The Optimist

Doing More with Less

Dwindling funding for the global fight against AIDS doesn't mean the battle is lost -- but it does mean we have to think about what we're getting for our money.

Last week, the Global Fund, the world's largest multilateral source of financing for the fight against AIDS, made a grim announcement: its donors had cut their funding by $1.6 billion, a big enough bite out of the organization's budget that the fund would be bankrolling no new AIDS treatment projects until 2014.

The announcement casts a pall on the international community's observance of World AIDS day this week, an occasion on which, the Global Fund's problems notwithstanding, we have a great deal to celebrate.  Never before have we had the abundance of tools to fight the global AIDS epidemic that we have today. Male circumcision has proven a powerful means of reducing infection -- a free circumcision service offered in South Africa's Orange Farm township, for example, reduced HIV prevalence there by 55 percent. An article published in the New England Journal of Medicine suggested that putting HIV-infected patients on antiretroviral drugs immediately after they were diagnosed dramatically reduced the risk of infecting their partners. Looking forward, although hopes for the impact of a microbicide gel to reduce infection amongst women appear dashed -- at least for the moment -- early stage HIV vaccine trials have shown 90 percent success.

Meanwhile, 33 developing countries have seen annual rates of new HIV infections drop by a quarter or more from their peak. From 2006 to 2010, the number of people in developing countries on antiretroviral drugs tripled to over 6 million. Costs for those drugs have come down markedly; antiretrovirals that went for $1,100 a year in 2004 can now be had for $335. The annual death toll from the disease plateaued in the middle of the last decade and has since begun to drop. Between 2002 and 2006, AIDS mortality in Kenya fell by 29 percent.  These breakthroughs give new hope in the struggle against a disease that has devastated some of the world's poorest countries, killing 30 million people and infecting 30 million more worldwide.

But the breakthroughs don't amount to a global reprieve -- and last week's reminder of the perennial uncertainty surrounding the resources available to fight the epidemic, on top of news that donor funding for HIV/AIDS leveled in 2009 and then declined 10 percent in 2010, should be a wake-up call to focus on cost-effective responses.

Doing that requires getting our balance of treatment and prevention right. Because for all the promise of recent advances, we are not expanding treatment rapidly enough to cover the newly infected. For every new recipient of retroviral drugs, two people get infected. And while costs of treatment are dropping, they are not doing so fast enough. Today, as much as four-fifths of the cost of AIDS treatment in developing countries goes not to the drug but to the staff, health system administration costs, and testing necessary to deliver it -- costs that are harder to reduce with a technological breakthroughs.

Meanwhile, health economist Mead Over, my colleague at the Center for Global Development, suggests that even if the money were found to start everyone who tested positive for HIV on an early course of retroviral drugs, under even the rosiest of scenarios the number of people living with AIDS in Africa would continue to rise until 2046 -- as would the costs of treating them, which would hit $60 billion a year. That's nearly equal to total aid flows to Africa in 2010. In fact, according to OECD statistics, AIDS and other reproductive health services already suck up more aid money than all other health spending combined in Sub-Saharan Africa -- and they aren't delivering the biggest health bang for their buck.

For a start, AIDS prevention is not only better than treatment, it is cheaper, too: Mead Over estimates that adult male circumcision costs about $42 per year of life saved from lower HIV infection rates, compared to $780 per life year saved by antiretroviral treatments. Or compare AIDS programs to other underfunded health priorities in the region. The World Bank estimates that additional vaccination coverage against diseases like measles, tuberculosis, or diphtheria in Africa costs from $1 to $5 per life year saved. For bednets and mosquito nets used to fight malaria, the figure is between $2 and $24.

That's not to say AIDS funding should be reduced: there should be more resources for both AIDS and other health emergencies in Africa. And regardless, it is not clear that money dedicated to AIDS would be redirected to other health issues; to some extent treatment money is anchored by the implied commitment on the part of the U.S. government and other donors to continue funding in order to cover the treatment costs of those currently receiving drugs. If not for that anchor, there is little reason to assume funding wouldn't be withdrawn as part of general budget cuts.

Nevertheless, it does suggest the urgent need to focus resources on the combination of interventions that will allow for what Over calls an "AIDS transition," in which the number of new infections falls below the number of AIDS deaths, so the number of people on treatment --and the cost of that treatment -- starts to drop. He reports that Rwanda may be an early success story in that transition: 94 percent of those who are known to need antiretrovirals are being treated, while the rate of new HIV infections has dropped below AIDS deaths in 2007 and 2008. In part that's thanks to active counseling, near-universal testing of partners of people infected with HIV, and ubiquitous testing of pregnant women.

If we can't rapidly achieve a similar transition worldwide, we may have to start contending with painful tradeoffs. Researchers at the University of Cape Town have discussed the idea of choosing between "comprehensive treatment to fewer patients or universal access to a more limited package of benefits" -- limits might include only providing access to the cheapest antiretrovirals, limiting laboratory testing, and deploying nurse-driven rather than doctor driven treatment, for example.

Without a lot of additional money -- and that doesn't look likely any time soon -- each new person put on treatment takes resources that could be used to stop additional people getting infected in the first place, through programs like cash payments to girls who remain in school, for instance, or funding free adult male circumcision. It is an unquestionably grim choice to have to make, but prioritizing prevention is the best way to do the most good for the most people.


The Optimist

Counting Our Blessings

From Twitter to vegetarianism, 10 things to celebrate this Thanksgiving.

It's been a tough year, and one in which a lot of people around the world might be struggling to find things to be thankful for. In the United States, unemployment remains stubbornly high, growth stubbornly low, and good sense on Capitol Hill stubbornly absent. European debt, meanwhile, looks about as secure as a Las Vegas mortgage. But look more broadly at the state of the world and there's a lot going right -- so give that thanks and pass the gravy.

1. Let's start with the good news … for turkeys: Vegetarianism in the United States may have expanded by as much as two-thirds since 2009. As many as 5 percent of Americans now claim they don't eat meat. From a fowl's perspective, the cloud to that silver lining is that Americans are eating less red meat and more poultry. But the last 20 years have seen meat consumption per capita plateau in developed countries around the world, according to research from the National Institutes of Health. And some of the biggest and fastest-growing developing countries remain comparatively safe places for a gobbler: Forty percent of Indians, for instance, don't eat meat. That's good for the rest of us as well, of course -- in an age where we are trying to use the same land and fewer resources to feed a larger and more affluent global population, a diet that switches out meat for the stuff meat eats is one of the most effective tools we have.

2. People are healthier than ever. According to World Bank data, roughly two million children born this year worldwide will live to their fifth birthday who would have died were mortality rates what they were 10 years ago. And this year has seen further progress in the fight against child mortality -- not least in the effort to vaccinate children everywhere against a growing range of illnesses. A particularly exciting advance was the rollout of a new vaccine for pneumococcal diseases like pneumonia and sepsis, which kill 1.6 million people a year. One selfish reason to cheer this progress in the United States: If we contain a disease worldwide, the misguided evil of parents who refuse to vaccinate their kids against it here at home won't matter as much.

3. The world is richer than it has ever been. Even as stagnation and popular angst gripped the U.S. economy this year, a historically unprecedented decline in levels of absolute poverty continued worldwide. In 1981, half of the developing world was living on less than $1.25 a day. Today, that proportion is less than one-sixth. That's reason enough for cheer in the United States, because those richer people are new consumers of American goods. U.S. exports to the 19 fastest-growing economies worldwide over the past decade grew approximately fivefold.

4. We're getting smarter. Technological and scientific advance in the United States and other developed countries continues at a remarkable pace -- this was the year, after all, that Google premiered a robot that could attend boring meetings in your place, and we discovered 21 more planets orbiting distant stars. And never before have so many people been able to share in that knowledge. Even in Sub-Saharan Africa, the most recent statistics suggest more than three-quarters of primary-age children are enrolled in school. There's a big gap between being in class and learning the three "R's," but it is a powerful step in the right direction. And for all we talk about a crisis of education in the United States, the most recent National Assessment of Educational Progress reported the highest scores since testing began in 1990.

5. We're more peaceful than we used to be. The last decade has seen fewer war deaths than any decade in the past century, as Joshua Goldstein recently observed in Foreign Policy. The United States -- embroiled as it was in two wars and continuing military activities in Iraq -- sadly, did lead the world in overseas combat deaths last year, but at least the troops have begun to come home. On the domestic front, violent crime continued its downward trend through the start of the recession -- from more than 1.8 million reported violent crimes in 1990 to 1.2 million in 2010.

6. Freedom and democracy are spreading. Tunisia went to the polls a few weeks ago, elections are still (in theory) scheduled in Egypt, and Libya has finally dealt with the Qaddafis. The road from autocracy to stable democracy is rarely free of twists and potholes, but at least large parts of the Middle East and North Africa have at last begun the journey; perhaps Burma won't be far behind. And that's good news for the United States, because democracies really do fight less often.

7. Social networking is bringing us all closer together. Tweets alone may not be responsible for the Arab Spring, but they did help organize it -- and spread news about what was happening (without YouTube, the violence in Syria would be a matter of unconfirmed reports). Meanwhile, advances in communications technologies are strengthening relationships across the globe. So, even if they can't sit down at the same table this week, the families of 214 million international migrants worldwide -- and the millions more who have moved around within their home countries -- can talk to their loved ones at a fraction of the old cost: a few cents per minute from the United States to Africa, for example, compared to dollars only a decade or so ago. And America -- a land that celebrates its immigrant heritage this week -- should be particularly happy about this; closer communications leads to more trade and investment, making people better off both here and abroad.

8. Money is not just stuck in big banks. On the strength of the same technologies, global remittances have climbed from $132 to $440 billion over the course of the past decade. With advances in mobile banking and ID technology, it is possible to directly transfer cash to more and more of the world's most disadvantaged people -- providing a straightforward way to end global poverty at an affordable price.

9. Technology really does make our lives better, and longer. 2011 was the year that research suggested we may be closing in on a powerful AIDS vaccine, that we came even closer to the global annihilation of polio, and that we learned renewable energy investment in the developing world had outstripped such investments in rich countries. Alongside strong economic growth in developing countries and the spread of peace, democracy, and learning, continued technological advances will underpin a healthier, wealthier, more stable, and more sustainable world in the years ahead.

10. And to conclude with what Thanksgiving is all about: There are more families and more people to be friends with than ever before. This year the world's population crossed the seven billion mark. That's seven billion people to share a meal with and 14 billion shoulders to cry on when the basting gets to be too much. What's more, World Values Survey data suggests this bigger global population is overwhelmingly content. In China and India, over three-quarters of the population claimed to be quite happy or very happy. In Brazil, it was 90 percent. The vast majority of the planet is glad to be here -- and we should be glad, too. To be sure, we face the challenge of moving the world onto a more sustainable path of consumption. (Do your part: skip the second helping of pumpkin pie.) But combined with the global spread of education, a larger population means there are far, far more potential geniuses like Norman Borlaug or Maurice Hilleman out there who can help create solutions to that challenge.

Give thanks this week for those near and dear to you, then, and also for a world in which there are more people who are leading a higher quality of life than ever before in recorded history. But while there are few people worldwide less fortunate today than there were last year or the year before, there are still far too many living lives of unnecessary suffering. So, before the tryptophan haze sets in, spare a thought for what you and your country can do to make the world an even better place next year.