The Long Emergency

Barack Obama's administration is taking an expansive, ambitious approach to global health. Does that mean giving up on combating HIV/AIDS?

Is AIDS still an emergency?

How you answer that question probably says a lot about whether you think U.S. President Barack Obama's approach to fighting HIV/AIDS abroad is a good idea or a dangerous detour.

In recent weeks, a growing number of organizations have stepped forward to criticize the Obama administration for allegedly backtracking on a global health battle the world was starting to win. Groups as diverse as Médecins Sans Frontières and the Congress of South African Trade Unions argue that Obama is flat-lining funding for lifesaving anti-retroviral (ARV) treatments, just as the financial crisis is biting hard at other international funding too. They worry that the world could start to lose momentum, failing to keep up with the epidemic's alarming advance.

The U.S. administration counters that more money than ever is going into global health -- it's just no longer myopically focused on HIV/AIDS. The United States responded to the HIV/AIDS emergency a decade ago, the policy's defenders say; now it's time to take a broader, more sustainable approach that can eventually move patients away from their reliance on the United States. As congressional appropriations come up for 2011, battle lines are being drawn.

The fact that this debate is even taking place is a credit to the unsung legacy of a man global AIDS campaigners never expected would be their biggest ally: George W. Bush.

Bush's plan for combating the disease, called the President's Emergency Plan for AIDS Relief (PEPFAR) was an astounding success, exceeding all hopes. When his administration launched the program in 2003, HIV/AIDS was ravaging the developing world, taking the harshest toll on Africa. In some countries in southern Africa, as many as one in four were infected. Public awareness about infection and prevention was minimal, and ARV treatments, which help suppress HIV in infected patients, were scarcely available outside the West. The death rates were staggering -- 8,000 a day worldwide -- picking off adults in the prime of their economic lives and robbing countries of able-bodied workers.

PEPFAR was nothing less than a breakthrough. Bush offered $2.4 billion in its first year alone, pumping funds into preventing the disease through an ABC approach (Abstinence, Be faithful, use Condoms), testing patients for HIV infections before they spread, and treating patients with ARV drugs. Today, about 2.5 million people receive ARV treatment through PEPFAR -- more than half of the global total of patients on ARV treatment.

It was also a breakthrough politically. By focusing heavily on treatment, liberal and conservative members of Congress dodged the political flashpoints of abortion and condom use and forged an overwhelming consensus of support. "The United States is doing far more for Africa today than a decade ago largely because evangelicals became a strong constituency for the Pepfar AIDS program and the PMI malaria program," New York Times columnist Nicholas Kristof explained in February. With the Bush's firm backing, PEPFAR also avoided the kind of slow, cumbersome bureaucracy that has long held back the U.S. Agency for International Development, for example, and became one of the single most efficient aid efforts of the last half-century.

When the Obama administration came into office, PEPFAR's success was clear. But there were also two big concerns: how sustainable the program would be in the long run, and whether it was too narrowly focused, when much of the mortality in the developing world is not related to HIV. "We're in a constrained environment with people asking tougher questions about health impacts from the dollars invested," said J. Stephen Morrison, director of the Global Health Policy Center at the Center for Strategic and International Studies. "The desire is to move into a greater emphasis on health systems ... taking a strategic look over the long term rather than short term."

A paper co-written by Ezekiel J. Emanuel, now a senior advisor at the White House, for the Journal of the American Medicine Association seemed to crystallize the point (though an administration official denied that it was alone in motivating a policy shift). "[D]oubling or tripling PEPFAR's funding is not the best use of international health funding," the authors argued, questioning Bush's 2007 call for Congress to double U.S. HIV/AIDS funding. "By extending funds to simple but more deadly diseases, such as respiratory and diarrheal illnesses, the US government could save more lives." They offered a dramatic example: For the amount now spent on ARV treatment, 44 million children could be vaccinated against "diphtheria, pertussis, polio, tetanus, and measles," and their families could receive insecticide-treated bed nets.

The Obama administration's answer to these concerns was the Global Health Initiative, a $63 billion "whole-of-government approach" unveiled in May 2009 that took PEPFAR under its umbrella and shifted the focus from HIV/AIDS to including malaria, tuberculosis, maternal health, child health, nutrition, family planning and reproductive health, and neglected tropical diseases, according to the program's initial consultation document. On HIV/AIDS specifically, that has meant a greater emphasis on prevention, in addition to treatment. "I believe everyone agrees that we can't treat our way out of the HIV/AIDS epidemic," the U.S. global AIDS coordinator, Ambassador Eric Goosby, told Foreign Policy. The new program also implies giving local governments a bigger share of the stakes, getting them on board for the long haul so that patients are not dependent on U.S. funding.

"I don't think I'd describe it as a shift, as much as an expansion," a senior White House official explained. "We took a look at the foundation that had been laid by President Bush ... and asked ourselves: How can we build on this and get greater outcomes? Our conclusion was that the HIV and AIDS piece is critically important, which is why it will remain the largest piece by far, but that in order to address the global health deficit, we have always got to be able to do some other things."

But the administration's plan set off alarm bells within the HIV/AIDS advocacy community. The president's fiscal year 2011 budget proposal increased PEPFAR funding 2.3 percent -- an amount that activists claim is tantamount to a cut because the infection rate and inflation dwarf it. At a Feb. 11 House committee hearing, Peter N. Mugyenyi, executive director of the Joint Clinical Research Centre in Uganda, said that "the twin realities of the economic crisis and flat-lining of funding for PEPFAR threaten to reverse ... positive changes and miss opportunities to defeat the epidemic." He continued, "We are forced to turn away desperate patients daily." Weeks later, nearly 300 health professionals wrote to Rep. Nita Lowey, who chairs the House Appropriations Committee's State, Foreign Operations, and Other Programs Subcommittee, warning, "We cannot retreat from the lifesaving mission we as a nation embraced in 2003 through the creation of the PEPFAR program." The letter continues, "The President's FY 2011 budget reflects such a retreat."

Then, on May 27, Médecins Sans Frontières (MSF) released a report that warned of a decline in political will to fight the disease. Emi MacLean, the U.S. director of MSF's Access to Essential Medicines Campaign, told me the U.S. government had taken on "both the ethical and financial responsibility for patients enrolled under PEPFAR -- which is something that the U.S. government wants to step away from now." Additional concerns were raised about a $50 million budget cut for the Global Fund to Fight AIDS, Tuberculosis and Malaria, a multidonor vehicle that funds projects across the developing world. The New York Times followed the MSF report with dramatic reporting from the field, describing the growing number of patients turned away from treatment and prompting swift rebuttals from the administration that it was not, in fact, backing away on HIV/AIDS.

The administration has a strong case. It plans to scale up ARV treatment to 4 million people in the coming years, nearly double the current total. Getting countries invested in their own health systems, as PEPFAR's strategy aims to do, is certainly the best long-term way to ensure that patients have access to treatment. And on top of AIDS, who wouldn't love to see malaria, tuberculosis, and diarrheal diseases stop killing the millions that they do each year?

The only trouble is that there's really no guarantee that it will work. "Building health systems" is essentially what the development community has been trying to do for decades. Billions of dollars in aid and decades later, bilateral, multilateral, and private aid to the developing world has -- with notable but few exceptions -- failed to create health systems in poor countries that can respond to crises of the magnitude of HIV/AIDS.

"In the 1970s and the 1980s, people were saying we need, one, economic growth and, two, to build [health] systems. And then once we have that, we have all the elements; therefore we have health -- you know, as a consequence," Michel Kazatchkine, head of the Global Fund, told me. "But that doesn't work, and it didn't work. That's how we failed to respond to the AIDS crisis, and that's how we kept malaria a neglected disease."

The administration official disagreed. "PEPFAR showed you can fix the supply-chain problem -- that you can deliver complex treatments in rural areas and can train people to deliver these kinds of interventions," the official told me. "We have more experience than we have in the past in developing health systems."

Still, in the case of PEPFAR, many wonder if it is wise to fix something that wasn't really broken, especially in Washington, where the politics of health were always delicate. A State Department official put it to me this way: "The key to all this [stopping HIV/AIDS] is prevention, but [PEPFAR] was pragmatic enough to know that it's the absolute epicenter of all social and moral debates, and we could not allow that to get in the way of providing efficacious medical care."

The Obama administration's renewed focus on maternal health and family planning could, some fear, put that consensus on the rocks. (One Hill staffer told FP, "Hopefully people have learned some things over the last couple of years, and we won't find ourselves bogged down in debates like that.") Either way, however, some in PEPFAR are feeling marginalized, according to a former State Department official -- no longer enjoying the same freedom from bureaucracy to do their work.

On the ground, too, there are real concerns. Many argue that the proposed shift to more long-term care simply comes too soon. Kazatchkine and MSF, among others, say that we are still in the emergency phase of the epidemic and treatment should still come front and center; administration officials disagree. The Obama administration has not proposed dollar cuts in PEPFAR funding, but the pace of funding increases has slowed -- a trend that began with the Bush administration.

So, is HIV/AIDS still an emergency or not? Unfortunately, there are 33 million people around the world whose lives depend on the answer. And the trouble is, the answer is neither "yes" nor "no"; it's "both." On the one hand, three decades after the first cases of HIV, infection is no longer a death sentence. Treatment is increasingly available; mothers with HIV can give birth to virus-free children; awareness is up; and societies are finally coming to grips with the crisis.

On the other hand, the emergency could come back at any moment, and many fear it will if treatment stops. If the absolute number of patients on ARV treatment stays constant but the epidemic grows, the ranks of untreated patients could soar to dangerous levels, with potentially devastating consequences for their health, their families, and their societies.

Prevention is certainly key to bringing down those numbers. Yet the funding choice between preventing and treating is a false one. For starters, there is a preventive aspect to ARV treatment; a recent study cited by Joanne Carter, executive director of Results, an anti-poverty advocacy group, in her March congressional testimony found that ARV treatment lowered risk of infection 92 percent in discordant couples -- ones in which one partner is HIV positive and the other is not.

The prevention benefit goes further. "When you find out you are HIV positive, you have two choices," explains Joseph Amon, head of the global health program at Human Rights Watch. "You can do something with that knowledge -- and what people want is to get treatment and feel like they are being supported -- which leads to behavior change. The other option is to find out you're positive, but we don't have any drugs available for you, so come back in a few years. That doesn't lead to behavior change." One aid worker in Nigeria echoed that concern: "If we test 185,000 people [this year for HIV] and we find 7,400 positive [but have less than half that many treatment slots], what are we going to do with them?"

The gap between U.S. ability and patient needs is one reason that the administration has emphasized a need to get other donors on board, in addition to local governments. The $50 million cut to the Global Fund, however, has been met with concern by the same groups that have criticized Obama's global-health policy, and Kazatchkine calls it "a big test for the multilateralism and the move to multilateralism for the administration."

The bigger test will be whether Obama's health initiative can really build the environment that would be conducive to a shift from emergency to long-term HIV treatment, strengthening health-care systems where many have tried before and failed. In an ideal world, there would be enough money to fund both emergency and long-term solutions. But here's the truth: There isn't. So this was an inevitable juncture: A global recession, constrained budgets across the developed world, and a simple realization that treating HIV/AIDS is expensive have forced the U.S. government and other governments to answer hard questions about how their dollars will be spent. If Obama can make those hard decisions and manage the transition from emergency to long term, the fight against HIV/AIDS will be on a more sustainable footing. A wrong turn, however, could endanger the incredible gains made in recent years. And that's what advocates fear most of all.


The David Petraeus I Know

The general’s former executive officer tells FP what to expect in Afghanistan.

From February 2007 to May 2008, Peter Mansoor was Gen. David Petraeus's right-hand man in Iraq. Now a retired U.S. Army colonel teaching at Ohio State University, Mansoor worked closely with Petraeus as the general's executive officer, assisting with the implementation of the "surge" strategy and preparing his congressional testimony -- including the grueling hearings in September 2007 that Petraeus later said were "the most miserable experience of my life." FP senior editor Benjamin Pauker caught up with Mansoor in the wake of Petraeus's dramatic nomination to take over command of U.S. forces in Afghanistan from Gen. Stanley McChrystal, who was fired by President Obama in the wake of a Rolling Stone profile gone wrong.

Mansoor describes his former boss as "a very hard man to keep up with" who will do whatever it takes to succeed. As for the mission, Mansoor worries about a divided team on the ground, declining morale among U.S. soldiers, and a poor understanding of counterinsurgency warfare. "Hearts and minds have nothing to do with it," he says. Excerpts:

Foreign Policy: Having served under Gen. David Petraeus, how would you describe him as a leader?

Peter Mansoor: General Petraeus is a very focused, intelligent leader. He drives himself hard and he expects the people around him to put everything they have into the mission. And he also cares for the people around him. He takes care of them, both in the current assignment and future assignments. He is a very competent leader, and that's what he looks for in the people around him. My experience was very positive. He's a very hard man to keep up with [laughs] given the pace he keeps. It was very refreshing to be around an intelligent leader who was in this war to win it, and not just managing his way through the conflict.

FP: How is his health?

PM: He had a bout with prostate cancer, which was treated with chemotherapy, and supposedly that has been completely cleared. Then there was the episode where he fainted when talking to the Senate Armed Services Committee. I don't think it was so much exhaustion as it was coming back from a long, overseas trip where he was dehydrated already, given the plane travel; he was suffering from some sort of bug, and then he failed to eat breakfast the morning of the hearing and didn't drink anything, because as you know -- or maybe you don't [laughs] -- they don't give you bathroom breaks during those Senate hearings. As a result, he was dehydrated, lacked fluids, hit a wall, and fainted.

FP: Is there a concern about his stamina given the requirements of the job?

PM: No, General Petraeus has done more than any other general -- maybe except for Stan McChrystal -- to ensure that he keeps in good shape. He's very attentive to his health. Of course, this is going to be very difficult for his family; this is his fourth combat tour since 2003 -- and two of them were at the four-star level -- which is very psychologically and mentally challenging. So this is not going to be an easy assignment. But physically, he'll be up to the task. It will be important for the folks around him to make sure that he gets the sort of rest and exercise needed to keep him mentally engaged at a top level.

FP: What kind of hours does he keep?

PM: This was part of my role, because his natural instinct is to drive himself into the ground and, as his executive officer, I worked to readjust the battle rhythm to make sure he got eight hours of sleep a night, and that he got to run and do physical training at least three times a week. These are the kinds of things that keep a senior commander going. You could just see him emerge refreshed in the morning, after he had a good sleep or a nice run. It would help the clarity of his thinking.

FP: Do you think General McChrystal's reported four hours of sleep might have affected the clarity of his thinking?

PM: You know, he's a different person, so I can't really speak for General McChrystal, but I do know that General Petraeus did much better when he had eight hours of sleep.

FP: As you've said, it's not an easy assignment. Certainly, Iraq wasn't easy either, but if anything, Afghanistan seems even more complex.

PM: People tend to forget just how complex and difficult Iraq was at the end of 2006. The success of the surge was not preordained. Those who say the Afghanistan war is lost without even implementing the chosen strategy fully reminds me of a comment by Sen. Harry Reid in April of 2007 when he said that the surge has failed and the war is lost, when we hadn't even gotten all the surge troops on the ground yet. I think we're at the same stage right now in Afghanistan. The surge troops haven't arrived and the operations in Kandahar haven't yet begun. It's also unclear what sort of relationships General Petraeus will be able to build with President [Hamid] Karzai and the other leaders in the region. So, I think it's far too early to tell. We'll be in a much, much better position in July 2011 to determine how the strategy has succeeded or not and then to determine the way ahead, whether that be a drawdown, as is currently planned, or something else.

FP: In terms of troop levels, it's widely known that McChrystal wanted more than the 30,000 that have been allocated in the surge. Does General Petraeus think that that's a sufficient number, or is he likely to use his leverage with the Obama administration to push for even greater numbers?

PM: It would be very unlikely at this point, I think, for General Petraeus to say, ‘Well, the strategy that I helped formulate now needs more resources for its execution.' It could happen, though. I mean he could get on the ground and realize, as we did in [in Iraq] in January 2007, that things were much worse than he had realized. But he has had a number of trips to the region and he's had constant contact with General McChrystal, so I think it'd be highly unlikely that he would ask for more troops.

FP: Some people have called for General Petraeus to come in and make a clean sweep of the team that was around McChrystal. Do you have any sense of who he will bring in?

PM: You know, they're all folks well under the radar. I don't think there'll be any famous names in there. But again, what I think he'll do when he gets to Afghanistan is forge relationships with the folks that he needs to forge relationships with, and that includes Hamid Karzai, it includes Ambassador [Karl] Eikenberry, and he already of course has a relationship with Ambassador Holbrooke, which, by all accounts, is fairly good. I think President Obama should be very clear that if the team can't work together that more changes will be made. He's already made the change in the military side that would suggest that if Ambassador Eikenberry is not supportive, or if the president feels that Ambassador Eikenberry's relationship with Karzai is damaged to the point where he's ineffective, he may have to change him out.

FP: As Petraeus takes over command, what do you think some of the critical factors are in turning the war around and making sure the strategy can be successfully executed? If you could point to three things, what would they be?

PM: I think the first thing would be developing a solid relationship with Hamid Karzai, and a solid relationship with Ambassador Eikenberry, or whoever fills that position. It is that triumvirate -- the U.S. ambassador, the senior military commander on the ground, and the president of the host nation -- that have to develop the kind of relationship that will lead to success and unity of effort in the counterinsurgency we are waging.

The second thing is that he has to continue to engage the Pakistanis. He has forged relationships with them already, and he should leverage those to ensure the Pakistanis do whatever they can to reduce the insurgent sanctuaries along the Pakistani side of the border. As long as those sanctuaries exist, the Taliban will have a life left.

And then the third thing I would say is that he needs to reinstill confidence in the troops: confidence in the strategy, confidence in the leadership. I think one quick thing he could do is to readdress the rules of engagement. The rules should be permissive enough to allow the troops to fight the enemy while being very cognizant of collateral damage. But perhaps the pendulum has swung too far in the direction of risk aversion and as a result we're not engaging the enemy effectively. I think the troops sense that, which is why we saw those comments by the platoon in Rolling Stone, and I don't think you can ignore them just because they're in a magazine .

FP: Have you gotten a sense that there is a morale issue for U.S. troops in Afghanistan?

PM: I think there is. The folks coming back from the region tell me they feel like their hands are tied; they capture insurgents and they have to free them for lack of substantial evidence. We're not keeping people locked up. At the height of the surge in Iraq, we had 25,000 people in our detention facilities. We have less than 1,000 in Afghanistan. That doesn't make sense to me. The troops feel as though their hands are tied in terms of the use of firepower. That's going to be part of a natural pushback to the rules of engagement, but part of it might be an accurate description of commanders who are too risk-averse. It's very difficult for soldiers to go into combat and then feel as though they don't have the tools to do the mission, and rules of engagement are one of those tools.

FP: That brings up an interesting point. Is there a concern that this is becoming more of a drone war rather than by troops on the ground? Much of the surge in Iraq was successful because there were troops in neighborhoods. There was a presence on the ground that people felt.

PM: And by the way, there was also a lot of fighting! Folks forget that 2007 was the bloodiest year of the Iraq war. And now we get comments from troops preparing to go into a village along the lines of, ‘OK, we're going to go into that village and do some of that COIN shit.' That shows a fundamental misunderstanding of counterinsurgency warfare and the role of security operations within it.

FP: Does that mean there's a sense that COIN has become too civilian-focused? They're just playing too nice?

PM: No, just the sense that counterinsurgency is nothing more than handing out goodies to the population and trying to win their hearts and minds -- and really, hearts and minds have nothing to do with it. It's about earning the trust and confidence of the people and controlling the population so that the insurgents can't survive among them. And I don't know what we've done to control the population in Afghanistan. We certainly have not instituted measures to the extent that we did in Iraq with the extensive blast barriers, checkpoints, and biometric identity devices. We haven't held a census. There's a lot of standard counterinsurgency tools we haven't deployed in Afghanistan, and until we do, we are not going to be successful. Some of them are going to be disagreeable to the population but we have to go there or we're going to lose the war.

FP: As his former executive officer, would you consider joining General Petraeus again, if he asked?

PM: Well, I'd have to consult with my family but it'd be an honor to work with General Petraeus again. Again, he surrounds himself with really talented people, and I'm sure he'll make a clean sweep of General McChrystal's personal staff and bring in his own team from Tampa. So, I doubt they'll need someone off the bench from Columbus, Ohio.

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