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6 September 2004

How to waste a $15bn opportunity

George Bush and Tony Blair have a lot of money to spend on Aids in the developing world - but don't

By Peter Gill

Pity the ministers and officials who have to sustain Tony Blair’s rosy vision of the special relationship. First there was climate change. Then came the war and British detainees in Guantanamo. Now there is an issue where hundreds of thousands of lives are at stake – Aids in the developing world.

The United States and Britain are the world’s biggest Aids donors. George W Bush has committed $15bn over five years, and Gordon Brown has just come up with £1.5bn over the next three. These are huge sums, and there is big influence to match. When Bush and Blair sat down in Downing Street last November and gave some time to the Aids issue, they also agreed on a joint task force to co-ordinate their approach. Since then, both the US and the UK have come out with strategies for how to spend the money. They certainly appear to be discussing the same epidemic and they agree on the statistics. But there the meeting of minds ends. Their Aids policy-makers inhabit different planets.

The first thing to note about the two strategy documents is the pictures. In the president’s Emergency Plan for Aids Relief there are 13. Nine are of George and Laura Bush and two are of Randall Tobias, the former pharmaceutical industry boss who is running America’s Aids programme. This leaves two pictures for people out there in the real Aids world.

The British document, Taking Action, has a foreword by Blair, but no photographs of him. The illustrations have a documentary feel – an Aids funeral in Zambia; a home for destitute women in India. Some would not meet with Washington’s approval. There is one of a needle exchange in Kiev and two of condoms being handed out in India. The cover picture is of an Indian health volunteer demonstrating how a condom works to a female labourer in Tamil Nadu. This would outrage the Bush people.

After promoting condoms around the developing world for decades in response to population worries, the Americans under Bush have taken against them just as they are most needed. Under the influence of the Christian right and its congressional allies, the Bush document spells out the new policy. Condoms are to be distributed only to so-called high-risk groups – prostitutes, drug users and couples where one partner is HIV-positive – while others must either abstain from sex, in the case of young unmarrieds, or remain faithful, in the case of marrieds. As an approach to Aids, it is untested and unrealistic, and it will lead to confusion and possibly disaster in the 15 countries, 12 of them African, where the US is spending its $15bn.

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Taking Action, by contrast, points out that Britain once had a good record in containing Aids at home through awareness campaigns and initiatives such as clean-needle exchanges. US policy prohibits needle exchange. According to the latest figures, the US has an Aids prevalence rate six times that of our own. Attitudes towards prostitution further divide the British and Americans. The British support programmes among developing world sex workers, a disadvantaged group at immediate risk both of infection and of spreading HIV. Specifically, they encourage women to insist that clients use condoms. The Americans say they want to increase condom distribution around brothels, but also stipulate they will fund only organisations that explicitly oppose prostitution. Excellent charities in poor countries are having to revise principles if they want US dollars.

Such moralising towards sex would be bad enough. But the Bush administration approach to the Aids disaster is flawed in other ways. The US pharmaceutical industry breathed easy when President Bush appointed one of its own, Randall Tobias, former head of Eli Lilly, as his global Aids co-ordinator. To be fair, Tobias has shown some inclination to balance the interests of US pharmaceutical giants with those of the developing world, particularly over the question of cheap copies of expensive American drugs. But it has been a struggle. The Americans have yet to approve the distribution of any developing world drugs and several have been rejected.

Worse still is the way in which the US plans to spend the money. It has adopted a “Washington knows best” strategy, sidelining effective international institutions such as the World Health Organisation and the Global Fund to Fight Aids, Tuberculosis and Malaria. And it has gone a remarkable step further, marginalising its own development experts. Under the Bush plan, the US ambassador in each of the focus countries, rather than the top US aid official, will be in charge of the country programmes. African officials are already complaining about lack of consultation.

The British are emphatic that this is not the way to go. Under Hilary Benn, the Department for International Development (DfID) is far too polite to say the Americans are out to lunch in their approach to Aids planning, but the Taking Action document makes plain that this is what the department thinks. It insists on the merits of each country having a national approach to Aids, and says that foreign donors have a duty to subscribe to it. As a caution, it quotes the case of Uganda, where last year no fewer than 25 separate foreign Aids missions trooped in to dispense individual largesse. “Some countries are spending a year simply completing the necessary forms to apply for funding while funds already allocated sit unspent,” say the British.

So is there anything the British and Americans actually agree on? Unfortunately there is. In the see-saw debate over funding for prevention versus funding for treatment, both DfID and the Bush administration have plumped substantially, and probably wrongly, for treatment. Benn goes so far as to say that the British will support “increased, and eventually universal, access to treatment and care for people with HIV and Aids”. It is a staggering ambition because, as DfID also points out, the global provision of such care would cost about $46bn a year, roughly what the whole rich world now gives in aid to the developing world.

The urge to do something for people living with HIV and Aids, wherever they live, is quite proper. The right to decent health should be a universal human right. Uniquely, people with Aids around the world have fought hard against terrifying prejudice to demand, and in some cases acquire, the right to these life-prolonging drugs. The objection to it is in part practical – it would bankrupt the aid-givers – but there is also a suspicion that it is aimed more at public opinion in the west than at people in the developing world.

The cruel fact is that the vast majority of people with HIV do not know they are infected. They live in parts of the world where getting hold of a few aspirin is hard enough, let alone gaining access to an expensive combination of drugs that must be taken under medical supervision and certainly for ever. Consider also the distorting effects of supplying quantities of expensive antiretrovirals to people with Aids when many more are dying for lack of treatment of diarrhoea and malaria. The British do not specify how they will allocate funds between treatment and prevention. The Americans are clear. More than $10bn of Bush’s $15bn will go on treatment and care.

The public health priority in tackling Aids in the developing world continues to be prevention, just as it was in Britain and the US in the 1980s. The American view is that since most prevention efforts have failed over the past 20 years, including in the US, we must try something else. This means spending $1bn on campaigns in poor countries against sex before marriage. It will not work, and could cost many thousands of lives. The British rightly reject this approach, but are also in danger of ignoring the lesson that past prevention efforts failed mainly because politicians and officials did not pursue them vigorously enough.

Taking Action is studded with bullet points saying what the British government is going to do next. In the months leading up to his big African year, Tony Blair might consider adding a few more, with or without reference to Washington. He could insist that we spend much more on filling the huge condom gap in poor countries and then he could remind the world that we have undertaken to contain and reverse the Aids epidemic, not just treat it.

Peter Gill ran a BBC Aids campaign in India and is researching a book on the politics of Aids

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