Global AIDS Policy in the Age of Obama

An excerpt from my piece in the Journal of HIV/AIDS and Social Services

This editorial is based on a short trip I took to South Africa earlier this year.
April 2009

In 2006, then-U.S. Senator Barack Obama and his wife Michele traveled to Kenya, Obama’s father’s homeland where many of the senator’s extended family still lived. The Obamas publicly took an HIV test during their trip, an important moment as sub-Saharan Africa is the region most affected by the HIV/AIDS crisis, with more than 2/3 of the world’s infections.

For every outspoken leader on HIV/AIDS like Uganda’s Yoweri Museveni, there have been as many or more AIDS denialists like South Africa’s former president Thabo Mbeki and his shamefully ignorant health minister Manto Tshabalala-Msimang who at one time suggested that beetroot and garlic were effective treatments for HIV. Given the new U.S. president’s Kenyan heritage, Barack Obama may be uniquely placed to speak to the African people about the dangers of HIV and steps they can take to protect themselves. While Obama may have this special connection, larger currents will constrain his ability to advance the fight against HIV, a product of both the positive and negative legacies of the George W. Bush administration….

Given that there is no cure for AIDS, the extension of treatment to those who are HIV-positive is perhaps a deeper responsibility than people realize. Donors assume moral responsibility to extend ARV therapy for the remainder of those people’s lives.  Repudiation or interruption of that commitment would be extremely damaging, as those people would die unless the cost of treatment were picked up by some other donor, the person’s government, or the individuals themselves. Of course, people who never receive treatment will also die, but it would be even more unseemly to extend treatment only to later take it away. Before the donor community continues the practice of putting people on treatment when they are already quite sick, leaders should re-evaluate the efficacy of those efforts.

At the same time, it would be a tragedy if the global community decided to “walk off the field” by allowing their attention to lapse or stray. Nearly a decade into the world’s ambitious effort to address the AIDS pandemic in the developing world, there is a great danger that the financial crisis, other priorities, and the continued spate of new infections will cause donors to lose heart. The Obama administration should seize the moment to infuse the donor community with a new sense of purpose, focusing on the most promising avenues to reduce the rate of new infections. That would be change we could believe in.

Making Markets for Merit Goods

Making Markets for Merit Goods
with Ethan Kapstein

This is from a blog post at the Center for Global Development about a new working paper available at CGD. Sorry it’s been so long for me to post here again, but I hope to channel a few new pieces here periodically.

Our research on the political economy of antiretrovirals (ARVs) is motivated by a key puzzle: why were AIDS activists and AIDS policy entrepreneurs successful in putting universal access to treatment on the international agenda when so many other global campaigns–whether in health care or other issue areas like climate change–have either failed or struggled to have much impact. In our paper, we make the case that the market for ARVs was politically constructed, meaning that activists had to bring the demand and supply sides of the market together through a variety of tactics and strategies (Tim Bartley makes a similar argument on forest certification schemes).

Merit Goods and Market Failures. The idea that motivated the activists was that AIDS drugs should ideally be “merit goods,” meaning goods that are available to everyone regardless of income. However, when ARVs first came on the market, poor people in the developing world lacked the financial resources to buy the drugs, which were exceedingly expensive. AIDS activists successfully lobbied donor nations to use foreign aid to buy the drugs, and they pressured pharmaceutical companies to lower their prices, while encouraging generic firms to enter the market which had an even bigger impact on affordability.

How did these developments evolve into the universal access to treatment regime? We focus on three factors in this piece:

- Permissive Material Conditions. The success of this strategy was ultimately conditional upon permissive material conditions—falling ARV prices, increases in foreign aid, and a growing global economy. However, these favorable material conditions were not enough.

- A Compelling Moral Argument. The effort to extend treatment would not have happened without a compelling moral argument, which helped build broad political support for the policy.

- Convergence on a Prescription. Finally, activists were fortunate to converge on a single policy in the treatment arena. AIDS prevention policies, by contrast, have been much more politically contested and suffered accordingly (see Jeremy Shiffman’s CGD working paper for a similar argument).

Looking ahead, we worry the lack of success in AIDS prevention may compromise the treatment regime’s long-term trajectory (see Mead Over’s CGD paper for expression of similar concerns).

Lessons for Other Campaigns. We believe that activists who focus on other issue-areas, again whether in the health care space or in other domains, could learn something of importance from our research. The basic difficulty and costs of certain policies may make some problems harder to solve than others. Even where a policy enjoys favorable material conditions—low costs, large benefits, demonstrated feasibility—this may not be enough. A clear prescription and a resonant moral argument may be necessary for an issue to receive adequate political support.

Brief comment on Pope Benedict’s “irresponsibility”

UNAIDS got into the fray.

Let me say that I normally like this pope. At least as much as a non-RC can.

But what he said in a one-off comment is more than “irresponsible”, as some have called it. It is a lie and will lead to unneeded deaths among those Benedict says need the world’s most special efforts—the poor.

Washington DC is West Africa

This article should put us on high alert. Maybe this is how Michelle Obama could get involved with the family’s new city.

HIV/AIDS Rate in D.C. Hits 3%
Considered a ‘Severe’ Epidemic, Every Mode of Transmission Is Increasing, City Study Finds

By Jose Antonio Vargas and Darryl Fears
Washington Post Staff Writers
Sunday, March 15, 2009; A01

At least 3 percent of District residents have HIV or AIDS, a total that far surpasses the 1 percent threshold that constitutes a “generalized and severe” epidemic, according to a report scheduled to be released by health officials tomorrow.

That translates into 2,984 residents per every 100,000 over the age of 12 — or 15,120 — according to the 2008 epidemiology report by the District’s HIV/AIDS office.

“Our rates are higher than West Africa,” said Shannon L. Hader, director of the District’s HIV/AIDS Administration, who once led the Federal Centers for Disease Control and Prevention’s work in Zimbabwe. “They’re on par with Uganda and some parts of Kenya.”

“We have every mode of transmission” — men having sex with men, heterosexual and injected drug use — “going up, all on the rise, and we have to deal with them,” Hader said.

In addition to the epidemiology report, the city is also releasing a study on heterosexual behavior tomorrow. That report, funded by the CDC, was conducted by the George Washington University School of Health and Health Services.

Among its findings: Almost half of those who had connections to the parts of the city with the highest AIDS prevalence and poverty rates said they had overlapping sexual partners within the past 12 months, three in five said they were aware of their own HIV status, and three in 10 said they had used a condom the last time they had sex.

Together, the reports offer a sobering assessment in a city that for years has stumbled in combating HIV and AIDS and is just beginning to regain its footing. A more accurate accounting of the crisis offers a chance to contain what is largely a preventable disease.

So urgent is the concern that the HIV/AIDS Administration took the relatively rare step of couching the city’s infections in a percentage, harkening to 1992, when San Francisco, around the height of its epidemic, announced that 4 percent of its population was HIV positive. But the report also cautions that “we know that the true number of residents currently infected and living with HIV is certainly higher.”

The District’s report found a 22 percent increase in HIV and AIDS cases from the 12,428 reported at the end of 2006, touching every race and sex across population and neighborhoods, with an epidemic level in all but one of the eight wards. Black men, with an infection rate of nearly 7 percent, carry the weight of the disease, according to the report, which also underscores that the District’s HIV and AIDS population is aging. Almost 1 in 10 residents between the ages of 40 and 49 has the virus.

The report notes that “this growing population will have significant implications on the District’s health care system” as residents face chronic medical problems associated with aging and fighting a disease that compromises the immune system.

Men having sex with men has remained the disease’s leading mode of transmission. Heterosexual transmission and injection drug use closely follow, the report says. Three percent of black women carry the virus, partly a result of the increase in heterosexual transmissions.

“This is very, very depressing news, especially considering HIV’s profound impact on minority communities,” said Anthony Fauci, director of the National Institutes of Health’s program on infectious diseases. “And remember: The city’s numbers are just based on people who’ve gotten tested.”

Ron Simmons, who is black, gay and HIV positive, said he’s not shocked by the study’s findings. “You have a high incidence of HIV among African Americans, and a lot of African Americans live in the city,” said Simmons, who is a member of a black gay support group. “D.C. also has a high number of gay men, and HIV is high among gay black men.”

Charlene Cotton, a D.C. resident who got an HIV positive diagnosis five years ago, said breaking the taboo on discussing HIV is the key to moving forward. “You need to start at home and talk about it,” Cotton said. “It’s so hush-hush.”

Mayor Adrian M. Fenty (D) said he is aware that some advocates have called on elected officials and others to more aggressively and publicly address the crisis. He praised the city’s recent efforts, however, and expressed his frustration about the struggle ahead.

“In order to solve an issue as complex as HIV and AIDS, you have to step up,” he said. “It’s the mayor and certainly other elected officials. But it’s also the community. You have this problem affecting us, and you tell people how serious it is and it literally goes in one ear and out the other.”

David Catania (I-At Large), chairman of the D.C. Council’s health committee, said that although the District’s testing and monitoring have improved in the past two years, the AIDS office is still playing catch-up. The city was in the forefront of the crisis when it created the office in 1986, but it fell far behind. Hader took control in 2007. She is its 12th director and the third in five years.

“Frankly, there can be no excuse for the state of the HIV/AIDS Administration that I found in 2005,” Catania said. “I cannot speak to why it was not a priority previously. For years prior to 2005, mayors and previous individuals allowed things to exist in an unacceptable way. And I do blame this government for part of the epidemic we’re confronting.”

Until recently, the District’s AIDS office lacked a fully staffed surveillance unit to collect, analyze and distribute data. Inevitably, the office lost credibility, and although it has received millions in federal and local funds — $95 million this year — some care providers questioned whether resources were being properly allocated.

Critics also say congressional control over the District had restricted the AIDS office’s ability to combat the virus among drug injection users by banning the use of local tax dollars for a needle exchange program. After almost a decade, the ban was lifted last year.

The study is the most precise count to date, according to the authors. The document is an update of a breakthrough 2007 report, which brought into clearer focus a picture of a city in the grip of a complex and “modern epidemic” that had traveled from a mostly gay population to the general one and disproportionately hit blacks.

For years, District HIV/AIDS workers depended on estimates that put the rate at 1 of 20 living with HIV and 1 of 50 living with AIDS.

The current study notes that its tracking occurred as the city made a switch from a code-based counting system to a name-based one. The surveillance unit interviewed medical providers to find unreported cases, pressed providers who did not consistently report to the administration and searched databases for unreported cases.

More than 4 percent of blacks in the city are known to have HIV, along with almost 2 percent of Latinos and 1.4 percent of whites. More than three-quarters — 76 percent — of the HIV infected are black, 70 percent are men and 70 percent are age 40 and older.

Heterosexual sex was the principal mode of transmission for blacks with the disease, 33 percent. Men having sex with men was the chief mode of transmission for white residents, 78 percent; and Latinos, 49 percent. Black women represent more than a quarter of HIV cases in the District, and most, about 58 percent, were infected through heterosexual sex. About a quarter of black women were infected through drug use.

The companion study, “Heterosexual Relationships and HIV in Washington, D.C.,” is a detailed look at those whose social networks include individuals at high risk of infection and aims to analyze people’s choices and actions before they set foot in a clinic or get HIV.

The 750-participant study targeted four areas in wards 1, 2, 5, 6, 7 and 8 with both high rates of AIDS and poverty. Salaries of a majority of participants — 60 percent — were under $10,000 yearly; a similar percentage had never been married; and 43 percent were unemployed.

The survey’s methodology — interviewing those with connections to high-risk networks rather than those who exhibit high-risk behavior themselves — highlights a shift in the direction by the CDC, which developed the survey protocol.

There is good news in the AIDS office’s report: More people are getting HIV diagnoses early, while they are still healthy, as a result of a policy of routine testing implemented by the city in mid-2006. Publicly supported HIV testing expanded by 70 percent.

Walter Smith, executive director of the DC Appleseed Center for Law and Justice, praised the study but also lamented that it did not offer more current data on new infections. The report said that detailed information on new HIV cases is not included because the transition from the code-based tracking system to a name-based one takes five years to be mature, according to the CDC.

“I’m not criticizing them for that,” he said. “But we’ve had more testing, more needle exchange programs. We don’t have, at this moment, any understanding about what impact the new programs have had.”

Staff writers Jon Cohen and Jennifer Agiesta contributed to this report.

War on Drugs also war on anti-HIV efforts

Well, this will just cause all sorts of problems.

And before anyone lectures me about the morality of drug legalization or illegalization, what I care most about is keeping people from getting HIV. “Harm reduction” (which includes things like needle exchange) is the best we’ve got right now. If we can figure out a better way that coincidentally legalizes or bans drugs, I’ll be for that.

U.N. Anti-Drug Efforts Contributing to Spread of HIV, Advocates Say

Members of the United Nations this week are expected to sign a declaration to extend a “war on drugs,” a policy that some critics argue is ineffective and contributes to the spread of HIV, Reuters reports. The U.N. Office on Drugs and Crime is drafting the declaration, which calls for a 10-year renewal on efforts to eradicate all narcotics by using law enforcement to target traffickers and producers and end drug use worldwide.

Some critics of the policy say the declaration’s lack of focus on harm-reduction strategies, including needle-exchange programs for injection drug users, has increased the spread of HIV and other diseases. In addition, some drug policy advocates, social scientists and health experts say that the strategy has not been successful, with statistics indicating that drug production, trafficking and use have increased during the past 10 years. The cost of law enforcement also has increased, according to statistics. UNODC Director Antonio Maria Costa said, “The crime and corruption associated with the drug trade are providing strong evidence to a vocal minority of pro-drug lobbyists to argue that the cure is worse than the disease. This would be a historical mistake, one which United Nations member states are not willing to make.” Reuters reports that the declaration is expected to be signed in Vienna, Austria, on Wednesday or Thursday (Baker, Reuters, 3/10).

A statement released on Wednesday by Human Rights Watch, the International AIDS Society and the International Harm Reduction Association called for member governments not to support the declaration because “critical elements” to prevent HIV were stripped from the final document. The statement said, “What is at issue is a series of measures known collectively as ‘harm reduction services,’ which have been endorsed by U.N. health and drug-control agencies,” including the UNODC, UNAIDS and the World Health Organization. According to the statement, such measures include needle- and syringe-exchange programs and medication-assisted therapy, inside and outside prisons, which are “essential to address HIV among people who use drugs.” According to the groups, a “wealth of evidence proves harm reduction is essential to HIV prevention for people who use drugs.” Up to 30% of all HIV infections outside sub-Saharan Africa occur through unsafe injecting drug use, the groups said, adding that there is “clear evidence that harm-reduction interventions can halt or even reverse HIV epidemics among people who inject drugs” (HRW/IAS/IHRA release, 3/11).

End of an Era – A High-Water Mark in AIDS funding?

The pending Wall Street bailout reminds us that the buoyant global economy of recent years created permissive conditions for international altruism on global health and development. With America’s economy staggering, the effects are being felt further afield among other major industrialized economies, the UK included. Prime Minister Gordon Brown, who has for more than a decade, been one of the stalwart supporters of funding for global development now faces economic troubles at home and a political crisis. Under the Labour Party, UK foreign assistance soared.

In 2007, the UK surpassed the United States as the largest donor to IDA, the World Bank’s wing for the poorest countries in the world. The UK has also shouldered a disproportionate share o funding for global AIDS efforts. Should Brown be ousted in a leadership competition or if the Conservatives win, will Brown’s successor be as pro-development? Will Britain even be able to sustain its contributions at the level it has over the past decade? Donors haven’t come close to meeting their pledges of an additional $50bn per year by 2010. With advanced industrialized country economies struggling, campaigners should be worried that foreign assistance funds may subject to much greater fiscal discipline by donors and AIDS funding may be subject to donor fatigue.

Given the variety of demands from advocates, competition for those funds will likely increase, and campaigners in the public health arena need to be thinking about political priorities — sustained and/or deepened provision of ARV’s, more support for health systems, a turn towards other health priorities like maternal health and child survival, a focus on other issues like climate change and education, etc. These are critical times for the global economy and could signal a turning point in the political effectiveness of the development advocacy in coming years.

Postscript: We may be poised to be entering a global recession or at least a downturn among the world’s advanced economies. One of the most prescient and clear voices on the global economy, Nouriel Roubini, had this to say this morning in the FT:

The real economic side of this financial crisis will be a severe US recession. Financial contagion, the strong euro, falling US imports, the bursting of European housing bubbles, high oil prices and a hawkish European Central Bank will lead to a recession in the eurozone, the UK and most advanced economies.

Even if foreign assistance constitutes a small proportion of donor budgets, aid and development circles are worried their concerns are among the most vulnerable to cuts, or at the very least, stagnant budgets.

PEPFAR reauthorization signing ceremony

As the global AIDS community prepares for the conference beginning Sunday in Mexico City, President Bush is signing the reauthorization bill for PEPFAR today. It has been named after Tom Lantos and Henry Hyde, Democratic and Republican members of Congress who passed away within the past year. When Elizabeth Dole attempted to name the bill for recently deceased Senator Jesse Helms, there was much backlash, given Helms’ early opposition in the 80′s and 90′s to AIDS spending, a disease he saw as a result of deviant behavior. Helms would go on to have a near deathbed conversion to support the cause of HIV/AIDS, at least in the developing world, but naming the bill after him would have been a bridge too far.

In any case, it is the Lantos and Hyde bill which includes authorization for $48bn for PEPFAR for 2009 (and, as I understand it, will require Congressional appropriation in the coming months). More than half of the money will have to go to treatment, but the restriction that 1/3 of the prevention money be spent on abstinence and fidelity programs has been lifted. Given that there were still more than 2.5 million new infections last year, the inadequate focus on prevention is troubling, as we have blogged about here and for which there is a new CGD blogpost.

The Washington Post has an interesting story on how the open-ended commitment to treatment is unprecedented in terms of U.S. foreign assistance. The article: “AIDS Funding Binds Longevity of Millions to U.S.: Open-Ended Commitment of Money Is Implied” is worth a read.

Foreign aid for health care has traditionally been used to put up buildings, buy equipment and train workers. Direct medical care of individuals was limited to one-time interventions such as vaccinations, emergency treatment after natural disasters, and curative treatments of limited duration for diseases such as tuberculosis or leprosy.

Bush’s program is fundamentally different. So far, it has purchased vast quantities of antiretroviral drugs and supported day-to-day medical care for more than 1.4 million people whose survival depends on continued treatment.

“It is the first time I can think of where we have foreign aid treating a chronic disease,” said Michael H. Merson, director of Duke University’s Global Health Institute and a former head of the World Health Organization’s AIDS office. “It’s a challenge to take this on. I think the questions it raises are going to be important ones for the future.”

We have a moral obligation to continue treatment for those who are on it already. Taking someone off treatment who is on it would constitute a death sentence. However, unless we really put much more emphasis on prevention, the treatment budget is going to continue to grow.

For our readers out there, I know that ARV therapy in the West has enabled people to live an indefinite amount of time. In developing countries, my understanding is that donors are extending ARV to people, for the most part, who are already very sick, meaning that treatment, on average, only extends people’s lives for years, maybe 3-5 years. However, we don’t actually have that many years of experience with people on treatment in developing countries so I wonder if those averages are being extended. For people who have experience administering these programs, we would welcome comments and feedback about how this is carried out in practice. I wonder if those worried about this “entitlement” have incorporated into their estimates of future costs that a good proportion of the people donors have “saved” will die in the coming years.

From a moral perspective, the important thing is that the lives of people on treatment are extended, giving them more hope for the future. They can hope they are among those who exceed the average and at the very least, they’ll have more time with their children before.

Senate moves on PEPFAR Reauthorization

The Senate voted 65-3 on a cloture motion on PEPFAR reauthorization last Friday. Here’s a story in today’s Times about PEPFAR reauthorization. More details on Kaiser.

Looks like Sen. Jim Demint made an ass of himself before his colleagues on Friday when he insisted on a Friday evening procedural vote on cloture and then didn’t show up. He called for cutting the bill’s pricetag down to $35bn.

In so doing, he likely ensured that the full $50 billion gets appropriated (which was more than what the President wanted). The bill no longer has a mandate that 55% of funding be spent on treatment (which was part of the previous PEPFAR authorizing language and what the bloc of holdout Senators wanted). The legislation leaves it a little vague and says more than half will be spent on treatment.

While this is good news, the bill hasn’t passed yet. Debate is this week. Republicans are offering a series of amendments to try to divert the spending for domestic purposes.

Here is an excerpt on Demint’s gift to his colleagues.

After finally breaking a procedural logjam, the Senate this week will move ahead with a $50 billion AIDS initiative that has the support of Democrats, Republicans and the White House. It would seem like a sure bet – except for Senator Jim DeMint.

Mr. DeMint, a Republican from South Carolina, forced the Senate last week to take a rare Friday evening procedural vote in order to begin debate on the legislation that seeks to step up AIDS treatment and prevention efforts in Africa, Asia and elsewhere. He then missed the vote he had instigated, provoking scattered boos from the floor – an occurrence more typical of the House than the Senate.

In one of the chief challenges to the AIDS bill, Mr. DeMint is scheduled to offer a proposal to reduce the five-year cost of the legislation to $35 billion. He has complained that Democrats were unfairly trying to limit efforts to change the bill. Given that both Republicans and Democrats were very unhappy with his decision to force them to take a Friday vote he then missed, it is hard to envision a successful outcome for his proposal.

Global health reporting

The Kaiser Family Foundation (supported by the Gates Foundation) hosts this site of news sources on global health, including upcoming events. I will add to the blogroll but here is the link to globalhealthreporting.org.

Japan announces $560mn contribution to the Global Fund

In advance of the Hokkaido G8 summit in July, Japan just announced last week a new contribution to the Global Fund of $560mn, spread out over an unspecified period of years. This is the second reasonably large pledged contribution from Japan since then Prime Minister Koizumi pledged $500mn back in 2005. Here is summary from the Kaiser Foundation’s news archive:

Japan on Friday announced that it had pledged $560 million to the Global Fund To Fight AIDS, Tuberculosis and Malaria, AFP/Google.com reports. Prime Minister Yasuo Fukuda said the funds will be allocated “in the coming years” from 2009, but he did not specify over how many years the aid will be disbursed. A foreign ministry official said that the pledge aims to “demonstrate Japan’s diplomatic efforts to help Africa” as Japan prepares to host an internal conference on aid to the continent next week, as well as the Group of Eight industrialized nations summit in July. According to AFP/Google.com, Japan hopes to make Africa a primary focus while it chairs the G8.

The Japanese appear to be wanting to make a big splash at the upcoming G8 meeting. These summits seem to occasions in which international donors like to fall over themselves to make grand promises. Germany did something similar last year when it hosted the G8 Summit. Campaigners have done a good job making global health a popular development cause, and this may prove to be a more politically tractable issue for the Japanese to garner international prestige compared to climate change, which has been touted as another signature issue for the Japanese at the upcoming G8 meeting (lots of luck there with the Bush Administration!).

Japan’s changing position on international AIDS funding is interesting. They have lagged behind other contributors, as I’ve written about here. They are just coming out of a long recession, during which Japan’s ODA contributions declined dramatically. Anybody with an inside story of these transformations in Japan’s approach to global AIDS funding (which still seems largely directed multilaterally rather than bilaterally like other donors) should e-mail me.

I have written on the particular salience of international cooperation for the Japanese in my piece on debt relief that came out in International Studies Quarterly last year. On the issue of AIDS, the Japanese appear to be particularly proud that the idea for the Global Fund came out of a meeting hosted in Japan by Prime Minister Mori in 2000. I also have a draft manuscript on the politics of HIV/AIDS donors that I’ve been working on for about three years. Get in touch if either piece is of interest.

As promising as this change in Japan’s policy promises to be, there is some concern in the advocacy community about the ambiguous time frame for when Japan will actually make good on its pledge. Japan’s move I understand may also signal a renewed concern from the donor community to address support for health systems, as I have previously supported here on this blog before (see here, here).

On that theme, Michael Reich and his co-authors have an important article in March 2008 Lancet on Japan opportunity to boost support for health systems at the upcoming G-8 Summit. They write:

The G8 summit in Toyako offers Japan, as the host government, a special opportunity to influence collective action on global health. At the last G8 summit held in Japan, the Japanese government launched an effort to address critical infectious diseases, from which a series of disease-specific programmes emerged. This year’s summit provides another chance to catalyse global action on health, this time with a focus on health systems.

However, as optimistic as they are about this emerging direction of the donor community, it is unclear if anybody actually knows how to build health systems. It seems like the record on this may be as poor as the one on broader development and good governance. Reich et al. write:

What can be done when a health system is broken—ie, when a health system is unable to deliver its services effectively, or efficiently, or fairly? Governments around the world (in both rich and poor countries) have struggled with this question for decades. One conclusion is clear: there are no easy solutions to the problems that arise in health systems. National efforts aimed at reforming such systems have achieved mixed results.

The mechanics and politics of health systems support requires much greater development. The U.S. Congress, for example, strongly supports treatment programs in part because you can scale up quickly, in part with American contractors, and track the number of people on drugs. How can you judge success in health systems capacity? It’s not, as Reich et al. note, just a function of training doctors and counting them up. This is a huge task, and one that foreigners may fail at markedly, particularly in places where the quality of governance is so bad.  I think this is why Senator Coburn, as short-sighted as his logic may be, wants to support treatment so heavily as part of PEPFAR. From his perspective, money spent on health systems will get siphoned off in ways that ultimately don’t generate capacity, only graft and consultancy fees.

One interesting question is how can islands of excellence be established? I’m reading Tracy Kidder’s account of Paul Farmer’s clinics in Haiti. Certainly, some people have more success than others in building local capacity. Are these scale-able? We’ll certainly revisit this topic.