Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
AIDS remains an exceptional issue
- Paul De Lay (9 May 2008)
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Do not undermine the international response to HIV
- Mark Harrington (9 May 2008)
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Misreading the Writing on the Wall
- Gregg S Gonsalves (9 May 2008)
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Don't Derail the Engine for Expanding Health Care Capacity
- Brook K. Baker (9 May 2008)
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Roger England was clearly right about one thing
- David Rasnick (9 May 2008)
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Prevailing stigma demands continued leadership from UNAIDS
- Christo Greyling (10 May 2008)
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No Trade off in Health Care Financing
- Otwoma Tom Otwoma (10 May 2008)
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Response to AIDS and Strengthening of Health Infrastructure are not mutually exclusive
- Lesley-Anne Knight (10 May 2008)
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Fighting Aids is not in opposition to strenghening health systems
- Mariangela Simao (10 May 2008)
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England needs nuance
- Alan W Whiteside (12 May 2008)
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Human rights are critical to the HIV response
- Jonathan E. Cohen, Francoise Girard and Ralf Jurgens (13 May 2008)
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An exceptional issue but a business-as-usual response
- Michael L Rekart (13 May 2008)
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Author's reply to UNAIDS
- Roger England (14 May 2008)
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Writing on the wall
- James E Parker (14 May 2008)
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The Consequences of Methodology
- Jeremiah Norris (14 May 2008)
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The foundations of "exceptionalism": exceptional ignorance, prejudice & bigotry
- Richard J Jefferys (15 May 2008)
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Statement in Response to Letter by Roger England published in the 10 May 2008 BMJ entitled, “The writing is on the wall for UNAIDS”
- Pedro Cahn, Julio Montaner, Craig McClure (16 May 2008)
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"AIDS Spending harms health systems": Passionately disputed but hardly refuted
- Mead Over (23 May 2008)
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Strengthening Health Systems with Vertical Programs
- Donna J Barry, Dr. Joia S. Mukherjee, Medical Director (23 May 2008)
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The reality of our lives
- Fiona J Pettitt (24 May 2008)
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The truth is always bitter
- Subir K Kole (26 May 2008)
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The "Competition for Resources" is a false debate
- Aditya Bondyopadhyay (27 May 2008)
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Conflicted
- Dominic D Montagu (2 June 2008)
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England’s Misguided Missile
- Simon Rushton (18 June 2008)
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Paul De Lay, Director, Evidence, Monitoring and Policy Department, UNAIDS Geneva, 1211
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Dear Sir, In his Personal View published in BMJ on 10 May 2008, Mr Roger England suggests that the AIDS epidemic is like every other health problem and doesn’t deserve an exceptional response. He couldn’t be more wrong. HIV was and still is an emergency requiring an unprecedented response. AIDS doesn’t fit neatly into a health box. Yes, AIDS is a disease and there are specific health needs, but AIDS has its tentacles in all sectors. AIDS is mostly about sensitive issues—sex, gender inequality, sex work, homosexuality, drug use, stigma and discrimination—all have proved to be enormous barriers to government and civil society. For these reasons and more, the United Nations Joint Programme on HIV/AIDS was created as a secretariat, not an agency, coordinating the UN’s response in an innovative way. That means working with ten UN Cosponsors such as UNICEF on AIDS orphans and with the World Health Organization on HIV treatment. It also means partnering with civil society in a meaningful way and focusing our efforts on global advocacy and country action. We are beginning to see clear progress—for example Namibia enacted legislation to guide greater effort on HIV by a broad array of national ministries and sectors. This work is paying off with improved coverage for prevention and treatment initiatives, and favourable behavioural and epidemiological trends. Knowledge of HIV, and condom use have increased, while sex before the age of 15 and sex with more than one partner in the last 12 months have decreased. Adult HIV prevalence appears to have stabilized, while HIV prevalence in young women declined from 18 per cent in 2003 to 14 percent in 2007. However, despite the achievements the epidemic continues to outpace the response. Over 60 million men, women and children have become infected with HIV since its discovery in 1981. AIDS has already killed 25 million people in as many years. AIDS remains the leading cause of death in Africa. Resources are still desperately short in almost every area of public health in low- and middle-income countries. In low- and middle-income countries total health expenditure was estimated at just $644 billion in 2006. The percentage spent on HIV from all sources including donors, governments, international foundations and from the pockets of people affected was a mere 1.4% of these health expenditures in low- and middle- income countries. Despite the relatively small percentage of available funds spent on HIV, funding does provide an opportunity and entry point for health and social service systems strengthening. In many African countries, HIV services and treatment keep desperately needed health workers alive, well, and able to work. And in countries where a large proportion of hospital beds are occupied by patients with AIDS, HIV treatment is reducing hospitalizations, freeing up health workers and valuable resources to dedicate to other health care. Mr England would like to see AIDS dealt with by only health services but even the best health services in the world cannot tackle AIDS alone. They certainly play a major role in providing HIV treatment, but health ministries do not cover other vital elements of the AIDS response such as working directly with vulnerable populations to reduce their risk of HIV infection, caring for orphans, providing food support and social welfare, and tackling gender inequities. With 5 new infections for every 2 people on treatment in 2007, it is obvious that we are never going to treat our way out of this epidemic. Mr. England gives short shrift to the social dimensions of HIV and to the well known facts of HIV prevention. He trivializes the immediate needs for human rights protection of vulnerable groups, and writes off multisectoral programmes entirely -- although the key decisions and policies needed to protect human rights and provide social protection for orphans and vulnerable children are rarely under the control of the health sector. AIDS funding can and does bolster health systems more widely—providing wins for both AIDS and health in general. The bottom line is that we need a strong AIDS response as much as we need to strengthen public health. Paul De Lay
Competing interests: None declared |
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Mark Harrington, Executive Director, Treatment Action Group New York, 10012
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Roger England's attack on UNAIDS is part of a broader effort to undermine the international response not only to HIV but also to other priority diseases like TB and malaria. He never considers recommending expanding the health funding pie to cover the other needs identified but rather uses the AIDS exceptionalism trope to claim that we would all be better off if global health programs were uniformly underfunded and inadequate as they were in the 80s and 90s. He is pitting poor sick people with one disease against poor sick people with other diseases. Yesterday at the HIV STAC we heard from Tony Harries that the only programs that work in Malawi are the HIV program and the TB program, and they work because they have routine program data embedded in the program to follow patients, and they don't have commodity stockouts, whereas the general health system funded under a so-called sector-wide approach is rife with stockouts and obtains horrible results. For example in the recent Lancet special issue on maternal and child health targets towards the MDGs Malawi was reported to have the 2nd worst rate of maternal deaths in the world (above only DRC and right below Nigeria). That is not the fault of the AIDS program or of the international AIDS activist movement and mobilization but is due to woeful underfunding for health care overall, and can only be resolved by increasing health spending to cover all the MDG target health areas as well as other components of a comprehensive primary health care system development package. Competing interests: None declared |
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Gregg S Gonsalves, Co-ordinator AIDS and Rights Alliance for Southern Africa, Cape Town, South Africa 8001
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Roger England makes a common mistake in assuming correlation indicates causation when he blames spending for HIV/AIDS for the crisis in health systems in developing countries. Funding for health in developing countries from both external and domestic sources is far below the level needed to create sustainable systems. Even if funding for AIDS was to be reallocated, health systems would remain in a crisis of fiscal insufficiency, that is, without the necessary financing "to strengthen national health systems so that a range of diseases and health conditions can be managed effectively." By pitting AIDS against other health concerns, England misreads the current situation. In order to provide comprehensive primary care, rich and poor countries need to devote far more to health spending in the developing world. Without this money, governments will always be in the position of making untenable choices about who lives and who dies instead of being able to ensure that no one perishes of any disease just because they are poor. Without addressing this essential point, England is making a gruesome case: let's sacrifice people with HIV/AIDS so that others may live, simply parceling out inequities in health more evenly rather than confronting the inequities themselves. AIDS has brought needed attention to the health concerns of millions of poor people around the globe and can be a stepping stone to push for "health for all," a call that has languished for decades since the Alma Ata Declaration in the 1970s. Indeed, the future of AIDS treatment depends on strengthening primary care for chronic disease in the developing world, which will bring broad based benefits to many people with other conditions. Instead of "putting HIV in its place," perhaps we should put our leaders in theirs: it is the abdication of presidents and prime ministers of their duties to provide health care for their people that has brought us to this moment, not the millions of poor people with HIV/AIDS who have stood up for their own right to health. Competing interests: None declared |
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Brook K. Baker, Law Professor Northeastern U. School of Law, 400 Huntington Ave., Boston, MA 02115
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Roger England once again seeks to drive the nail into the coffin of AIDS exceptionalism with error-filled rhetorical blows. His four biggest claims are that AIDS is not exceptional, that AIDS diverts attention and resources from other health priorities, that AIDS financing builds aid dependency, and that the global HIV industry is out of control. All of these claims are demonstrably false - and dangerous to the goals of Universal Access and Health Care for All and to the social movement that has energized global attention not only to HIV/AIDS but to health needs in developing countries more broadly. AIDS is exceptional because it kills people in the prime of their lives, because it is sexually transmitted, because it is linked with a worsening tuberculosis pandemic, and because its cumulative impacts in sub -Saharan Africa are calamitous. England says that "HIV is a major disease in Southern Africa, but it is not a global catastrophe" somehow suggesting that what happens in Africa is not important globally. This is North-centric at best and racist at worst. Likewise, contrary to England's assertion that "the poverty argument has been exposed as baseless," evidence shows that HIV incidence is higher in mobile populations and in income groups that can afford to buy sex, but that it has its most devastating effects over time in poor communities that lack access to health services. AIDS programming does not divert attention from other health needs - those needs have been neglected for decades by both rich and poor countries and by international financial institutions that used macroeconomic and structural adjustment policies to dismantle weak but improving health systems throughout the 1980s and 90s. This neglect preceded so-called AIDS exceptionalism, and it has persisted to this day with some exceptions, e.g. childhood immunization and polio eradication. England insists on claiming that HIV spending damages health systems without confronting the evidence that AIDS programming often strengthens health service delivery more broadly, especially where donors are convinced to integrate programming and to spend money diagonally, as both the Global Fund and PEPFAR are now doing, but should do more. AIDS spending does not create aid dependency and a lack of sustainability. The impoverishment of many developing countries in the existing neo-liberal economic order guarantees that the right to health cannot be realized within the "fiscal envelope" of poor countries unless complicit donors make substantial, long-term, and predictable investments in both priority disease programming and in more horizontal health system strengthening. The HIV industry is not out of control nor is it a single issue campaign. Unlike most health initiatives, the AIDS movement has actually empowered people and communities to demand their right to health and to construct the response to the disease that afflicts them. The AIDS movement fights inequality, gender and sexual orientation oppression, the economies that structure vulnerability, the corporations that withhold life-saving medicines, the weak health systems that restrict scale-up, and the national and international political systems have mounted a lethargic response at best. The AIDS movement is and has been the catalyst for health-related demands on power. And, it is seeking an increasingly strong alliance with health systems proponents who want the IHP+ and other HSS initiatives to put real money on the table. Instead of seeking to divide and weaken this strong and emerging coalition, England should be celebrating the convergence of a social movement and of mutually beneficial priority disease programming and health systems strengthening that might actually achieve health care and public health needs. Competing interests: None declared |
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David Rasnick, Chief Science Officer Boveran, Inc. 94607
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The Rapid Responses to Roger England’s commentary demonstrate one of his points: “Putting HIV in its place among other priorities will be resisted strongly. The global HIV industry is too big and out of control. We have created a monster with too many vested interests and reputations at stake…” David Rasnick, PhD Member of The Presidential AIDS Advisory Panel, South Africa Competing interests: None declared |
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Christo Greyling, Board Chair: African Network of Religious Leaders Infected or personally affected by HIV and AIDS Johannesburg, South Africa, 1746
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Is HIV and AIDS different than any other disease? Does it demand a separate body such as UNAIDS? By all means - YES! We believe that HIV is more than a disease. HIV, AIDS and its resulting effect on children, families and society are driven by stigma. People continue to be infected and die from a preventable and manageable disease due to self-stigma and the fear of societal stigma. At the end of 2006 only 28% of people who immediately needed to have access to ARVs were able to access it. UNAIDS has been instrumental to provide leadership and to unite activists and scientists, political leaders and people living with HIV. Through their leadership governments made commitments towards UNGASS. Through the energy of UNAIDS local governments worked towards developing strategic HIV and AIDS plans. HIV and AIDS remains a disease that cries for immediate and constructive leadership. UNAIDS provides this leadership at global, regional and country levels. Until HIV has become a normalized disease, stigma has been defeated and all people have access to comprehensive treatment (including ARVs, treatment for Opportunistic infections, STIs and all related services) we will need a body at the level of the UN to provide this leadership and momentum. As the African Network of Religious Leaders Infected or personally affected by HIV and AIDS (ANERELA+) we support UNAIDS, and will continue to call on decision makers to recognize HIV and AIDS as a disease that demands an organization such as UNAIDS to provide the global leadership it deserves. Competing interests: None declared |
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Otwoma Tom Otwoma, HIV/AIDS BCC Leader Nairobi,Kenya
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People like Roger England will always be there and articles like the one he puts across now will always be with us. However, before reading or writing such an article, people need to note two issues: 1 that in budgeting and health care financing, including in health and HIV/AIDS resource allocation, there can never be a trade off. Never! You cant take resources from HIV to respond to other ailments, say child and maternal deaths. If anything, health resource allocation is still unacceptably low; 2)The Joint United AIDS programmme on AIDS (UNAIDS) is a different entity from HIV and AIDS. Even when a writing will be in the wallfor HIV and AIDS, thiswriting on the wall (or mind) willnot extend to UNAIDS. Some of the challenges in the health and development sector have not been occasioned by UNAIDS. Instead, UNAIDS is trying to respond to these challenges. In many countries,inluding Kenya, health resource allocation to HIV and AIDS still outside the UNAIDS infrastructure(Natinal AIDS Council). More importantly, it is unacceptable to look at HIV and AIDS against other diseases and/or conditions. If one wants a better way of comparing things, including budgets, one may need to move beyond the health sector. Look at defence, for example. Nevertheless, even if you look at defence, there is no room for trade-off. You can increase resource allocation to health and health care without putting any writing on the wall orin your mind (Otwoma Tom, Kenya) Competing interests: No competing interests |
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Lesley-Anne Knight, Secretary General -Caritas Internationalis Caritas Internationalis, Palazzo San Calisto, V-00120 Vatican City Europe
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As Secretary General of Caritas Internationalis, the global confederation of national Catholic humanitarian assistance, social service, and development organizations operating in more than 200 countries of the world, I am writing to register my urgent concern in response to the mean-spirited and inaccurate "personal view" by Roger England published in the British Medical Journal, on 10 May 2008 (Volume 336). For a publication that prides itself on communicating "evidence-based information", the BMJ has committed a grave error to disseminate Mr. England's personal opinion, which is not at all substantiated by the lived experience of millions of people currently living with or affected by HIV and of the additional millions who already have died - most an early age - of AIDS-related illnesses. If AIDS is not an "exceptional" situation (which goes far beyond the health sector but touches the very core of the family and of local communities), we ask Mr. England to explain the desperate decline in life expectancy, mostly in sub-Saharan Africa. As an organization which primarily serves the poorest of the poor in low-, middle, and high-income countries, Caritas Internationalis invites Mr. England to visit such persons in order to learn from them how poverty serves both as cause of vulnerability to and as effect of HIV infection among those segments of the population. It is interesting to note that Mr. England ignores the Southern African countries when he puts forward the hypothesis that HIV prevalence is highest among the middle class and more educated people. Since only some 10% of people know their HIV status, one would have expected Mr. England to discern the fact that the middle class and more educated people have much more easy access to HIV testing while the poor. The writer spouts off statistics that AIDS deaths are responsible for only 3.7% of global mortality. Yet he fails to acknowledge the fact that Africa has only 11% of global population yet carries some 60% of the global HIV burden. Caritas staff and volunteers throughout the world, but most especially in sub-Saharan Africa, witness firsthand the dramatic effects of access to anti-retroviral medications that have been made possible through funding from the Global Fund to Fight AIDS, TB, and Malaria and through PEPFAR. Parents who were at the brink of death and whose death would have caused serious increases among the millions of AIDS orphans, have been able to return to work, provide for their families, and are able to serve as responsible members of civil society, many of whom are lending their own efforts to increase access to HIV education and treatment among their peers. If there is any defect in funding mechanisms such as the Global Fund, it is that the majority of the funds have been tied up in government bureaucracies, to which Mr. England apparently wishes to channel more, and not enough have been shared with civil society, most especially with faith - based organizations which supply up to 40% of the health care infrastructure in many developing countries, particularly in the most rural areas and among the most marginalized populations. Mr. England might be quite surprised to learn that many, perhaps most, AIDS treatment programmes are far from vertical. They facilitate access to early HIV testing, anti-retroviral treatment for those found to be living with HIV; diagnosis and treatment of HIV-related Opportunistic Infections, of co- infections, such as tuberculosis and Hepatitis C, and of other sexually transmitted infections; prevention of mother-to-child transmission of HIV and safe motherhood and baby programmes; nutritional supplements; economic development; educational programmes for AIDS orphans; emotional support; self-help; and (in the cases of faith-based organizations) spiritual assistance when such is requested. The very existence of UNAIDS stands as a model for a coordinated approach to an otherwise overwhelming threat to the human family. As an global faith- based organization, Caritas Internationalis is most appreciative of its Memorandum of Understanding with UNAIDS, first signed in 1999 and then renewed in 2003, in which our two organizations pledged mutual collaboration in those areas where our missions and mandates coincide and mutual understanding and respect in those areas in which we differ. Mr. England should not be seeking to dismantle UNAIDS but rather to celebrate it as a model to tackle other global health and development emergencies, not only because UNAIDS promotes a unified programme and budget among its ten co-sponsor UN agencies but also because it stands out as a shining example of collaboration with civil society responses to HIV, including those of faith-based organizations. Mr. England should not be posing an "either/or" scenario for AIDS care vs. strengthen of health care infrastructure but should advocate for adequate funding of both. Ms. Lesley-Anne Knight Secretary General of Caritas Internationalis Rome, Italy Competing interests: None declared |
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Mariangela Simao, Director National STD/Aids Program/ Misnistry of Health/Brazil
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Not recognizing Aids as an exceptional challenge and that it has be faced as a potential global threat is somewhat baffling, specially from a public health perspective. It is a sexually transmitted disease, a chronic disease, it does not have a cure, its treatment is long term and very costly, and we have different epidemics around the world. If not addressed with appropriate resources, given its characteristics, the potential to further burden health systems is enormous. Unless, of course, we are talking about not treating people, which is, by the way, a human rights issue, or ignoring the huge burden that stigma and discrimination surrounding place on Aids patients and vulnerable populations. The author of “The writing in on the wall for UNAIDS” clearly focus on a biased analysis. It may sound repetitive, but clearly Aids cannot be fought only by the health sector. It brought us, health professionals in Brazil, working on building up our national health system for the past 20 years, the need to act on a concerted manner with other governmental sectors, as fighting Aids means also promoting human rights of vulnerable groups and discussing the implementation of public health policies with civil society organizations. Had we not treated Aids as exceptionality in my country, and that does not mean resources were “siphoned” from other health priorities, we would have more than double the estimated number of infected people. And this would certainly burden even more our national health system. Maybe it will help bring this discussion on the right perspective if we compare the fight against Aids with strategies to combat violence in our countries. If we focus only on the much needed structural changes, expressed in better education and equal opportunities for young people, for example, which are certainly long term goals, and ignore the need to address crime here and now, what would happen in our societies? I am not downsizing the need to strengthen health system, but I would like to end by saying we, governments, and UN agencies as well, have to tackle structural changes at the same time we address immediate needs, expressed in the fight against Aids by addressing the needs of people needing treatment and social inclusion, as well as prevention strategies, including vulnerable groups, which show their results on a long term basis. UNAIDS is playing an extremely strategic role on this fight, helping focus UN efforts towards strengthening national responses to fight this epidemic. Competing interests: None declared |
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Alan W Whiteside, Professor HEARD Durban 4031
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I have just published'HIV/AIDS A Very Short Introduction' with Oxford University Press. It is only 37 000 words, which means every word is important.The final chapter focused on major issues around HIV and AIDS including some of the uncomfortable 'realpolitik'. It states HIV/AIDS would receive less attention as other concerns hit the global agenda. This is inevitable and I think what we need to do is work with the reality. However and more relevant there is a section on AIDS exceptionalism. This was the most difficult section to write and went through six drafts with me havering between it being exception then saying perhaps not. In the end I said: AIDS is exceptional Should AIDS be treated differently from other diseases? Should it be dealt with as a crisis or as a long-term development issue? This is an ongoing debate with no single or simple answer. Let me sum up the points. AIDS is primarily a sexually transmitted infection affecting young adults. The spread is silent and the long incubation period means the virus has infected many people before illnesses manifest and the threat is apparent. Eminent British scientist Professor Roy Anderson modelled the course of the epidemic and estimated it will take 130 years to work through the global population. There is no cure. There are treatments but these remain relatively expensive. In poor countries the cost of treating one AIDS patient is many times the average expenditure on health. Even if money were no object, there are human resource-constraints to providing treatment. Science has made huge strides but there will be no vaccine or microbicide available in the medium term. AIDS is already having a devastating impact on some countries. In Swaziland the chance of a 15-year-old boy living to 50 years is 28%, for a girl it is just 22%. Before AIDS it was 92% and 97% respectively. The UNDP estimated 2004 life expectancy in Botswana to be 34.9 years. Populations in some African countries are projected to decline. Reversing life expectancies and falling populations are events unknown in the past 200 years. Economists question whether economic growth is possible in these circumstances. Sociologists and political scientists have not begun to consider the ramifications. The debate between normalisation and exceptionalism is sterile. AIDS is exceptional and needs to be treated as such. But the measures needed to deal with the schisms and fractures that give rise to the epidemic are long-term. Preventing AIDS means equitable development: providing education, health, employment opportunities and social support. These are development goals, and not (just) about HIV/AIDS Perhaps a more pertinent question is why don't the leaders and officials in the worst affected countries treat the edpidemic as exceptional? Why is is so often the activists who take this up? The reality is that the decision makers don't care about what happens in Africa and some African leaders DON'T CARE about health and HIV/AIDS as is witnessed in very concrete terms by the lack commitments to various declarations. Competing interests: None declared |
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Jonathan E. Cohen, Director, Law and Health Initiative Open Society Institute, 400 W. 59th St. New York, NY, USA 10019, Francoise Girard and Ralf Jurgens
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Many "magic bullets" have been offered as a solution to the global AIDS crisis. Roger England, quoting himself liberally, offers a new one: stop paying so much attention to HIV, and somehow the stigma and discrimination associated with the disease will subside. This is a curious proposal. Human rights violations against people living with and affected by HIV run rampant throughout the world. Gay men avoid HIV services for fear of being arrested on sodomy charges. Women hide their pills from their husbands to avoid domestic violence or eviction. Drug users share syringes to avoid being caught with their own syringes by the police. The human rights violations suffered by many of those at highest risk of HIV not only offend human dignity, but also undermine the goal of universal access to HIV prevention, treatment, and care. Instead of calling for a less exceptional response to HIV, England should praise the efforts of AIDS and human rights activists to end this epidemic of abuse. Human rights activists have achieved great gains in the fight against AIDS: the right to nondiscrimination on the basis of HIV status; the right to treatment as part of essential health care; and the right of people living with HIV and AIDS to participate in the development of AIDS policies and programs. Some have criticized these activists as being more concerned with “individual rights” than with the public’s health. In fact, contrary to what England implies, human rights are essential to public health and to a successful response to HIV. Human rights activists were among the first to emphasize the importance of increasing access to HIV testing. When proponents of "routine" HIV testing accuse human rights activists of allowing the “three Cs” of consent, counseling, and confidentiality to override the importance of widespread and early detection of HIV, they forget that it is possible to increase access to HIV testing without sacrificing the three Cs, and easier to engage people in sustained HIV prevention and treatment efforts if the three Cs are protected. Moreover, efforts to increase access to HIV testing must be accompanied by vastly scaled-up efforts to confront the stigma and human rights abuses that deter people from seeking HIV tests in the first place, as well as increased access to antiretroviral treatment and evidence-based HIV prevention. Human rights activists have also led the fight for increased access to effective HIV prevention measures, insisting that governments provide access to information, condoms, needles and syringes, methadone, drugs needed to prevent HIV transmission from mother to child, and protection from violence and property rights abuses that increase vulnerability of women. These demands have been based both in human rights and in effective, science-based HIV prevention. Jonathan Cohen
Competing interests: None declared |
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Michael L Rekart, Director, STI/HIV Prevention and Control British Columbia Centre for Disease Control, 655 West 12TH Avenue, Vancouver, BC, Canada V5Z 4R4
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Roger England has shined a light into a dark corner of the collective psyche of all of us who work to prevent HIV infection and deal with its ramifications. Why has so much effort to contain HIV spread in middle and low income countries produced so few results? This is an honest and important question which should not be dismissed with either a recitation of the terrible living conditions of people at risk or an exaggeration of our paultry successes. Is HIV exceptional? Yes! The HIV pandemic fits the definition of exceptional, "unusual, not typical". We all know this in our hearts and, if we need reminding, the why's are summarized in the preceding responses to this provocative essay. Can a single-minded, single-disease global effort be successful? Again, the answer is yes! One has only to recall the total success of the small pox eradication campaign of the mid-1900s and the remarkable advances of the STOP-Polio campaign today. Since the world community is expending more money, time and effort pro-rata on HIV (with far less success) than we devoted to small pox and polio combined, there must be something(s) missing. The obvious difference is that we have vaccines for the latter but not the former. Vaccines indeed are the most powerful tool in disease prevention and control. I would posit, however, that the second and more relevant missing piece is that we have relied on a routine, business-as-usual response to an exceptional pandemic. This can be fixed. Nation-to-Nation partnering - HIV aid projects and funding too often respond to the priorities of donor countries and global agencies rather than the needs of recipient countries, leading to an overlapping, uncoordinated patchwork of initiatives. With no single plan or lead donor, the impact of aid is compromised and no one sees these failures as their responsibility. Let us debate the feasibility of partnering individual high and low income nations, perhaps with a middle income country as a third team member. The partners could develop a single, detailed plan into which all external aid would play a clear, coordinated and non-overlapping role. Success could be better monitored and the team members would be more likely to own the process and feel a responsibility to succeed. Centripetal programming - In Vietnam, we have been intrigued to find an inverse relationship between urbanization and success. Our most successful STI/HIV clinics and outreach programs, and those most likely to be sustained, are located furthest from large cities. On the other hand, most projects to improve health systems capacity to respond to HIV and AIDS begin centrally and many of these fail before they can be scaled up to rural areas. Let us explore the hypothesis that capacity building that starts in rural areas and works its way in to urban centers (centripetal) can be more successful and cost effective than those that start centrally and work their way out to rural areas. Unless an HIV vaccine magically appears, the war against AIDS can only be finally won by addressing the critical, upstream social determinants of health and vulnerability such as poverty, gender inequality and lack of basic education. In the meantime, let's get creative with the tools at hand. Competing interests: None declared |
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Roger England, Chairman Health Systems Workshop, Grenada WI
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I am not sure the response from UNAIDS addresses the points I made in my article. These are: 1. That the propositions used to gain HIV its exceptional status are false. UNAIDS only restates the view that HIV is an emergency, supporting this with the estimate that 25 million people have died of HIV in the last 25 years. But pneumonia has killed 50 million children alone in this time, and an additional 25 million neonates have died from pneumonia/sepsis.[1] Why is this not an emergency? 2. That HIV receives a disproportionate share of financing in relation to its share of deaths or burden of disease (BOD). UNAIDS cites expenditure biased by big countries with low prevalence. This casts little light on the issue. In Rwanda HIV is responsible for 15% of the BOD, but receives well over 60% of health aid. A analysis of recent DAC and WHO data shows that this is not an isolated case. In the chart below, all countries above the line are receiving more aid for HIV than is justified by its share of BOD. In many African countries, HIV aid is now more than the total domestic health budget.
source: Mark Pearson (personal communication) 3. That much HIV money is being spent on ineffectual interventions and would be better spent in strengthening public health. It is not just my view that multi-sectoral expenditure is ineffectual. World Bank evaluations have concluded the same thing, including about its own MAP money, much of which was handed out to weak community projects. Jim Chin points out that billions have been wasted on youth and workplace education outside SSA to ‘prevent’ general epidemics that were never going to happen anyway.[2] We know that the big numbers in SSA are about heterosexual sex and concurrent partners.[3] It is not clear why UNAIDS thinks strengthened and focused public health activities using modern communications is not the preferred intervention here. My point is that we have not done enough of that and continue to waste billions whilst calling for more. 4. That the way HIV money is being delivered and used is weakening health care systems. Exceptionalism has justified the earmarking of aid to HIV and its provision outside of country planning and budgeting mechanisms, and countries must dance to the tunes of PEPFAR and the Global Fund because that’s where the money is. This has frustrated country attempts to harmonise financing and align it to their priorities, which are to strengthen their public health and health care services so as to be able to prevent and treat all diseases better, including HIV. UNAIDS is being forced to recognise this and is starting to make windy noises about how HIV money can bolster health systems. And thereby hangs the HIV tail wagging the health systems dog. HIV should get its proper share of the total health aid pot whether that pot is one billion or fifty billion dollars, but the size of the pot cannot be set by HIV activists with the argument that some of it will rub off on general health improvements. For one thing, what would that do for millions of poor in West Africa and parts of SE Asia where HIV prevalence is low but public health and health care needs are huge? First and foremost aid must be available to help countries build their public health and health care services (and water supplies), not as a by- product of the HIV industry. And this is exactly why we don’t need dedicated HIV funding or UNAIDS. [1].http://www.unicef.org/immunization/files/Pneumonia_The_Forgotten_Kill er_of_Children.pdf [2]. James Chin. The Myth of a General AIDS Pandemic. The Campaign for Fighting Diseases January 2008 http://www.fightingdiseases.org/pdf/Jim_chin_AIDS.pdf [3]. Potts M, Halperin DT, Kirby D, et al. Reassessing HIV Prevention Priorities. Science 320, 749 (2008) Competing interests: None declared |
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James E Parker, Retired Paediatrician 289 McCallum Rd Abbotsford, B.C. Canada V2S 8A1
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I find myself in agreement with Dr Michael Rekart (Responses 13 May 2008) when he states "Roger England has shined a light into a dark corner of all of us who work to prevent HIV infection..." Roger England is 'spot on' in his analysis of HIV/AIDS. The mismanagement of declaring a specific disease to be exceptional in the obstruction of conventional public health methods (routine testing, contact tracing etc.) has played an important role in the present situation. Dr Rekart states that HIV fits the designation of being exceptional in having no vaccine or obvious cure. And yet for a period of some hundreds of years another sexually transmitted disease - Syphilis fell into the same category. In those days counseling was simple. 'One night with Venus, a lifetime with Mercury' ! James E Parker Competing interests: None declared |
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Jeremiah Norris, Director, Center for Science in Public Policy Hudson Institute 20005
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After the expenditure of some $50 billion by donors on global AIDS over the past several years, finally a professional health authority has stepped forward and called our attention to the inherent absurdity of its provenance in our community. In the beginning, UNAIDS grossly overestimated HIV. In November 2007, it issued an updated report, acknowledging that the AIDS pandemic was not increasing or expanding. UNAIDS stated that “global HIV incidence peaked in the late 1990s and has been decreasing since. UNAIDS estimate of global HIV prevalence for 2007 (33.2 million) was lower by over 6 million from its 2006 estimate (39.5 million). The enormity of overestimates can better be appreciated by looking at UNAIDS’ estimates of global HIV incidence (new infections) in 2006 of 4.3 million and its lowed estimate for 2007 of 2.5 million.” (1) UNAIDS response to these lowered estimates is to call for huge increases, as the author states: “from US$9 billion today to US$42 billion by 2010 and US$54 billion by 2015”! While UNAIDS expresses no concern about the consequences of an unprecedented resource flow into the developing world for a single disease entity, the International Monetary Fund isn’t as reluctant. In a July 2004 Survey, when expenditures were $8 billion for AIDS, the IMF cautioned on the macroeconomic risks associated with large grants “including high inflation, which retards growth and acts like a tax, especially on the poor; real appreciation of the currency, which can hinder the poor from exporting commodities vital to their livelihood; rising domestic interest rates; and, a squeeze on social spending by raising public debt service payments.” (2) Global AIDS has attracted large grants, but it is not alone for its ability to generate funds and distort local health systems.. Half of the Millennium Development Goals are health related. A 2005 OECD report detailed the cost of 740 technical advisors working on the MDGs in Cambodia. “Their costs exceeded the combined wages of Cambodia’s 166,000 civil servants.” (3) The author of the BMJ study correctly defined our collective dilemma by sourcing it in the original proposition that HIV was exceptional. This led to such public health diversions as the discouragement of routine testing in resource limited settings, the use of substandard drugs, and a focus of efforts on the poor. This encouraged the Global Fund to promote Option C in drug use: procurements of products not reviewed by a regulatory authority. In a 2007 report, the Fund said “of 2,254 single or limited source products procured, one-fifth were purchased using Option C, and half were found to be non-compliant to [the Fund’s] QA policy.” (4) Most importantly, in the treatment of a chronic disease, the principles of clinical medicine were abandoned in favor of an advocacy campaign which effectively posited that price was the barrier on access to medicines for the poor. They became the cause celebre around which evocative exhortations were relentlessly pressed with the media and global donors—while ignoring the incipient causes of HIV and AIDS. “The prime mover of the epidemic is not inadequate antiretroviral medications, poverty or bad luck but our inability to accept the gothic dimensions of a disease that is transmitted sexually. Only when we cease to dodge this fact will effective HIV-control be established. Until then, it is no exaggeration to say that our polite behaviour is killing us.” (5) Not only is AIDS weakening health systems in the developing world, but it is also having a pernicious effect on Official Development Assistance. It is estimated that AIDS funding from the Government of the United States will consume more than 50% of its ODA by 2016, and “squeeze out U. S. spending on other global health needs [creating] a new global entitlement.” (6) For the first time, our international health community doesn’t lack for funds; it does, though, as the author intimates, not know how to put them to the best use for patient care. A continuation of the methodology of AIDS would be self-serving to its advocates and perpetuate the dire circumstances of the poor by labeling them as optional patients. Sources: 1. James Chin, The Myth of a General AIDS Pandemic, How Billions are Wasted on Unnecessary AIDS Prevention Programmes, Campaign for Fighting Diseases, International Policy Network, London, January 2008. 2. IMF, Peter Heller, et al., “Sizeable Boost in HIV/AIDS Assistance Will Challenge Low Income Countries”, IMF Survey, July 12, 2004. 3. OECD, Development Cooperation Report, Vol. 7, No. 1, OECD, Paris, 2006. 4. Global Fund, Global Fund “Option C” allows procurement of products not reviewed by a regulatory authority, Global Fund, 6th Portfolio Committee Meeting, Geneva, February 22-23 2007. 5. Kent A. Sepkowitz, M. D., “One Disease, Two Epidemics—AIDS at 25”, New England Journal of Medicine, Vol. 344, No. 23, June 8, 2006. 6. Mead Over, “Preventing Failure: The Ballooning Entitlement Burden of U. S. Global AIDS Treatment Spending and What to do About It”, Center for Global Development, Washington, D. C., May 5, 2008. Competing interests: None declared |
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Richard J Jefferys, Michael Palm Project Director Treatment Action Group, NYC 10012
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England writes: "The foundations of exceptionalism were laid when the "rights" arguments of gay men succeeded in making HIV a special case that demanded confidentiality and informed consent and discouraged routine testing and tracing of contacts, contrary to proved experience in public health." In light of this offensive attempt at revisionist history, it is worth noting that it was the exceptional ignorance, bigotry and prejudice of many people - including those whose responsibility it was to launch the public health response to AIDS - that laid "the foundations of exceptionalism." That bigotry and prejudice is now typically articulated in less overt terms than it was in the 1980s, but it certainly persists, and extends to many groups seen by bigots as marginal to "mainstream" society or the "general population," not just gay men. Here are two excerpts from the first few press conferences at the Ronald Reagan White House where the topic of AIDS arose.[1] At the time of the first one, over 800 people had already died. THE WHITE HOUSE Office of the Press Secretary PRESS BRIEFING BY LARRY SPEAKES October 15, 1982 The Briefing Room 12:45 p.m. EDT Q: Larry, does the president have any reaction to the announcement—the Centers for Disease Control in Atlanta, that AIDS is now an epidemic and have over 600 cases? MR. SPEAKES: What’s AIDS? Q: Over a third of [the victims] have died. It’s known as “gay plague.” (laughter) No, it is. I mean it’s a pretty serious thing that one in every three people that get this have died. And I wondered if the president is aware of it? MR. SPEAKES: I don’t have it. Do you? (laughter) Q: No, I don’t. MR. SPEAKES: You didn’t answer my question. Q: Well, I just wondered, does the president— MR. SPEAKES: How do you know? (laughter) Q: In other words, the White House looks on this as a great joke? MR. SPEAKES: No, I don’t know anything about it, Lester. Q: Does the president, does anybody in the White House know about this epidemic, Larry? MR. SPEAKES: I don’t think so. I don’t think there’s been any— Q: Nobody knows? MR. SPEAKES: There has been no personal experience here, Lester. Q: No, I mean, I thought you were keeping— MR. SPEAKES: I checked thoroughly with [Reagan’s personal physician] Dr. Ruge this morning, and he’s had no—(laughter)—no patients suffering from AIDS or whatever it is. Q: The President doesn’t have gay plague, is that what you’re saying or what? MR. SPEAKES: No, I didn’t say that. Q: Didn’t say that? MR. SPEAKES: I thought I heard you on the State Department over there. Why didn’t you stay there? (Laughter.) Q: Because I love you Larry, that’s why (Laughter.) MR. SPEAKES: Oh I see. Just don’t put it in those terms, Lester. (Laughter.) Q: Oh, I retract that. MR. SPEAKES: I hope so. Q: It’s too late. Nothing I could write could be more damning than this, could it? And by the time of the following conference, over 8,000 people had died. THE WHITE HOUSE Office of the Press Secretary PRESS BRIEFING BY LARRY SPEAKES December 11, 1984 The Briefing Room 12:03 p.m. EST Q: An estimated 300,000 people have been exposed to AIDS, which can be transmitted through saliva. Will the President, as Commander-in-Chief, take steps to protect Armed Forces food and medical services from AIDS patients or those who run the risk of spreading AIDS in the same manner that they forbid typhoid fever people from being involved in the health or food services? MR. SPEAKES: I don't know. Q: Could you -- Is the President concerned about this subject, Larry -- MR. SPEAKES: I haven't heard him express-- Q: --that seems to have evoked so much jocular-- MR. SPEAKES: --concern. Q: --reaction here? I -- you know -- Q: It isn't only the jocks, Lester. Q: Has he sworn off water faucets-- Q: No, but, I mean, is he going to do anything, Larry? MR. SPEAKES: Lester, I have not heard him express anything on it. Sorry. Q: You mean he has no -- expressed no opinion about this epidemic? MR. SPEAKES: No, but I must confess I haven't asked him about it. (Laughter.) Q: Would you ask him Larry? MR. SPEAKES: Have you been checked? (Laughter.)
1 The White House transcripts are quoted at the beginning of Jon Cohen's book, Shots in the Dark: The Wayward Search for an AIDS Vaccine, W. W. Norton & Company (December 2001) p3-4 & p15-16. Competing interests: None declared |
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Pedro Cahn, President International AIDS Society, Switzerland, 1216, Julio Montaner, Craig McClure
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Statement in Response to Letter by Roger England published in the 10 May 2008 BMJ entitled, “The writing is on the wall for UNAIDS” By Pedro Cahn, President, Craig McClure, Executive Director, Julio Montaner, President-Elect, International AIDS Society In a desperate plea for increased attention to the urgent need to strengthen health systems in developing countries, Roger England angrily lashes out at the international AIDS community, calling for the abolition of the Joint United Nations Programme on HIV/AIDS (UNAIDS) and arguing that increased funding for HIV in recent years is to blame for the chronic underfunding of broader health systems. While the inflammatory nature of Mr. England’s proposal is sure to garner attention, his use of a rather simplistic analysis of how global health priorities are established risks pitting natural allies against each other, and obscures the very real synergies that exist between the global response to HIV and the push to strengthen health systems in poor countries. The argument that AIDS is exceptional and therefore requires a similar response is not, as Mr. England states, a function of politics, but of facts. HIV is a special virus, with genetic mutability unseen before that constantly challenges a “status quo” approach to treatment and research. Unlike many other diseases, HIV’s link with sex and drugs demands a social, as well as medical, response. And, because HIV attacks young adults in the prime of their economic and reproductive lives, the effects on economies and societies are long-term and intergenerational. In some African countries with generalized epidemics, AIDS-related mortalities have all but eliminated gains in life expectancies resulting from decades of development. And, in countries with more concentrated epidemics, the impact on particularly vulnerable populations – including men who have sex with men, injecting drug users and sex workers -- has been hugely disproportionate. In sub-Saharan Africa, the estimated number of children under 18 orphaned by AIDS more than doubled between 2000 and 2007, currently reaching 12.1 million. While such statistics may not convince Mr. England that we are in midst of a global catastrophe, they have fortunately been persuasive for policymakers and much of the general public. The success of the global response to HIV, including treatment and prevention scale up, is not in competition with the goal of strengthening health systems, but rather depends on it. In fact, strengthening health systems is at the very core of the global response against HIV/AIDS. No one understands this better than AIDS professionals on the frontlines who regularly struggle to do their jobs, often with insufficient physical and human resources. Blaming the AIDS response for a shortcoming that was many decades in the making is unwarranted. It fails to recognize how the roll out of HIV treatment has in many cases eased the pressure on such systems by reducing demand for hospital beds, thereby allowing them to be used for non-HIV patients, and by putting health care workers living with HIV back to work. The creation of new diagnostic laboratories, clinics and medical training facilities has and will continue to have broader, positive effects on public health, as will more aggressive screening and care for pregnant women living with HIV. Moreover, performance-based financing, such as that used by the Global Fund to Fight AIDS, Tuberculosis and Malaria, is surely a model that other health initiatives could use to encourage local flexibility while maintaining financial and programmatic accountability. The push for universal access has also had a major effect on global health advocacy by galvanizing patients to demand their right to health care and combating stigma and discrimination against vulnerable populations. It also has engaged iconic figures such as Bill and Melinda Gates, former President Clinton, former President Mandela and Bono to great effect. For the first time in decades, global health issues are front and centre on the international agendas of such bodies as the United Nations, the G8 and the African Development Forum. Rather than fight this trend, many advocates for primary care, pre- and post-natal care, maternal health and sexual and reproductive health are finding ways, at the country and international levels, to join forces with those working on HIV to develop an even stronger movement for global health. These advocates and providers understand that it is the rare politician who is motivated by calls to “strengthen health systems”. Instead, it is the mobilization of real people, with specific health conditions and with tangible needs, who are best able to move this shared agenda forward. As the AIDS movement gains traction and recent investments begin to demonstrate tangible progress, it’s no surprise that criticisms from those outside the field would increase. But demanding a bigger slice of the global health funding pie, which was never big enough in the first place, is short-sighted, at best. The magnitude and exceptionalism of AIDS provides an opening and a mandate to address the chronic under-financing of health systems in developing countries. If we, as a global community, allow this opportunity to slip away, it may never return. Competing interests: None declared |
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Mead Over, Senior Fellow Center for Global Development, 1776 Massachusetts Ave, NW, Washington, DC 20008 USA
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Roger England's article on "AIDS exceptionality" in the British Medical Journal argues that AIDS has received a larger share of total health spending than its contribution to the burden of disease would justify and that this large increase is having negative effects on the rest of the health care system in recipient countries. His article has so far generated 17 often passionate and lengthy responses. Some of the effort of responders is devoted to demonstrating that the effects of AIDS are worse than its burden of disease would indicate. This effort to justify donor spending on AIDS seems futile, since the same is true of many other diseases, including tuberculosis, motor vehicle deaths, smoking caused disease, etc.. (In any case, cost-effectiveness should play a larger role than the total burden of disease in guiding the allocation of public health spending.) Much of the rest of this prodigious rhetorical effort asserts that AIDS spending is really helping, not harming, the rest of the health sector. If Roger England's assertion that AIDS spending harms the health sector could have been refuted by data, one of those posting would have cited such data and the others would not have felt the need to post. The problem is that we really don't know, in any general way, what the extraordinary scale-up of AIDS spending has done to other parts of the health sector. An interview I had last November with the nurse who was responsible for managing a health center in Western Kenya is perhaps revealing. His district health center had tripled in size due to the addition of clinic, lab, waiting and storage space for treating AIDS patients and for warehousing the fresh produce, cooking oil, flour and other groceries given to supplement the diets of many AIDS patients. The staff nominally reporting to him had increased by several young physicians, who had received special training in AIDS case management. I asked this gentleman if he could compare the treatment his patients received in the two parts of his clinic. He said, "The patients who receive AIDS treatment leave with a smile. Those here for other problems do not. As I've told my ministry, we now have two systems of health care in Kenya." Then I asked him, "As the manager of this particular center, is there anything you can do to redress this imbalance?" He said, "I insist that all of my staff, including the physicians who have been specially trained in AIDS treatment, rotate through all parts of the clinic, taking their turns serving non-AIDS as well as AIDS patients. I hope that the specially trained AIDS personnel carry some of their motivation and skill from the AIDS treatment part of the clinic to the non -AIDS part." On the one hand, this story supports Roger England's claim that the resources going to AIDS treatment are vastly greater relative to the burden of disease than the resources available for other health care problems. On the other hand, the story suggests, especially to those of us who have known how poor have been the conditions of African district health centers, that the presence of AIDS spending has tended to improve non-AIDS care as well, even if by much less than it has improved AIDS care. This comment also appears as a blog on our site at: http://blogs.cgdev.org/globalhealth/2008/05/aids_spending_harms_1.php together with other blogs that discuss this issue. Competing interests: None declared |
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Donna J Barry, Advocacy & Policy Manager Partners In Health 02115, Dr. Joia S. Mukherjee, Medical Director
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Dear Editor, Several excellent responses to Roger England’s Personal View, ”The writing is on the wall for UNAIDS”, have been published on BMJ.com. One wonders how many times the topic of AIDS funding as a threat to other health interventions must be raised. During the last 18 months, this debate has been ongoing in a variety of media from The New York Times1 to the journal Foreign Affairs2. Paul Farmer’s response to Laurie Garrett in the latter could be reprinted verbatim as a response to England’s assertions3. The staff at Partners In Health and the patients we serve believe that this is is a false debate. Rather than siphoning resources away from other areas, the interest in and funding for HIV and AIDS has allowed us to lay bare the woeful underfunding in health systems and has given us a long awaited chance to invest their development. We have documented that when HIV testing and treatment is integrated into the delivery of primary care4 rather than simply directed as a vertical program, health systems are strengthened5 as are services to the most vulnerable6. PIH has now replicated this model in 4 countries and more than 23 public facilities. There are both programmatic and financial collateral benefits to AIDS programs. First, when we adopt the logic frame that prevention, testing and treatment of HIV and AIDS are inseparable from the most basic aspects of health care, including the case detection and treatment of tuberculosis and sexually transmitted diseases and the provision of women’s health, then it follows that vertical funds should be used to support health systems. This approach has allowed us to justify the use of such monies earmarked for AIDS to provide adequate compensation for general medical staff, improve public infrastructure to allow for the management of both acute and chronic diseases and provide tools for the provision general health services. As previously moribund public health clinics are reanimated by staff, drugs, diagnostics and even some fresh paint, they become more attractive to donors who see that it is possible to provide even complex care thus leveraging the funding for AIDS to attract other monies. At Partners In Health, we have seen concrete benefits of this approach. HIV is our “chwal batay” (battle horse) in Haiti’s Central Plateau where we currently have 3,500 patients on AIDS treatment and performed more than 76,000 HIV tests in 2007. In addition, from January 2006 to September 2007, over 65,000 prenatal visits were completed, 4,200 institutional births were attended, 301 Ceasarian sections were done at our hospitals, and nearly 40,000 women were using hormonal contraception. Reproductive health and obstetric care constitute just one of many other health interventions that can be strengthened by improved health systems that are boosted with vertical funds. Similar trajectories have been witnessed in a second state in Haiti, three health districts in Rwanda, six clinics in Lesotho and three in Malawi. The global pie of funding for health has increased rapidly over the past decade—not because the wise sages of public health called for it but rather due to the righteous indignation of people living with AIDS and those who work in solidarity with them. Public health has never had such a forceful voice. It is tragically short sighted to quelch the movement which started as a call for HIV treatment equity and now has, at its core, a rights based approach to health care and health systems strengthening. Arguments made by England and others are neither based on evidence nor on good will but rather rooted in a public health nihilism that would keep millions of people without AIDS treatment to go back to the “good old days.” As an organization who serves the poorest, many of whom are on our staff and living with diseases that 5 years ago would have claimed their lives, we believe that the movement of justice and equity in HIV/AIDS treatment should spark a fire that results in the scorching of the acceptance of under-resourced health systems and rising from the ashes, a system of rights based, public sector comprehensive health care will emerge.. 1 Halperin D. Putting a Plague in Perspective. Op-Ed. The New York Times. http://www.nytimes.com/2008/01/01/opinion/01halperin.html?_r=1&scp=1&sq=daniel+halperin&st=nyt&oref=slogin. Last accessed: 21 May 2008. 2 Garrett L. The Challenge of Global Health. Foreign Affairs. 2007;86(1):14-38. 3 Farmer P. From “Marvelous Momentum” to Health Care for All. Success is Possible with the Right Programs. Foreign Affairs. 2007;86(2):155-161. 4 Ivers LC, Freedberg KA, Mukherjee JS. Provider-initiated HIV testing in rural Haiti: low rate of missed opportunities for diagnosis of HIV in a primary care clinic. AIDS Res Ther. 2007; 4(1):28. 5 Mukherjee JS, Eustache E. Community health workers as a cornerstone for integrating HIV and primary healthcare. AIDS Care. 2007; 19 Suppl 1:S73-82. 6 Walton DA, Farmer PE, Lambert W, Léandre F, Koenig SP, Mukherjee JS. Integrated HIV prevention and care strengthens primary health care: lessons from rural Haiti. Journal of Public Health Policy. 2004;25(2):137- 158 Competing interests: None declared |
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Fiona J Pettitt, ICW Member and Project Co-ordinator London N1 7BJ
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The International Community of Women Living with HIV/AIDS (ICW) thought long and hard about whether to deploy its scarce resources to respond to Roger England’s controversial article. However, its tenor caused us great concern and given its imminent publication in the BMJ, a respected publication which is read throughout the world, we felt strongly that a response was necessary. ICW was founded in 1992 and is the only international network of women living with HIV/AIDS, with a membership spanning 138 countries. We challenge Roger England’s personal view that HIV/AIDS is not exceptional. As women living with HIV our lives are inextricably intertwined and impacted by living with the exceptional consequences of an exceptional health condition which has no cure, for which access to treatment is increasing but is not available to all, which is surrounded by stigma and discrimination rather than support and solidarity, and shrouded in taboo areas of peoples lives. ICW’s work over the last 16 years has contributed to reducing the impact of HIV, it has also provided us with a unique insight into the lives of our members, and the role poverty plays in the pandemic. We challenge Roger England’s view that ‘the poverty argument has been exposed as baseless’. HIV thrives in environments of poverty, and casts people who are diagnosed HIV positive into poverty. And how does one define poverty? Many of our members are women who do not have an independent income and rely on their partners for economic survival, which places them in a position where they are unable to make decisions about their own lives, including in relation to HIV. For many years now, women's rights advocates have highlighted the fact that a household is not a single economic unit: a rich man does not mean a rich wife/partner in terms of access to and control over resources. The need for an exceptional response will continue until HIV/AIDS is no longer an exceptional disease, and leadership at all levels is crucial in achieving this. ICW supports the role that UNAIDS plays on a multisectoral/multilateral level. ICW and other networks of people living with HIV have walked side by side with UNAIDS, supporting their work and being supported by them in our work. Together we have played a role in making positive change, which is something Roger England fails to acknowledge. Amongst these changes are: · an increasing number of ICW members, and other people living with HIV, accessing treatment and living healthy, productive lives · an increase in the number of people living with HIV who have chosen to be open about their status and are playing a key role in addressing the impact of HIV at many different levels · an increase in the number of projects which address HIV, and at the same time address gender inequalities · an increase in knowledge about the immune system through research into HIV and treatment which will be of benefit to all · specific to the UN is the formation of UNPlus, which supports HIV positive staff workers within the UK system More needs to be done, and we cannot be complacent. We should continue to build on the work of those courageous gay men who were among the first to address HIV, and to step up our response – not at the expense of other health conditions, but in addition to. We certainly should not be questioning the existence of one of the key actors in HIV and suggesting that the ‘writing is on the wall’ for UNAIDS. Competing interests: None declared |
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Subir K Kole, Lecturer, Dept. of Political Science, University of Hawaii at Manoa, Honolulu HI Honolulu HI 96822
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England is exceptionally right! All the rapid responses that I am reading here come from those groups of people whom England demonstrate in his article as "monsters with too many vested interests." Yes, these are the people who "live ON HIV/AIDS (for their survival), but do not live WITH the virus." So England's arguments hit at the root of survival for those people, who for maintaining their own comfort-level, go on justifying a higher level of funds for HIV/AIDS. And the result is obvious when anybody's survival is at stake. I have seen how poor people in Asia and Africa struggle for their own survival. And now I can also see how “HIV-elites and monsters” struggle for their survival at the cost of the poor.
Competing interests: None declared |
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Aditya Bondyopadhyay, Coordinator APCOM Secretariat New Delhi: 110075
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Dear All, As a person who has been in the "HIV industry" (as the author of this article calls it) for all of his working life, I must say that I have benefited enormously from it, and therefore I feel a moral obligation to jump up in its defense. This is not withstanding the fact that the de facto status of 'chamber of commerce' for this particular industry bestowed on the UNAIDS by the author is a wee bit misplaced. Shorn of the footnotes, references, and rhetoric, lets face it, this article is a polemic for the moolah by the late risers in the health 'industry?'. The author lets the cat out of the bag, maybe inadvertently so, in the very last line of the article, when he speaks of tripling of health care workers salaries. Speaking of which, it ties into my first point, my own benefits from the industry. Being in the industry from my pre-college days I must say that today I can lay claim to serious upper-middle-class-dom, at least by Indian standards. I have a low end diesel small car, I have rent to pay for an apartment, I can support the periodic fancies of a boyfriend who lives with me, I have acquired a dog, and I can often take a day off in a place I am visiting on work and pretend that it's a vacation I am making. The only problem is that if I had not stayed in the industry and instead concentrated on developing a legal career, as most of my classmates from law school did, I would probably today be buying a house of my own and driving a high end saloon, not to speak of those real holidays spent in uninhabited exotic beach resorts. And this is the crucial point that the author totally misses. Yes, there is more money in HIV compared to other diseases. But that has not happened because of any largess that various funding sources suddenly discovered one day. It happened because of mobilisation over years by those that were being treated as outcasts by society at large. HIV was and continues to be a disease that disproportionately affects those who are considered the dregs of society. The author should try and do a bit of research to find out the last time someone was accused of being a faggot or a whore, simply because s/he had pneumonia or diabetes. But it is a daily occurrence with HIV, almost 3 decades after the onset of the epidemic. And because it disproportionately affects people like us, hundreds like me took a decision to forgo that big car for a bigger stake at dignity. HIV gave us the perfect opportunity to do so. Here was a disease that could not be tackled unless you tackled these other uncomfortable questions and dealt with these other uncomfortable people whom you thus far had refused to even acknowledge. Some of the best brains (even if they were faggots or whores) got mobilised behind a disease, probably for the first time ever in human history, and claimed a seat at the table. And they were successful. This success is not a competition with other illnesses for resources. It is mobilisation for a dignified treatment, period!! The above is the real 'proposition of exceptionality' of HIV. It is not material poverty as the author has made out, it's the poverty of the human race in treating some amongst themselves with dignity and respect. And almost all those that the author has quoted in this article to emphasise the point of 'less money for HIV, more for others' are those whose governments (if not they themselves) believe that homosexuals should be stoned to death. For them this argument is a good bogey to challenge the relative success of the HIV movement to attract some resources, which in turn go to 'undesirable' people. Look at the blood safety situation in India and you would see how HIV has strengthened and reformed certain parts the health sector from which everyone has benefited. One can claim this success as the exception that proves the rule, but I would say that this is the compass that shows the direction it should take. With care and support becoming ever more important, with ARV roll outs in many parts becoming ever more possible, this compass should be clutched even more firmly. The areas of compatibility with the mainstream health sector are increasing and the opportunities this provides to strengthen the overall health sector should not be lost out on. The fact should not be missed that most of the HIV funds available today are not part of budgetary allocations that governments and ministers make. In other words they have not enough control over these. No wonder they are miffed, if not outright pissed. That much of these funds go towards meeting the health needs of and for serving communities of undesirables is again a matter of outrage. So, the simple question is what is stopping these esteemed governments from allocating more funds in their national budgets to the health sector? And if there is nothing to stop them, and yet they are not doing so, then the so called competition for resources that the author avers to is nothing but a false debate. Yet these venerables do not stop spouting about the competition for resources and how more need to be available for 'health sector' and they even know the source of that more, take it from what is available for HIV. Shorn of rhetoric all they say is that they should be the ones spending the money now available for HIV, not some collective of faggots, whores, or shooters. In case their designs are realised, I cannot say much about the 'health sector', but the one sector that would surely benefit are those of Swiss Bankers managing numbered accounts. So where does that bring us to as far as the real writing on the wall is concerned? Simply this, WHO is a great organisation, so are all other UN organisations. But all of them collectively have either never exercised their minds, or have not had the occasions to expressly state that faggots and whores are human beings that deserve human dignity and respect. UNAIDS have done so, and in the process have carried the burden of the failings or omission of the entire UN system on their back. That they have also done a competent job of managing and controlling HIV along the way is just an aside. That they would continue to do so is a given. Till diabetics organise enough to stake a claim to their own UN body, not to speak of an entire stream of parallel funding to meet their needs, let UNAIDS continue as the UN agency for faggots and whores. In the process if Swiss Bankers manage a wee bit less business, it's really their loss. Best regards to all Aditya Bondyopadhyay Competing interests: None declared |
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Dominic D Montagu, Assistant Professor UCSF, USA, 94707
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Dear Sir, I read with great interest Mr. Roger England's article arguing that AIDS should no long be treated as an exceptional disease and that the existence of UNAIDS is no longer justified. I was particularly struck by the vehemence and the provenance of the responses published by the BMJ. Sir, if the Director of the Institute for the Promotion of Tobacco Use were to write an article in the BMJ arguing that second hand smoke from cigarettes is less harmful than popularly believed, and claim that she had no competing interests, she would be excoriated for her hypocrisy: her salary, her title, her career, and her continued employment by a funded institution clearly have the potential to bias her opinion. Although as a scientist we may expect her to rise above those biases, as concerned readers we would be scornful if she neglected to acknowledge them. Now replace "Institute for the Promotion of Tobacco Use" with "UNAIDS", "Treatment Action Group", "AIDS and Rights Alliance", or similar institutions, and replace "second hand smoke" with "HIV". Having read through the BMJ's guidance on declaration of competing interest I note that point 2 asks "Have you..., in the past five years been employed by an organization that may in any way gain or lose financially from the results of your .. letter?" and point 1 asks "Have you..., in the past five years accepted the following from an organization that may in any way gain or lose financially from the results of your... letter: reimbursement for attending a symposium, a fee for speaking,... funds for a member of staff, fees for consulting?" If the answer to either of those two points is "yes" then the BMJ considers that competing interest which should be declared. My concern regarding the debate which Mr. England has initiated is that it has quickly devolved into a moral argument rather than a science based argument, and that morals are apparently open to interpretations which do not move us forward towards greater truth. If the tobacco industry, being evil, must declare competing interests, but the AIDS industry, being good, is not obliged to declare similar interests, then we have left behind rules based science and entered a realm of subjective moral certitude from which, I fear, we are unlikely to emerge either wiser or better informed. Competing interests: None declared |
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Simon Rushton, Lecturer in International Politics Centre for Health and International Relations, Aberystwyth University, SY23 3FE, UK
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