JAMA Letters Examine U.S. Health Aid

The Journal of the American Medical Association in its April 1 issue published two letters to the editor in response to an earlier commentary piece by Colleen Denny and Ezekiel Emanuel of NIH. Summaries appear below.

• Kenneth Mayer and Carol Dukes Hamilton: The commentary by Denny and Emanuel is "correct in saying that diarrhea and other illnesses exact a terrible toll on infants and children in resource-limited settings," Mayer of Brown University and Hamilton of Family Health International write. They add, "However, their proposal to shift funds from the President's Emergency Plan for AIDS Relief to maternal and child health programs could result in unintended adverse consequences for the women and children they seek to protect." According to the authors, the bill reauthorizing PEPFAR "includes a large increase for tuberculosis and malaria programs ... and it authorizes $10 billion for the U.S. contribution to the Global Fund To Fight AIDS, Tuberculosis and Malaria over a five-year period." They add, "Children experience high rates of morbidity and mortality from both malaria and tuberculosis. In addition, the bill includes important targets for strengthening health care systems, which will benefit primary care generally." Denny and Emanuel did not "discuss the central reasons that intensified and specific action on HIV/AIDS remains a global health imperative," the authors write, adding that the earlier commentary does "highlight a fundamental problem: the lack of adequate funding for global health programs generally. But the answer is not to scale back PEPFAR, which has a much broader impact than these comments acknowledge, but to greatly increase the overall amount of U.S. foreign assistance so that all effective programs, including essential maternal and child health programs, are appropriately funded" (Mayer/Hamilton, JAMA, 4/1).
  
  
• Denny and Emanuel: Mayer and Hamilton are "correct in noting the significant achievements of PEPFAR," Denny and Emanuel write, adding, "The program has unmistakably demonstrated that a large influx of U.S. resources can produce enormous health benefits in developing countries, even in as short a time as five years. Thus, the United States has clearly proven its power to save thousands of lives through directed contributions." According to the authors, the "very fact of PEPFAR's success creates a heightened responsibility. If the United States has the power to save lives, it also has an obligation to do so ethically and effectively." The U.S. "does not and will not have sufficient funds to address all the serious health problems of developing countries," the authors write, adding, "Choices will have to be made. Spending limited resources on any one health care intervention will necessarily mean that other types of interventions will go unfunded." According to Denny and Emanuel, three "principles should determine which programs receive priority" -- the first being which programs "save the most lives," the second being which programs "save children's lives," and the third being which programs "achieve these goals in a cost-effective manner. We do not argue that PEPFAR is an unjust or misguided program. Rather, in light of its demonstrated capacity to save lives, we believe the United States should fundamentally rethink how it distributes its resources, focusing on achieving these goals." The authors write that there are "many reasons why it would be unwise and unjust to dismantle existing aid programs such as PEPFAR, including such practical concerns as increased drug resistance. But new international aid funding ... should be distributed not simply according to what the United States has done in the past but to overtly and justly provide maximal health benefit" (Denny/Emanuel, JAMA, 4/1).