Big spending on AIDS seen as go-it-alone plan
By John Donnelly, Globe Staff, 1/30/2003
But activists said the proposal also suggests that the United States wants to act unilaterally and does not trust global coalitions.
Advocates said they were pleased that for the first time the administration wanted to move beyond pilot projects and spend large amounts of money for treatment in 14 African and Caribbean countries.
As details of the AIDS plan began to emerge yesterday following Bush's announcement in his State of the Union address, US officials said the five-year initiative includes $10 billion in new funds, starting with $2 billion in the budget year that begins in October. Half of the new money will be spent on treatment.
A third of the money would be spent on prevention - including programs that teach abstinence and provide condoms - and about 15 percent for care. Previously, the US government has spent several billion dollars on AIDS globally in the last two decades, but only a few million dollars on small treatment programs.
''What this does is to take AIDS from being a secondary concern, barely scraping along, to a potentially tide-turning approach,'' said Dr. Nils Daulaire, president of the Global Health Council. ''I think the formal recognition by the president that treatment and care need to work hand in hand with prevention will do a lot to take off the table the endless and fruitless arguments over the last few years.''
But the president's initiative would put 90 percent of the money into projects directly administered by US agencies, rather than work more closely with international groups, such as the Global Fund to Fight AIDS, Tuberculosis, and Malaria, which would receive about $1 billion under the plan.
That decision was criticized by health and development officials as a missed opportunity to use Washington's new commitment to leverage more funds from the European Union countries and Japan.
''The sheer ambition of this, the size of it, is fantastic and truly scales up the response to AIDS,'' said Mark Malloch Brown, administrator of the United Nations Development Program. ''The trick for the United States is that if it wants to leverage its money and get the world to spend $10 to $12 billion a year on AIDS, you can't do it unilaterally.''
Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, told reporters in a conference call that the administration favored controlling the bulk of the money.
Some US officials question the effectiveness of international organizations, but Fauci offered no criticism yesterday. ''By no means are we downplaying the Global Fund, but we are putting an extra strong emphasis in this case on bilateral intitiatives,'' he said. ''We hope that we will see other countries give additional funding to the Global Fund.''
Anil Soni, a senior official at the Global Fund, said he hoped that the $1 billion US contribution would spark giving by others. He also added pointedly: ''We have no expectation that $1 billion to the Global Fund is a ceiling. It is a starting point, and a strong point to begin.''
Complicating the issue yesterday was a US delegation's effort in Geneva to elect Health and Human Services Secretary Tommy G. Thompson as the new board chairman of the Global Fund. While two senior US officials lobbied for Thompson's candidacy, a Swedish official, Lennarth Hjelmaker, challenged him.
The vote is set for tomorrow. ''There's a worry that there will be a very negative reaction from the US if Thompson is not elected to be the chair,'' said one board member, speaking on condition of anonymity.
Analysts said the issue of who spends the money is of great consequence, because much of the battle against AIDS and other infectious diseases, like worldwide efforts to eradicate smallpox and polio, depends on detailed plans in each district of each country. With multiple donors and their demands, governments of poor countries are often overwhelmed in their attempts to coordinate programs.
The other major concern expressed by activists yesterday was the selection of the 14 countries, which was the same list of nations presented last year by the administration, to fund programs to prevent transmission of the disease from mother to child. That $500 million program has not yet begun, because the funding has not yet been approved.
US officials said yesterday that the bulk of the new money would go to these 14 countries, which they said represented 50 percent of the HIV or AIDS cases globally. Around the world, 42 million people are infected with the disease, 70 percent of them in sub-Saharan Africa.
But 36 sub-Saharan African countries were excluded from the list, including four with some of the highest infection rates in the world: Zimbabwe, Lesotho, Swaziland, and Malawi. The countries that will receive money are Botswana, Ivory Coast, Ethiopia, Guyana, Haiti, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, and Zambia.
''To get the kind of strategic approach to fight AIDS, to get the real global effort, begs the question of what about the other countries,'' said Malloch Brown, who pointed out the absence of Malawi, India, and China.
US officials, however, said that they wanted to put money in the countries best prepared to rapidly develop large-scale prevention, care, and treatment programs.
Senior officials have been working on the AIDS initiative since last fall. Secretary of State Colin L. Powell played a major role by seeking an increase in AIDS funding by arguing that the disease would prove to be more important than the battle against terrorism. Fauci also assumed a defining role, as did the new Senate majority leader, Bill Frist of Tennessee.
Five other administration officials quietly crafted a blueprint for the president, aides said.
On Nov. 13, in Room 248 in the Old Executive Office building, next to the White House, the group of five hosted a key meeting for three hours with outside specialists. The officials were Joshua B. Bolton, White House deputy chief of staff; Robin Cleveland, head of national security and international affairs at the Office of Management and Budget; Gary Edson, deputy national security adviser; Joseph O'Neill, head of the White House Office on AIDS; and Jay Lefkowitz, deputy assistant to the president for domestic policy.
They brought in people who knew how to treat AIDS patients in the poorest of countries. ''There were years of experience and thousands of AIDS patients represented in that room,'' said Daulaire, who was among the specialists consulted by the White House.
Other specialists included Paul Farmer, head of the Cambridge-based Partners in Health, which has put together a strong record of treating AIDS patients in Haiti; Jean William Pape, a Cornell medical professor who has been treating AIDS patients for more than 15 years in Haiti; Peter Mugyenyi, the special guest of Laura Bush during the State of the Union address, who has been treating AIDS patients in Uganda; and Eric Goosby, a senior AIDS official in the Clinton administration.
The outsiders, all doctors, said that treating AIDS in poor countries could now begin in earnest.
''It was clear at that time they decided they needed to do something big, and it needed to have a treatment focus,'' Goosby said. ''The talk focused on whether there was enough medical infrastructure for us to be successful at it, and also whether we have to go through countries only, or whether [nongovernmental organizations] are capable of having a direct relationship with the US. The consensus was that the NGOs could have a direct relationship and receive money directly.''
Goosby and other participants said the administration understood the need for a long-term pledge. ''They understood that you can't pull people off treatment after two years,'' Goosby said.
Administration officials rushed to put the plan together before Bush's previously scheduled trip to Africa this month. When the trip was canceled, there was little word about the initiative until recent days.
John Donnelly can be reached at firstname.lastname@example.org. Material from the Associated Press was used in this report.
This story ran on page A1 of the Boston Globe
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