An Epidemic Failure
Whatever happened to Bush's pledge to combat AIDS in Africa?
By GERALDINE SEALEY
When President Bush introduced his global AIDS initiative in January 2003 -- calling it "a work of mercy beyond all current international efforts" -- the plan certainly sounded promising. Bush pledged to spend $15 billion over five years to provide life-saving drugs to at least 2 million people with HIV, prevent 7 million new infections, and care for the sick and orphaned in fifteen countries. Most of the money, the president declared, would go to sub-Saharan Africa, home to the majority of the world's 40 million people living with HIV and AIDS. In the hardest-hit countries, nearly forty percent of the population is infected, and 12 million children across the region have lost at least one parent to the disease. "I believe God has called us into action," Bush declared during a trip to Uganda in 2003. "We are a great nation, we're a wealthy nation. We have a responsibility to help a neighbor in need, a brother and sister in crisis."
Dubbed the President's Emergency Plan for AIDS Relief (PEPFAR), the ambitious agenda provided the administration with some much-needed PR at the very moment it was preparing to defy international will by invading Iraq. But from the start, Bush has failed to deliver on the funding he promised -- and what little money he has provided is being used to promote a right-wing agenda that undercuts international efforts and puts millions of people in AIDS-ravaged countries at greater risk of infection and death.
Thanks to the president's foot-dragging, his "emergency plan" took its sweet time getting going. Bush requested only $2 billion for PEPFAR in its first year -- a billion less than one would expect. Then, when Congress decided to approve $400 million more than the president asked for, Bush unsuccessfully fought to block the increase. By the time the first relief funds arrived in Africa, nearly a year and a half had passed since the president announced his plan -- a costly delay in fighting an epidemic that claims 8,500 lives every day.
The administration insists it will meet its goal by 2008, saying it planned all along to gradually "ramp up" the program. But public-health experts say it looks increasingly unlikely that Bush will fulfill his promise -- and that even if he does, the money will fall far short of what is needed. According to UNAIDS, a partnership involving the World Bank and nine other international aid groups, the world needs to spend $20 billion a year by 2007 to wage an effective war against AIDS. What Bush proposes to spend annually, if funding remains constant, is less than half the $6.6 billion that America would be expected to contribute based on the size of its economy. "The fact that the United States can spend $300 billion on the wars in Iraq and Afghanistan but cannot find a relative pittance to rescue the human condition in Africa -- there is something profoundly out of whack about that," says Stephen Lewis, the secretary-general's special envoy for HIV/AIDS in Africa.
The president's AIDS initiative, like his invasion of Iraq, is a go-it-alone affair that ignores the clear global consensus on how to fight AIDS. In launching his own initiative, Bush has shifted the bulk of U.S. money away from the Global Fund to Fight AIDS, Tuberculosis and Malaria, an international organization that has funded projects in 128 countries and is widely recognized as the best way to distribute AIDS funds. "Bush is starving the fund," says Dr. Paul Zeitz, executive director of the Global AIDS Alliance. "It's despicable, frankly."
In addition to shortchanging international relief efforts, Bush is using AIDS funds to place religion over science, promoting abstinence and monogamy over more effective measures such as condoms and sex education. Before overseas groups can receive U.S. funding, for example, the Bush administration requires them to take a "loyalty oath" to condemn prostitution -- a provision that AIDS workers say further stigmatizes a population in need of HIV education and treatment. Brazil recently became the first country to rebel against the oath, announcing in May that it was rejecting $40 million in AIDS grants from the administration. "What we're doing is imposing a really misguided and ill-informed ideology on top of a public-health crisis," says Jodi Jacobson, executive director of the Center for Health and Gender Equity in Takoma Park, Maryland.
Bush's plan calls for an "ABC" approach to HIV prevention -- which stands for abstinence, "be faithful" and condom use -- but the administration is stressing the "A." In its first year, PEPFAR spent more than half of the $92 million earmarked to prevent sexual transmission on promoting abstinence programs. Studies show that such programs actually increase risk by discouraging contraceptive use. What's more, focusing on abstinence and monogamy ignores the reality facing young women and girls in Africa and other impoverished regions, who are often infected by wandering husbands or forced to have sex in exchange for food or shelter. Among fifteen- to twenty-four-year-olds in sub-Saharan Africa, studies show, more than three times as many young women are infected with HIV as young men.
"It's only a matter of time before the impact of abstinence-only programs can be measured in needless new HIV infections," says Jonathan Cohen, an HIV/AIDS researcher with Human Rights Watch.
The emphasis on morality is being driven by social conservatives, who have made spreading the gospel of abstinence and monogamy to Africans their primary mission. "Condoms promote promiscuity," says Derek Gordon of the evangelical Christian group Focus on the Family. "When you give a teen a condom, it gives them a license to go out and have sex." At a congressional hearing in April, Rep. Henry Hyde threatened to cut funding for organizations that promote condoms. "The best defense for preventing HIV transmission is practicing abstinence and being mutually faithful to a non-infected partner," Hyde declared.
Nowhere is the effort by conservative Republicans to turn back the clock on sex education more pronounced than in Uganda. By aggressively promoting condom use and sex education, Uganda has managed to cut its HIV rate from fifteen percent of the population to barely six percent during the past decade, making it Africa's biggest success story. But under pressure from the Bush administration, Uganda has taken a dangerous turn toward an abstinence-only approach. In April, the country's Ministry of Education banned the promotion and distribution of condoms in public schools. To make matters worse, the government has even engineered a nationwide shortage of condoms, issuing a recall of all state-supplied condoms and impounding boxes of condoms imported from other countries at the airport, claiming they need to be tested for quality control. As of this year, a top health official announced, the government will "be less involved in condom importation but more involved in awareness campaigns: abstinence and behavior change."
The Bush administration is supporting the shift by pumping $10 million into abstinence-only programs in Uganda. "One can put a dollar figure on the political pressure," says Cohen, who has closely studied the initiatives in Uganda. "Groups know the more they talk about abstinence, the more they'll get U.S. funding. And they fear that if they talk about condoms they'll lose funding -- or, worse, get kicked out of the country."
Ambassador Randall Tobias, who serves as Bush's global AIDS czar, issued written guidelines in January that spell out the administration's agenda. Groups that receive U.S. funding, Tobias warned, should not target youth with messages that present abstinence and condoms as "equally viable, alternative choices." Zeitz of Global AIDS Alliance has dubbed the document "Vomitus Maximus." He says, "I get physically ill when I read it. It has the biggest influence over how people are acting in the field." And under a proposal being pushed by Republicans on Capitol Hill, Tobias would be given the power to divert even more money toward promoting abstinence. "All Republicans can think about is making Africans abstinent and monogamous," says a Democratic staffer involved in the negotiations. "It's the crassest form of international social engineering you could imagine."
The anti-condom order issued by Tobias is already having a chilling effect among the groups most effective at combating AIDS. Population Services International, a major U.S. contractor with years of experience in HIV prevention, says it can no longer promote condoms to youth in Uganda, Zambia and Namibia because of PEPFAR rules. "That's worrisome," says PSI spokesman David Olson. "The evidence shows they're having sex. You can disapprove of that, but you can't deny it's happening."
What's more, conservatives are attacking PSI for promoting condoms -- a campaign that prevented an estimated 800,000 cases of HIV last year. Focus on the Family recently denounced PSI as a "shady" and "sordid" organization that is leading Africans into immorality by promoting condoms. And in April, conservative Republicans in the House invited Martin Ssempa, a Ugandan minister, to Capitol Hill, to berate PSI and other public-health groups for "promoting promiscuity and condoms" in his country. This year, for the first time, U.S. funding for PSI has been reduced.
Groups that support the president's religious agenda, meanwhile, are beginning to receive money that has traditionally been devoted to more experienced organizations. The Children's AIDS Fund, a well-connected conservative organization, received roughly $10 million last fall to promote abstinence-only programs overseas -- even though the group was deemed "not suitable for funding" by an expert review panel. FreshMinistries, a Florida organization with little experience in tackling AIDS, also received $10 million. "Bush has enacted policies that will redirect millions of dollars away from groups that have experience fighting HIV and AIDS and toward groups that don't but are members of his religious constituency," says Cohen.
In the end, say public-health experts, the administration's diversion of funds away from tried-and-true HIV prevention methods is more than a misguided experiment -- it's a deadly game of Russian roulette that could mark a calamitous turn in Africa's attempts to get a handle on the AIDS epidemic. As Bush fails to make good on his promises, Africans continue to contract HIV and die from AIDS in the same numbers as they did during the worst phases of the epidemic.
"People will look back and say, 'Why didn't they stop the dying?' " says Zeitz. "Why don't we show our compassionate selves? What kind of country are we?"
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