When I talk about the gravity of the AIDS pandemic, I feel a little like Al Gore. Or Chicken Little.
I have become the person no one wants to sit next to at a dinner party.
The planet is melting I say. The sky is falling. AIDS is spreading. It is not just an African disease. It is in India, in China, in Central and South America, in Russia, the Pacific Rim and all over the United States. In Kansas. Iowa. South Carolina. It could be in your body right now.
And in response, I hear well-educated, world-traveled people say things like:
“Is AIDS really still a problem? I thought they'd cured that by now.”
“Well, I'm not worried about it because only poor blacks and the gays get AIDS.”
“Well, I don't have to worry because I am heterosexual and married. And monogamous.” (The last phrase is often offered emphatically—a clear indication there's some doubt about that.)
And, two of my favorites:
“Perhaps AIDS is just the planet's way of self-correcting overpopulation in places where there are so many people that they are starving to death. Maybe it's a good thing.” (Um, because dying from AIDS is preferable to starving to death? I see.)
“I'm glad it's spreading. Those people need to be killed for being promiscuous and for using drugs.”
Really. This is what we're up against. And why it's increasingly hard to get the political and financial capital we need to fight a disease that is outpacing our ability to stop it. And why in the midst of a global recession we must fight that much harder to come up with the cash to crush it.
Nearly 30 years into one of the worst pandemics in recorded human history (topped only in severity by the Black Death), we continue to try to stop the spread of HIV/AIDS in a world where everyone thinks it's someone else's disease—until it happens to them, their partner, their parent or their child. In a world where the truth and information about the disease don't get properly spread because governments, parents, school boards and churches don't let us talk plainly and openly about sex. Which is something one must do when discussing how to avoid a—100 percent preventable mind you—sexually transmitted infection.
We're fighting one of the nastiest diseases ever in a time when everyone's tired of hearing about that disease, in a moment when people are ready to put the money earmarked for HIV/AIDS somewhere else. But just because we're over AIDS doesn't mean it's over. In fact, turning our back on AIDS now ensures it will make the Black Death look like a summer cold.
The brightest, richest, fiercest, most dedicated people have been stymied by HIV for three decades. And now, exhausted and exasperated, they're asked to continue their good work with fewer resources in a climate of ignorance, denial and apathy.
Those are two words that should never be joined at the hip: AIDS and apathy.
How anyone could be apathetic about more than 25 million people buried six feet under is beyond me. Those who are indifferent to the 33 million people roaming the seven continents harboring HIV in their bodies—many unaware they are HIV positive, many others aware but not on treatment—should have their global citizenship revoked. And anyone who doesn't care about the more than 15 million children orphaned by the disease—some with HIV in their own blood, many tossed aside simply because their parents carried the virus—has obviously never stared into the eyes of a child orphaned by AIDS. (Please look at the children on the cover of this issue and those on these pages. Our failure to support the fight will likely render them new statistics.)
The numbers are so overwhelming that they lead the very people who have led the fight against AIDS to cry “Uncle!”
For every person put on treatment, 2.5 people become newly infected, according to UNAIDS. On May 9, The New York Times ran a front page story, “At Front Lines, AIDS War Is Falling Apart” (written by Donald G. McNeil Jr.). It highlighted the grim reality of our inability to stop AIDS and raised the question: What will happen next when the need grows and the money shrinks? The article foreshadowed a return to the '80s and '90s when people living with HIV became the walking dead before actually dying. The tragedy is that now, in 2010, we have the knowledge and medicine to prevent that from happening. We just don't have the dinero.
Michel D. Kazatchkine, MD, executive director of the Global Fund to Fight AIDS, Tuberculosis and Malaria, was quoted in the Times saying, “[I am] hugely frustrated. The consistent answer I hear is: ‘We love you, we hear you, we acknowledge the fund's good results, but our budget is tight, our budget is cut, it's the economic crisis.'”
In the same piece, Ambassador Eric Goosby, President Obama's global AIDS coordinator and the man who administers the President's Emergency Plan for AIDS Relief (PEPFAR), said, “I'm worried we'll be in a ‘Kampala situation' in other countries soon.” (In Uganda, 500,000 need treatment, 200,000 are getting it, but each year, an additional 110,000 are infected .*)
Having harbored the virus in my bloodstream since 1996, I get why we're all exhausted. I, too, am really sick and tired of HIV/AIDS. I'd love to fight a weaker enemy instead. Let's prevent mothers from dying in childbirth. Put an end to infant diarrhea. Wrap whole countries in malaria nets and hand out polio vaccines like they were Snickers bars at Halloween.
Which is exactly what some influential people want to do. Ezekiel J. Emanuel, MD, PhD, brother of Rahm Emanuel and health advisor to the White House, has suggested that the Obama administration reconsider its commitment to fighting HIV/AIDS and focus, instead, on the Global Health Initiative—an endeavor that plans to focus on child and maternal health. To do this, monies previously set aside for AIDS will be reallocated.
When a catastrophe starts being counted in numbers so big the head can't hold them, it's human nature to drift mentally away, toward something more cheerful, more likely to be conquered. Every time I fill up my gas tank lately, I cringe thinking of the unstoppable flow of oil from the broken rig in the Gulf of Mexico. When it first happened, I was ready to go down and scoop up armfuls of fish, clean off the crabs, wipe the sludge from the sea birds' backs. But at some point, the disaster became overwhelming. So now, I pray that rich, smart people will find a way to cap the geyser of deadly oil. And I hope that the U.S. government will acknowledge it as a state of ecological emergency and bring in the needed cash and know-how. (As we go to press, that's happening.)
It happened, too, with HIV. In 2003 President George W. Bush started the President's Emergency Plan for AIDS Relief. Initially pledging $15 billion over five years, it was the “largest effort by any nation to combat a single disease.” In 2008, PEPFAR's budget rose to a staggering $48 billion dollars for the next five-year allocation. While some of PEPFAR's policies have come under criticism—such as funding conservative agendas and failing to address HIV among sex workers and IV-drug users—few argue that the program has saved millions of lives. And it created a great deal of pro-American sentiment along the way.
Two World AIDS Days ago, I saw former President Bush interviewed by evangelical leader Rick Warren. When asked what it felt like to visit a nation where PEPFAR funds had helped implement lifesaving programs, Bush said, “It was a strange feeling walking up to a crowd of people yelling and waving at me. And to realize they weren't waving their middle fingers!”
I have seen PEPFAR dollars hard at work in Vietnam and Africa, and I can confirm that it is important proof to the world that we go, as a nation, into other countries for more than power and oil. PEPFAR proves that America is both capitalist—and humanitarian.
But now, given the global recession and the Obama administration change of heart about HIV/AIDS, the funding for PEPFAR is in danger.
In light of the today's worldwide financial crisis, in what have become viciously frugal times, some people will lose out—and die. It's just a Darwinian truth.
But given HIV/AIDS's exponential power to kill and how the resultant hundreds of thousands (maybe millions) of deaths in India, China, the Pacific Rim and other places could further undermine global economic stability, I'd like to make the case that it's wildly financially irresponsible to spend less on HIV/AIDS. And, what's more, we need to spend more.
Let's be honest. For years, people across sub-Saharan Africa have died of AIDS. And there have been those who shrugged and said, “Well, you can't solve every problem in the world.” Those people didn't care because the deaths of the Southern Africans would never impact their lives.
But imagine if HIV/AIDS seriously diminishes the workforces of India, China and Mexico, or other countries the United States depends on for supplies. Who will make our cars? Our 3-D TVs? Our sneakers, sunglasses and solar panels? Not only will the global economy suffer, but the resulting desperation and poverty could turn a nation into a security threat.
And what will happen if we pull our support (delivered through PEPFAR and other programs, some run by U.S. foundations) out of countries where we have saved so many lives? The pro-American sentiment generated by our international aid for AIDS programs may not only wither; it may turn rancid.
In troubled times like these, an imploding economy leads us to focus on our immediate personal safety and that of our families—or, if we are government leaders, that of our home nations. But we can't neglect the needs of the world at large. Because if we do, we risk having much bigger problems in the not-so-distant future. Ironically, any sense of safety created by our self-protectionism will only come back to bite us.
PEPFAR funding is not the only issue. Our current appropriations for dealing with AIDS in America fall seriously short of our need. To reduce our PEPFAR pledge now, and to fail to come up with the dollars we need to deal with our domestic epidemic until health care reform kicks in and covers that need, is to create a far more expensive and perhaps dangerous situation in the future both inside and beyond our borders.
We are at a tipping point in our fight against HIV. If we take the pressure off now, we risk letting it get the upper hand forever. I am deeply concerned that those who will make the decisions that could end AIDS think that this is an unwinnable fight—and that therefore they will choose to mark their time in office with a win that will get them re-elected—future health, economic stability and well-being of the planet be damned.
I told you I sound like Al Gore.
But what to do? Some argue that the world can't just keep asking for more and more money to stop AIDS. Of course that's true. But the question of whether we've ever spent enough relative to the scale of the problem is the $100,000 question. And many whom I have asked say that if we'd spent a lot more, a long time ago, we wouldn't be where we are today.
We can't repeat the mistake and find ourselves in a place of impossibility and grave repercussions later because we wimped out now. And we can't allow those who would let that happen get away with it. We need to keep the pressure on the Hill to ensure that those who vote on federal budgets understand the financial downside of not funding the fight against HIV/AIDS.
To more effectively lobby, we need to get a grip on how many—and what kind of—people have HIV. We must encourage doctors not to profile people based on perceived risk factors and not to worry that asking a patient to get tested for HIV will make the patient feel profiled. We must teach doctors and patients alike that everyone who's ever had unprotected sex—even once—needs an HIV test.
We need to arm our AIDS advocates and lobbyists with accurate and complete numbers reflecting who has HIV/AIDS in America. If we test the nation and identify clear pockets of incidence, we will be able to do a much better job targeting our testing, prevention and connection to care efforts. We need to fund the Centers for Disease Control and Prevention to do better HIV/AIDS surveillance. One senior government official who spoke off the record said we know more about who has HIV in Africa than we do about who has HIV in America.
We need more leadership with a greater presence on Capitol Hill to keep awareness up and the heat on. There are some amazing people working themselves to the bone on Capitol Hill to advocate for people living with HIV. But we need reinforcements. We also need fresh celebrities. The greatest respect to Elton John and Elizabeth Taylor and Cyndi Lauper and Bono and so many others not withstanding, we need the likes of Taylor Swift and the combined casts of True Blood and Twilight. (Blood, sex, AIDS, get it?) We need the help of the media to put HIV/AIDS—both in America and around the world—on the radar. We can talk cheerfully over our Cheerios about vaccinating kids against human papillomavirus (HPV), a sexually transmitted retrovirus that can lead to deadly cervical, anal and penile cancers. So why can't we speak of AIDS regularly on Good Morning America?
We need momentum to overcome denial, ignorance and apathy. We need prominent people to come forward and admit they are living with HIV to help destigmatize the disease.
And we need the president of the United States to go on television to tell people that not only is AIDS not over, but that it is very much alive and well and ready to take the lives of millions more people who don't believe that's possible.
But while we advocate for more dollars, we must also learn how to use the dollars we have more efficiently and effectively.
Late last year, I interviewed Ambassador Eric Goosby who explained the evolution of PEPFAR's mission. A grossly oversimplified version of what he eloquently explained to me is rather than continuing to pump massive amounts of cash into countries needing help staving their HIV epidemic, PEPFAR would rather use funds to develop sustainable programs that would work to stop AIDS long after the Americans went home and U.S. funds dry up. It makes perfect sense. It needs to happen. Except for the fact that you can't push a baby bird out of the nest before it has feathers and its tendons are strong enough to hold the weight of its wings and expect it to fly. If you do that, it will fall to the ground and die.
It is true that the only way we'll ever stop AIDS from spreading without bankrupting America in the process is to teach those we help to help themselves. But we need a little more time before some nations are ready for their solo flights.
We also need to call in the reinforcements. The governments of the countries we help must also spend their own money to fight HIV/AIDS in their nations. And they must also step up to deliver political capital and leadership. (Look at what happened when South African President Mbeki was replaced by Zuma.)
And we need to continue to ask for help from private public partnerships. We need to continue to support the foundations (including those run by the pharmaceutical companies who make AIDS medicines). We need to promote the development of innovative global financing solutions (like MassiveGood.com, an initiative launched this year by Unitaid that allows travelers to donate $2 to the fight against AIDS when booking travel).
John Tedstrom, president and CEO of the Global Business Coalition on HIV/AIDS, Tuberculosis and Malaria, said that we need $25 billion a year to address today's HIV pandemic. In the New York Times story, Michel Sidibe, executive director of UNAIDS, claimed that donors give about $10 billion dollars a year while the current need is closer to $27 billion. Annually.
Currently, about $14 billion is allotted to fight HIV/AIDS globally, and that includes the cash flows of nations like India and China that don't depend on America to treat their citizens who are living with HIV.
Some ask whether we could save money by focusing cash flow into one of the three arms of attack: prevention, treatment and search for a vaccine/cure.
But ask any AIDS expert or specialist in each field this question and he or she will likely give you a similar answer. We need the trifecta of prevention, treatment and a bloody cure.
One must also ask: If we do a better job finding people who are positive and linking them to care and treatment, wouldn't the increased volume worldwide allow the drug manufacturers to lower the price of the drugs? It's a complicated equation between development cost and pricing, but it's worth asking.
Those who say we should stop spending money on fighting HIV/AIDS should also consider that our continued investment will allow us to reap more benefits than merely the avoidance of great costs in the future. Because ironically, the path to the end of AIDS leads straight through the heartland of improved overall health for all on the planet.
In order to stop AIDS, we will have to link most of the population to testing and care. In order to stop AIDS, we will have to resolve racial disparities that make some people unable to access health care. We will have to improve infrastructures in countries where they are bad—or nonexistent. Find and deliver clean water and food. Address cultural issues such as homophobia, religious and political extremism, gender imbalances, sexual and domestic abuse, wrongful criminalization of positive people and corruption in government.
It's not America's sole responsibility to pony up and save everyone on the planet. Our president is asked to spend the federal budget in a way that will save the most lives. And given the limitations of those resources it is a powerful argument that the money planned for AIDS might be more effective in the short term spent elsewhere.
And it would certainly feel good to see the numbers of the deaths of women and children decline.
But what is the point of reducing infant mortality rates and saving people from dysentery only to let them die of AIDS?
It's the very notion of fiscal responsibility that makes me wonder how a nation devoted to saving money and lives could not clearly see the financial destruction that is coming our way if we stop spending money to end AIDS. If we turn away today, the price we will ultimately pay will be astronomic both in terms of its sheer economic punch—and in terms of the humanity we will have lost.
* The asterisked sentence above has been updated from the original version.
Pay It Forward: Why the World Can't Afford to Stop Funding AIDS
As with other cataclysmic challenges facing our generation, we must ask ourselves: What cost will generations to come pay for our inability to see into and plan for the future of the planet? Here, an argument for why the world—especially in a time of global recession—can't afford to stop funding the fight against HIV/AIDS. And, a few suggestions for what we might do to up the ante.
When I talk about the gravity of the AIDS pandemic, I feel a little like Al Gore. Or Chicken Little.