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    Q&A: The promise and peril of a 'PEPFAR for COVID'

    Devex speaks to journalist and activist Emily Bass about her new book, "To End a Plague: America's Fight To Defeat AIDS in Africa," and the lessons that PEPFAR can offer for fighting COVID-19.

    By Michael Igoe // 06 August 2021
    A man holds up a "Fund PEPFAR" sign at former U.S. President Barack Obama's speech at a campaign event at Herman Park in Boone, Iowa. Photo by: Larry Downing / Reuters

    In 2002, journalist and activist Emily Bass was arrested outside the White House during a protest of then-U.S. President George W. Bush’s failure to respond to the global HIV crisis.

    The next year, in his 2003 State of the Union address, Bush launched the largest global health program for a single disease in history: the U.S. President’s Emergency Plan for AIDS Relief. It called for $15 billion in funding over five years, the prevention of 7 million new HIV infections, treatment of 2 million HIV-positive people, and care for 10 million adults and children with HIV.

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    Since PEPFAR’s inception, the U.S. government has invested $85 billion in global AIDS response and saved an estimated 20 million lives.

    In 2004, Bass received a Fulbright Program grant from the U.S. government to travel to Uganda and witness what happened when HIV drugs finally arrived in places that had largely been left without treatment. Last month, she published a book — “To End a Plague: America's Fight To Defeat AIDS in Africa” — telling that story.

    Devex spoke to Bass about what makes PEPFAR unique in the history of U.S. efforts to tackle global health challenges. At a moment when the country is once again facing down a health crisis that is wreaking havoc at home and abroad, PEPFAR’s example holds valuable lessons for marshaling a meaningful response — and how things can go off track.

    Emily Bass, journalist and activist. Photo by: Emily Bass via Twitter

    “What I see when people these days are like, ‘We need a PEPFAR for COVID’ ... or, ‘We need Bush to be the vaccine czar,’ I feel like our amnesia, our selective memory of what PEPFAR actually was and is — I don't really say this lightly — but it could end up killing us,” Bass said.

    This interview has been edited for length and clarity.

    What did your experience in Uganda lead you to believe about the Bush administration's motivations for launching PEPFAR and its choices about how to structure the initiative?

    One of the things that's really extraordinary about PEPFAR to me is the rigor with which this initiative was designed.

    It's not a facile thing to say our aid system isn't set up to report on targets; it's literally that we had to build a new way to input information. Now, why does that get built? It gets built because Bush has this team inside the West Wing. … This small team of advisers basically take it upon themselves to deliver to the president a sort of venture capital-vetted version of an AIDS initiative that Tony Fauci and Mark Dybul — [medical professionals who helped architect PEPFAR] — are charged with delivering.

    This is not the way that, for example, we do aid to countries that have experienced earthquakes or tsunamis or major disasters. The check doesn't always have a rigorously researched, data-based plan behind it with impacts and targets.

    And it's really interesting because at the same time that this is happening, Bush is also planning to go to war. The drumbeat to Iraq is happening. If you call this a war on AIDS in Africa, it's got an enormous amount of vetted, verified intelligence behind it that is iterated until everybody thinks, no, we really do have a sense of the [target] numbers that are possible.

    When people ask about Bush's motivations and why he did this ... when he writes about it, he really resonates with [a visit to] the Gambia, with a sense of history as he absorbed it from “Roots,” from visiting slave ports. There's something there that I think is a real attachment and motivation. And even if this came from a different place in the post-9/11 context, the reality is it was really, really thoroughly researched and thought through, and that sets it apart from a lot of other things.

    As HIV and COVID-19 collide, questions loom over PEPFAR's future

    While the COVID-19 pandemic has highlighted the need for strong health systems, U.S. President Joe Biden faces difficult choices about the role for America's flagship HIV initiative.

    It seems as though PEPFAR has become shorthand for something that PEPFAR actually wasn't. “The PEPFAR of X, Y, or Z” just means a big, ambitious foreign aid program — lots of money with some sort of visible leader. But you're saying that there are many more — and probably more important — ingredients to it than that.

    Yes, and it's really wonky. But also it is of existential-level importance, which I didn't necessarily expect when I wrote a book about PEPFAR. This is about the political economy of a big investment — what was, at the time, the largest disease-specific foreign aid investment that America had ever made and that had ever been made in the world in terms of a bilateral program.

    I'd written this [Fulbright] proposal that said I want to see what it looks like when the world changes because of PEPFAR. And what immediately became clear when I arrived [in Uganda] is that's not how the world works.

    PEPFAR itself, on the ground as a program, vanished pretty quickly. The closer I got to it, the clearer it became that the different government agencies within PEPFAR — which is particularly USAID [the U.S. Agency for International Development], the Centers for Disease Control and Prevention, Department of Defense, Peace Corps, and then the State Department — all of those groups were tasked with working together at a country level, a team level to develop these plans.

    And if you go to a country to this day, there are differences between how CDC and USAID run their programs. And so you realize that PEPFAR isn't an approach; it's multiple approaches.

    And then I began to understand both the productive tensions and the damaging tensions between those agencies and what it means and how unusual it is in the U.S. government to have a “whole-of-government” approach, which is essentially all of these agencies having to work together. Prior to PEPFAR, they did not. USAID and CDC did not have to coordinate their HIV work. … And so when people say, “Let's have a 'PEPFAR for X,’” if it doesn't have all of those pieces, it's not going to be a PEPFAR for X.

    And you see that happening now when people call for a “PEPFAR for COVID” or something similar?

    Right now [with the response to the COVID-19 pandemic], history is sort of repeating itself. ... A bill that just passed out of the Senate Foreign Relations Committee with Sens. [Jim] Risch and [Bob] Menendez as the primary sponsors is signaling that there's bipartisan endorsement for a major fund and a major presidential initiative, which is really good. One would hope that you would then have the next step, which is a presidential initiative that actually picks up on that signal and owns it and leads it.

    But in this bill, there are different approaches. The leadership roles between USAID, CDC, and so on are not as clear or well defined as they were with PEPFAR. We have to pay attention to that. Where is this going to sit? Who's getting the power? Who's getting pushed aside? Because those tensions and conflict and occasional moments of innovation through juxtaposition of agency philosophies are fundamental to our success with PEPFAR.

    What isn't happening in the current legislative and administration-level thinking around a large-scale global pandemic response initiative that did happen when PEPFAR came together successfully?

    At the administration level, it's hard to discern. … We are these many months into [the pandemic] in a situation where the administration itself has not done some of the things that the Bush administration did with PEPFAR, which are to adopt one of many suggested targets — including targets that are in the Risch-Menendez bill, like let's vaccinate 60% of the world. U.S. ownership of specific targets related to the global COVID response would be the thing that would be analogous to the treatment target in PEPFAR, and we don't have that yet.

    PEPFAR gets all these agencies together under the auspices of the State Department because there's so much money available. It's like a gravitational force. It keeps people in their chairs because there's never been anything like it.

    But there's a throughline in the book that is also really important to be watching, which is that USAID really thought that it should have been the home for PEPFAR. There's a real sense that a mistake was made among many folks. I would characterize it as a sense of grievance.

    And one of the things that unfolded in the [former President Barack] Obama [and then-Vice President Joe] Biden administration was a fairly concerted effort to move PEPFAR into USAID. The global AIDS [coordinator for the U.S.] ... at the time, Eric Goosby, told me that it happened three different times and that PEPFAR itself, under his leadership, had to spend a lot of energy to stay at the State Department.

    Where is our U.S. global COVID leadership going to land? Is it going to land on “we're going to build on the thing that worked”? Is it going to land on “let's try to resolve this long-standing analysis that's held by some folks related to USAID that PEPFAR actually, structurally, was a mistake”?

    Tell me how you see things right now. A lot of the same people from the Obama-Biden administration are back in government. I've seen white papers about shifting PEPFAR into USAID and transitioning to a broader health systems approach. I take it you are concerned.

    I'm really, really worried, and I'm not alone in being worried. … It’s been 7.5 months, and there is no U.S. global AIDS [coordinator]. … It's not unusual for there to be a little bit of a lag, but this is a really long lag. You can project all sorts of things into that vacuum or into that absence of a political appointee.

    The team at PEPFAR has done a remarkable job of steering the program. Angeli Achrekar, who was Ambassador [and former Global AIDS Coordinator Deborah] Birx's deputy and is the acting leadership, is excelling and is doing everything she can, and so is her team. But a political appointee both has a leadership role and visibility and a moment that sends a signal about the executive branch's relationship to this program.

    So onto this vacuum, what do I project? With no evidence, a concern would be that at a moment when HIV, tuberculosis, and malaria are all grievously exacerbated by COVID-19 and are actually emergencies on a level that really earns the "E" in PEPFAR — President's Emergency Plan for AIDS Relief — are we moving towards a world where the PEPFAR head is less elevated, not a global AIDS ambassador, not an ambassador level? ... Are we seeing perhaps a shift down the hierarchy of priorities for fighting global AIDS, tuberculosis, and malaria?

    Do I worry about the PEPFAR head becoming a middle-management-level position? I do. Do I have a factual basis for that? No, I don't. Do I think that would be disastrous for AIDS, tuberculosis, and malaria, but also for an incredibly successful program that has contributions to make to COVID? Yes, I do.

    I know that many folks who have worked in this field are looking at that unfilled political appointee position and wondering at this point about the organogram or the approach to broader global health that may be coming into focus that would see a deprioritization at a really dangerous moment.

    “U.S. ownership of specific targets related to the global COVID response would be the thing that would be analogous to the treatment target in PEPFAR, and we don't have that yet.”

    — Emily Bass, author, “To End a Plague: America's Fight To Defeat AIDS in Africa”

    What lessons do you see in the Bush administration’s success in launching an unprecedentedly large global health program for political leaders today who are hoping for something similar in response to COVID-19?

    The Risch-Menendez bill is bipartisan. There's evidence that a big initiative — if the president proposed it — could secure bipartisan support, and I think that's a really important signal. … Congress was proposing action on global AIDS for years before we had PEPFAR, but they were also sending signals that “there's bipartisan appetite for this, Mr. President, if you act.” And so I think that signal is there [now for a pandemic initiative].

    The other lesson is that always — first, foremost, and always — activism and activists and civil society engagement forces enabling conditions where the impossible becomes inevitable.

    Harnessing civil society activism at the country level where the pandemics are raging [and] using this energy between groups and folks that say it is not OK to have intellectual property [rights] prioritized over people's lives, it is not OK to accept the failure of a COVAX-esque initiative [for sharing drugs globally, and] we can and must solve these access problems — there is a movement that can also be harnessed and essentially is making it unacceptable not to act.

    The conditions for action, I think, are quite good for saying, “As the president, I am going to do something unprecedented and ambitious, and I'm going to tell you how you're going to know whether it's succeeded.”

    With PEPFAR, it was 9/11; we were in crisis, and we were global citizens in a way that we had not been. And we are in crisis now. COVID is different from 9/11, but it has pitched us into global community in a way that can also be capitalized on. So I think that it is all there, and it must trigger action.

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    About the author

    • Michael Igoe

      Michael Igoe@AlterIgoe

      Michael Igoe is a Senior Reporter with Devex, based in Washington, D.C. He covers U.S. foreign aid, global health, climate change, and development finance. Prior to joining Devex, Michael researched water management and climate change adaptation in post-Soviet Central Asia, where he also wrote for EurasiaNet. Michael earned his bachelor's degree from Bowdoin College, where he majored in Russian, and his master’s degree from the University of Montana, where he studied international conservation and development.

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