Missed Opportunities: Governance of Global Infectious Diseases
Garrett, Laurie, Rosenstein, Scott, Harvard International Review
Addressing the UN General Assembly Special Session on HIV/AIDS in June 2001, UN Secretary-General Kofi Annan declared, "For there to be any hope of success in the fight against HIV/AIDS, the world must join together in a great global alliance." Earlier, in September 1995, US President Bill Clinton's Committee on International Science, Engineering, and Technology designated infectious disease as a threat to national security. By the turn of the century it seemed possible that years of neglecting the surging HIV pandemic and other lethal infectious diseases might be reversed. Large-scale initiatives from multilateral agencies, deep-pocketed foundations, and the US government infused hope into an area that has historically been underfunded and overshadowed.
But today the optimism is dangerously close to slipping away. Now that real money is on the table, the entire global health effort seems to be descending into bureaucratic and economic quicksand similar to that which has trapped other international development programs for decades. Programs are competing with each other, and key donors are shying away from the multilateral Global Fund in favor of bilateral programs. Implementation of the World Health Organization's (WHO) program to put three million people on life-saving HIV/AIDS treatment by 2005 is proving staggeringly difficult and demoralizing for much of the WHO staff. US President George W. Bush's Emergency Plan for AIDS Relief (PEPFAR) has become so highly politicized that its achievements are obscured by controversy. Similarly, the Global Fund has become a lightning rod for debate regarding nearly every aspect of public health funding and implementation. Tuberculosis experts, having long struggled to implement so-called Directly Observed Therapy using very cheap drugs for only months per patient, now shake their heads and say, "I told you so: the drugs are not the issue; it is the infrastructure."
The approaches and effectiveness of the major players in the global health arena must be reexamined. As these efforts move forward, new avenues of communication and cooperation must be established to mitigate current obstacles while capitalizing on new opportunities.
It will never be possible to create a disease-free world or to eliminate the potential for the emergence of new deadly microbes. Policies aimed at such goals will always fail. For example, scientists now understand that the Ebola virus is an ancient organism that has for centuries infected isolated individuals in central Africa. That cannot be stopped. But scientists also understand that Ebola epidemics have occurred when individuals infected with the virus entered desperately poor hospitals, where dearths of sterilizing equipment and basic protective gear conspired to offer the virus spectacular opportunities for transmission. Inadequately supplied hospitals act as disease amplifiers, giving the isolated infection opportunity to become a full-blown epidemic.
With very few exceptions, the disease amplifiers in the world today are manmade and therefore humanly controllable. Within health systems, they include lack of infection control in hospitals, reuse of syringes, and unscreened blood supplies. More broadly, exotic animal markets, unclean urban water supplies, lack of proper sewage systems, and unstable, conflict-ridden environments provide excellent breeding grounds for infectious diseases to spread and wreak havoc on already vulnerable populations. Yet it would be shortsighted to think of infectious disease as a problem for solely the poor and powerless. These diseases do not discriminate; they are undeterred by state borders, party affiliation, or socioeconomic status. With air travel and human migration on the rise, so too is the possibility that deadly microbes can and will circumnavigate the globe with speed and precision.
Global health investment is therefore an issue not only for do-gooders. …