Sustainability: A Core Value of the President's Emergency Plan for AIDS Relief

Let me begin with an image. Imagine waking up one morning, turning on the radio, and hearing that twenty 747s around the world, each fully loaded with 400 passengers, had crashed, killing everyone aboard. Imagine what a devastating shock such a tragedy would be.

Then imagine waking up the next morning and hearing that the exact same tragedy had happened again. And waking up the morning after that, and the morning after that -- every day, in fact, and hearing that 20 jet airliners had crashed, leaving no survivors.

Believe it or not, that is the toll AIDS takes every day around the world. 8000 people are dying every day due to this killer. This disease is not just an epidemic, it’s a destroyer of communities, families, and individuals. To try to make this pandemic real for you, let me describe a recent experience.

A few months ago, I visited a home-based care program we are funding, a program run by volunteers in Mozambique, one of the poorest countries in southern Africa.

Along with the head of this program, I visited a patient in her home -- a typical dwelling perhaps 12 feet by 12 feet, dirt floor, mud brick walls, corrugated metal laid across the top as a roof, dark inside with no windows. Tragically, the woman living there was days if not hours from passing away from AIDS.

Sitting on the edge of the woman’s mattress was her 5-year-old daughter. I asked the home-care volunteer to tell me who was taking care of the little girl now and what would happen to her when her mother was gone.

She simply shrugged her shoulders in despair. She told me the child’s father was already dead, from AIDS, and she had no other family. While the neighbors looked in on her when they could, it was not clear that anyone would be able to help after her mother was gone. This was a child destined for the street. This is a tragedy that in one form or another is repeated 8,000 times each day.

In trying to comprehend 8,000 deaths a day, or 3 million deaths a year, it is easy for these numbers to become just statistics. But it’s important to remember that each one is an individual, with a name, a family, a story. And the image of this woman and her little girl is never far from my own mind.

From the early days of his Administration, President Bush considered global AIDS an emergency unlike any other. He concluded that the world’s response, to put it bluntly, has not worked -- that it was simply not enough. The President also believed that the United States had a unique ability to lead the world in rising to this challenge.

So President Bush created the Emergency Plan for AIDS Relief. It is $15 billion over 5 years -- the largest financial commitment any nation has ever made to an international health initiative dedicated to a single disease.

President Bush led us into an era of action. He insisted that we stop talking about the reasons why we couldn’t do anything to stop AIDS, overcome those things, figure out what we could do, and do it -- with urgency. He has made it crystal clear to me that "business as usual" is not acceptable.

I was honored that the President asked me to lead the development and implementation of a Five-Year Strategy to implement his Emergency Plan. Under this strategy, America is now fighting AIDS in over 100 countries around the world.

We are also placing a strategic focus on 15 countries that are especially severely affected, accounting for over one-half of the world’s HIV infections. The President decided to place a special focus on this group of countries, to commit intensive resources in order to turn the tide in them. This will show that it can be done, that there is hope of winning this fight. The world needs this hope right now.

In these 15 countries over the next 5 years, we will:

• Support provision of lifesaving drug treatment to 2 million HIV-infected people;
  
• Prevent 7 million new HIV infections; and
  
• Support care for 10 million people infected and affected by HIV/AIDS, including orphans and vulnerable children.

These are clear, quantifiable goals; we are holding ourselves, and the organizations we are funding, accountable for achieving them. We expect to be able to measure the results from that investment, to increase the funding for the programs that produce results, and to stop the funding for the programs that do not produce results, something that is not always done with international aid programs.

I’m pleased to report that we have been able to make very encouraging early progress. For example, the Emergency Plan has made a commitment to support lifesaving antiretroviral drug therapy on a scale never before attempted. In just the first eight months of our program, we were able to support treatment for over 155,000 people in our 15 focus nations.

That means that the United States was able to support treatment for more people after just the initial months of our program than any other donor in the world had been able to support until then. And we’ve continued to scale up our programs since, so the number is now far higher.

I think it’s fair to say that there was a lot of doubt about whether treatment could successfully be delivered in resource-poor settings on a large scale. But the answer is becoming very clear that, if we work with our host nations and invest in system-wide improvements, indeed we can do it. Success today is the best foundation for hope for the future.

We have also made impressive progress in providing care for those infected and affected by HIV/AIDS. We have scaled up our programs under national strategies for orphans and vulnerable children, and for palliative care for HIV-positive people.

In the early months of implementation, the U.S. supported care for more than 1.7 million people infected and affected by HIV/AIDS, including over 630,000 orphans and vulnerable children. When people see that those who are infected with HIV, or who lose parents to AIDS, are well cared for, that too brings hope. There’s so much more to do, but it is a promising start.

Now, these numerical goals I have outlined are 5-year goals, through 2008. The tragic reality, however, is that the nations suffering most from HIV/AIDS are many, many years away from getting their pandemics under control. So even while we focus on responding to the daily emergency I described earlier, we must also focus on creating a sustainable response. That’s why this conference is so timely, by the way. In focusing on sustainability, I believe you are really going to the heart of the matter.

Among the greatest challenges we will continue to face for the indefinite future is helping our host nations build the capacity to respond to their HIV/AIDS emergencies. The challenge of sustainability is entwined with that of capacity.

In so many of the nations where we are working, the capacity to deliver health care is severely limited by a history of poverty and neglect, war and political instability. Our ability to put resources to work in a nation is constrained by its health care infrastructure and supply of trained health workers.

All the AIDS drugs in the world won’t do any good if they’re stuck in warehouses, unable to be provided to those in need, because of a lack of infrastructure, or because of a shortage of trained personnel. Consider this: in the U.S., we have 279 physicians for every 100,000 people. In Mozambique, however, there are only 2.6 physicians for every 100,000 people. That means that just 500 physicians serve the needs of the entire country -- a population of 18 million.

In some countries, the "brain-drain" of trained medical personnel is an enormous problem. In Ethiopia, where there are only 2.9 physicians for every 100,000 people, a physician there told me recently that there are more Ethiopian-trained physicians practicing today in Chicago than in all of Ethiopia. This is why we have invested so much effort in expanding capacity in these places.

Of course, our capacity-building work is not primarily about making it possible for the United States -- or other outside donors -- to do more in the future. Rather, the Emergency Plan is building local and host-nation capacity so that national programs can achieve results, monitor and evaluate their activities, and sustain their responses for the long term.

Without local capacity, nations cannot fully "own" the fight they must lead against HIV/AIDS. I am pleased to note that we are seeing these hard-hit nations take ownership of their own responses.

Here’s one way the Emergency Plan seeks to facilitate that development: fully 80% of our more than 1,200 partners working on the ground were indigenous organizations including faith- and community-based partners. That hasn’t been easy to do, but we are committed to bringing even more indigenous partners into the Emergency Plan.

Let me highlight some of our initial strides in helping host nations develop their capacity to respond. These are discussed at length in our recent First Annual Report to Congress.

Health infrastructure is a major challenge. In the early days of the Emergency Plan, the U.S. has had success in promoting the expansion of existing health care networks and the development of new public and private network systems to enhance the delivery of HIV/AIDS services in remote areas.

For those networks to be effective, they require trained personnel. Responding to the critical shortage of trained health workers at all levels, the Emergency Plan has supported training that covers a broad range of services, from prevention -- including mother-to-child prevention -- to antiretroviral treatment, to palliative care, to counseling and testing, to orphan care. The American people, through the Emergency Plan, are helping people in our host nations develop the skills to meet their neighbors’ needs.

The Emergency Plan has also fostered indigenous leadership in the fight against the HIV/AIDS pandemic. The U.S. has provided technical assistance for appropriate policy development, including policies protecting women and girls, and for strengthening local institutions and organizations, including organizations of persons living with HIV/AIDS.

Other components of local capacity on which we have focused include surveillance, reporting, evaluation, and strategic information. These tools allow us to maintain the accountability that is a cornerstone of the Emergency Plan, and to adjust our programming based on what works. Even more importantly, these tools allow host nations to monitor and adjust their national responses.

Our host nations have warmly welcomed our commitment to partnership with them, and our support for their national responses. At this early stage, U.S. support is still needed -- in fact, it is indispensable. Our support is essential to allowing host nations that have recently been able to begin antiretroviral therapy on a broad scale to maintain and expand that work. We can help to ensure that the gains we have made are not allowed to slip away, but are built upon.

Let me emphasize this, however: while I believe we are on the right track in focusing on capacity-building and sustainability, we have a long way yet to go. Issues this fundamental cannot be resolved in a few months, or a few years. They will require a continued, concentrated focus over many years. We must all maintain that focus.

Local ownership of this fight is essential if the programs we build are to be sustainable in the long term, as they must be. As someone observed to me, we must provide both fish and fishing poles. Down the road, we want these countries to be able to do all the fishing for themselves.

Now, as I’ve mentioned, we’ve greatly emphasized working with indigenous partners -- people who have demonstrated a commitment to these nations, and are committed to contributing to a sustainable response.

When you think of the people who live in the most remote regions and in the most hopeless slums -- who has been there to help them?

Who already has people on the ground who are trusted?

Who will help those who must persevere in the face of being stigmatized in their own communities?

And who will help replace stigma with compassion and understanding?

The fact is that the churches, the monasteries, the temples, the mosques, and the synagogues are among those who have gone where no one else would go. Faith-based organizations have built trust and provided hope to generations of individuals in places where hope is scarce.

Last summer I met with a Buddhist Monk in Vietnam who has started a home for children in Ho Chi Minh City. Many of those children are living with AIDS. He talked with me about the children's desperate need for treatment, but he also talked about how these children are finding hope and some relief through the work of his program.

In Ethiopia, I met with the Patriarch of the Ethiopian Orthodox Church. About 40 million people are members of the Church -- more than one-half of the people in the country. We're partnering with them because they represent a highly motivated way to reach people, including young people, with prevention messages, and because they have a level of credibility in the country that foreigners simply don't have.

I had an opportunity to hold a videoconference with key personnel of the Holy See in Rome. In countries with few resources throughout the world, the Roman Catholic Church provides much of the basic health care system. Catholic institutions, clergy and laity are putting themselves on the front lines of the HIV/AIDS fight. We’re already working with them in many countries, and we’re discussing ways to expand that partnership.

Our focus has to be on the bottom line -- saving lives. If we were to work in developing countries but refuse to work with faith-based organizations, we would be harming our ability to save lives -- and that is just incomprehensible to us.

Common sense must be part of everything we do, so America will continue to take advantage of the expertise, experience, and passion of faith-based service providers to help build a sustainable response throughout the world.

Let me turn to another mechanism for building sustainability: leadership from the business community.

The private sector is a powerful engine for change, as companies must rapidly adapt to change and find creative approaches to challenging problems. That’s the kind of leadership we need to turn the tide on the HIV/AIDS pandemic.

Let me offer an example of farsighted business leadership. For enterprises in countries facing the pandemic, HIV/AIDS isn’t just a humanitarian crisis, it’s a threat to their workforce. Some have responded in counterproductive ways that contribute to stigma.

In South Africa, however, Ford took a different tack. It offered its workers prevention education, HIV testing, and even antiretroviral drug treatment if needed. It did so in non-stigmatizing ways that treated employees with respect. Ford addressed the needs of the people on whom the company depends.

After seeing the tremendous success of this program, Ford began to reach beyond its workforce to the surrounding communities. Simply put, Ford is treating its employees like family -- and its communities like extended family. I’m proud to see American companies exercising wise leadership in countries that desperately need it.

The needs posed by this epidemic are so vast that there are limitless opportunities for private sector leaders to become involved. My vision is that the struggle against global HIV/AIDS will not be carried forth by only a handful with a special interest, but that all of us will find ways to get our organizations involved in helping nations respond.

Leadership, in my view, is about far more than producing results through one’s own initiative -- it’s about producing results through others. It’s not only governments who have an opportunity to help provide fishing poles to those who need them. It’s all of us.

I want to acknowledge the contributions so many of you are making to this cause. Thank you for all you are doing, and please know that the United States Government will continue to work alongside you in this fight.