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Is America Losing Its ‘Big Heart’?

While visiting Bangkok this month to attend my third consecutive International AIDS Conference, I met a kind Thai woman who gently asked me where I was from. I responded that I was from America. She immediately declared with a deep enthusiasm, “America Has a Big Heart!” While I nodded in agreement, I really wanted to share with her my perplexed feelings about America’s response to the AIDS epidemic=

I wanted to say to her that many Americans do have big hearts, but unfortunately a few powerful Americans have lost their way. Being witness to the actions of our leaders at the Bangkok AIDS conference, I was once again struck and surprised by the missed opportunities for America and wondered if we could ever regain our credibility.

Last year, the Bush administration announced a five-year, $15 billion initiative to address the HIV/AIDS pandemic. The President’s Emergency Plan for AIDS Relief (PEPFAR) was a welcome – and long overdue – step forward in bringing American leadership, know-how and funding to bear on a disease that is now killing over 8,000 people each day. Unfortunately, I guess it’s one step forward, and two steps back, as the quantity of funding we bring to the table is not matched by the quality of our policies and programs.

At his opening press conference in Bangkok, Ambassador Randall Tobias, Bush’s AIDS czar and former CEO of Eli Lily pharmaceutical company, stated that America was ready to work together with everyone. He said he hoped that we could all stop fighting amongst ourselves and join together to start fighting AIDS. Sounds fine! However, actions speak louder than words, and “working together” does not seem to be this administration’s operating style.

Earlier that day I had met with the head of the National AIDS Commission in a country where Bush’s Emergency Plan for AIDS Relief was now in operation. This local leader reported that his government had never been consulted about joining the “President’s Plan”; instead, his government was simply informed in January of this year that they were the beneficiaries of grants approved in and by “Washington.” No consultation, no local perspectives, and no local ownership. This local leader and many others at Bangkok reported similar examples of American arrogance, but most were too fearful to talk on the record.

The lack of local consultation – and the Bush administration’s adherence to rigid ideological canards like “abstinence-only” – has meant that the content of the PEPFAR funding rarely accords with local realities and needs. For example, AIDS statistics reported at Bangkok highlighted the enormous impact of AIDS on women, who now make up the majority of those infected in Africa. In response, there were calls for expanding women-controlled prevention approaches, such as microbicides, and other strategies to empower women to prevent infection by men who commonly have multiple partners and dominate sexual relationships.

In a bizarre and bewildering disconnect with the facts presented at Bangkok, Bush’s team unashamedly and aggressively defended abstinence-only programs as the way forward for prevention programs. Not surprisingly, they didn’t present any scientific evidence that these programs are effective in reducing HIV transmission, nor did they explain how abstinence-only programs will work for the young married women who are now most affected by the epidemic.

The conference theme of “Access for All” focused much of the attention on ensuring widespread access to lifesaving anti-retroviral AIDS medicines. The World Health Organization (WHO) reported that only 440,000 people of the 6 million in immediate need in poor countries are currently getting treatment. To meet this need, WHO has developed a safe and effective process to screen and approve generic drugs, which cost less than a fourth of the cost of the brand name pharmaceuticals required by the United States. At the conference, scientific evidence was reported that confirmed that generically manufactured AIDS medicines are safe and effective and are being used by UNICEF, the World Bank, the Global Fund, the host countries for Bush’s emergency plan, and leading non-governmental organizations like Doctors Without Borders.

Despite these scientific facts and reports of programmatic success, the Bush administration continues to undermine WHO and its drug approval process. It has insisted on setting up its own parallel “fast track approval process” at the FDA, and will not allow any U.S. funds to be used for the purchase of generic drugs until and unless they are proven “safe” by the FDA. When Tobias was asked how many branded or generic drugs have been approved by the new FDA process, the answer was “none.”

At the last International AIDS Conference in 2002, there was a clear consensus among public-health experts that pooling technical and financial resources was necessary to create an effective global response to AIDS. Public, private, and civil society stakeholders joined together to create a multilateral partnership called the Global Fund to Fight AIDS, Tuberculosis and Malaria. Since then, the Global Fund has approved $3 billion in grants in 128 countries. Many of its initial grants have performed better than expected, and the demand for additional funding has risen accordingly.

Nonetheless, the Bush administration prefers a go-it-alone approach on par with our approach to Iraq and global warming. Despite calls for increased U.S. support for the Global Fund from Kofi Annan, Nelson Mandela, the leaders of some of the worst-affected countries and people living with AIDS, Tobias made it clear that this “was not going to happen.” Needless to say, this go-it-alone attitude stunned delegates and exacerbated the existing undercurrent of anger and frustration about America’s role in the world.

I’m proud of America’s good heart, but with the current leadership in Washington, that heart is not beating in sync with the rest of the world. The cost is not only the good will and credibility of the United States with the rest of the world, but millions and millions of lives.

Dr. Paul S. Zeitz is the executive director of the Global AIDS Alliance.

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