Cambridge, Mass. - ALTHOUGH the United Nations recently lowered its global H.I.V.
estimates, as many as 33 million people worldwide are still
living with the AIDS virus. This pandemic requires continued
attention; preventing further deaths and orphans remains
imperative. But the well-meaning promises of some presidential
candidates to outdo even President Bush's proposal to nearly
double American foreign assistance to fight AIDS strike me, an
H.I.V.-AIDS specialist for 15 years, as missing the mark.
Some have criticized Mr. Bush for requesting "only" $30 billion
for the next five years for AIDS and related problems, with the
leading Democratic candidates having pledged to commit at least
$50 billion if they are elected. Yet even the current $15 billion
in spending represents an unprecedented amount of money aimed
mainly at a single disease.
Meanwhile, many other public health needs in developing countries
are being ignored. The fact is, spending $50 billion or more on
foreign health assistance does make sense, but only if it is not
limited to H.I.V.-AIDS programs.
Last year, for instance, as the United States spent almost $3
billion on AIDS programs in Africa, it invested only about $30
million in traditional safe-water projects. This nearly 100-to-1
imbalance is disastrously inequitable - especially considering
that in Africa H.I.V. tends to be most prevalent in the
relatively wealthiest and most developed countries. Most African
nations have stable adult H.I.V. rates of 3 percent or less.
Many millions of African children and adults die of malnutrition,
pneumonia, motor vehicle accidents and other largely preventable,
if not headline-grabbing, conditions. One-fifth of all global
deaths from diarrhea occur in just three African countries -
Congo, Ethiopia and Nigeria - that have relatively low H.I.V.
prevalence. Yet this condition, which is not particularly
difficult to cure or prevent, gets scant attention from the
donors that invest nearly $1 billion annually on AIDS programs in
I was struck by this discrepancy between Western donors'
priorities and the real needs of Africans last month, during my
most recent trip to Africa. In Senegal, H.I.V. rates remain under
1 percent in adults, partly due to that country's early adoption
of enlightened policies toward prostitution and other risky
practices, in addition to universal male circumcision, which
limits the heterosexual spread of H.I.V. Rates of tuberculosis,
now another favored disease of international donors, are also
relatively low in Senegal, and I learned that even malaria, the
donors' third major concern, is not quite as rampant as was
assumed, with new testing finding that many fevers aren't
actually caused by the disease.
Meanwhile, the stench of sewage permeates the crowded outskirts
of Dakar, Senegal's capital. There, as in many other parts of
West Africa and the developing world, inadequate access to safe
water results in devastating diarrheal diseases. Shortages of
food and basic health services like vaccinations, prenatal care
and family planning contribute to large family size and high
child and maternal mortality. Major donors like the President's
Emergency Plan for AIDS Relief, known as Pepfar, and the Global
Fund to Fight AIDS, Tuberculosis and Malaria have not directly
addressed such basic health issues. The Global Fund's director,
Michel Kazatchkine, has acknowledged, "We are not a global fund
that funds local health."
Botswana, which has the world's most lucrative diamond industry
and is the second-wealthiest country per capita in sub-Saharan
Africa, is nowhere near as burdened as Senegal with basic public
health problems. But as one of a dozen Pepfar "focus" countries
in Africa, this year it will receive about $300 million to fight
AIDS - in addition to the hundreds of millions already granted by
drug companies, private foundations and other donors. While in
that sparsely populated country last month, I learned that much
of its AIDS money remains unspent, as even its state-of-the-art
H.I.V. clinics cannot absorb such a large influx of cash.
As the United States Agency for International Development's
H.I.V. prevention adviser in southern Africa in 2005 and 2006, I
visited villages in poor countries like Lesotho, where clinics
could not afford to stock basic medicines but often maintained an
inventory of expensive AIDS drugs and sophisticated monitoring
equipment for their H.I.V. patients. H.I.V.-infected children are
offered exemplary treatment, while children suffering from much
simpler-to-treat diseases are left untreated, sometimes to die.
In Africa, there's another crisis exacerbated by the rigid focus
on AIDS: the best health practitioners have abandoned
lower-paying positions in family planning, immunization and other
basic health areas in order to work for donor-financed H.I.V.
The AIDS experience has demonstrated that poor countries can make
complex treatments accessible to many people. Regimens that are
much simpler to administer than anti-retroviral drugs - like
antibiotics for respiratory illnesses, oral rehydration for
diarrhea, immunizations and contraception - could also be made
widely available. But as there isn't a "global fund" for safe
water, child survival and family planning, countries like Senegal
- and even poorer ones - cannot directly tackle their real
problems without pegging them to the big three diseases.
To their credit, some AIDS advocates are calling for a broader
approach to international health programs. Among the presidential
candidates, Senator Barack Obama, for example, proposes to go
beyond spending for AIDS, tuberculosis and malaria, highlighting
the need to also strengthen basic health systems. And recently,
Mr. Bush's plan, along with the Global Fund, has become somewhat
more flexible in supporting other health issues linked to H.I.V.
- though this will be of little use to people, especially outside
the "focus" countries, who are dying of common illnesses like
But it is also important, especially for the United States, the
world's largest donor, to re-examine the epidemiological and
moral foundations of its global health priorities. With 10
million children and a half million mothers in developing
countries dying annually of largely preventable conditions,
should we mutiply AIDS spending while giving only a pittance for
initiatives like safe-water projects?
If one were to ask the people of virtually any African village
(outside some 10 countries devastated by AIDS) what their
greatest concerns are, the answer would undoubtedly be the less
sensational but more ubiquitous ravages of hunger, dirty water
and environmental devastation. The real-world needs of Africans
struggling to survive should not continue to be subsumed by the
favorite causes du jour of well-meaning yet often uninformed
Daniel Halperin is a senior research scientist at the Harvard
School of Public Health.