Thursday, June 01, 2006
> By Sebastian Mallaby
> Monday, May 29, 2006; Page A23
> The Bush administration's critics should give credit where it's due. And
> when it comes to the global AIDS crisis, it is due -- big-time.
> Five years ago, the U.S. government's total contribution to fighting
> HIV-AIDS abroad stood at $840 million. The Bush team was rightly pilloried
> for trade policies that impeded poor countries' efforts to buy cheap generic
> AIDS drugs. But at the start of 2003, the administration had a hallelujah
> moment. In that year's State of the Union address, President Bush promised
> $15 billion over five years to fight the pandemic. It was the biggest
> commitment to a global health challenge announced by any government, ever.
> Naturally, there were skeptics. The administration's envoys endured boos and
> yells at international AIDS conferences; they will probably face more at
> this week's United Nations AIDS summit. But three years after Bush's $15
> billion pledge, the skepticism has proved mostly unfounded.
> One doubt was that the administration wouldn't back its rhetoric with money.
> Well, since the president's pledge, spending on global AIDS programs has
> risen steadily: to $2.3 billion in 2004, $2.7 billion in 2005 and to $3.3
> billion this year. The administration's budget for 2007 requests $4 billion
> from Congress, more than quadruple the level in 2001. So the Bush team is on
> target to exceed the $15 billion promise.
> A second doubt was that the administration would waste money by purchasing
> branded AIDS drugs. Generics are not only cheaper than patented medicines;
> by combining two or three drugs into a single pill, they also make it
> simpler for patients to take their meds as they're supposed to. But the Bush
> administration began by refusing to buy pharmaceuticals that lacked approval
> from the U.S. Food and Drug Administration, effectively closing the door to
> non-branded AIDS therapies.
> Starting in 2004, the administration fixed this problem. It directed the FDA
> to license generics for use in U.S. global AIDS programs, even when those
> generics could not be sold in the United States because they infringed U.S.
> patents. The skeptics continued to insist that obstacles lurked in the FDA's
> complex rules. But generic after generic was soon licensed, and in some
> countries around two-thirds of U.S. spending on AIDS drugs now goes to
> non-branded medicines. Given how often foreign aid is tied to exports from
> donor countries, it's remarkable that the Bush team stiffed Big Pharma in
> favor of cost-effective help for AIDS patients.
> A third doubt about the administration's AIDS promise concerned sexual
> abstinence. When it agreed to back Bush's AIDS initiative, Congress laid
> down that a third of the prevention budget should be used to advocate
> abstinence and faithfulness. The scientific literature suggests that
> combining abstinence messages with teaching about condoms can delay sexual
> debut and save lives but that abstinence-only messages are ineffective. So
> the congressional earmark, to which the administration acquiesced, seemed
> like a classic Republican mistake: a triumph of social-conservative ideology
> over science.
> This complaint is right -- but should not be exaggerated. Most of the U.S.
> AIDS budget goes toward treating people and caring for the dying and
> orphans. Abstinence and faithfulness teaching consumes only 7 percent of the
> total, and an unknown fraction of that is constructively combined with
> teaching about condoms. The critics cite a few wacko preachers who have
> received U.S. money even though they proclaim that condoms don't work, and
> the Government Accountability Office has described how the abstinence
> earmark complicates the work of front-line AIDS groups. But it's wrong to
> paint the entire Bush AIDS program as a Christian-conservative plot when the
> abstinence-only stuff is relatively limited.
> The most serious criticisms of the Bush AIDS program are that it involves
> too little collaboration with local governments and fellow donors and that
> pouring millions into AIDS sucks health workers away from other vital
> diseases. But even these criticisms can go too far. When the Bush program
> was set up, the noncollaborative approach was a way to get results quickly;
> now, by some accounts, collaboration is improving. In the early stages,
> equally, pouring money into AIDS programs was bound to siphon health workers
> away from other things. But there's talk that the administration may correct
> this problem, maybe by launching a program to train community health workers
> in poor countries.
> It's not that the Bush program is perfect, and it's not that the
> administration is the lone hero of the AIDS crisis. The Global Fund to Fight
> AIDS, Tuberculosis and Malaria, which was set up just four years ago, has
> channeled $5 billion toward those diseases; the Bush team should acknowledge
> its contribution less grudgingly, especially since the United States
> provides 30 percent of the fund's resources. Yet the bottom line is that the
> administration has faced up to a killer that's taken 25 million lives in the
> 25 years since its discovery. There's much more to be done -- 5 million more
> people get infected every year. But if you want to denounce rich countries
> for their negligence, the United States is the wrong target.