The President's Emergency Plan for AIDS Relief (PEPFAR) is moving toward a cloture vote in the Senate, a vote that will determine whether the $50 billion reauthorization lives or dies. That same life or death question applies to millions of people in Africa, and comparing actual life or death in Africa to the political legacy of President Bush, as many people see PEPFAR as his greatest achievement, is appalling. Doubly so when the politicians and mainstream media refuse to demand fixes to PEPFAR's problems. Like the rest of President Bush's legacy, PEPFAR, as successful as it has been in part, is a go-it-alone strategy that has alienated much of the rest of the world's public health community.
The reality is this: as successful as PEPFAR has been getting life-saving treatment to nearly two million people, it has failed to slow the infection rate because it has been hampered by unnecessary ideological restrictions. For every two people who receive treatment, five are newly infected with HIV, according to a letter from leading public health advocates circulating on Capitol Hill.
The current legislation will not change that.
At that rate of infection, fiscal conservatives like Sen. Jon Kyl (R-AZ) are right to question the amount of money being spent and if it makes sense, because unless you stem the infection rate, no matter how many people get treated there will always be more than twice as many who don't. Unless the bill is fixed to eliminate ideological provisions, touted by Sen. Tom Coburn (R-OK) that have hampered PEPFAR's prevention efforts in its first five years, and promise more of the same if the current bill passes, PEPFAR will not be as successful in fighting HIV in Africa as it could be.
Unfortunately, that is not the heart of Sen. Kyl's objections. He and other fiscally-conservative Republicans who've been blocking the bill have taken some heat in editorials recently for standing in the way of "the greatest foreign policy achievement since the Marshall Plan," according to PEPFAR supporters quoted in a Wall Street Journal editorial. Given the continued infection rates and failure to address PEPFAR's flaws to turn the tide, the comparison to the Marshall Plan could only be accurate if Europe were still in shambles.
The Las Vegas Sun writes,
A small group of Republican senators, though, is spoiling the momentum by arguing that the legislation costs too much and includes money for unrelated poverty programs.
Poverty is indeed related to the spread of HIV and anyone who doesn't get that yet isn't paying attention. Poverty is at the heart of why prevention efforts are so challenging and must be changed, and why putting treatment ahead of prevention is the proverbial cart-before-horse problem. They must work together, and only prevention can ultimatley lessen the burden of treatment.
We should all celebrate the two million lives with us today that otherwise would not be because of PEPFAR treatment. The stark realities of those lives are documented beautifully in a special exhibition, Access to Life, at the Corcoran Gallery in Washington, DC, sponsored by The Global Fund on AIDS. The photos tell the story of people from every imaginable walk of life, mostly women, often young, always on the margins -- who because of treatment are alive today, working, raising families, educating others about HIV/AIDS.
Every Member of Congress should be forced to visit this exhibit before voting on PEPFAR, because as much as it speaks to the life-saving power of treatment, the exhibition also speaks truth about the need to set ideology aside in favor of reality-based education and prevention efforts, now. Had ideology not stood in our way for the first 25 years of the AIDS pandemic, many of these people might never have been infected in the first place. Prevention is and always will be the key to fighting HIV.
Christianity Today, yesterday lamenting the delays, wrote this,
Jon Kyl, the junior senator from Arizona, pretty much has sterling conservative credentials and a "solidly conservative voting record" in the words of the Almanac of American Politics.
So what is his beef with the reauthorization of PEPFAR, perhaps the most relatively untarnished legacy program of the Bush administration?
Certainly, sticker shock and mission creep are legit concerns. But here's some op-ed commentary, published in the Tuscon Citizen:
Yet despite the program's widespread support and irrefutable success, Kyl and a handful of Republicans think the price tag of $50 billion over five years is too high. It would be one thing for legislators thing to balk at expanding a program that had not delivered its intended results, but quite another to stop one that works.
The Baltimore Sun said,
Republican leaders must rein in the conservative flank of their party and put lives before votes. Otherwise, the president's biggest achievement abroad may come undone, and millions of children will suffer the dire consequences
Most of these editorials also referenced that Bush needed PEPFAR to be passed before leaving for the G-8 Summit in Japan last week. That was great, if unsuccessful, spin and most people recognize that the agreements at the G-8 did not hinge on PEPFAR. In fact, as Jill Sheffield notes from the G-8 Summit, once again the world's wealthiest nations continue to disappoint with regard to HIV:
Related language in the whole health section of the final G-8 Communiqué is weak and convoluted:
"G-8 will take concrete steps to work toward improving the link between HIV/AIDS activities and sexual and reproductive health and voluntary family planning programs, including preventing mother-to-child transmission, and to achieve the MDGs by adopting a multi-sectoral approach and by fostering community involvement and participation." Really, couldn't they have done better than "work toward improving"?
While the editorial writers have part of the PEPFAR story right, that there are conservative politicians putting roadblocks in the way of solid public health policy, they have completely missed out on the story of PEPFAR's well documented problems and the fixes that are necessary. RH Reality Check has been covering those problems extensively since negotiations began, noting that it is not just the fiscally conservative wing of the GOP that is causing delays, but the social conservative wing as well, insisting on ideological provisions like failed abstinence-only requirements, and using completely irrelevant issues like abortion to gain negotiating advantage over squeamish Democrats. These tactics have complicated negotiations and will prevent improvements to prevention efforts. At least the fiscal conservatives aren't pretending they care about HIV/AIDS as the ideologues try to do, while ignoring public health realities.
But the PEPFAR spin-fest has been a bipartisan affair. The Democratic Majority has shirked its oversight responsibility to learn from the first five years of PEPFAR and improve efforts by applying proven public health strategies. Instead, they have acted more like a minority, allowing the negotiations to be handled between the fiscal and social conservative wings of the GOP in an effort to avoid dealing with social issues during an election year.
But even at this late hour, because of fixes required on the treatment side of the bill, it is possible for Congress to improve PEPFAR in order to slow the infection rate as well, which in the long term, could mean less money required for treatment once the spread of the disease is slowed.
Global public health advocates at the American Jewish World Service, Center for Health and Gender Equity, International Women's Health Coalition, the National Council of Jewish Women and the Sexuality Information and Education Council of the US clearly articulate these improvements as:
This bill will set the policy for the United State's global HIV/AIDS programs. As the cloture vote approaches, and assuming it passes, there will still be opprotunities to set better policy on how we spend $50 billion over the next five years. There are concerns on both sides of the aisle, and the Senate should take those issues on, vote on them, and pass a bill that has the greatest impact in saving lives.
This post originally published on RH Reality Check.