Washington, DC — The US$15bn President's Emergency Plan for Aids Relief announced by President George W. Bush in his January 2003 State of the Union address "is too near-term in orientation and too narrow in scope to achieve its long-term objectives," according to a report released Monday by the Council on Foreign Relations and the Milbank Memorial Fund.
The report, which estimates that US$9-$12bn a year is needed for the long-term costs of treatment, was directed by the Council's Ralph Bunche Senior Fellow in Africa Policy Studies, Ambassador Princeton N. Lyman, and Daniel M. Fox, president of the Milbank Memorial Fund. Experts from more than 30 private and government health organizations were consulted.
"As laudable and as valuable as the President's initiative is, in and of itself it will not be sustainable or achieve its goals" unless it is accompanied by a large, coordinated international effort, Lyman said Monday at a briefing at the Council's Washington office.
The Bush plan, which was signed into law last year on May 27, targets 12 African and two Caribbean nations, providing US$10bn in new money for them with the aim of providing treatment for two million people, care for 10 million children and the prevention of seven million new infections over a five-year period. Almost 70 percent of those infected with the Aids virus live in sub-Saharan Africa. Of the estimated 25 million children who will have lost one or both parents to Aids by the year 2010, 20 million are likely to be living in Africa. Congress has told the administration to add a 15th country from another region of the world to the list.
"Building health infrastructure is perhaps the most important part of a successful, sustainable attack on the pandemic," the report argues, giving five reasons why the current U.S. emergency approach "will fail to yield long-term success." The first is the scale of the problem. Because there are 20 million people already infected in the 14 countries targeted by the administration's program, "a much more robust health infrastructure will be necessary." The facilities aren't there to handle the required testing and treatment, and 95 percent of Africans and 95 percent of people infected globally do not know their HIV status.
In addition, "preoccupation with Aids" leads to neglect of other pressing health problems. HIV/Aids "flourishes" where health is generally poor. The brain-drain that has resulted in a shortage of skilled health care workers is not addressed by the President's program. And, targeting a diseases that affects 20-30 percent of a population risks "political backlash against donor insistence on this priority."
While agreeing that the HIV/Aids pandemic in Africa is an "emergency," as Bush has declared and as the numbers indicate, the report says "the broader and long term approach that is required must meet the basic health needs of developing countries." Malaria kills a million people in Africa every year, the report points out. Other diseases also take a "vast toll". The World Health Organization (WHO) estimates that providing basic health care to developing nations will require financial assistance of US$27bn a year by 2007 and up to US$38bn annually for the next eight years after that.
"As urgent and necessary as it is to address the plight of the 20 to 30 percent of a country's population infected by HIV/Aids, to overlook the health needs of the other 70 to 80 percent with other health needs is neither politically nor financially sustainable as host countries strain to support two separate health systems," the report states.
In addition to urging commitment to greater effort directed toward building basic health infrastructures in affected countries, the report makes six other specific recommendations:
* a "high level international commission to address the long-term issues" associated with HIV/Aids treatment programs;
* a "comprehensive approach" that focuses on how the pandemic spreads, particularly the "vulnerability of women and girls" and the importance of the military;
* an "ideology-free" approach that relies on solid scientific evidence in both prevention and treatment efforts;
* careful monitoring and evaluation of programs from the beginning;
* flexibility in the effort to reach community-based groups; and
* recognition that tackling HIV/Aids will take "decades of international involvement and the funding of programs well beyond the emergency focus of the next five years."
According to Laurie Garrett, a former Pulitzer Prize-winning reporter for Newsday who is senior fellow for global health at the Council on Foreign Relations, the need for an "ideology-free" approach was illustrated by reaction to two recent studies of Uganda's widely touted anti-Aids campaign. Various groups have seized onto specific findings that support their own priorities, she said, rather than recognizing that the research points to a broad range of factors contributing to Uganda's success in dramatically reducing HIV prevalence. "We need to act on what the science indicates will work," she said.
The Bush administration has heralded Uganda's "A-B-C" campaign, emphasizing the "abstinence" and "be faithful" tenets and downplaying the importance of the third component - condoms.
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Lyman, Fox and Garrett all said that uncertainties hang over acceptance of the report's recommendations as well as the long-term international effort to combat Aids. The rapid spread of Aids in Russia, Asia and parts of the former Soviet Union could set up competition for resources. "You could see resources for Africa shrinking," said Lyman. With domestic political pressures rising over health costs and budget deficits, it is not clear how much money can be expected for the long-term fight overseas. "People may start to ask 'whose responsibility is this"," Lyman said.
Because there is no end in sight for the fight against HIV/Aids, policymakers must face the fact that a long-term commitment is required, Lyman said. Once treatment is begun for those infected with the disease, it can't be stopped without killing them. "We can't start down this path unless we are committed in perpetuity," Garrett said. "There is no vaccine in the pipeline."
One step at a time, said the Milbank Memorial Fund's Fox. "If one of the results of reports like ours is to direct attention to the [best way for] implementation of policy, that will be a major step forward," he said.
