option of AIDS treatment for Africans claiming they couldn't tell time (see http://www.africaaction.org/docs01/nat0106.htm). Now it is assumed across the political spectrum not only that addressing AIDS and other health issues in Africa is essential, but also that it is something for which politicians are eager to claim credit.
The change was the result of mobilization by activists in Africa, the United States, and around the world. In the United States, Congress, and then the administration as well, responded to popular pressure to address the issue, coming not only from "liberals" but also from many in Bush's conservative Republican base. The result, albeit not satisfactory to activists in either quantity or quality, was a significant shift from previous administrations. Ironically, President Clinton's own significant contributions to the fight against AIDS came not when he was in office, but in his postpresidential incarnation.
The debate about AFRICOM, with President Bush forced to deny that the United States is seeking new military bases, nevertheless ignored the extent to which the U.S. focus on anti-terrorism has already shaped U.S. military intervention, such as its encouragement for the Ethiopian invasion of Somalia in 2006-2007 and support for highly disruptive counter-insurgency operations in the Sahel in 2004 (see http://www.africafocus.org/docs07/sah0701.php and sources cited there).
More generally, on the fundamental issues of security, democratization, and economic development, the Bush administration has given more rhetorical attention to Africa than did the administration of his predecessor President Bill Clinton. But neither administration systematically prioritized peacemaking over sporadic diplomacy nor met African development issues with responses going beyond the conventional economic policies of freemarket fundamentalism.
This AfricaFocus Bulletin contains brief editorial notes and links to relevant AfricaFocus Bulletins on a range of issues in USA/Africa relations. Given the prominence of President Bush's AIDS program in coverage of the trip, also included are a set of recommendations for improvement of that program, coming from a meeting of African civil society organizations in December 2007.
A new page on the AfricaFocus website ( http://www.africafocus.org/country/usa-africa.php) highlights previous AfricaFocus Bulletins with a focus on bilateral relations, as well as other links to background information. AfricaFocus welcomes suggestions for additional links for this page, particularly to substantive analyses exploring the options for a new post-Bush agenda.
For the official White House site on President Bush's trip, visit http://www.whitehouse.gov/infocus/africa/trip2008
For a special collection of critical articles, see Pambazuka News, 346 for February 18, 2008 ( http://www.pambazuka.org/en/issue/346
For historical perspective, see the annual Africa Policy Outlooks, from 1995 to 2008, from Africa Action and its predecessor the Africa Policy Information Center (http://www.africaaction.org/resources/page.php?type=18)
For AfricaFocusPlus, providing a custom search of AfricaFocus, Pambazuka, Africa Action, and other selected partner sites. visit http://www.africafocus.org/plus/search1.php
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HEALTH
The shift in assumptions and funding levels for HIV/AIDS since the year 2000, at both multilateral and bilateral levels, represents significant change. This gives a political starting point for further advances, and for consolidating the perspective that global health is not an issue of charity or party politics but of fundamental human rights. But neither the fight against AIDS and other pandemic diseases nor the effort to foster Africa's health more generally are yet close to meeting the need.
Brief Issue Checklist
Funding levels - current U.S. congressional proposal includes $50 billion over 5 years for PEPFAR, increasing President Bush's flatrate funding proposal of $30 billion over years.
Restrictions - current U.S. congressional proposal eliminate current restriction that 1/3 of prevention funds be spent on abstinence-until-marriage programs. President Bush opposes lifting the restriction..
Overall levels of funding for programs, including PEPFAR, the U.S. malaria initiative, the multilateral Global Fund to Fight AIDS, TB, and Malaria
A comprehensive approach to global health, including building capacity of health services and the supply of health professionals
Links for more background
See http://www.africafocus.org/healthexp.php and http://www.africafocus.org/country/usa-africa.php
For a summary of the positions of U.S. presidential candidates on global health issues, see http://www.health08.org/issue_globalheath_hivaids.cfm
Document
African Civil-Society Recommendations on the Next Phase of U.S.
Global AIDS Assistance
December 11, 2007
http://www.globalaidsalliance.org/index.php/803
On December 10-11, 2007, representatives of 21 civil-society organizations, including representatives of PLHA organizations as well as large PEPFAR AIDS treatment providers, met in Nairobi to provide feedback and recommendations on the future of U.S. global AIDS policy. The meeting was hosted by the Kenyan AIDS Treatment Access Movement, Global AIDS Alliance, and Health GAP. In light of the upcoming debates on PEPFAR reauthorization, we respectfully submit the following recommendations from people living with HIV/AIDS and working on the front lines of the AIDS pandemic. The following summarizes our prioritized recommendations, and a full report will be made available shortly.
Numbers on treatment versus measuring healthy patients: PEPFAR is doing a historic and important job of getting people on ARV treatment. However, counting a person who is receiving AIDS drugs is not the same as supporting health for people with HIV. The urgent and important work of attempting to meet treatment targets is not integrated with more comprehensive support for actual patient health. When patients are only provided one part of what we need to survive, however important, the end result is poor health outcomes, questionable accounting practices, and unacceptable loss to follow up.
The second five years of U.S. global AIDS initiatives should measure longer-term patient health outcomes in addition to simple numbers of people on ARV treatment. This should be backed up by independent patient satisfaction surveys and spot audits of PEPFAR-supported medical facilities.
Opportunistic infection drugs are not available: Many programs provide free ARVs, which are urgently required and profoundly appreciated. However, efforts to scale up access to AIDS treatment is taking place without an eye toward actually increasing patient survival. While anti-AIDS medicines are almost always free, medicines to treat the opportunistic infections that accelerate our death are often unavailable from clinics and too costly for patients to purchase from pharmacies. Stock-outs at medical facilities and dispensaries are also common and very harmful to patient health.
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