The Battle for Global Treatment Access
In the early '90s, it was hard to surprise activists in organizations like ACT UP. Nothing seemed too strange to believe. AIDS might mean the end of civilization as we know it, or it might wipe out an entire generation of gay men, injection drug users, and poor Americans (who were predominately African American). Some even felt that the government purposefully unleashed this killer to deal with a variety of social "problems" like gays, the poor, and blacks.
But many of those same activists were truly surprised by the extent of the global AIDS pandemic. The numbers themselves are so huge that they can be difficult to comprehend. There are 33 million people with HIV worldwide, but as of 2008 only 3 million of the 12 million who need treatment have access to it. The severity of the problem gets lost in the math and, like all social justice struggles, in the distance between "us" and "them."
But we shouldn't be surprised, because the story of this pandemic is the same story we've heard before: the most vulnerable people in the world are the most affected. Back in 1999, many people fighting AIDS had little idea of both its extent and the factors that were fueling it. It was left to a few trade and patent experts, like Rob Weissman of Essential Action and Jamie Love of Ralph Nader's Consumer Project on Technology to spread the word that millions of people around the world could not access lifesaving medications simply because the pharmaceutical industry insisted that the U.S. prioritize patent rights over drug access.
South Africa Makes the First Move
Because AIDS was a national health crisis in South Africa, its government passed the Medicines and Related Substances Control Act, which allowed it to import cheaper generic versions of lifesaving medicines from other countries. This was legal under World Trade Organization agreements but the U.S. challenged the Act and 39 drug companies sued South Africa to prevent any generic drugs from being imported.
Rob and Jamie told AIDS activists that Vice President Al Gore, who sat on the U.S.-South Africa Binational Commission, had close ties (like many politicians) with the pharmaceutical industry. That was all a group of activists from ACT UP Philadelphia, ACT UP New York and Fed Up Queers needed to know. Al Gore wasn't simply the Vice President -- he was weeks away from announcing his candidacy for the U.S. Presidency. So activists planned a carefully choreographed series of direct actions, disrupting Gore's first three announcements of his candidacy for President: in Carthage, Tennessee; Manchester, New Hampshire; and New York City. With simple banners that read "AIDS Drugs for Africa," a movement was born.
The activists' demands soon became international news and within three months, the U.S. had reversed its position and announced that "... the two governments have identified common ground with respect to South Africa's implementation of its so-called Medicines Act." This was later expanded to include all of sub-Saharan Africa when President Clinton issued an Executive Order stating that "...the United States will henceforward implement its health care and trade policies in a manner that ensures that people in the poorest countries won't have to go without medicine they so desperately need."
Durban: A Watershed
The next year, the International AIDS Conference was held in Durban, South Africa. According to Amanda Lugg of African Services Committee, "Durban blew the lid off the secret about the international AIDS crisis." By this time, reporters, politicians, and most importantly, AIDS activists all understood the complexity of global trade policy and the ways in which U. S. government complacency fueled the injustice.
Shortly before the Durban conference, the U.N. had established the "Accelerating Access Initiative" which was a collaboration between various U.N. agencies and several large pharmaceutical corporations. Countries would agree not to import cheaper generic medications and would be rewarded with price cuts from the manufacturers. While this would get some drugs into bodies, it also maintained the power of the pharmaceutical industry to name its price and continued to limit access to lifesaving medications.
In response, in large part, to activist pressure, AIDS was discussed by the U.N. Security Council in January of 2000. This was the first time that a disease was presented as a threat to the security of the world. In 2001, the U.N. held its first General Assembly Special Session on HIV/AIDS. At this forum, the "Declaration of Commitment to HIV/AIDS" was finalized. This document set concrete goals and commitments to provide treatment for people living with HIV in each U.N. member country. The countries had benchmarks to achieve, including ending discrimination against people with HIV and dramatically increasing access to HIV treatment. The ultimate goal was to provide treatment for 85% of those who needed it.
The Global Fund
One of the major steps in increasing access to treatment was the creation of the Global Fund to Fight AIDS, Tuberculosis and Malaria -- a "war chest" for treatment. Activists from around the world got themselves invited to (or just crashed) the first meeting of the Fund and applied pressure for a fair and accountable Fund. With groups like Health GAP (Global Access Project) on the outside and the International Council of AIDS Service Organizations on the inside, activists were able to barrage meeting attendees with ideas for funding levels, calls for distribution systems led by the communities themselves and the need for people with HIV to be on the Global Fund's board. But the U.S., which made the first contribution to the Fund, unfortunately set the bar low, committing only $200 million. As expected, other nations followed the U.S. lead and contributed even less.
By 2003, with a Republican in the White House, many had little hope that there would be any real commitment to combat HIV, yet President Bush used his State of the Union speech to announce "the opportunity to save millions of lives abroad from a terrible disease." He created the President's Emergency Plan for AIDS Relief (PEPFAR). This historic commitment provided $15 billion over five years to fight HIV in the poorest countries in the world -- the largest single commitment by one nation. Congress authorized support to provide treatment for two million people with HIV in 15 "focus countries" by 2008 and to prevent seven million new infections. In fact, this year Congress approved spending nearly $6 billion on global AIDS programs alone, $600 million more than the President initially requested.
Fast forward to 2008. The Global Fund is deciding how to distribute its eighth round of funding, and PEPFAR is up for renewal. On May 30, 2007, in a speech in the Rose Garden, President Bush dramatically undercut his own program by proposing to "double" PEPFAR to $30 billion over 5 years -- $6 billion per year. But the U.S. was already planning to spend about $6 billion in 2008, so what the President announced was not a doubling, but in fact a flat-funding of a program that should be accelerating toward universal access.
This backsliding of PEPFAR II was most apparent in the targets for the number of people treated. In the first five years of PEPFAR, the U.S. aimed at treating 2 million people. But, by the end of the second five years (2013), President Bush proposed to only treat 2.5 million, or an additional ? million over five whole years. Because the U.S. controls a third of the world's economy, activists feel it should fund a third of the response to the global AIDS crisis, or $59 billion during the next five years.
If we commit to the U.N. goal of providing treatment to 85% of those who need it, 19.2 million people would be on treatment at the end of 2013. But under the Bush scenario, there will be only 7.5 million on treatment by that date. When you subtract 7.5 million from 19.2 million, you are left with 11.7 million extra people dying for lack of treatment.
According to Health GAP's Brook Baker, "The AIDS pandemic continues to kill at an alarming rate -- 3 million people are newly in need of treatment each year. Although new infections are finally falling, orphans and vulnerable children continue to overwhelm social support systems. Weak health systems are pushed to the breaking point. In this environment, President Bush's treatment, prevention, and care goals in PEPFAR II all decrease dramatically -- the only thing that doubles is deaths."
'08 Stop AIDS
Given this information, Health GAP joined with other AIDS advocacy groups such as Housing Works, Global AIDS Alliance, Results, and the Student Global AIDS Campaign to create the '08 Stop AIDS Campaign. Activists used the tactic of "Birddogging" at each Presidential campaign stop to win real commitments from the candidates and to shift the public debate. Birddogging is a tactic that allows activists to directly confront key decision makers like Presidential candidates. Over 400 students, religious leaders, and people living with HIV have been trained to show up and ask detailed questions about the U.S. commitment to fight global AIDS.
In the months leading up to the first Democratic Presidential debate, AIDS activists urged each candidate to sign a commitment to fund PEPFAR II at the amount needed to truly reverse the AIDS pandemic: $50 billion. In addition, ACT UP Philadelphia organized one of the most photogenic demonstrations the U.S. has seen in years, using vivid torches and red flares to make their point. By the time of the debate, each Democratic candidate had caved into the pressure and the threat of the demonstrations, and committed to the $50 billion. The public debate had been altered and the President's meager commitment of $30 billion became obsolete and widely accepted as being too low.
However, the battle to ensure that PEPFAR II is effective is still being waged. Both the House and Senate Committees on Foreign Affairs authorized $50 billion for PEPFAR II. But with the addition of tuberculosis and malaria, and a very detailed list of lifesaving activities, the bill now needs to be funded at $59 billion.
The Global Gag Rule
Just before the House Committee on Foreign Affairs was about the mark up the PEPFAR II bill, Congressmember Tom Lantos, a hero to the global AIDS community, passed away. Immediately following his death, the new Chair, Congressmember Berman, met with the President's staff, and created a compromise bill. Months of work on the bill, which would have created a truly comprehensive and effective proposal to fight AIDS, tuberculosis and malaria was flushed down the toilet by compromises that were made that night behind closed doors.
One of the worst additions was confusing and ultimately dangerous language about family planning programs. The new bill suggests that only family planning programs that agree to the "Global Gag Rule" will be eligible for funds to provide HIV education, counseling and testing. (The Gag Rule prevents organizations that get U.S. funds from taking funding from any source to perform abortions or to provide referrals for abortion.) AIDS activists have repeatedly told legislators that the Gag Rule should be repealed. Family planning services need to be a part of a comprehensive plan to end the global AIDS pandemic. By increasing access to contraceptives and reducing unwanted pregnancies, not only do you advance women's health, you also reduce the number of children born with HIV.
Health Care Workers
Activists are also fighting to strengthen health systems in the developing world. In the early days of global AIDS activism, the pharmaceutical industry and naysayer politicians liked to point out that health care barely existed in many countries throughout the world. While they pointed this out to explain why it would be impossible to actually provide lifesaving medications in those countries, activists responded by saying we should fix the problem. Hence the campaign for healthcare workers was formed.
AIDS is taking a major toll on the health workforce, from the illness and death of the health workers themselves to the enormous stress AIDS is placing on health systems. In addition, the U.S. and other Western countries have long engaged in the practice of taking the best and brightest people from other countries and bringing them here to treat our sick. How quickly are health workers leaving? As of 2001, only 360 of the 1,200 physicians trained in Zimbabwe during the '90s were still practicing in the country. In 2002, more than 3,000 nurses who trained in Africa moved to the United Kingdom. Ethiopia is losing about 9.6% of their public doctors every year, primarily to other countries and the private sector.
We know that funding is needed to support 140,000 new doctors and nurses. The U.S. needs to contribute its fair share of funding for these workers, but also must ensure that it doesn't lure health care workers away from developing countries. It must support in-country training and retention of foreign health care professionals. And the campaign to win more funding for healthcare workers goes beyond AIDS. Funding will strengthen public health systems throughout the world and provide medical professionals to treat malaria and tuberculosis and to advance maternal and child health.
The Senate version of PEPFAR II only mentions 140,000 new "healthcare professionals and paraprofessionals." That vague language is no mistake. It could provide wiggle room that would allow the U.S. to focus on training poorly-paid community health workers and not the more highly-trained doctors, nurses, and pharmacists needed to provide the U.S.'s one-third fair share. Of course we need community health workers to bring treatment and care to rural communities, but those local efforts can only succeed along with strong training, supervision, and referral systems. If we are not serious about strengthening health infrastructures throughout the world now, the crisis will just get worse.
Just ten years ago, we thought that universal access to HIV treatment was a utopian dream, but now it is a real possibility. The one very real barrier to maintaining HIV medication regimens is the number of doctors, nurses, and other health workers needed in developing nations to distribute them.
We shouldn't be surprised by these new life-and-death battles in the struggle for PEPFAR reauthorization. It is the same story: family planning gets left out because the groups that engage in this lifesaving work get painted as abortion providers. Funding is provided for only a fraction of those who need treatment. Women, girls, and sex workers get left out simply because "they" think they can get away with it. Let's take the next couple of months and prove to them that they can't.
Jennifer Flynn is the Managing Director of Health GAP (Global AIDS Project).
This article was provided by ACRIA and GMHC. It is a part of the publication Achieve. Visit ACRIA's website and GMHC's website to find out more about their activities, publications and services.