By Sebastian Mallaby
Monday, May 29, 2006
The Bush administration's critics should give credit where it's due. And when it comes to the global AIDS crisis, it is due -- big-time.
Five years ago, the U.S. government's total contribution to fighting HIV-AIDS abroad stood at $840 million. The Bush team was rightly pilloried for trade policies that impeded poor countries' efforts to buy cheap generic AIDS drugs. But at the start of 2003, the administration had a hallelujah moment. In that year's State of the Union address, President Bush promised $15 billion over five years to fight the pandemic. It was the biggest commitment to a global health challenge announced by any government, ever.
Naturally, there were skeptics. The administration's envoys endured boos and yells at international AIDS conferences; they will probably face more at this week's United Nations AIDS summit. But three years after Bush's $15 billion pledge, the skepticism has proved mostly unfounded.
One doubt was that the administration wouldn't back its rhetoric with money. Well, since the president's pledge, spending on global AIDS programs has risen steadily: to $2.3 billion in 2004, $2.7 billion in 2005 and to $3.3 billion this year. The administration's budget for 2007 requests $4 billion from Congress, more than quadruple the level in 2001. So the Bush team is on target to exceed the $15 billion promise.
A second doubt was that the administration would waste money by purchasing branded AIDS drugs. Generics are not only cheaper than patented medicines; by combining two or three drugs into a single pill, they also make it simpler for patients to take their meds as they're supposed to. But the Bush administration began by refusing to buy pharmaceuticals that lacked approval from the U.S. Food and Drug Administration, effectively closing the door to non-branded AIDS therapies.
Starting in 2004, the administration fixed this problem. It directed the FDA to license generics for use in U.S. global AIDS programs, even when those generics could not be sold in the United States because they infringed U.S. patents. The skeptics continued to insist that obstacles lurked in the FDA's complex rules. But generic after generic was soon licensed, and in some countries around two-thirds of U.S. spending on AIDS drugs now goes to non-branded medicines. Given how often foreign aid is tied to exports from donor countries, it's remarkable that the Bush team stiffed Big Pharma in favor of cost-effective help for AIDS patients.
A third doubt about the administration's AIDS promise concerned sexual abstinence. When it agreed to back Bush's AIDS initiative, Congress laid down that a third of the prevention budget should be used to advocate abstinence and faithfulness. The scientific literature suggests that combining abstinence messages with teaching about condoms can delay sexual debut and save lives but that abstinence-only messages are ineffective. So the congressional earmark, to which the administration acquiesced, seemed like a classic Republican mistake: a triumph of social-conservative ideology over science.
This complaint is right -- but should not be exaggerated. Most of the U.S. AIDS budget goes toward treating people and caring for the dying and orphans. Abstinence and faithfulness teaching consumes only 7 percent of the total, and an unknown fraction of that is constructively combined with teaching about condoms. The critics cite a few wacko preachers who have received U.S. money even though they proclaim that condoms don't work, and the Government Accountability Office has described how the abstinence earmark complicates the work of front-line AIDS groups. But it's wrong to paint the entire Bush AIDS program as a Christian-conservative plot when the abstinence-only stuff is relatively limited.
The most serious criticisms of the Bush AIDS program are that it involves too little collaboration with local governments and fellow donors and that pouring millions into AIDS sucks health workers away from other vital diseases. But even these criticisms can go too far. When the Bush program was set up, the noncollaborative approach was a way to get results quickly; now, by some accounts, collaboration is improving. In the early stages, equally, pouring money into AIDS programs was bound to siphon health workers away from other things. But there's talk that the administration may correct this problem, maybe by launching a program to train community health workers in poor countries.
It's not that the Bush program is perfect, and it's not that the administration is the lone hero of the AIDS crisis. The Global Fund to Fight AIDS, Tuberculosis and Malaria, which was set up just four years ago, has channeled $5 billion toward those diseases; the Bush team should acknowledge its contribution less grudgingly, especially since the United States provides 30 percent of the fund's resources. Yet the bottom line is that the administration has faced up to a killer that's taken 25 million lives in the 25 years since its discovery. There's much more to be done -- 5 million more people get infected every year. But if you want to denounce rich countries for their negligence, the United States is the wrong target.