A Response to Roger England

This is a letter written by Nathan Geffen in response to some public health advocates who say that AIDS funding has been detrimental to public health.

Click here to read yet another article promoting a line of thought given credence by Roger England in 2007 in the BMJ. England argued that too much money was being spent on AIDS, to the detriment of public health systems.

You might think that because two members of the AIDS establishment, Alan Whiteside and Daniel Halperin, are quoted in this article supporting Roger England's argument, it must be a good one. But it isn't. I hope Halperin and Whiteside, for whom I have much respect, will respond to this email by saying they were misquoted. I've seen an article by Halperin which makes similar arguments so I'm not hopeful.

The mistakes in the arguments made in the Observer article below have been repeated in nearly every similar such article.

* It is because of AIDS advocacy that malaria and TB spending has massively increased. The GFATM is a consequence of AIDS advocacy.

* The article refers to patients dying because of lack of insulin. But this was also a problem a decade ago; it is not a consequence of increased AIDS funding. If anything, AIDS highlighted the disparity between developing-world and first-world health-care. The solution is not to divide up the small funding pie, but to make the pie bigger. That was the beauty of the Global Fund; it increased massively the amount of spending on TB and malaria. And it was almost entirely due to AIDS advocacy; and hardly at all due to the then old and decaying public health establishment working in TB and malaria. I agree: Let's treat hypertension, non-AIDS diarrhoea and diabetes in Africa and other developing countries. But by emulating the best of what AIDS activists and public health people have done, not undermining it.

* The corruption with AIDS money will be no less if it is diverted to "health systems" or other interventions. In fact, given the vagueness of what "health systems" can mean, it will probably mean more corruption. Short memories here: public health corruption was no less a problem before the GFATM. It was worse I suspect (just with less money). The GFATM has strong systems for monitoring expenditure, with information about project performance publicly available on the internet. Can any pre-AIDS intervention claim the same? This is pioneering and we should emulate (and improve) it, not destroy it. Most donor AIDS money is not spent corruptly; it is mostly spent saving 3 million lives. Name another donor-funded public health intervention that achieves the same. That is not to deny that there is a problem with corruption and wastage in the AIDS world, but it would be no better and probably a lot worse if we followed Roger England's advice. Also, because of AIDS NGOs, civil society has grown much more conscious about health care issues.

* Nicoli Nattrass and Gregg Gonsalves have published work showing that AIDS spending as a proportion of total health spending in sub-Saharan African countries is on average less than disability-adjusted life years (DALYs) lost due to AIDS as a proportion of total DALYs. This is entirely ignored by England's followers.
See: http://www.cssr.uct.ac.za/sites/cssr.uct.ac.za/files/pubs/WP254.pdf.

* In a somewhat separate argument, but one that always seems to get made by those supporting England's thesis, Whiteside is quoted repeating the mantra about prevention rather than treatment. Too much money has been spent on treatment at the expense of prevention the argument goes. Is Whiteside concerned that PMTCT has received too little money? This is funded with the AIDS money the Observer article laments. >From Halperin's other writing I gather he thinks too little is spent on voluntary male medical circumcision, a point I agree with. But critically, there is emerging evidence that HAART reduces HIV incidence. So as treatment activists have been saying since 1998 (probably earlier), stop separating treatment and prevention.

Gregg Gonsalves describes what is going on succinctly:

"As someone said to me just now, the case was made against 'vertical' vaccination programmes thirty years ago, leading to massive defunding and increases in child mortality. Then they criticized 'vertical' family planning and reproductive health services, with similar impact. These people have some theoretical notion of how health systems should work but when their hand is on the tiller things get worse. Remember, there was NO WHO AIDS program for years--is that a reasonable response to an epidemic!? We stepped in because they failed and had a long history of failure. The experts want us to go back to old-style sector wide approaches to health where governments get a blank check from donors and there is no civil society engagement at all. They also won't give "new" money--they aren't interested in supporting health systems but doing "just" enough to keep ministers happy. Look at the International Health Partnership--this is the framework around which it is being built. AIDS has created another model and for all it's faults has brought new money, new energy, new popular engagement, new transparency and oversight to health--and they don't like it."