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Gregg Gonsalves is a longtime AIDS activist and has worked for the Treatment Action Group, Gay Men’s Health Crisis and the AIDS and Rights Alliance for Southern Africa. He is currently a board member of the International Treatment Preparedness Coalition and a student at Yale University in New Haven, Connecticut. On World AIDS Day, December 1, he spoke at a symposium titled “HIV Scale-up and Global Health Systems,” hosted by Columbia University’s International Center for AIDS Care and Treatment Programs in New York City. These are his remarks.

Gregg Gonsalves

For those of you who know me, I am about to say something shocking. I miss George W. Bush. Well, not really. He was a terrible president in so many ways. However, he was exceptional in one. The President’s Emergency Plan for AIDS Relief (PEPFAR), despite its flaws, saved millions of lives around the world.

People seem to forget what the world was like before PEPFAR and its multilateral sister effort, the Global Fund to Fight AIDS, Tuberculosis (TB) and Malaria, arrived on the scene. Before the turn of this decade, the fight against AIDS in the developing world was a joke. Great leaders like Nelson Mandela failed to understand and react to the gravity of what was emerging in his newly free republic. President Clinton, for all his heralded work since he left office, did absolutely nothing when he was in office to stem the rising tide of death and new infections across the globe. Even the World Health Organization ignored the epidemic ravaging dozens of countries wholesale in Africa, exploding in specific populations in other nations on other continents.

It was ordinary people, people living with AIDS and those who loved them, who spoke up, demanded action. Activists in Brazil, Thailand, South Africa, Uganda and elsewhere shamed their countries, the world into action. The establishment of the Global Fund and the World Health Organization’s 3X5 effort—to get 3 million people on AIDS treatment by 2005—were all swept into place by the force of the voices crying out for justice only a few years ago.

It is almost 10 years later and we’re in danger of losing everything we’ve achieved on AIDS this decade. For the past two years, there has been a pernicious and false rhetoric rising up in academic journals, in think tanks and now in governments and international agencies that goes something like this: The fight against AIDS has misdirected our energies toward broader goals in health and development; the provision of antiretroviral therapy is a folly—it’s too expensive and isn’t worth the money to continue its expansion; efforts against AIDS are destroying health systems and promoting unnecessary deaths from other simpler-to-treat diseases and conditions such as childhood diarrhea.

One of the most vocal proponents of these ideas sits in the White House advising the president: Ezekiel Emanuel, a doctor and bioethicist whose November 2008 paper in the Journal of the American Medical Association has become a key document in what I call the “AIDS backlash.” But there are others, such as Bill Easterly at NYU and a mysterious fellow named Roger England who seems to be quite the favorite of the editor of the British Medical Journal. Even Newsweek gets into the act this week, with their call to scale back PEPFAR.

Many of the people making these charges of course are the people who did little to stem the tide of AIDS and TB in the 1990s. They posit that the fight against AIDS has been a malevolent force in public health and development, while ignoring the fact that before AIDS supposedly came along to suck all the air out of the room, other areas of health—for instance, maternal health and childhood immunization in Africa—languished terribly under their watch. They conveniently refuse to acknowledge that chronic underinvestment in health, structural adjustment policies that crippled the public sector in many developing countries and corruption at the highest levels and other factors decimated health systems across the world. AIDS has become the new bogeyman—deflecting attention from the culpability of national governments in the North and South for the long-standing crisis in health and development around the world.

We’ve made great strides in fighting AIDS, but now as a recent report by the Nobel Prize–winning organization Doctors Without Borders has suggested, the world is about to punish success. Some are now calling for a redistribution of funds, to cut up the current pie of global health money, so that other illnesses and conditions profit from the largesse lavished on AIDS. The problem is that the pie of current funding for AIDS still represents a fraction of what is needed to combat the epidemic—asking for a redistribution of funds is akin to starting a fight for crumbs from the table of our national leaders.

The true scandal is that in the age of bank bailouts, fiscal stimulus packages and multimillion dollar bonuses, it isn’t AIDS that is overfunded, it’s the fact that the U.S. and other donor nations have systematically underfunded health and development overall for decades. Justice isn’t cutting up a too small pie into more evenly distributed smaller pieces, but is putting more money on the table for global health and development.

We need to spend more on health and development, promote stronger health systems and work toward a comprehensive package of health interventions for all conditions in developing countries. However, accomplishing this won’t happen by essentially weakening the AIDS response, but by building on its tangible successes. Have we done everything right in AIDS? Of course not. But we’ve done the impossible in 10 years’ time. When the experts said treating people with AIDS wasn’t going to work because “Africans can’t tell time” or because it wasn’t cost-effective or sustainable, we showed that it was. We’ve brought a yes-we-can attitude and higher aspirations to global health and development than the field has had in decades.

The choice right now is between building on the successes of AIDS to strike out against other diseases and conditions or to go back to the future, to the golden days of the ’80s and ’90s, which were not so golden at all. What is being proposed right now from many quarters is a return to sector-wide approaches in health—or SWAPs as they are known—in which governments will get a fixed sum from donors for health and program it to ostensibly strengthen their health sectors overall.

It all sounds so good. Rather than having all these different pots of money at the national level, it will all be rationalized and coordinated through ministries of health, and all directed toward a set of coherent national policies. SWAPs were the darling of development agencies and the U.N. throughout the 1990s. They are theoretically appealing to those who work in the field and who have devoted their lives to building health systems, but often what looks good on paper doesn’t work in the real world. There are scant data on the effectiveness of SWAPs on health, with even strong proponents saying it would take 10 or more years of investment in this approach to see tangible impacts on real outcomes. In the worst cases, such as health sector reform in Zambia in the late 1990s, SWAPs destroyed the country’s TB program, and it had to be built up from scratch. SWAPs are based on the idea that vertical programs, disease-specific programming are essentially destructive, when the truth is that health systems need breadth and focus, strong structural foundations but also targeted efforts on the major killers of in their midst.

Almost directly after the Alma-Ata Declaration 30 years ago, which launched a progressive movement for health for all, the critics arose to say that it couldn’t be done.  That is, health for all is a utopian fantasy and that we need to be satisfied with doing small bits of good with small pots of money for a small amount of people. The post-Alma Ata consensus is a Malthusian one and finds its real rationale in a late ’70s/early ’80s conservative notion of the role of the state, which was ably promoted by [British Prime Minister] Margaret Thatcher and [U.S. President] Ronald Reagan in the ‘80s: The less government the better; the less governments do the better. Those who survive on the largesse of government are welfare queens undeserving of our support. This is all a far cry from the progressive politics that gave rise to the British National Health Service or the Medicaid/Medicare programs in the U.S. up until then. The big idea since 1980 is that we are not our brothers’ or sisters’ keepers at home or abroad.

The fight right now is for the soul of global health and the lives of millions of people around the world. It’s not just about AIDS. It’s about a return to the 1990s, a post-Reagan consensus on social services and foreign aid, the stagnation in public health that stood for progress in so many areas. It’s about a failure to remember what it was like back only a short time ago. These people had the keys to the car back then and made a wreck of things. Now they want to be back in charge and nowhere is this more apparent than in the debates happening in the White House, where the Obama administration risks turning its back on a decade of real progress against HIV/AIDS, turning back the clock to failed or untested approaches to health and development because the “experts” like Zeke Emanuel or Bill Easterly say this is the right thing to do. Get beyond their complaints about AIDS or AIDS treatment and their vision for the future is bleak.

Perhaps it is old-fashioned to think that there can be real progress for poor people, for the most despised of us on the planet. Perhaps it’s quaint to believe that the provision of national health care in most of the developed world, Social Security and Medicaid in the U.S. in the last century were not aberrations in human history but some of our finest achievements over adversity. The fight against AIDS is part of those earlier struggles for social justice and equality and is part of the struggle for health for all. We won’t fight among ourselves for crumbs from our leaders’ tables. We won’t be told that care and treatment for AIDS or any other disease is unsustainable or not cost-effective, when that calculus changes for your own family once you become an elected official sitting in an office in the capital.

The president has a choice. He can stand with all of us fighting for social justice and health care for people around the world, or he can join the ranks of the new Malthusians, who say let’s do the least for the least number of people with the least amount of money. In the current health care debate in the U.S. where the president has shown very little stomach for pushing through a robust set of reforms in deference to conservative Democrats and moderate Republicans, the outcome of his choices will mean an open-ended postponement of key changes in the American health care landscape. However, if the president takes the advice of the current crop of noisy critics of AIDS, he risks making things worse and setting us back a decade or more, not just on HIV but on progress in global health overall.