Obama and the ethics of reining in global AIDS treatment programs
On the face of it, one can see the protests as a reaction to broken promises: the Obama administration promised, during the election campaign, to add one billion US dollars per year to the funding of the President's Emergency Plan for AIDS Relief (PEPFAR). But this year he asked Congress for only $366 million, the lowest increase in funding since PEPFAR began, citing the recession as justification. But this is part of a general pattern. The US government has also reduced its contribution to the Global Fund to Fight AIDS, Tuberculosis and Malaria by $50 million. There are memos from major US funders circulating around, instructing clinics and programs abroad not to enrol new patients unless they are replacing others who have left or died. The general slowdown in funding is bound to have the concrete consequence of excluding HIV-positive persons from accessing needed treatment. Sick persons will be turned away. No wonder the activists are up in arms.
On the other hand, there is something Frankensteinian about PEPFAR and similar HIV/AIDS treatment programs. The first decade of the twentieth century saw calls for aggressively increasing access to AIDS treatment in the developing world: ambitious targets were set, and programs strove to meet them. Clinics and labs were built. Persons were hired and trained. There were (partial) successes, measured in numbers of persons on treatment. But oftentimes the infrastructure and manpower developed by these foreign-funded programs sat uneasily beside (chronically underfunded) local health care systems. Local governments did not 'take ownership of them' (as the public health jargon goes), for the simple reason that they did not really own them. In the recent past, foreign funders have simply kept on increasing funding to AIDS treatment programs, but there are good reasons to doubt the wisdom of this approach: treatment for AIDS is lifelong, and more and more persons are in need of AIDS treatment each year. Are these global AIDS programs to be bankrolled by foreign institutions, at increasing rates, forever -- or at least until a cure for AIDS is found? Of course, stopping or severely reducing funding is not an ethically palatable option either: it condemns very poor and sick persons to death. Stopping treatment risks creating resistant strains of the virus. Once you start up with these programs, lives literally depend on them.
The Obama administration seems to acknowledge that increasing funding ad infinitum to non-sustainable AIDS treatment programs is untenable, recession or no recession. The administration is banking on smarter ways of using available funds, including treating the sickest patients first, shifting attention and resources to HIV prevention, and (importantly) working towards the goal of local governments supporting and delivering HIV/AIDS-related services themselves. The chance of this pragmatic approach appealing to AIDS treatment advocates is next to nil, so expect a lot of heated speeches outside the St. Regis tomorrow night.