The HIV/AIDS pandemic has confirmed the unmistakable: leadership in a public health crisis is crucial. Millions of lives and trillions of dollars are at stake. In Africa and the African Diaspora, the epidemic has disproportionately disastrous consequences with corresponding challenges to leadership and governance. This article explores four such challenges: 1) getting out of the gate--acknowledging the problem; 2) understanding and handling mistrust; 3) building public health infrastructure; and 4) confronting poverty--the greatest threat to health. The lessons gleaned from leaders and their responses to these challenges can be used to chart the way forward and set standards for responses to future epidemics.
THE HIV/AIDS BURDEN IN AFRICA AND THE DIASPORA
The numbers are staggering and the tragedy unimaginable. Nearly a quarter of a century into this global pandemic, the good news is scarce. HIV/AIDS has taken a tremendous toll on health and economies throughout the world. The disproportionate impact on poor people, Africans, and people of the African Diaspora is predictable because epidemics and disasters tend to have a greater impact on those already at a disadvantage. Oppression, economic despair, a history of abuse and discrimination, imbalances in power, and multiple existing health problems are fertile ground for an epidemic. In these circumstances, disproportionate impact is predictable, but nonetheless tragic.
This disparate burden on Africans and people of color in the United States is evident in the worldwide statistics on HIV/AIDS that are available from the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the United States Centers for Disease Control and Prevention (UNAIDS/WHO 2004; CDC 2005). Of the 39.4 million people now estimated to be living with HIV/AIDS, 25.4 million (64 percent) are in sub-Saharan Africa. Of the 4.9 million people who were infected in 2004, 3.1 million (63 percent) are in sub-Saharan Africa, where an estimated 20 million people have died from HIV/AIDS since 1981. While the global adult infection rate is 1.1 percent, in sub-Saharan Africa it is 7.4 percent.
In the United States, African Americans are 12.3 percent of the population according to the U.S. census, but they account for 40 percent of all the U.S. HIV/AIDS cases ever diagnosed. African Americans make up 49 percent of those cases diagnosed in 2003, and African American women make up 67 percent of women diagnosed in 2003. Tragically, African American children share a disproportionate burden as well, making up 68 percent of U.S. children younger than thirteen with a new AIDS diagnosis (CDC 2005). This disproportionate burden reflects a similar set of preexisting conditions that represent a fertile ground for an epidemic. Poor people, the descendants of slaves, and those victimized by discrimination and oppression are at greater risk, and the associated challenges to leadership and governance require particular attention.
In Africa and the African Diaspora, HIV/AIDS takes a greater toll on life and health regardless of the variables measured or the assessment methods. In addition to the tragic loss of life, the economic burden of HIV/AIDS in sub-Saharan Africa is considered a major threat to life and health. The loss of trained members of the young adult professional and working classes has blunted economic development and growth. The death of even a few bankers and teachers can devastate a developing country that already has too few members of the professional classes. Addressing this disproportionate burden--a virtually unmanageable task--requires strong leadership from elected officials, as well as the principals of grassroots and non-governmental organizations and people living with HIV/AIDS. Examples of leadership from elected officials are found in the heads of state of sub-Saharan African countries and African American elected officials in the United States. …