Continued AIDS Investment When We are at the Tipping Point!

During the period July 23-27, the International AIDS Conference was held in Washington, D.C.  On the 23rd, a spirited debate at the World Bank was conducted between Mead Over ofCGD,  Roger England of Health Systems Workshop, Michel Sidibe of UNAIDS, and Jeffrey Sachs of The Earth Institute.  Charles Holmes from the Office of the US Global AIDS Coordinator did the introduction and the debate was moderated by Richard Horton, Editor, The Lancet. The proposition was: “Continued AIDS investment by donors and governments is a sound investment, even in a resource constrained environment”.

Over and England took positions against the motion; while Sachs and Sidibe took positions for the motion. In essence, Over felt that “while AIDS spending has accomplished much good, there are many more millions of healthy years of life available in Africa at only a few dollars each, far more cost-effectively than even the most cost-effective of HIV/AIDS interventions. Thus, there is a need to rebalance global health spending”. For his part, England commented that “the $100 billion that has been spent on AIDS has created an ‘AIDS-industrial complex’, and the international AIDS meeting in Washington this week is its trade fair. UNAIDS should be disbanded and its $500 million annual budget spent on cost-effective health care interventions for the poor”.

Sachs countered by saying “this debate is a sham because resources are not really scarce. With financial transaction taxes and higher taxes on the rich we would have more than enough money to address all the health problems of the world.”  Sidibe’s views were that “the struggle against HIV/AIDS has raised billions of dollars that otherwise would have been unavailable for health. This spending not only saved millions of lives but also transformed societies towards more inclusiveness and greater social justice”.

At the debate’s beginning, the moderator asked for a show of hands for or against the proposition. There was lop-sided support for the proposition. While the audience seemed to be moved by Sidibe’s argument on “progress with global social justice, and tempted by Sachs assertion that enough resources could be cajoled from the rich, neither provided any evidence to support these views. Both felt that the proposition should have been discarded so that the debate could then be held on different premises and metrics”.

In addition to their points, there are two critical factors which should have been in play:

Firstly, there is a global transition in epidemiology and demography, one that affects all disease categories and thus the allocation of resources to address them—most particularly from a political perspective in donor-assisted countries. Between 1950 – 2000, the average fertility rate in developing countries fell by half—from 6 to 3, that is, three fewer children in each family in just 50 years! Furthermore, non-communicable diseases are on the rise. In Brazil, the number of CVD (cardio-vascular disease) deaths in women aged 150-34 is twice that from pregnancy related causes. In addition, the number Brazilian CVD deaths in the decade after prime child bearing years, 35-44 years, is nearly five times the deaths from pregnancy-related causes during the two decades of ages, 15-44.  This pattern applies in China, South Africa, and India.

Secondly, the US PEPFAR program is now moving resources, and the responsibility to use them, to partners with resident capabilities in the developing world, rather than through US contractors. In response, countries themselves are now funding more in AIDS than ever before—South Africa being a prime example. The US share of total funding has now dropped from 65% to 35%.

Most countries aren’t hemorrhaging in their health budgets from the ever-decreasing burden of communicable diseases. But, the attention drawn to these diseases by international agencies has diverted countries from the unfunded, macroeconomic liabilities being set in train by the sequential increase in the number of chronically sick people in their working populations. The central policy issue faced by these economies lies not in the realm of a continued focus on communicable diseases. Rather, by failing to assign a proper value to the consequences of chronic diseases , policy-makers in the donor community drastically underestimate the societal costs involved when assisting those countries to sustain a competitive economy in the 21^st Century.

The unrelenting forces of demography and epidemiology suggest that Over and England are supporting a position that will soon place them on the right side of history. There is an unintended consequence to shifting responsibilities and funding for AIDS onto recipient countries. (He who pays the Piper gets to call the tune.)  It gives them the opportunity to tailor domestic expenditures to their burden of disease rather than to donor preferences. Taken individually, CVDs, cancers, and diabetes kill more than AIDS combined.  They have huge indirect costs to societies in terms of lost labor productivity and their competitive positions in international trade and commerce. Thus, there will be neither political nor fiscal support to sustain the primacy of global AIDS funding within local governing structures at the expense of NCDs.

Given that Mead Over, since his days as the World Bank’s chief economist on global AIDS, and now conducting research at the influential Center for Global Development, has taken this position, it can be stated unequivocally that we have reached the tipping point on global AIDS.