From PEPFAR to PEPFAR-plus

Posted by Peter Luckow on November 15, 2008

Over the past two decades, the global AIDS pandemic has wreaked havoc in developing countries around the world.  More than 25 million people have already died of AIDS, a treatable and preventable infectious disease.  Children have been orphaned, economies have suffered, and the health workforce in the hardest hit countries has been weakened.

The past decade has seen a major surge in funding for global health, much of it being dedicated to combat the AIDS pandemic.  On May 27, 2003, President Bush authorized the US President's Emergency Plan for AIDS Relief (PEPFAR), committing $15 billion from 2003-2008 for global AIDS relief for prevention, care, and treatment.  Just this past July, President Bush reauthorized PEPFAR, pledging $50 billion for the next five years.  Many say that PEPFAR will be Dubya's greatest (positive) legacy, despite some ideological shortcomings attached to the funding.

While PEPFAR has brought important strides in the fight against AIDS, its narrowly-focused prevention and treatment efforts have not gotten to the root causes of the pandemic. In Structural Violence, Poverty, and the AIDS Pandemic, Joia Mukherjee provides invaluable insight into the root causes of the global AIDS crisis - poverty, gender inequality, lack of access to education, neoliberal economic reforms, and exhorbitantly priced medicines. According to Mukherjee, these root causes are representative of the structural violence that is being inflicted on the poor throughout the world.  She defines structural violence and its relationship to AIDS:

Structural violence, defined as the physical and psychological harm that results from exploitive and unjust social, political and economic systems, is the shadow in which the AIDS virus lurks.

The $50 billion pledged through PEPFAR to fight the AIDS pandemic will be a huge boost to advance further prevention, care, and treatment.  However, a worthy fight against AIDS must include a broader sense of prevention and treatment that goes beyond preaching abstinence and distributing ARVs, to preventing and treating the devastaingly powerful effects of structural violence. 

Health is a right? (by Jon Shaffer)

Posted by Peter Luckow on October 9, 2008

Jon Shaffer, the President of GlobeMed at Northwestern University, recently posted this fantastic entry on his blog:

Here is a really interesting post on The Health Care Blog by Maggie Mahar who rights on the Health Beat blog. In it she criticizes the use of rights language when talking about health care reform. Money quote:

"I have to admit I often have found the language of healthcare “rights” off-putting. Yet the idea of healthcare as a “right” is usually pitted against the idea of healthcare as a “privilege.” Given that choice, I’ll circle “right” every time.  Still, when people claim something as a “right,” they often sound shrill and demanding. Then someone comes along to remind us that people who have “rights” also have “responsibilities,” and the next thing you know, we’re off and running in the debate about healthcare as a “right” vs. healthcare as a matter of “individual responsibility."

I vehemently disagree with her. Her main thesis is that rights language is not specific enough, and tends to polarize the discussion. In my opinion, it is exactly the type of language that we need to get things moving. The language of human rights is very specific. The only body that can guarantee rights to people are sovereign governments - no private entity can ever grant rights. For that simple reason, we must use rights language to describe health. Health care cannot be bought and sold on the open market because, by economic definition, there will be people who cannot afford the price set by the intersection of supply and demand. By casting access to reasonable health care as a human right, we can move beyond the idea that health is something that can be bought and sold, and move toward universal access.

Is this "shrill and demanding"? I certainly hope so. Guaranteeing all people the ability to see a doctor when they are sick is certainly one of the most pressing issues of our time.

Bucking the trend

Posted by Victor Roy on September 22, 2008

To leave, or not to leave? Unfortunately, that's not even the question for many medical students in sub-Saharan Africa. "How can I leave?" is more often the worry for so many promising medical professionals. With low pay, dangerous working conditions, and greater incentives elsewhere, more and more "would-be leaders" are leaving for Europe and the US.  

Dr. Julian Atim, a graduate of Makarere's medical school in Uganda, is trying to buck the trend. She remains deeply committed, after losing both of her parents to HIV/AIDS in Uganda, to developing a stronger public health infrastructure in her home country. Building the infrastructure for medical training and retention which can produce more stories like Julian's is absolutely necessary.   

While other solutions for addressing the problems created by the brain-drain also need to be explored - and we'll do that here in coming posts - how do we create an environment where educated professionals will want to stay on the African continent

Horizontal, vertical, or diagonal?

Posted by Victor Roy on September 8, 2008

Debates about the design and financing of public health programs can be heated. Do vertical, disease-specific programs, such as TB, malaria or HIV/AIDS interventions, miss the point? The development of "horizontal" health systems and infrastructure, capable of addressing a broader spectrum of diseases, many say, should be the goal. A disease-specific emphasis, however, has been more effective at bringing billions of new $$$ to the table for global health, through schemes such as the Global Fund for HIV, TB, and Malaria and President Bush's AIDS program, PEPFAR.  

More and more, people are seeing both sides of the argument. That's why the "diagonal" is in. Partners in Health's Dr. Joia Mukherjee puts this emerging perspective clearly:  

"Interest in and money for AIDS allowed us to rehabilitate basic health infrastructure in Haiti's central department. Our philosophy was that we could not find AIDS cases or treat them if clinics stood understaffed, empty and without essential medicines.  Thus, the investment in AIDS became our Chwal Batay, or battle horse-a tool to bring us into a larger battle against poverty, inequality and poor health."

If HIV/AIDS gets more funders involved and interested than "building primary care systems", then why not use the funding for AIDS programs to do more, as Dr. Mukherjee describes? The effective treatment of these specific diseases will rely on this anyways. What do you think? Will the debates about vertical vs. horizontal go away? Is the "diagonal" approach here to stay? Or should we be creating new visuals in our head?