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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The Catalan cauldron

The prospect of the break-up of Spain poses yet another challenge to Europe.

As Britain prepares to mark the centenary of the bloodiest battle in the First World War, the Somme, in July, Spain is bracing itself for an even more traumatic anniversary. In July 2016 it will be 80 years since the start of a civil war that tore the country apart and continues to divide it today. In the four decades since the return of democracy in the mid-1970s, Spaniards slowly inched towards rejecting the extreme violence of the Francoist right (and elements of the opposing left) as well as acceptance of various federal arrangements to accommodate the national sentiments of the Basques and Catalans, whose aspirations Franco had so brutally suppressed. In recent years, however, this consensus has been called fundamentally into question, with severe potential consequences not only for the unity of Spain, but the cohesion of the European Union.

On 27 October 2015, after the Catalan elections, the new parliament in Barcelona passed a declaration requesting the start of a formal secession process from Spain, to be in place in 18 months. The immediate reaction of Spain’s prime minister, Mariano Rajoy, was to announce that the state was entitled “to use any available judicial and political mechanism contained in the constitution and in the laws to defend the sovereignty of the Spanish people and of the general interest of Spain”. The preamble to the constitution proclaims the Spanish nation’s desire to “protect all Spaniards and the peoples of Spain in exercising their ­human rights, their cultures and traditions, languages and institutions”. Probably the most disputed articles are 2 and 8, which state, respectively, that “the constitution is based upon the indissoluble unity of the Spanish nation, common and indivisible patria of all Spaniards” and that “the army’s mission is to guarantee the sovereignty and independence of Spain, to defend its territorial integrity and the constitutional set-up”. Rajoy’s implication was clear: the unity of the country would be maintained, if necessary by military means.

It was Madrid, however, that broke with the federal consensus some years ago and thus boosted secessionist sentiment in Catalonia. José María Aznar’s government (1996-2004) failed to respond to demands for greater autonomy for Catalonia, at a time when secession was not even mentioned. This led to an increasing awareness among Catalans that the federal transfer system within Spain left them with an annual deficit of 8 per cent of Catalonia’s GDP because of the financial arrangements established by the Spanish state, an issue aggravated by the effect of the global financial crisis. Catalan nationalism thus became a matter of not only the heart, but also the pocket. Even more important was the Spanish legal challenge to the Statute of Autonomy of Catalonia 2006 and its subsequent dilution, after it had been sanctioned by the Catalan parliament, and by both the Spanish congress of deputies and the senate, not to mention the Catalan people in a legally binding referendum.

According to the Spanish high court of justice, some of the statute’s content did not comply with the Spanish constitution. This outraged many Catalans, who could not understand how the newly approved statute – after following all the procedures and modifications requested by Spain’s political institutions and constitution – could still be challenged. Four years later, the Spanish high court finally delivered its verdict on 28 June 2010. It removed vital points from the Statute of Autonomy 2006 and declared them non-constitutional. All this led to a revival of Catalan nationalism, culminating in a symbolic, non-binding referendum in November 2014, which was boycotted by opponents and produced a majority of 80 per cent in favour of independence.

The roots of this antagonism go deep, to the civil war that broke out on 17-18 July 1936 when some sectors of the army rebelled against the legitimate government of the Second Republic. The rebels rejected democracy, the party system, separation between church and state, and the autonomy of Catalonia, the Basque Country and Galicia. Their primary objective was to re-establish “order” by eliminating all vestiges of communism and anarchism, then quite strong in some parts of Spain.

High on the list of General Franco’s targets was Catalan nationalism, which had been growing since the late 19th century. The industrialisation of Catalonia and the Basque Country left the most economically developed parts of the Spanish state politically subject to the less prosperous Castile. By the end of the 19th century and influenced by German Romanticism, la Renaixença – a movement for national and cultural renaissance – prompted demands for Catalan autonomy, first in the form of regionalism
and later in demands for a federal state.

Catalan nationalism did not emerge as a unified phenomenon. Diverse political ideologies and cultural influences gave rise to various types of nationalism, from the conservative nationalism of Jaime Balmes to the federalism of Francesc Pi i Margall, to the Catholic nationalism of Bishop Torres i Bages and the Catalan Marxism of Andreu Nin, among others. Catalonia enjoyed some autonomy under the administrative government of the Mancomunitat or “commonwealth” from 1913 onwards. This was halted by the 1923 coup d’état of the dictator Miguel Primo de Rivera. Autonomy was granted again during the Second Spanish Republic from 1931-39 – but abolished by Francisco Franco’s decree of 5 April 1938.

Franco’s victory led to the suppression of Catalan political institutions, the banning of the Catalan language and proscription of all the symbolic elements of Catalan identity, from the national flag (the Senyera) to the national anthem (“Els Segadors”). In February 1939, the institutions of the autonomous Generalitat went into exile in France. In 1940 the Gestapo arrested the president of the Generalitat, Lluís Companys, and handed him over to Spanish officials. He was interrogated and tortured in Madrid, then sent to Barcelona, where he was court-martialled and executed at Montjuïc Castle on 15 October 1940. The most important representatives of the democratic parties banned by the regime went into exile, or were imprisoned or executed. The authoritarian state designed by Franco crushed dissent and used brute power to suppress the historical nations included within its territory. The regime’s aim was to annihilate the Catalans and the Basques as nations.

***

After almost 40 years of Franco’s dictatorship, Catalonia recovered its government, the Generalitat, in 1977 – before the drafting of the Spanish constitution in 1978 – and sanctioned a new statute of autonomy in 1979. The 2006 statute was expected, at the time, to update and expand Catalans’ aspiration for further devolution within Spain: never secession.

At present, a renewed nostalgia and enthusiasm for Francoism can be found among some sections of the Spanish right. One of the main challenges of the newly democratic government from the mid-1970s onwards was to get rid of the symbols of Francoism that had divided Spaniards between “winners” and “losers” in the civil war. It was only in 2007 that the then prime minister, José Luis Rodríguez Zapatero, guided the Law of Historic Memory through parliament with the aim of removing hundreds of Fascist symbols reminiscent of the Franco era from public buildings. It also sought to make reparations to victims of the civil war and the ensuing dictatorship.

There still exist hundreds of other references to the Fascist regime, however, with streets, colleges and roads named after Franco and his generals. The most controversial of these is the Valle de los Caídos (“Valley of the Fallen”), near Madrid, commissioned by Franco as his final resting place. It supposedly honours the civil war dead, but is primarily a monument to the general and his regime, housing the graves of Franco and José Antonio Primo de Rivera, the founder of the fascist Falange political party. Roughly 450,000 people visit it every year, and while most of them are foreign tourists, groups of Falangists and supporters of the old regime who come to pay tribute to the dictator have frequented it. Nostalgics for Francoism, though still a small minority within modern Spain, are becoming vociferous. They find common ground with far-right-wing conservatism, particularly in their shared aversion to federalism.

On 3 August last year Artur Mas, the then president of Catalonia, called an extraordinary parliamentary election after all attempts to negotiate and agree on a legally binding referendum with the Spanish government failed. Supporters of independence immediately announced that the forthcoming Catalan elections would be regarded as a plebiscite on independence.

On a turnout of more than three-quarters of the electorate, supporters of outright independence gained 48 per cent of the vote, while those backing a unitary state secured 39 per cent. On 9 November 2015 the Catalan parliament formally declared the start of the process leading to building an independent Catalan state in the form of a republic. It also proclaimed the beginning of a participative, open, integrating and active citizens’ constituent process to lay the foundations for a future Catalan constitution. The Catalan government vowed to move forward with its secession process. Immediately, the Spanish Constitutional Court suspended the Catalan law setting out a path to independence and warned that defiance could lead to criminal charges.

Worse still for Madrid, secessionism is gaining strength not only in Catalonia but also in the Basque Country, whose premier, Iñigo Urkullu, demands a “legal consultation” on the northern region’s future in Spain. He supports a new statute for the Basque Country and defends its status as a nation in the EU. Similarly to Catalonia, the Basque Country has a distinct language and culture, and benefits from the so-called concierto económico, an advantageous financial deal with the Spanish state.

***

The Spanish government’s refusal to engage constructively with Catalan nationalism contrasts markedly with London’s more relaxed and ultimately more successful response to Scottish nationalist aspirations. The “Edinburgh Agreement” between the British Prime Minister and the then first minister of Scotland to allow a binding referendum on Scottish independence stands in sharp contrast to the Spanish government’s outright opposition to a similar vote in Catalonia. Basques and Catalans find deaf ears regarding further devolution and binding referendums on self-determination. This highlights the distance between various conceptions of democracy that coexist inside the European Union, rooted in the diverse political cultures of nations with varying historical backgrounds.

All this matters, not only to Spain but to the EU, because it is part of a broad trend across the continent. In mainland Europe, demands for self-determination are running strong in Flanders as well as parts of Spain. In turn, tensions between Italy and Austria over control of South Tyrol (Trentino Alto Adige, to the Italians) remain high, as do demands advanced by the South Tyrol­ean secessionist movement. Bavarian regionalism is critical of the present German (and European) political order. Further to that, modern Venetian nationalism and its long-standing demands for independence have prompted a renewal of Venetian as a language taught in schools and spoken by almost four million people.

Matters are now coming to a head. Catalonia and Spain are in flux following two inconclusive elections. In January, after a prolonged stand-off, the sitting Catalan president, Artur Mas, made way for a fellow nationalist, Carles Puigdemont. He was the first to take the oath of office without making the traditional oath of loyalty to the Spanish constitution and the king. Felipe VI, in turn, did not congratulate Puigdemont.

The new president has announced that he plans to draw up a constitution, to be voted on in a referendum “to constitute the Catalan Republic” at the end of an 18-month consultation process. Puigdemont’s strategy envisages not a dramatic unilateral declaration
of independence, but a more gradual process of disconnection in constant dialogue with the Spanish government and Catalan political parties. Let no one be deceived by this “softly-softly” approach: it is designed to culminate, in a year and a half, perhaps sooner, in a vote on establishing a separate, sovereign state of Catalonia.

Meanwhile, Spanish politics are in flux. The elections to the Cortes on 20 December 2015 resulted in a victory for Conservatism, but also the most fragmented Spanish parliament ever and, as yet, no government. Almost the only thing the Spanish parties can agree on is opposition to Catalan independence, yet even here there are divisions over whether more autonomy should be granted and what response to make to unilateral moves by the Catalans.

The stakes are high for both sides. By pressing too hard, too early, Catalan nationalists may provoke Madrid. This would be a mistake. Strategy is important and recent events in Catalonia will weaken the Catalans’ democratic, peaceful and legitimate desire to hold a referendum on independence. Likewise, a heavy-handed response from Madrid will not only destroy the residual bonds between centre and periphery in Spain, but put the central government in the dock internationally. A confrontation will also cut across the only possible solution to this and all other national conflicts within the eurozone, which is full continental political union. Full union would render the separation of Catalonia from Spain as irrelevant to the functioning of the EU, and the inhabitants of both areas, as the separation of West Virginia from Virginia proper in the United States today.

In a nightmare scenario, radicalisation and unrest could emerge in Catalonia, with division between Catalans and memories of the Spanish Civil War coming to the fore. In this context, it might become very difficult to prevent violence.

This is the last thing that Brussels wants to hear as it grapples with the euro crisis, Russian territorial revisionism, Islamist terror, the migrant question and the prospect of Brexit. A meltdown in Catalonia will create dilemmas for Europe, starting from problems with Schengen, and raise questions about continued membership of the EU. It will also work against Catalans’ expectations of receiving EU support in their quest for independence, as turmoil in Europe will prompt nation states to close ranks. The EU will not be expected to intervene, because this scenario would – at least initially – be defined as an “internal affair of Spain”. Conflict between Barcelona and Madrid would shatter one of Europe’s biggest member states.

In that event, the peninsula will become the hottest point in an emerging “arc of crisis” across the southern flank of the EU, stretching from Portugal across Spain, an Italy struggling along with everything else to cope with the flow of migrants, the troubled Balkans, to Greece, which is perpetually perturbed. This highlights yet another flaw in the EU. It has no institutional framework for dealing with Catalan demands to become a nation within the Union, or those of other populations. Merely insisting on Spanish state sovereignty will not make the problem go away for Brussels, or for Europe as a whole. This is a potential matter of life and death not only for Spaniards and Catalans, but perhaps for the EU itself.

Brendan Simms is the director of the Forum on Geopolitics at the University of Cambridge and president of the Project for Democratic Union Montserrat Guibernau is a visiting scholar in the Department of Politics and International Studies at Cambridge and a member of the Forum on Geopolitics

This article first appeared in the 21 April 2016 issue of the New Statesman, Shakespeare 400 years Iater