You're not invited to these discussions
Dear Minister Thomas (and Ambassador Goosby), You know, I guess after decades of being an empire, the British can't give up easily. On 9th March, DfiD is hosting a high-level meeting in London, with the heads of UNAIDS, the Global Fund, PEPFAR, and African ministers to decide the fate of AIDS in Africa. It's clearly a framing meeting, to decide what the "new" message is that will come out at the next G-8 and G-20 meetings, and that message to millions of people with AIDS in Africa is:
1) you're not invited to these discussions--you don't count enough to be part of the decision-making about your own lives--we know what's best for you;
2) AIDS treatment is dead. "While we want a strong focus on prevention, we need to see UA clearly guiding the prevention focus.
It is also important to remember treatment although we will not focus on it." as one of the circulating emails about the meeting says.
It's time to call out DfID and the US government: for whatever reason, you've decided after many studies, a decade of successful scale-up of ART, that the strategy of universal access to treatment is no longer cost-effective, and access to ART will become less and less of priority in your funding and your programs. Thank you Gareth Thomas, thank you Zeke Emanuel. You can spin it whatever way you like, but from the highest level of the UK and the US government, we've heard the message loud and clear: we need to go back to the old days, before ART was such a distraction, to the 1990s and the days of sector-wide approaches, where people most affected by health care policy sat quiet and let the experts decide their fates. DfiD is under the impression that the old ways of working were thrown off course by 10 years of too much talk of ART, of human rights, of uppity activists who simply were rent-seekers, pushing their ownparochial interests about staying alive.
For DfID, the 90s were golden era I suppose. Except the truth is maternal health and immunization programs in Africa floundered, HIV and TB exploded, and health systems crumbled all on the sage advice of the experts at DfiD and USAID, at WHO and UNAIDS. DfiD and it's partners are pushing a regressive, back-to-the-future agenda that absolutely refuses to learn anything from history. I have some news for you: we're not going to die quietly.
We've been fighting for health care for our communities for 30 years--not just AIDS treatment, but national health care in the USA to a people's health service in South Africa. We've made astounding gains, by bringing new energy, ideas and focus to the field of global health when the idea of health for all that was in the words of Paul Farmer and David Walton at Harvard a joke before AIDS activists came along. So, have your new "Berlin Conference" in London on the 9th without a single HIV+ African in the room. Push the IHP+, which underfunds and overpromises, and which is only SWAPs by a new name. Tout the new Obama Global Health Initiative which talks in glowingly warm development-speak then cuts the US contribution to the Global Fund and drops treatment targets to whatever Dr. Emanuel thinks is cost-effective. By all means, get down to the real business of global health in London on March 9th. Ministers and their experts sitting around the table deciding the fates of millions. You've all done such a wonderful job in the past.
Gregg Gonsalves
- Comrades's blog
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Dear Minister, I am extending an apology to you
Dear Minister Thomas--
We don't know each other, but I am extending an apology to you.
Colleagues and friends have written to me over the past few days to tell me that I had the wrong impression about upcoming meeting on universal access. Most have said the facts are that the Canadians want no mention of AIDS at the upcoming G8/G20 meeting and that you are personally committed to honoring the global commitment to universal access and want the G8 to highlight this issue. They fear I was playing into the hands of our enemies by criticizing this gathering.
If this is so, the meeting in London would be a good thing. Still, it would be important to include HIV+ African delegates to ensure that it isn't simply the voices of ministers in these conversations.
Additionally, any suggestion by UNAIDS that prevention should be emphasized over treatment should be ignored. Prevention and treatment go hand in hand, programmatically (in increasing testing rates),
biologically (with ART for instance) and logically, false dichotomies not withstanding.
I don't follow the ins-and-outs of UK institutional politics. My initial reaction to this meeting was because there are people at DfID who are "old-school" development types who never supported ART, are
radical horizontalists and see no need for disease-specific programming or funding, and have ignored the innovations that AIDS has brought to the field of global health. I don't count you as one of them, but you have colleagues, dinosaurs, at DfID who are doing more harm than good these days.
So, please, please, I hope this meeting happens.
The world made a commitment to universal access. If the promise is to be broken, why should anyone believe in the latest round of promises centered around the IHP+ or the US' new Global Health Initiative? We
can build on the successes of AIDS, including treatment, for a more robust and broader response to health and development.
For those of you who thought my initial message was too harsh, perhaps overstated. Let this be clear too. I don't retract the essential point that there has been a backlash against AIDS programs and that this backlash is bad for global health in that it represents a return to failed policies of the past. The IHP+ in its current form and the nascent US GHI don't look forward. They look back to days of chronic underfunding, low aspirations, minimalist interventions based on narrow notions of cost-effectiveness, no outside accountability or transparency, no hard targets.
So to everyone on this list. Stand up for AIDS. Stand up for health systems. Stand up for TB. Stand up for government accountability on health in the North and South. Stand up for real targets and
milestones. Stand up for maternal and child health. Stand up for
health workers. Stand up.
The new conventional wisdom circulating in some, not all, offices in the White House and at 1 Palace Street, among academics and guns-for-hire is that we made a mistake in treating AIDS, in scaling-up the response to the epidemic and it's time to move on to the real, serious work of health and development.
These are the "experts" who ran global health into the ground for decades paving the way for the explosion in HIV/AIDS and the stagnation of health systems in the 90s. Do not give them back the keys to the car.
Gregg
gregg.gonsalves at gmail.com
I have to disagree with Ambassador Goosby
On activists, I have to disagree with Ambassador Goosby. US-based activists are not asking for anything more than what was legislated 2 years ago with co-sponsorship by the now-President, Vice President, and Secretary of State. The promise was $48 billion over five years to do the US’s part in the fight against AIDS, TB, and Malaria. If this administration were living up to that then we would not be arguing about funding–but simply arguing that other donors are not doing their part and therefore the US isn’t obliged to make good on promises is inexcusable. As for African activists, Ambassador Goosby would do well to meet with the Treatment Action Campaign and ARASA… you can see more about their work at: http://www.huffingtonpost.com/matthew-kavanagh/african-activists-demand_b_245560.html I think we can applaud the work PEPFAR is doing on promoting generics and look forward to hearing more about the details. With savings we certainly should see more than 1.6m added to the treatment roles in the next 6 years.
Matthew Kavanagh , Health Gap
http://www.healthgap.org
http://sciencespeaks.wordpress.com/2010/02/08/ambassador-goosby-discusse...
Ambassador Goosby Discusses Key Points
Dr. Eric Goosby, the US global AIDS ambassador, spoke with John Donnelly about a number of issues surrounding PEPFAR and the Obama administration’s new Global Health Initiative, including how the administration hopes to ramp up treatment and prevention efforts with small increases in overall funding and how PEPFAR is constantly responding to emergencies in the field – including the move in December to give the South African government $120 million after the country had an unexpected funding shortfall in nine provinces.
Q: Roxana Rogers, USAID’s South Africa health team leader, said recently in South Africa that, “US government funding is going to come down dramatically over the next five years.” True?
A: No, it’s not true. Every year there’s been an overall increase in funding for PEPFAR, and we’ve also not been in a situation where we’ve had a decrease in any country, certainly not in South Africa. Our funding for South Africa is over a half billion dollars a year. Our resources that go into South Africa are having a huge impact, and I’m not understanding that (comment by Rogers).
We also committed to $120 million recently over two years to specifically address an unexpected shortage of funding for antiretroviral drugs in South Africa in nine provinces. The South African government asked us to be silent (about it during that time.) … It made a lot of sense for us to fund it for the simple reason that we not allow services to be interrupted and allow South Africa to respond to the increase in demand.
Roxana’s statement is based on the fact – I think – that she was used to PEPFAR funding that went up in huge increments every year — so much so they scrambled to find meaningful applications to use the funding for programs. Now we are in an economic crisis, with nowhere near the increase in funding like that, so on a relative level it may feel like a drop in funding.
Q: What happened in South Africa’s shortfall of funding for treatment?
A: PEPFAR has not run out of any antiretroviral drugs in any country, including South Africa. .. But for multiple times we’ve been asked to bail out a country for one or two months (because of drug shortages in the national program or funding shortages). South Africa had run out of resources to pay for the medication in nine provinces, starting in November. It was a significant outlay of resources for us and a real example of cooperation. In addition, we were able to work with the government to ensure their Treasury picks up the bill thereafter, so it doesn’t happen again.
Q: You have said, “Our commitment to universal coverage hasn’t wavered.” With the increase in demand for treatment and prevention around the world, how can you make that commitment with just a $141 million increase in your budget – and with some of that money earmarked for the Global Health Initiative?
A: We are committed to universal access. We are partnering with implementing countries to mount their response. Our expectation was never that we would be the sole source of funding to fight the epidemic. … PEPFAR or any other single funding line will not be able to successfully respond to the unmet need. … It’s not within one single program’s ability to mount that response.
I don’t know if PEPFAR ever presented itself that it was going to cover the entire need for prevention, care, and treatment for any country. We are definitely providing larger than the bulk of the funding – 50, 60, or 70 percent of it– in our focus countries already.
Q: You have talked in the past about finding savings in PEPFAR’s budget that would free up additional funds for treatment and prevention. What are you doing in finding these savings, including in trying to reduce the price of ARV medication?
A: We have been in long-term negotiations in every country we’re in to have the predominant purchasing (for drugs) occurring with generic manufacturers. We saw a shift two years ago, and now we’re in the high 80s, low 90 percent (of all drugs being generics) We have had discussions with South Africa … and they needed to move from about a 65 percent brand dominance to somewhere down to 10-15 percent range, which they have started to do.
We are engaged with the Clinton Foundation to look at generic pricing arrangements, toward a commitment that creates and introduces a competitive component to generic pricing. After that initial deal is cut (in a country for generic drugs) competitive pressure from another generic manufacturer in that region will continue to drive that price down.
For other efficiencies, we have looked at the Clinton Foundation and Synergos (Institute in New York City) and other organizations that have a history of this type of work. We try to understand how we can use the experiences they have had with other countries, not with PEPFAR, to learn lessons that enable us to identify efficiencies for treatment and for prevention interventions.
Q: You are now helping to create partnership forums with countries on the HIV/AIDS response. How will you be able to ensure the representation of civil society groups in situations like the one unfolding in Uganda now – with the proposed law that would outlaw homosexuality?
A: PEPFAR has played a central role in being the dominant response in Uganda to the epidemic. We are now and always have been treating gay men in Uganda. Whether the country has admitted that or acknowledged that is a different issue — they never have. From day one, the Infectious Diseases Institute and TASO (The AIDS Support Organization) have been central in that response, and that will continue. In addition, PEPFAR is in a position to play a role in the partnership frameworks to engage in a substantial dialogue with country leadership about the public health impact from such a law. … With such a law, there is a fear that this will stop the flow of patients into testing and into treatment. We will always fight against that in the way our programs are implemented. PEPFAR also has an opportunity to identify – and fund – higher risk populations.
Q: How does that strategy work?
A: We could fund non-governmental organizations that do outreach, that create support groups. … Then there is a growing number of individuals who feel safe and who are willing to take those risks who coalesce in a group that can be funded as a separate NGO. In China now, there is an increasing number of NGOS created specifically for high-risk groups, especially men who have sex with men. … There is a need in creating these safe islands of safety so they can be tested and treated.
Q: For many years, you were on the outside of government, an activist, giving advice to those in power. What should activists be focusing on today?
A: Activists have played from the beginning of the epidemic a central role in reflecting a conscience for policymakers and for governments to understand their responsibility in orchestrating an effective response to this epidemic.
What I think is most needed today is for advocates to look at the larger picture of responsibility, i.e., who is responsible for the response, and to start to talk about it as a shared responsibility, not just dependent on any one country to model a response, but (about the US) playing an appropriate needed role as a world power, an economic power, a political power.
Also, the advocacy originally in the US was by those most impacted by the disease. There needs to be advocacy now coming from the infected and affected communities in countries where we’re most engaged.
http://sciencespeaks.wordpress.com/2010/02/08/ambassador-goosby-discusse...