LET US NOW praise initiatives taken by the comfortable in behalf of the afflicted. Governments of the world's richest nations have launched significant responses to the rampant health crises of those living in the poorest nations. Wealthy individuals, like Bill and Melinda Gates, are also making extraordinary interventions. A measure of this hopeful movement's unexpectedness lies in the fact that one of its leaders is the American president, George W. Bush.
In last month's State of the Union address, the president called on Congress "to double our initial commitment to fighting HIV/AIDS by approving an additional $30 billion over the next five years." This request for a reauthorization of the President's Emergency Plan for AIDS Relief solidifies what will likely be regarded as the Bush administration's finest act. The war in Iraq costs far more, of course, but still this aid program is major.
Since the initiative began in 2003, with a commitment of $15 billion, nearly 1.5 million Africans have been receiving antiretroviral treatment. Almost 3 million orphans and vulnerable children are being cared for. Bush's renewed program aims to expand the ARV treatment by a million, and to provide care for an additional 12 million infected people, including 5 million children.
Such are the complexities of health and global intervention, however, that even these proposals spark controversy. Last November, the United Nations AIDS Epidemic Update offered estimates of the disease's spread that were lower than previous assessments. Around the same time, some experts began advocating cuts in AIDS funds in favor of improving "health systems" in poorer countries, like clean water, nutrition, and maternal care.
"AIDS has grossly distorted our limited budget," an editor of the British medical journal Lancet said. Some argue that the entire "disease specific" approach, including programs aimed at tuberculosis, polio, and malaria, is equally misguided. Instead, these advocates insist that donors should be shoring up health infrastructures, not targeting particular diseases.
What the past five years of the President's Emergency Plan for AIDS Relief show, however, is that disease-specific strategies do create systemwide collateral benefits, making the dichotomy false. The point now is for planners and politicians to make a conscious effort to enhance that pattern. Opportunities must be seized to expand in-country workforces of health professionals. The focus on particular prevention programs must simultaneously broaden to encourage in ordinary people the fuller health consciousness on which systems depend. When insecticide-treated bed nets are introduced into communities for malaria prevention, for example, all measures of health have been shown to improve. That lesson must be built upon.
The benefits of narrowly targeted interventions can be general, even beyond health, and they, too, should be nurtured. When women are supported, women's equality grows. When children are protected, a sense of children's rights is enhanced. When aid programs are rooted in on-the-ground needs of sick people, outcomes can be measured, education spread, and funds more efficiently used. Such results are crucial for systemwide improvement.
The demands of multiple health crises must not be reduced to a zero-sum game, with care for malaria or preparation for Avian flu set against the needs of those infected with HIV. By doubling the American dollar commitment to AIDS/HIV in Africa, Bush gave an example of what is needed - which is a drastic expansion of financial support for the health of people living in poorer nations.
As such programs expand, the eyes of donor nations and foundations must constantly adjust between foreground and background, taking in both immediate needs and broader systemic problems.
Measurable results in the near term must be calibrated to more abstract goals of improvement over the long term. Against a crippling brain drain, local health workers must be firmly supported in place, which will enable them to remain.
AIDS captured the attention of the world, for good reason. It, more than any other single factor, has generated a global political conversion, drawing a first serious commitment by the well-off to help the most desperate. AIDS has been our call to action. But a second, more nuanced call to action is needed now.
AIDS must not be seen as sucking the oxygen out of an enclosed global healthcare crisis, but as a wind blowing fresh air across the frighteningly open plain of what all humans on this planet need to live. Expanding our response to this disease can prompt a needed expansion of our responses to the others. And responding with focus to each disease can help the broader health systems of the world become what they must be.
James Carroll's column appears regularly in the Globe.
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