Category: Policy and Advocacy

Mark Green: USAID pick could be a silver lining if he does it right

by Jean Armas, posted in News, Policy and Advocacy

This post was developed collaboratively by the Section’s Communications Committee.

The Trump administration’s nomination of Mark Green, former congressman, ambassador, and frequent NGO board-sitter, was one of those hard-to-find silver linings in the current political thunderstorm (or downward spiral, if you prefer). He is a political unicorn of sorts, enjoying both bipartisan support from Congress and respect from development professionals, someone who knows how to navigate both the political and technical aspects of the job. Green, a four-term Congressional representative from Wisconsin, also served as the ambassador to Tanzania under George W. Bush and was involved with the creation of PEPFAR. He has served on the board of directors for Malaria No More and the Millennium Challenge Corporation, a bilateral aid agency that administers grants to countries for recipient-led initiatives based on a series of economic and governance indicators. He is currently the president of the International Republican Institute, which promotes democracy, civil society, and good governance practices abroad. Politicians like him, old USAID hats like him, think tanks like him – even aid groups (including ONE and Save the Children) like him.

All of this is lovely, but hold the champagne. The inevitable next question is, what will Mark Green be able to accomplish as head of a hamstrung agency with no money?

As many have been quick to point out, USAID is not without its problems and could benefit from some major reforms. The agency has certainly not been immune to criticism from global health and development commentators, including this Section. Many of its programs have been of questionable utility or badly managed (or both), and it has been slow to respond to calls for its programs to be rigorously and transparently evaluated.

However, USAID may at this point be facing a more fundamental, existential crisis. Explains the AP, “[t]he agency faces a starkly uncertain future, including potentially big budget cuts and the possibility of being folded entirely into a restructured State Department.”

“Restructured” in this case meaning disorganized, rudderless, and full of disgruntled and anxious employees.

An additional wrench was thrown in this week (although completely buried under ever more sensationalist headlines) with the announcement that the Global Gag Rule would be expanded to apply to all global health programs:

[T]he State Department [Monday] confirmed that, indeed, a massive expansion of the Global Gag Rule is underway. Whereas previous iterations of the Global Gag Rule only affected funds earmarked for reproductive health, the Trump version encapsulates all US global health programs. This includes programs for AIDS, Malaria, Measles, cancer care, diabetes, child nutrition — everything except emergency humanitarian relief.

In monetary terms, this expands the scope of the Global Gag Rule from about $600 million in reproductive health assistance to $8.8 billion in global health assistance around the world, including the $6 billion anti-AIDS program created by President George W. Bush known as PEPfAR.

So even if Congress pushes back against the administration to preserve USAID’s budget, Mr. Green may not have any recipients to give the money to.

What’s next for US global health funding?

by Jean Armas, posted in Aid Effectiveness, APHA IH Section, Policy and Advocacy

On April 30th, a bipartisan budget deal was passed which will keep the US government funded through the end of September this year. Although funding for global health programs remains largely intact this year (in some cases, budgets have even increased), the future of US global health funding is looking pretty bleak.

Trump’s “skinny budget” proposal for fiscal year 2018 includes steep cuts of nearly 30% to foreign aid and diplomacy delivered through the Department of State. Additionally Trump’s budget proposes cuts to the United Nations and its affiliated agencies, multilateral development banks like the World Bank, and the complete elimination of funding for the Fogarty International Center. And while we can all breathe a collective sigh of relief knowing that malaria programs, PEPFAR, the Global Fund, and Gavi have been spared, the proposed 25% cut to global health programs is disconcerting to all of us within the international development and global health community.

Although such dramatic cuts in US foreign aid spending impacting global health are rightfully shocking, a recent study published in the Lancet shows that financing for global health programs by all development agencies (which includes bilateral (government to government) assistance, multilateral development banks, international NGOs, and others) has already been slowing significantly in recent years. Between 2010 and 2016, development assistance for health grew annually at only 1.8% compared to 11.3% in the first decade in the millennium and 4.6% in the 1990s.

The United States is currently the largest contributor (in absolute dollar amounts) of bilateral foreign assistance even though we spent only 0.18% of our gross national income (GNI) in 2016 on foreign assistance. As a comparison, the OECD country which spent the most of its GNI on foreign assistance, Norway, spent 1.11%. (Just in case you’re curious, most of our federal tax dollars are budgeted toward defense, social security, and major health programs.)

With Trump touting an “America First” agenda and Americans grossly bigly overestimating the amount the US spends on foreign assistance (on average, those polled guessed 26%), it is probably safe to guess that the general public knows little about how foreign assistance can help contribute to a safer America. Although a majority of US foreign aid goes toward funding critical global health programs (including being the largest funder of HIV/AIDS projects), foreign aid isn’t completely altruistic. Foreign aid also helps bring peace and stability to countries where we can benefit from open trade and less volatile economies. In addition, foreign aid helps keep Americans healthy by preventing the global spread of deadly diseases.

In a recent op-ed for Time magazine, Bill Gates provides the proof in the pudding:

According to one study, political instability and violent activity in African countries with PEPFAR programs dropped 40 percent between 2004 and 2015. Where there was no PEPFAR program, the decline was just 3 percent.

….. A more stable world is good for everyone. But there are other ways that aid benefits Americans in particular. It strengthens markets for U.S. goods: of our top 15 trade partners, 11 are former aid recipients. It is also visible proof of America’s global leadership. Popular support for the U.S. is high in Africa, where aid has such a dramatic impact. When you help a mother save her child’s life, she never forgets. Withdrawing now would not only cost lives, it would create a leadership vacuum that others would happily fill.

As global financing for international health programs is expected to continue to slow, it is critical that the United States continues to provide foreign assistance not only because it keeps Americans safe and our economy healthy, but also because it is the right thing to do. While it’s true that foreign aid is in desperate need of extensive reform and that at some point a few low-income countries will be able to start financing a majority of their own health programs, change doesn’t happen overnight. Another Lancet study found that global spending on health is expected to increase from $9.21 trillion USD in 2014 to $24.24 trillion USD in 2040 with low-income countries growing at 1.8% and per capita spending expected to remain low. Failing to support global funding for health at adequate levels has serious consequences not only for the health and well-being of the millions of vulnerable individuals around the world who depend on our support, but in a world where we are inextricably linked, it also endangers the health and well-being of the American people.

The bipartisan deal reached by Congress provides a small glimmer of hope that Trump’s proposed cuts may be dead on arrival, but in such an unpredictable political climate, our collective cynicism is teaching us to expect the unexpected. Trump’s full budget proposal is expected to be released the week of May 22nd. Until then, let’s make sure we are fully prepared to fight in this uphill battle.

“You’re #fired”: Why the firing of the US @Surgeon_General matters to #globalhealth

by Jean Armas, posted in News, Policy and Advocacy

This post was developed collaboratively by the Section’s Communications Committee.

The capital and the news media are in a collective tizzy over the abrupt firing of FBI Director James Comey. Cable news chatter is reaching a fever pitch as talking heads make frequent references to Nixon’s Watergate, though we cannot yet know for sure whether Trump’s house of cards will fall the same way (or, frankly, why on earth he thought this was a good idea).

There is no shortage of rolling heads, and plenty of screaming headlines have rolled with them. While each decapitation dismissal is significant for its own reasons, one that has unfortunately not received as much attention was the firing of US Surgeon General Vivek Murthy at the end of April. Quiet chatter about the sacking has percolated through the domestic public health community, accompanied by a prickly letter from Senate Democrats last week demanding to know why Murthy was axed “[e]specially in light of your Administration’s pattern of politically motivated and ethically questionable personnel decisions.”

As this piece from Vox points out, the reasons why are pretty obvious:

Murthy…holds views on gun control that are at odds with those of the new administration. When President Obama nominated Murthy back in November 2013, the Senate blocked his nomination for more than a year, particularly after the National Rifle Association criticized a letter Murthy had co-signed in support of gun control measures.
…
Murthy was also a strong supporter of Obamacare. He co-founded Doctors for America in May 2009 — around the time the fight about the Affordable Care Act was heating up. “The country’s main doctor trade group, the American Medical Association, remained neutral on the Affordable Care Act. In founding Doctors for America, Murthy says he saw an opportunity to organize the doctors who very much did support Obamacare,” Sarah Kliff reported.

Most recently, Murthy’s office came out with a report that included clear, evidence-based suggestions about what steps need to be taken to combat the opioid epidemic — but Murthy wasn’t tapped to join President Trump’s recently announced opioid commission.

The implications for public health in the US are pretty obvious. However, this matters on the global health front as well – and not simply because the US is part of the global health picture. In addition to being “America’s doctor,” the surgeon general is in fact a kind of “general” of sorts (technically a vice admiral, equivalent to a lieutenant general). She or he leads the PHS Commissioned Corps, a uniformed service that deploys in public health emergencies, including global ones. PHS officers have deployed in response to humanitarian crises and global health pandemic responses including 2009 influenza pandemic, the 2010 Haiti earthquake, and the west Africa Ebola outbreak.

Past surgeons general have been vocal about the importance of global health. Perhaps more importantly, they also have a distinguished history of being a thorn in the side of the US presidents under which they serve by speaking truth to power on controversial public health issues. One of the most famous examples is C. Everett Koop’s educational brochure on AIDS that he mailed to every household in America in 1988, flying in the face of Reagan’s refusal to publicly reference anything related to the virus or its devastating epidemic. Considering that the position itself has relatively little authority, this kind of thought leadership that champions evidence-based approaches to public health problems, even when they are politically uncomfortable, is all the more important in a world that often looks to the US to set the standards for both science and practice in public health.

Of course, the next surgeon general’s ability to do that is limited under an administration led by a president who still acts like he’s the star of The Apprentice.

Since the election, there has been much (and very much justified) hand-wringing over clear global health setbacks, including looming budget cuts, the Global Gag Rule (and the future of reproductive rights in general), and the potential for ramped up defense spending to drive even more devastation to health through conflict. Doctors take an oath to always do what’s best for their patients. As public health professionals, we have a parallel responsibility to carry out our mission to benefit all people. Dr. Murthy’s legacy of fighting for every life – through his stances on gun control and affordable health care – are an example of this duty exercised faithfully. His final thoughts as surgeon general are striking:

We will only be successful in addressing addiction – and other illnesses – when we recognize the humanity within each of us. People are more than their disease. All of us are more than our worst mistakes. We must ensure our nation always reflects a fundamental value: every life matters.

While there is plenty to ring the alarm about outside the border, it is critical that those of us in global health also lend our voices to our public health allies whose work is focused stateside. We cannot afford to sit out US domestic public health issues, because they inevitably impact the whole world.

Policy on #HIV related travel restrictions adopted by @WFPHA_FMASP at #WCPH2017 now posted

by Jessica, posted in HIV/AIDS, Human Rights, Policy and Advocacy, Section Announcements

After APHA adopted its permanent policy statement on HIV-related immigration restrictions that we submitted at last year’s Annual Meeting, the IH Section worked with APHA’s WFPHA liaison, Dr. Deborah Klein-Walker, to submit a corresponding policy proposal on behalf of APHA to the World Federation of Public Health Associations, which held its 15th World Congress on Public Health this month in Melbourne, Australia. The proposal was accepted and passed by the WFPHA Policy Committee at the meeting, and has now been posted the website (PDF). The text of the policy (excluding references) is below.

Scientific evidence and treatment needed to combat the spread of HIV – not ineffective travel bans

Submitted by the American Public Health Association
(Contact person D. Walker)

Introduction
HIV-related restrictions against entry, stay, and residence remain common around the world. Various countries have policies that mandate HIV testing of all or certain groups of foreign nationals as a condition of obtaining a visa for employment. These policies have no basis in science and violate migrant workers’ human rights to confidentiality and informed consent to testing, exposing them to exploitation by their employers. According to UNAIDS, 35 countries currently have official HIV-related travel restrictions. Furthermore, HIV-related travel restrictions against foreign nationals have been shown by international treaty bodies, international legal scholars, and human rights organizations to constitute discrimination based on race, ethnicity, and/or country of origin.

Scope and Purpose
Restrictions on travel, immigration, or residence related to HIV status are a violation of the principles of nondiscrimination and equal treatment in all international human rights laws, treaties, and agreements. The International Covenant on Civil and Political Rights guarantees the right to equal protection under the law, free from discrimination based on race, color, sex, language, religion, political or other opinion, national or social origin, property, birth, or other status, and the UN Commission on Human Rights has determined that this includes discrimination based on health status, including HIV infection. According to the Siracusa Principles on the Limitation and Derogation Provisions in the International Covenant on Civil and Political Rights, while international human rights law allows governments to restrict rights in cases of emergency or serious public concern, the restrictions must be the minimum necessary to effectively address the concern – and HIV-related travel restrictions have been overwhelmingly ruled as both overly intrusive and ineffective public health policy. Within such restrictions, compulsory HIV testing is a serious violation of numerous human rights principles, including the right to bodily integrity and dignity. The accompanying deportation and/or loss of employment and residency status of HIV-infected migrants that frequently accompanies such testing violates the rights of PLWHA to privacy, work, and appropriate medical care. The International Labour Organization (ILO) has specifically stated that neither HIV tests nor private HIV-related personal information should be required of employees or job applicants.

Despite this robust evidence base, according to UNAIDS, 35 countries currently have official HIV-related travel restrictions openly acknowledged and enforced by the government. These restrictions vary from outright entry bans, which bar PLWHA from entering the country, to restrictions on stays longer than a specified period of time or to obtain employment visas or residency status. Others have inconsistent policies and/or intentionally misrepresent their policies with HIV-related restrictions. Such policies and practices, and the number of migrants impacted by them, are difficult to track because of differing or ambiguous definitions and a lack of data. Some of the most restrictive policies subject immigrants to mandatory HIV testing, either when applying for residency or for an employment visa, which is frequently required by states for legal residency.

The two primary justifications provided by governments for mandatory HIV tests for migrant workers and other HIV-related travel restrictions are to protect public health and reduce the cost burden on the country’s healthcare system imposed by providing HIV care services to foreign nationals. While countries have the right to employ measures to protect their populations from communicable diseases of public health concern, HIV is not transmitted by casual contact, meaning there is no scientific basis for attempting to control its spread via immigration policies. Furthermore, countries that do not have HIV-related travel restrictions have not reported any negative public health consequences compared to those that do, and recent analysis suggests that even migration from countries with generalized HIV epidemics does not pose a public health risk to destination countries.

In fact, immigration policies banning or restricting entry or employment based on HIV status often have the opposite effect of their protective intention, causing direct harm to the health of both of immigrants and citizens. They marginalize PLWHA, regularly discourage people from accessing HIV testing and treatment, and reinforce stereotypes and discriminatory attitudes against PLWHA in the general population. Regulations requiring HIV tests of immigrants can promote the idea that foreigners are dangerous to the national population and a public health risk, as well as creating a false sense of security by reinforcing the notion that only migrants are at risk for infection. Additionally, such attitudes can adversely impact the host country’s own HIV epidemic, as citizens who are unaware of their HIV-positive status, underestimating their own HIV risk and avoiding testing due to stigmatization, are more likely to transmit the virus to others, driving up infection rates.

State-enforced HIV screening of migrants costs far more than it saves in treatment costs. Screening travelers and migrants for HIV is impractical and expensive.[5][13][19] Labor migrants (both regular and undocumented) bring significant economic benefits to their host countries, in addition to themselves, and this cost-benefit balance remains even when migrants are HIV-positive and rely on the host country’s health care system for treatment and support.

Fields of Application:

  • National public health associations and their members
  • Human rights and HIV advocacy groups
  • UNAIDS
  • The World Federation of Public Health Associations

Action Steps:

The WFPHA joins with UNAIDS, the World Health Assembly, and other HIV and human rights organizations (e.g., Amnesty International, Human Rights Watch, ILO) to call on all countries that still maintain and/or enforce HIV-related restrictions on entry, stay, or residence to eliminate such restrictions, ensuring that all HIV testing is confidential and voluntary and that counseling and medical care be available to all PLWHA within its borders, including migrants and foreign nationals.

The WFPHA affirms the following principles:

  • All people have the right to confidential and voluntary HIV testing and counseling.
  • Persons living with HIV/AIDS (PLWHA) have the right to privacy, to work, and to appropriate medical care.
  • All HIV-related travel and immigration restrictions currently in place should be removed.
  • Agencies and businesses who employ foreign nationals should not use HIV tests as a means to discriminate against potential employees.
  • Governments should provide HIV prevention and treatment services that are equally accessible to citizens and foreign nationals.
  • Migrant workers should have access to culturally appropriate HIV prevention and care programs in languages that they can understand.

The WFPHA recommends that:

  1. Public health associations in every country should:
    1. Develop policies opposing HIV-related travel restrictions;
    2. Document and/or support human rights and HIV advocacy groups in documenting immigration policies that explicitly discriminate, or allow employers to discriminate, against migrants based on HIV status;
    3. Document and/or support human rights and HIV advocacy groups in documenting any HIV testing practices that are not voluntary or confidential;
    4. Inform their members and the public that HIV-related travel restrictions and compulsory HIV testing of foreign nationals is a violation of human rights and does not protect public health or reduce health care costs; and
    5. Advocate for the removal of any and all HIV-related travel restrictions enforced or condoned by their country governments.
  2. UNAIDS should take steps to ensure that its protocols to research and investigate countries’ HIV-related travel restrictions are sufficiently thorough by monitoring and documenting any reported instances of HIV-related discrimination targeting immigrants, particularly when presented with evidence demonstrating that recognition of a country’s removal of HIV-related travel restrictions is unwarranted, in order to ensure that governments are not able to misrepresent their policies in order to gain undeserved recognition for supporting human rights with regard to HIV/AIDS.

WFPHA supports the removal of all HIV-related travel restrictions and travel related mandatory testing.

The Relevancy of the United Nations and Multilateralism in an Increasingly Unilateral World

by Jean Armas, posted in APHA IH Section, Policy and Advocacy

The League of Nations was created after the first World War in order “to promote international cooperation and to achieve peace and security.” Sadly, the League proved to be ineffective and failed to prevent the second World War. The League was eventually replaced by the United Nations. In 1950, after the second World War, representatives from 50 different countries met in San Francisco to create the United Nations charter which binds its members to commit to maintaining international peace and security, develop friendly relations among nations, and promote social progress, better living standards, and human rights. The charter was eventually signed by 51 countries and its membership has now grown to include 193 countries.

The United Nations and its extended family of funds, programs and specialized agencies have had countless successes over the years, evident in the 11 Nobel Peace Prizes they have won. They have helped save millions of children’s lives, protected hundreds of world heritage sites like the Galapagos and the Giza Pyramids, and contributed greatly to the reduction of famine. They’ve even eradicated smallpox and helped reduce the emissions of chlorofluorocarbons to protect the ozone. Like any other organization, the United Nations has also experienced their fair share of failures over the years. One of its biggest disappointments was the failure of the UN Assistance Mission in Rwanda to stop the genocide of thousands of Tutsis. In addition, a UN peacekeeping force was held responsible for one of the worst outbreaks of cholera after the 2010 earthquake in Haiti.

As such, critics of the United Nations abound. More recently, they have been under intense scrutiny for failing to put an end to the Syrian conflict and being slow to respond to the Ebola outbreak. Accusations of corruption, inefficiency, waste, bureaucracy and bias have materialized over the years from both developed and developing countries. Although the UN has recognized its mistakes and tried to address them, things have not been getting better. A recent wave of frustrated member countries are currently considering withdrawing from some of the United Nations’ various councils, programs, and funds. The United States has recently been considering quitting the UN Human Rights Council as well as slashing its contributions. Several African nations have also been considering withdrawing from the International Criminal Court, citing bias against Africans.

Amid the criticisms and the frustrations of its member states, the question on the minds of many remains, “Is the United Nations still relevant?” While the values of the United Nations have proved to be timeless, execution has been problematic. Their policies are riddled with too much “what to do” and not enough “how to do it.” Many argue that the United Nations system has ultimately failed to prove its value.

The world has changed a great deal since the founding of the United Nations. Mounting skepticism on globalization and increased focus on politics at the local level has led to the rise of populism in France, Britain, and the United States. Global disasters stemming from climate change, famine, and emerging diseases are in the cards and threaten the world order. While it’s clear that the UN’s current mode of operations has had its disappointing moments, withdrawing from membership or cutting funding are not solutions to the problem. Both measures could throw the world order into chaos.

As such, the most insidious threat to world order lies not in impending famine, climate change, or emerging diseases, but in the increasing dissonance among nations over working together to maintain peace and progress worldwide. Critics favoring unilateralism argue that participating in global peacekeeping and progress takes away from achieving peace and progress at home. That being said, accomplishing peace and progress domestically requires countries to acknowledge the growing interconnectedness between our country and the world around us. The world is becoming more connected, not less. Embracing this perspective allows us to see that collaboration and negotiation with other countries is still the way to maintain peace and achieve progress and prosperity. Multilateralism is still the path forward.

This is a critical moment for the United Nations. A moment for them to restructure, reform, and reinvent. A moment for them to respond more agilely to the needs of a changing world. Change, however, is a long, painful (and expensive) process. A process which needs full buy-in, support, and participation from its members in order to succeed. This is the only way for the United Nations to survive and more importantly, for our world to continue to thrive.