Laurie Garrett paper 1

Missed Opportunities
Governance of Global Infectious Diseases
From International Health, Vol. 27 (1) - Spring 2005
Laurie Garrett is Senior Fellow for Global Health at the Council on Foreign Relations.
Scott Rosenstein is a research associate at the Council on Foreign Relations.
Addressing the UN General Assembly Special Session on HIV/AIDS in June 2001, UN Secretary-General Kofi Annan declared, “For there to be any hope of success in the fight against HIV/AIDS, the world must join together in a great global alliance.” Earlier, in September 1995, US President Bill Clinton’s Committee on International Science, Engineering, and Technology designated infectious disease as a threat to national security. By the turn of the century it seemed possible that years of neglecting the surging HIV pandemic and other lethal infectious diseases might be reversed. Large-scale initiatives from multilateral agencies, deep-pocketed foundations, and the US government infused hope into an area that has historically been underfunded and overshadowed.
But today the optimism is dangerously close to slipping away. Now that real money is on the table, the entire global health effort seems to be descending into bureaucratic and economic quicksand similar to that which has trapped other international development programs for decades. Programs are competing with each other, and key donors are shying away from the multilateral Global Fund in favor of bilateral programs. Implementation of the World Health Organization’s (WHO) program to put three million people on life-saving HIV/AIDS treatment by 2005 is proving staggeringly difficult and demoralizing for much of the WHO staff. US President George W. Bush’s Emergency Plan for AIDS Relief (PEPFAR) has become so highly politicized that its achievements are obscured by controversy. Similarly, the Global Fund has become a lightning rod for debate regarding nearly every aspect of public health funding and implementation. Tuberculosis experts, having long struggled to implement so-called Directly Observed Therapy using very cheap drugs for only months per patient, now shake their heads and say, “I told you so: the drugs are not the issue; it is the infrastructure.”
The approaches and effectiveness of the major players in the global health arena must be reexamined. As these efforts move forward, new avenues of communication and cooperation must be established to mitigate current obstacles while capitalizing on new opportunities.
The Problem
It will never be possible to create a disease-free world or to eliminate the potential for the emergence of new deadly microbes. Policies aimed at such goals will always fail. For example, scientists now understand that the Ebola virus is an ancient organism that has for centuries infected isolated individuals in central Africa. That cannot be stopped. But scientists also understand that Ebola epidemics have occurred when individuals infected with the virus entered desperately poor hospitals, where dearths of sterilizing equipment and basic protective gear conspired to offer the virus spectacular opportunities for transmission. Inadequately supplied hospitals act as disease amplifiers, giving the isolated infection opportunity to become a full-blown epidemic.
With very few exceptions, the disease amplifiers in the world today are manmade and therefore humanly controllable. Within health systems, they include lack of infection control in hospitals, reuse of syringes, and unscreened blood supplies. More broadly, exotic animal markets, unclean urban water supplies, lack of proper sewage systems, and unstable, conflict-ridden environments provide excellent breeding grounds for infectious diseases to spread and wreak havoc on already vulnerable populations. Yet it would be shortsighted to think of infectious disease as a problem for solely the poor and powerless. These diseases do not discriminate; they are undeterred by state borders, party affiliation, or socioeconomic status. With air travel and human migration on the rise, so too is the possibility that deadly microbes can and will circumnavigate the globe with speed and precision.
Global health investment is therefore an issue not only for do-gooders. A self-interest component to the global health debate has clearly emerged—thankfully, because purely altruistic efforts often fall short of international support and sustainability. The interconnected nature of the world makes ignorance of issues such as deadly infectious diseases not only immoral, but self-destructive. This argument is neither new nor unique. However, for much of the last century, the health community scrambled to get access to small amounts of funding to prevent and treat malaria, tuberculosis, HIV/AIDS, vaccine-preventable illnesses, and a host of other killers, even as leaders in the wealthy world declared microbial threats were, from their standpoint, conquered. It has long been argued that detailed, multilateral global surveillance efforts are imperative to stem the global spread of deadly diseases. But when epidemics of Ebola, nipah, hantavirus, and other deadly diseases broke out in the early and middle 1990s, WHO and the US Centers for Disease Control (CDC) had to go begging for funds for scientists’ plane tickets and laboratory supplies. Disease surveillance was haphazard at best.
It would be impossible to reverse the rising death toll of HIV/AIDS without attacking its partner diseases, most significantly tuberculosis. HIV-weakened immune systems make individuals more susceptible to tuberculosis. WHO estimated in 2004 that tuberculosis accounted for approximately 13 percent of AIDS deaths worldwide. “The world has made defeating AIDS a top priority. This is a blessing. But tuberculosis remains ignored,” warned former South African President Nelson Mandela at the 2004 Bangkok AIDS meeting. The window of opportunity to control tuberculosis is closing as drug-resistant forms of the bacterium emerge all over the world. We now have drugs that can cure non-resistant forms of tuberculosis infection for as little as US$10 per patient in developing countries. Yet, Mandela noted, a very simple and inexpensive strategy for control and cure of tuberculosis has been failing in much of the world, pilloried by funding shortfalls and desperately inadequate health infrastructures.
Lack of funding and infrastructure has, in turn, created human resource shortfalls that have nearly crippled the capabilities of institutions endeavoring to create sustainable programs that can be administered with local participation and ownership. A “brain drain”—or, better put, “talent drain”—is removing health professionals from already understaffed programs and countries. A 2004 report from the Joint Learning Initiative, a research group of more than 100 global health scholars and practitioners, estimated that Africa needs approximately one million more health care workers to deliver adequate care to its people. The report draws attention to the massive flow of experienced health care workers in developing countries who are leaving their homelands to find better paying jobs in the developed world—where health care workers are also in short supply.
To the Rescue?
With a mix of volunteerism, elbow grease, and paltry funds, public health advocates the world over did their level best to hold back the rising gap in life expectancy between rich and poor nations and control infectious disease outbreaks. Slowly, recognition began to build and key decision-makers began to see the value in tackling several pressing global health issues.
Under the leadership of economist Jeffrey Sachs, a team of economists and scientists pulled together an historic Macroeconomics of Health report, not only calculating the costs of dozens of infectious diseases, but also putting price tags on their prevention and treatment. The Clinton Foundation and Doctors Without Borders successfully negotiated prices for Highly Active Antiretroviral Therapy (HAART) for HIV/AIDS patients from generic manufacturers down to the point where it seemed possible to treat an HIV/AIDS patient for less than US$200 per year. Patent drug manufacturers responded by bringing down the prices of their drugs as well. To support this effort, more than 100 of the world’s most powerful corporations combined forces, creating the Global Business Coalition to fight HIV/AIDS. The Bill and Melinda Gates Foundation alone has committed hundreds of millions of dollars towards health interventions around the world.
In 2001, after Annan’s call for between US$7 and US$10 billion annually to address selected infectious diseases and the Group of Eight leaders’ in-principle endorsement of those funding levels, there was a noticeable shift. The Global Fund to Fight AIDS, Malaria, and Tuberculosis was created, offering an independent, accountable mechanism for funneling money from the wealthy world to the poor. The Global Fund was envisioned as an institution that could capitalize on the capabilities of both the private and the public sector to overcome the drawbacks of both. On the heels of the establishment of the Global Fund, WHO Director General Lee Jong-Wook ostensibly staked his new leadership of WHO on “3x5,” a campaign to get HAART to three million people in poor countries before the end of 2005.
For much of its existence, the World Bank took the position that economic development would naturally create improvements in health but rejected the converse notion that investment in the health sector would produce economic gains for the developing world. The World Bank had a change of heart regarding investment in the health sector: it recently began implementing its Multi-country HIV/AIDS Program for Africa and has become the largest overall funder of health-related programs in the developing world.
In 2002 the Bush Administration decided to pursue a program, PEPFAR, to combat AIDS largely on a bilateral basis in 14 countries. PEPFAR eventually added a 15th country, Vietnam, to its list of African and Caribbean nations. Its target is treatment of 200,000 people by June 2005.
The Results
Despite all these efforts, more people died of tuberculosis, malaria, and HIV/AIDS in 2003 than in any year in history. Drug resistance threatens the 20th century’s successes in battling a range of bacterial and parasitic diseases. Combined, these killers are continuing to reshape societies, producing dramatic demographic changes that threaten local, regional, and global stability. To be sure, it is still early for many of these initiatives. But the prognosis is not improving.
From a programmatic standpoint, many of the current infectious disease treatment and prevention efforts appear very narrow in focus, failing to consider the interconnected nature of these diseases. Tackling only HIV/AIDS without proper attention to tuberculosis means ignoring the number-one cause of HIV/AIDS-related death and allowing continued community spread of tuberculosis. Creating stand-alone HIV/AIDS clinics risks further stigmatizing individuals who visit these clinics, especially in societies that do not discuss HIV/AIDS openly and shun those known to be HIV-positive. It seems the exceptionalism of the international community’s approach to HIV/AIDS may ultimately reduce its likelihood for success and community acceptance.
Worse, there is a glaring lack of available institutional mechanisms capable of organizing and executing the ambitious programs currently being proposed or underway. The result is consistent interagency conflict: agencies are often either repeating others’ work or competing for resources. Health programs are fighting over poor countries’ dwindling pools of health professionals, bogus generic drug makers are knowingly selling poor products, ministries of health are sitting on, or siphoning off, millions of dollars in unspent donor funds for vital programs. Fighting over what remains an inadequate pool of funds for all has led many leaders and donors to complain that too much money is going to one health drive over another. Questions of patent rights versus generics, abstinence versus condoms, treatment versus prevention, faith-based versus secular initiatives, research versus implementation, and a host of other false dichotomies have overwhelmed these health debates.
In poor countries, the sudden plethora of health programs has spawned a seemingly endless stream of donor-mandated forms and a similarly large number of studies to conduct in order to demonstrate implementation and offer accountability. Simply keeping track of the demands of divergent benefactors requires the time and professional skills of a small army of English-speaking paper-pushers. The campaign to treat HIV-positive people with HAART threatens to devour the health talent of entire nations, undermining everything from child immunization programs to control of other sexually transmitted diseases.
Even with the influx of money into global health, key institutions are still struggling to make ends meet. WHO, with a core program budget just exceeding US$400 million, suffers from chronic under-funding. The institution is also suffering from an identity crisis as it struggles to continue providing technical oversight while rolling out its own ambitious large-scale projects such as the 3x5 program. The strain of this dual responsibility is beginning to show. WHO officials reported that the program was “just short” of the July 2004 treatment goal of 500,000, laying claim to all the estimated 440,000 people in the poor world now on the drugs. The likelihood that they will meet their target of three million people on antiretrovirals by the end of 2005 appears to be dwindling. Failure would be a substantial setback that could threaten donor and government confidence levels in WHO and current HIV/AIDS efforts in general.
The Global Fund also finds itself unable to meet its fiscal responsibilities. It has fallen far short of the US$8 billion donation requirements recommended by the WHO Commission on Macroeconomics and Health. To date, the Global Fund has committed only about US$900 million for its next round of grants to poor countries and nongovernmental organizations, though it has received more than US$3.6 billion in applications deemed scientifically sound. Disbursement delays have also hamstrung this fledgling organization. In a 2004 study by Ruairí Brugha and others in the Lancet, all four of the countries surveyed in sub-Saharan Africa cited as one of their main concerns “delayed disbursement of funds and difficulties in managing evolving Global Fund processes.” They also noted that “high expectations of rapid funding, when grant approval the previous year had received much national media attention, led to a crisis of expectation.”
Part of this funding shortfall can be attributed to the wealthy world’s lack of commitment. EU countries, as well as the United States, have failed to meet their responsibilities to the Fund. The Bush Administration argues that it has given more money to the Fund than any other country—US$683 million since 2001—and has indicated willingness to give more so long as the United States does not donate more than one-third of all contributions in a given year. In contrasting US contributions to the Fund with those of other nations, the US Department of Health and Human Services recently insisted that a US twelve-month fiscal year’s worth of donating be compared with just nine calendar-year months’ worth of EU contributions, drawing the ire of Europeans.
The United States prefers to focus on its own bilateral HIV/AIDS programs. As currently conceived, PEPFAR will treat two million people and provide other types of care to ten million by the end of 2008. As of September 2004, PEPFAR has actually spent 1.2 percent of its funds, directly providing treatment to 18,800 people.
For much of its existence, PEPFAR has been mired in fights over whether its dollars could be spent buying cheap generic drugs versus US-patented products, over condom promotion versus abstinence, and over how best to mete out funds through a laundry list of competing federal agencies (among them the CDC, the US Agency for International Development (USAID), the National Institutes of Health, and the Department of Defense). In a sense, PEPFAR is a global treatment access entitlement program. To the degree the United States continues to go it alone, the burden for maintaining the health of hundreds of thousands of people around the world will rest on US taxpayers for years, quite possibly decades, to come—a burden born, moreover, by a US populace that is decreasingly likely to have health insurance or be able to afford medications for itself. The foreign policy implications of stopping funding—in essence, committing medical murder—are obviously profound.
Congressional whims aside, should there be regime change in a recipient country, the United States would face a critical moral and political dilemma. The appropriations bill allocating FY2004 PEPFAR money stipulated that a third of prevention and education funds had to be spent on abstinence-promoting programs, none of the money could buy sterile syringes or needles for IV drug users, and faith-based organizations should receive special priority for receipt of treatment funds. Any organization or US program thought to promote access to abortions, or to chiefly promote birth control and condom use, has lost US government funding and support. In Uganda, for instance, the government claims HIV “prevalence” dropped from 30 percent in 1990 to 5 percent today. President Yuweri Museveni, signaling his allegiance to the Bush Administration, told the 2004 International AIDS Conference that the key to success was a campaign that pushed abstinence before marriage and fidelity after marriage. That no doubt helped, but the country’s only long-term study shows the number of new infections in southern Uganda dropped by about 40 percent between 1990 and 2002 without any significant changes in general sexual behavior. The only factor that changed, according to the study, was the increase to an 80 percent rate of condom use between casual sex partners.
Even the US Congressional General Accounting Office’s recently released report cites the Bush Administration’s programmatic restraints as an obstacle to PEPFAR’s success. Politicians may not like the idea of handing out sterile needles to heroin users, for example, but such a program in New York City pushed HIV among drug injectors down from a 1990 high of 50 percent to 15 percent in 2002.
Though PEPFAR funds are meant also to address tuberculosis and malaria, USAID cannot explain how it spends most of its tuberculosis and malaria money. In September 2004 testimony to the House Committee on International Relations, USAID representatives indicated US$65 million was spent in FY2003 for malaria efforts but could specify only US$4.2 million in purchases of anti-malaria bednets. The remainder was unaccounted for.
All the while, new infectious diseases, such as Severe Acute Respiratory Syndrome (SARS) and “Mad Cow,” continue to surface. Globalization ensures many more microbial surprises lurk in the future. The emergence of humanly transmissible strains of avian influenza, or “bird flu,” poses the very real possibility of a 1918-type flu pandemic, which killed between 20 and 50 million people in 18 months, including nearly 700,000 in the United States, and circumnavigated the globe in four months, infecting one-fifth of the global population. Although pharmaceutical improvements in treatment and vaccine possibilities offer hope that such a deadly flu strain might be controllable, grave concerns remain: the drugs have limited efficacy even under conditions of ideal use and supplies are limited. Worse, the United States can manufacture only enough vaccine, even under emergency conditions, to protect some citizens, and most of the world lacks any capacity to manufacture vaccine. In a pandemic, the United States would face the foreign policy implications of denying vaccines to billions of people while saving the lives of some of its own. WHO conservatively estimates, even with widespread vaccine and drug use, this pandemic could potentially infect up to 30 percent of the world’s population of six billion people, with approximately seven million deaths.
The Next Steps
The international community does not have its eyes on the right ball. HIV/AIDS is a devastating pandemic that requires a massive global campaign to reverse its course of societal destruction. But HIV/AIDS does not exist in a vacuum. It is impossible merely to reverse the course of the HIV/AIDS pandemic without addressing its companion epidemics of malaria, hepatitis, tuberculosis, and pediatric illnesses associated with orphans exposed to HIV.
One way forward is to integrate the prevention, diagnosis, and care of these interconnected diseases. The diagnosis and testing for all of these diseases would be matters of life-saving routine. Basic research would go hand-in-hand with treatment programs, not shoved to the side as an inconvenient impediment. Prevention and treatment of any particular disease would not be segmented off from others because of jurisdictional boundaries of a certain UN agency, US federal bureaucracy, or international program. Buttressing these efforts must be an infectious disease surveillance system that can synthesize well-founded data from around the world to stem potential scourges (such as SARS and avian flu) before they escalate to overwhelming, not to mention expensive, epidemics. The only way truly to achieve this is through comprehensive integration and communication.
Compartmentalizing HIV intervention programs has, from the beginning, reduced its potential for success. The only effective and sustainable way to reverse the course of the HIV/AIDS pandemic and its companion epidemics is to de-exceptionalize it. Stand-alone HIV prevention and care clinics should not exist. HIV and tuberculosis ought not to be treated as stigmatized outlier syndromes. Syphilis, gonorrhea, hepatitis C, pediatric dysentery—all must come under one tent. And in building that tent the world needs to recall that nearly 75 percent of global wealth is now in the hands of just nine nations, according to 2003 World Bank data. Combined, the poor countries of the world, representing the majority of the population, possess less than one percent of global wealth. By necessity, building a health tent must mean attracting funds from the wealthiest nine states to the needs of the poor, on a massive and sustained level. Given the scale of the challenge, coupled with the constant emergence of new disease threats and potential for manmade scourges, the key for policymakers is to build alliances, work with and strengthen existing multilateral agencies, and avoid bilateral approaches that can undermine and alienate members of the international community.
Local support for these programs is also imperative. This support is two-pronged: community acceptance for the programs being administered is necessary for their success, as are human resource support systems to make the programs sustainable after the international community departs. Integrating services and de-exceptionalizing HIV will go a long way to minimize the stigmatization of this disease and increase community “buy in.” To begin to repair the human capital issues, the obvious yet daunting answer is to lessen the developed world’s demand for foreign health care workers while creating incentives for developing countries’ health workers to stay home. These changes will not occur overnight, but even a gradual shift away from the current trends can make a substantial difference in program effectiveness and begin to reinforce the local confidence level that has been eroded by years of failed promises.
Strengthening multilateral institutions, building local capacity, and improving communication and coordination between agencies will not be an easy task. Humanitarian and development agencies are not known for their ability to play well with others, and many world leaders continue to deny the global catastrophe that is waiting for them if they continue to neglect the need for focused and realistic infectious disease interventions. In contrast to their relatively low ranking on foreign policy priority lists, these issues represent an immediate threat to the security and stability of both the developed and the developing world and can no longer be overlooked.
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