Obama stops thinking positive

A year on from his inauguration, the president stands accused of reneging on inspiring campaign prom

Once, no one wanted to talk about Aids. Now the global pandemic commands $14bn a year, roughly half of all spending on health worldwide. The single most important contributor to Aids funding is the US President's Emergency Plan for Aids Relief, or Pepfar for short.

Launched by George W Bush in 2003, Pepfar is the largest financial commitment ever made by any nation to combat a single disease. It wields a budget of $6.7bn for 2010 alone, and claims to have succeeded in putting more than 2.4 million people on antiretroviral therapy, particularly in its "focus" countries (primarily in sub-Saharan Africa). This includes some double-counting with the other major provider of antiretrovirals, the Global Fund to Fight Aids, Tuberculosis and Malaria, but the scope is impressive nonetheless.

The tentative optimism needs to be put in context. There are still 33.4 million people with HIV, and, as access to antiretrovirals improves, the number living with the virus continues to climb. Moreover, Aids-related illnesses remain a major cause of death globally, claiming two million lives a year. Initiatives such as Pepfar may have provided life-saving drugs to many, but some global health advocates feel that such organisations are at times more accountable to themselves than to the people enrolled on their programmes. And their sheer scale can disrupt the local health systems of small African countries.

Under Bush, Pepfar faced more criticism than most. Its initial refusal to purchase and disperse cheaper, generic antiretrovirals, in preference for only drugs approved by the US Food and Drug Administration, delayed the roll-out of life-saving medicines and demonstrated an unseemly interest in extending the market for overpriced (and usually US-manufactured) drugs. Equally controversial was the Bush-era insistence that a third of the money slated for reducing HIV infection be spent on promoting social values, including abstinence, delay of sexual debut and partner reduction. Such policies are straight out of the Republican book of morals. A focus on monogamy has little value as a preventive tool in countries such as Thailand, where the main mode of transmission is now between married partners.

Self-selective choice

With the election of Barack Obama a year ago, hopes were high that much of this would change for the better and that Pepfar might become a more positive standard-bearer in the global fight against HIV and Aids.

The new president was quick to repeal the most controversial of Bush's global health policies: the "global gag rule" - an outright refusal to fund any organisation that offered (or even provided information about) abortion. And with the appointment of the new US global Aids co-ordinator, Eric Goosby, the emphasis at Pepfar soon began to fall less on the "emergency" response and more on sustaining existing programmes. Sustainability is important to avoid the emergence of drug resistance, which can render antiretrovirals ineffective.

However, some activists argue that such talk merely disguises the harsh reality of funding cuts. As early as May last year (when his budget plans for 2010 exposed a $1.5bn shortfall in Pepfar funding), they were arguing that the new president had reneged on his campaign promises on Aids.
Since then, Obama has not responded convincingly to their concerns. His new five-year Aids plan, released at the end of 2009, is silent on the extent to which Pepfar intends to address concerns about the ongoing lack of transparency in its funding. This worries global health advocates, who wonder if the strategic interests of the US, rather than the health needs of people in its programmes, may be determining Pepfar's choice of which Aids programmes to fund and where. Addressing these problems will be difficult, but it is essential that Obama should do so sooner rather than later. For all the importance of treatment, it remains the case that, for every two people being put on antiretrovirals, a further five are being infected.

There are, however, systemic as well as political problems to overcome. Pepfar allocates a great deal of funding on the basis of evidence it receives from Aids programmes already in operation. But according to Vinh-Kim Nguyen, a doctor and social scientist with the University of Montreal's department of social and preventive medicine, such evidence of the efficacy of particular interventions can be self-selecting. Organisations promoting treatment interventions (rather than, say, simple prevention or safe sex) find it much easier to get hold of supporting data, because much of the data is taken from individuals already enrolled on programmes being evaluated. Anyone else is excluded, so there is little countervailing evidence (it's hard to provide data on a person not yet infected). But that also makes it difficult to know whether treatment-only approaches to HIV and Aids are always the most effective.

This should not be taken as an argument for scaling back antiretroviral provision, but it makes it much trickier to gauge how, when and where treatment would be more effective than a less costly alternative.

Social complications

The underlying problem with Obama's Pepfar is that - for all the lip-service Goosby has paid in recent months - it is not fully engaging with the constellation of problems associated with HIV and Aids: vulnerability to infection, impoverishment, disempowerment of women, stigmatisation and a persistent Aids denialism, to name a few. These are social issues that are not always easily quantified, and are often the consequence of relative inequality as much as outright poverty.

In sub-Saharan Africa, women aged between 15 and 24 are more than three times as likely as their male counterparts to be HIV-positive; in the United States, the prevalence of HIV among African-American males in the District of Columbia ranks alongside that of some of the worst-affected countries. The only consistent feature linking sub-epidemics among injecting drug users in the former Soviet republics, men who have sex with men in Asia and heterosexual women in sub-Saharan Africa is the way that HIV can be seen, in each case, to cut along and reinforce pre-existing socio-economic divides.

With funding for many global health initiatives likely to decline in the current economic climate, there is concern that these underlying causes of vulnerability will be pushed further to the margins in a drive for greater statistical accountability and savings in initiatives such as Pepfar. Pledges to the Global Fund are down. The lives of those who have already been enrolled on antiretroviral programmes in settings where there continues to be a lack of development in local health systems will be put at risk. So, too, will the lives of many more people as yet uninfected.

Simon Reid-Henry is director of the Centre for Global Security and Development at Queen Mary, University of London

DC doubles up as infection capital

A report published in March 2009 revealed that more than 3 per cent of the population of the District of Columbia - Washington, DC - is infected with Aids or HIV. This makes the area the most severely affected in the United States. According to Shannon Hader, director of the district's HIV/Aids administration, such rates are "on a par with Uganda and some parts of Kenya . . . higher than in West Africa".

Following another report - issued in 2007 - that aimed to emphasise the unsettling reality of what was called a modern epidemic, the 2009 document showed a 22 per cent increase in the number of cases of the illness (currently estimated at roughly 15,120).

Worse still, health professionals observed, the latest figures are based on those who agreed to be tested; as such, the actual number is likely to be far higher than the report suggests. And the rate is "on the rise", claims Hader, due to the widening scope of the condition. Once mainly affecting men who have sex with men, HIV/Aids is now a health risk for people of every age, race and sex.

The US government has been criticised for failing to confront the crisis effectively. Critics note how policies that prevent the use of public funds for social programmes such as needle exchanges have led to an increase in the rate at which drug users are being infected by the virus.

Others suggest that the key to tackling the crisis is open discussion, to break down the taboos surrounding HIV and Aids.

Harriet O'Brien

This article first appeared in the 01 February 2010 issue of the New Statesman, Unforgiven

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When heritage becomes hate: why my home town of Charlottesville needs to address its complex past

After an invasion of white supremacists, we need to see what our history means today.

Watching a tragedy happening in slow motion, without any way to stop it - that’s how it has felt to be from Charlottesville, Virginia in the summer of 2017. A city that used to always get voted “happiest town in the USA” when I was growing up was the target this weekend of an ugly white supremacist movement whose roots spread far from the city.

It was a huge surprise when we won the lottery of Nazi flags, with our stupid old statues that have become icons of international fascism, with a park named after a distantly forgotten old man becoming a site of struggle for an attempted racist coup of the United States. Our first reaction is: they aren´t from here. Our second: make them go away. Our third: a realisation we need to examine the way that our own ways of life, which we thought so harmless, have inspired such horrible feelings in strangers.

Maybe for my African-American classmates at high school the statue of Confederate general Robert E Lee, and the park when it was still named after him rather than Emancipation Park, always meant violence. Pulling the statue down says no more about the historical Lee than tearing down Lenin in '89 says about socialism. We've been invaded by people pretending to protect us from invasion, and the symbols of our past will never matter as much as living people do.

***

The invaders picked our town, probably, because Virginia was a confederate state, and was in fact where the southern gentry used to live. Lee exemplified this tradition. He was son of Lighthorse Harry Lee, a hero of the revolutionary war and governor of Virginia, and is a descendant of one of “Virginia’s first families,” the aristocratic Englishmen who emigrated to Virginia when it was a British colony. He is part of Charlottesville's heritage, and perhaps not even all that shameful a part. He opposed the secession of the confederacy, supported the reconstruction after the war, including giving rights to recently freed slaves. Not exactly woke, but for a confederate general, not as bad as some.

We were taught at Venable Elementary School that he fought only reluctantly, to defend his land, not slavery. In the version we learned, one would imagine Lee being very opposed to people from the Midwest coming to Virginia in cars with Ohio license plates to murder Virginians. Many non-racist Virginians, including quite a few friends, respect Lee deeply - the same is true in towns like New Orleans where other Lee statues are being taken down. Yet if once we could fool ourselves into thinking that the statue didn't represent hatred and racial hierarchies, we can't anymore. The discussion of local history has turned into one of national identity. The statue should be gone by Christmas. 

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The real hero of Charlottesville is the town’s founder, Thomas Jefferson, who was among the most enigmatic of the founding fathers, idealistic and hypocritical - a real American, in other words. His idea of the gentleman farmer is also part of our heritage. It was an alternative to Hamiltonian industrial capitalism, but lost out in the tustle to shape American history. Much like English contemporaries such as William Cobbett, Jefferson believed in a rural ideal, reading poetry by morning, farming by afternoon, playing the harpsichord by night. His thought is also present in our beautiful "academical village" of the University of Virginia which he also founded. It is one of UNESCO’s few world heritage sites in the United States, so I guess it is part fo the globe's heritage as well, and it is also where the white supremacists stomped around with their tiki torches.

It’s time for us to stop being romantic about Jefferson, too. The statue in our minds needs to come down. We can recognize the great parts of his work, of his thought, in Charlottesville today, but we can also recognise that he allowed himself to use violence to dominate others, that he owned slaves and raped them. And we can recognise that equivalent scenarios continue to play out today, and will continue to play out until we are willing to face the truth.

There can be no more excuses. It’s not about Jefferson, or Lee, after all. We use monuments, statues, heroes, to inspire ourselves. In the end, the “truth” about Jefferson or Lee is a matter of trivia and history. Today, for every white male in America, we need to deconstruct the parts of our identity built on the graves of others. It’s not easy.

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Jefferson's gentleman farmer was the forerunner of the people who populate the gentrified Charlottesville that exists today of expensive coffee-shops and celebrity-filled suburbs. This romantic idea, much like the lifestyles of the American and English elite today, seems to engender a lot of resentment from those who can only watch helplessly, and are often gentrified out. It’s not only immigrants or, in the United States, African-Americans, who are denied access to America's Williamsburgs and Charlottesvilles, London's Shoreditches and Oxfords. In Charlottesville, descendants of white sharecroppers and black slaves alike are unable to afford $15 glasses of local Virginia wine.

The paradox implicit in Jefferson’s beautiful idea is that in the end, it’s impossible to sustain this chilled-out and happy lifestyle without the labor being done by others, be they slaves, sharecroppers, or factory workers in China. If America is in trouble now, the conflict comes precisely from the fact that our universalist ideas of freedom, equality, and liberty correspond to an economy that is anything but universal. We actually did it, keep doing it, and unless we can use these ridiculous men dancing through our streets iin Halloween costumes as a funhouse mirror to make us see ourselves as we are, we’ll probably keep doing it.

I resent Jefferson for his hypocrisy, because in truth, I would love it if America looked more like Charlottesville than the industrialized and nasty-looking Interstate 95 highway that leads up the East Coast, the aftermath of Hamiltonian industrial-revolution factory America. The New Jersey towns, the gas stations, what we contemptuously call “McMansions,” suburban Northern Virginia... none of it is really authentic enough. Parallel to the rich and ugly suburbs, are poor and ugly towns, the sort of places with unemployment and discounts on cereal that tastes like sugary trash in the supermarket.

The residents of these towns don’t hate the residents of more gentrified towns for our organic granola, they hate the world for the structures of oppression that they can’t escape, even as an international class, an educated class, a well-meaning class, escapes without even needing to. We coexisted in the same place but not the same set of opportunities, and we glided on to new and bigger worlds of possibility, ones denied to those of different class backgrounds, regardless of their ethnicity.

***

Some of my African-American classmates at Charlottesville High School were likely descendants of Jefferson’s slaves, coming from poorer neighbourhoods and housing projects and taking "standard" level classes, with honors and AP classes for students whose parents worked in the University (very liberal, of course), a genteel place where every year, some kid wears blackface or a Nazi outfit to a party - as a joke, of course. While my classmates in AP and Honors classes got help from our teachers in applying to Ivy League schools, the general level classes saw black and white students who shared poorer backgrounds acting out to get attention from harried teachers. This was public school, but Charlottesville’s many excellent private schools, of course, didn’t even have the general level students at all.

Despite some southerners such as Lee supporting the post-war “reconstruction,” white resistance to racial equality led to a Jim Crow system that wasn’t much better than slavery, and an American South which dozed in sweaty decline while the rest of the country industrialised and modernized. From 1865 to 1965, not much happened in the South. True, there were intellectual movements like the Agrarians, whose 1920s manifesto “I’ll Take My Stand” I found one high school afternoon in the local bookstore, we had our Faulkners, our occasional geniuses. But as a society, it was stagnant. 

It was only when the civil rights movement began that the south began to actually rise again. UVa went from being a minor regional school to being a world-class one. Charlottesville went from being a mediocre gentleman’s club to a place that people of all backgrounds could make lives for themselves in the public service. And we, the public, gained so much - that’s why my family chose to live there.

I remember as a child strolling the beautiful downtown mall to go to dinner al fresco with my parents, my father pointed out a man in a turban; it was Satyendra Huja, a Sikh professor at the university who had planned the downtown mall, and made a useless street into one of the nicest places to congregate in town. In 2012, Huja became the mayor. I guess the former mayor of Charlottesville who single-handedly made Charlottesville one of the most charming towns in the country often gets told to “go home,” as if that's somewhere else.

Martin Luther King Jr.’s birthday is a national holiday in the United States, but in Virginia it used to be “Lee/King/Jackson” day, with two confederate officers added in just as a reminder. That’s not really our heritage, and as students, we were grateful for the day but always laughed at how immature it was that the powers that be needed to block out Dr. King’s achievements so much.

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Charlottesville is a southern town true to and even obsessed with our heritage - a place filled with museums, historians, bookstores - which wants to dissect that heritage to remove the parts of our forefathers (and mothers) lives that we can’t accept, like a sandwich that you open up, take the pickles out of, and then keep on eating. We love our heritage in Virginia. We read about it, celebrate it, live it every day. But heritage isn’t a static thing, fixed in time, and the walls between myth and history are thin. In fact, perhaps knowing about your heritage is the ultimate form of privilege. I doubt that either the descendants of slaves I went to high school  with, or the “redneck” (so-called because they got sunburned by working in the fields - “redneck” is a class slur) descendants of the illiterate sharecroppers of rural Maryland, do. 

What happened this weekend to Charlottesville could happen to any town as long as we those who are deprived of their history and who don’t feel at home in their hometown. But the Charlottesville I remember, and the one it is now, proves that you can go from war and conflict and institutionalised racism to one where people of all races and identities can coexist, for the most part, peacefully and happily. We can, if we try, honor Jefferson for his achievements without forgetting the slaves his beautiful buildings were built by. A “Memorial to Enslaved Laborers” is being built on the campus he founded.

For the first time, every one of my old friends is thinking about racism, white privilege, the origins of violence, and what we can do about it. We can honor Jefferson and General Lee’s memory best by trying to learn from their mistakes. Maybe, if it seems like we are able to solve these problems, I’ll have a child myself. I hope she goes to Venable Elementary School, and I’ll take her to Emancipation Park afterwards.

This article first appeared in the 01 February 2010 issue of the New Statesman, Unforgiven