Amid international financial meltdown and recession, the challenge of withdrawal from Iraq and the growing crisis in Afghanistan, there will be few "quick wins" available to President Obama. But fixing the US response to HIV/AIDS is one way he can do a lot of good relatively quickly and begin the move towards a new standard for international engagement. As the world prepares to reflect on its response to the pandemic, it is worth asking what Obama might achieve by World AIDS Day 2009.
Obama will inherit President Bush's Emergency Plan for AIDS Relief (the PEPFAR programme), which has helped to place hundreds of thousands of people on life-saving medication. PEPFAR was launched in 2003, and has spent some $19 billion so far with another $48 billion (including $9 billion for tuberculosis and malaria) pencilled in for 2009-2013. But while it is often cited as the only positive foreign policy accomplishment of the outgoing administration, it is also deeply controversial. The programme has been undermined by the US culture wars, the Republican assault on science and a unilateral and privatised approach to foreign policy. So what must Obama do about it?
There are a number of things that could be done quickly. First, he should cancel the Mexico City Policy (which was introduced by Reagan, repealed by Clinton and reintroduced by Bush) that denies US funds to foreign NGOs that even mention abortion in counselling or referrals, undermining the provision of comprehensive health services. Although Bush signed an order exempting PEPFAR from the policy, it still applies to all US family planning funding and should be repealed.
Second, social conservative positions on abortion have also led to HIV/AIDS-related programming becoming separated from reproductive health and family planning services. Reintegration would help to protect women and girls and boost maternal health.
Third, the first version of PEPFAR mandated that one-third of all money spent on preventing the transmission of HIV be focused on ineffective "abstinence-only" interventions rather than the comprehensive prevention strategies supported by the vast majority of experts and international opinion. The second phase (authorized by the Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008) removes this "hard earmark" but replaces it with a requirement for all country programs to report to Congress if they spend less than fifty percent on "abstinence-only" programs. This should be removed.
Fourth, PEPFAR II requires "at least half" of all funding to be spent on treatment and care. But many experts believe that with new HIV infections running faster than the roll out of treatment, the focus in stopping the pandemic must be on prevention, and that, in any case, the decision on what interventions to adopt should be decided in-country and not in Washington DC.
Fifth, PEPFAR II retains requirements for partner organisations to denounce prostitution and sex trafficking. While this might sound reasonable on the surface, it makes it impossible to reach groups who are vulnerable to HIV but also often oppressed by law enforcement agencies. It should be scrapped.
Sixth, PEPFAR II still allows partner organizations to opt out of best-practice, comprehensive programming if they don't like any aspects of it (the ‘conscience clause'). This too should go. Finally, the new legislation contains a clause that should make travel to the US easier for people living with HIV. This needs to be fully implemented.
Overall, too much of the programme has been influenced by earmarks and provisions that are geared to domestic political and economic constituencies rather than international best practice and assessments of need. At the same time, global HIV/AIDS policy raises larger questions about how the US engages with the world that the new President will also have to confront.
PEPFAR has been very closely linked to other aspects of US foreign policy, echoing their problems. In 2007 the US Institute of Medicine identified a lack of transparency and accountability to partners and recipients within the programme. The vast majority of PEPFAR funding is channelled bilaterally via US embassies and focuses on selected countries. This contrasts with the multilateral Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria, which is by no means perfect but aims to support all countries with viable action plans and is guided by scientific criteria. However, it remains underfunded. Meanwhile, the Bush administration has placed the fight against HIV/AIDS on the agenda of the Pentagon's new Africa Command, which has been hastily assembled and has proven deeply unpopular. A substantial shift towards a dialogue-based and partnership-driven approach is therefore required in global health and foreign policy alike. Other countries are well ahead of the US in setting themselves standards for the relationship between health and foreign policy. Though there is a long way to go in holding them to account, this does provide new openings for social movements to articulate their visions of global health.
It should be remembered that the biggest challenge in global health right now is not HIV/AIDS, tuberculosis, malaria, pandemic influenza or any individual disease. It is the chronic weakness or complete absence of health systems in the world's poorest countries, compounded by deep inequality and an overall lack of public health infrastructure. While PEPFAR has delivered life-saving drugs to hundreds of thousands of people, there is widespread concern that the international drive to focus on individual diseases is weakening health systems rather than strengthening them, a problem compounded by the Bush administration's preference for the contracting-out of foreign policy to private actors and its scepticism towards public bodies. Health system strengthening, increasingly a focus within global health, must be placed at the fore of US policy under Obama, but to achieve real progress a deeper rethinking of the political and economic forces shaping health and health systems is also required.
Ultimately, this calls for a new global health paradigm that confronts the deeply asymmetric nature of global economic interdependence and pervasive deficits of accountability and responsibility in the conduct of foreign policy. It must also reflect the balance of need rather than the balance of power. Developing such a paradigm can only be a collective endeavour.
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Alan Ingram is Lecturer in Geography at University College London. He researches relationships between global health, foreign policy and security and is a contributor to Global Health Watch.
Kris Peterson is Assistant Professor of Anthropology at UC Irvine and co-chair of the Association of Concerned Africa Scholars
