What About it?

NYU classes began full swing last week. Already immersed in Keep a Child Alive duties and thesis research, the formalization of readings and reports blends smoothly into my normal bustling schedule. My final International Relations elective is a course called "Solving Foreign Crises," taught by a favorite professor in the department, one who I reference often and whose research conclusions have consistently resounded with truth in my experiences working abroad, the man known as "BdM".

After a brief review of the selectorate theory, the cornerstone of his teachings, each student addressed our group of 15 by sharing an international policy crisis in which we are personally interested. Nuclear proliferation! Israel-Palestine! UN peacekeeping of civil wars! As my turn to speak approached, I fumbled around mentally with my topic of HIV/AIDS for a moment, realizing that in the face of the stated immediate violence and security threats, the relative 'aloofness' of AIDS might be a sub-par topic.

But of course I firmly stated, "HIV/AIDS", and of course, BdM stared me down,

"What about it?"

It is not that I did not anticipate that exact follow up phrase, but his tone hit me hard nonetheless. Despite rampant political rhetoric of caring about the world's disenfranchised, when the time comes to allocate budgets and take action, this seems to be an all too common catchphrase of policymakers. Hunger, sanitation, AIDS...what about it? How does it affect me? I won't be bombed if I don't pay attention to this issue, I'm not risking any national security or international stability. If the stakeholders, the people with the power, are not threatened, the issue is of secondary concern.

I know clearly and can defend easily that HIV/AIDS is an enormous policy issue as a public health emergency and threat to economic stability worldwide. But at our mock-Cabinet session, reviewing key policy issues, my topic was clearly out of place among the other high-ranking concerns. Not to say the high-rankers are not important! But policymakers, naturally, take far more seriously the issues that could tangibly effect their security in the short run. HIV has neither effect, as its spread is silent and difficult to track and see, and the problems emerge over the long run.

I have simple data to share with you, data that took far too long for me to gather! I have yet to come upon a website where HIV rates are posted coherently, consistently, and accurately for years before 1999, for every nation in the world. UNAIDS boasts meticulous methodologies and measurement protocol, but the actual consistent numbers are missing, or at least not publicized. It is frustrating to think that a majority of HIV/AIDS relief is all talk, and politicians make promises becaues they know those who most fiercely want to hold them accountable for keeping their promises are powerless or dying.

The countries in which HIV prevalence rates were highest in 2005 may not surprise you, although I hope you will visualize the immense implication of these estimates. These are national averages, and hidden within this number are the fact that some areas within the country suffer rates of 70%+, but are evened out by less infected areas.

2005
Swaziland 33.40
Botswana 24.10
Lesotho 23.20
Zimbabwe 20.10
Namibia 19.60
South Africa 18.80
Zambia 17.00
Mozambique 16.10
Malawi 14.10
Central African Republic 10.70

Nevertheless, imagine if we rephrased this to say 33% of the population is attacked by terrorists every year? Perhaps it is just the term "HIV" that feels harmless, while "terrorist" sounds frightening. We spend billions defining and measuring and controlling "fundamentalist Islam" which, like AIDS, is not tangible, can manifest itself through violence, and spreads silently but quickly and destructively. But AIDS is not given such attention nor considered such a threat. There is a facade of having control over the disease.

Consider now the rates of change -- where are we making progress, and where are there increases in transmission? Although Swaziland suffers the biggest burden, their present rate is 14% less than their 2003 estimate. The largest increases of 2003-2005 may surprise you:

Gambia 100%
Iran 100%
Ireland 100%
Lithuania 100%
Sweden 100%
United Kingdom 100%
Uzbekistan 100%
Papua New Guinea 200%
Moldova 450%

Although these stats reflect smaller prevalence rates doubling, the rapid increase is cause for concern. What is it about HIV/AIDS that makes it a foreign policy issue worthy of the time we also need to spend on national security, intelligence and defense?

HIV/AIDS will never kill the rich and powerful, but nuclear bombs and anthrax and assassinations could. Leaders will always find a way to escape drought, famine, and disease, so they do not need to invest as much time or serious energy in these issues. It is difficult to say what it is about AIDS that makes it an issue, because although it can attack anyone, those with resources can get treatment and care and never acknowledge they are infected, and never discuss the issue.

Ironically, HIV holds potential comparable to nuclear proliferation and transnational terrorism to destroy a population if the issue is left unchecked...but the risk is not immediate with HIV. An estimated 100,000 died at Hiroshima. Every death is a tragedy. Every of the nearly 3,000 American lives on 9/11 is a tragedy.

So why do we not take as seriously or as urgently the 28 million that AIDS has tragically killed?

Because we don't: Our collective response is somewhat laughable when put in such a context ( 'our' being both us as a rich nation and as a member of the G8 and the UN) Although it involves people who are no doubt committed to the cause, our actions seem to suggest otherwise. Instead of facing this issue head-on, we are creating what many of my African friends have called the "Fat AIDS" pandemic. Their logic reveals how much we do not realize the blatant failures of our nation to actually do good and act on promises and intentions. "There is skinny AIDS and there is fat AIDS," I have been told by several doctors and community workers. "We are dying here from skinny AIDS which makes us thin and weak, and the men in suits and ties fly around to meetings and conferences about AIDS saying all sorts of good things, and they get they paid to do this. They get fatter the more AIDS remains an issue."

Phrased well also by an African delegate interviewed by Michael Maren in his expose on foreign aid, "The Road to Hell", we read, "The more desperate our conditions are portrayed in the U.S media, the more money you American organizations seem to raise for your own overhead and projects." The skinny get skinnier, the fat get fatter.

So, AIDS...what about it?

Though it's a tough pill to swallow, we must acknowledge first that AIDS does not pose a significant threat to our world's most powerful.

But the problem is devastating and quite real.

HIV/AIDS is an issue, and we can decide whether to prioritize it or not. This does NOT translate to giving it more money, but rather, more thoughtful and strategic attention. We have the numbers on HIV -- like a fanatic ideologue, it is a loaded weapon. Someone with something invisible in them that they could spread to someone else without even realizing they are spreading it...but if it gets to enough people, we see complete collapse of that community, loss of stability, economic losses and unchecked spread.

Perhaps it is crude to parallel a disease like HIV with the complexities and immensely intricate concerns embedded in fundamentalist Islam...but in that case I demand, why haven't we fixed AIDS yet? If it's so simple, why is it still on the rise in so many places?

Sometimes it seems we spend so much time reactively averting destruction that we have no time to pro-actively prevent it. AIDS is at the root of all our broad, prioritized issues. Paying attention to health-care infrastructure, building roads, hiring doctors,and stabilizing daily life will do far more than the "aid" we give now, too often merely fostering secret deals and relationships with the main people in power who may not be in power the next day. We won't get rid of skinny AIDS until we wipe out fat AIDS, but getting rid of fat AIDS is unfortunately not a priority of the fat cats who allocate the budgets and carry out the plans.

Being a responsible global citizen and caring about each other are not sufficient motivators to stop this cycle. Thanks to BdM I am reminded that if bringing HIV under control is a true priority and worthy goal, it must appeal to the incentives of those in power, or those that elect and ensure the political survival of those in power.

On that conclusive note...Happy Super Tuesday! Get out there and vote and make sure your candidate does support goals that you feel are worthy of our time and funds.

It is ultimately we as the citizens of rich, democratic nations, that will have the opportunity to respond to "what about it?" Speak up!

A Messy Intersection

Flipping through television programs, lamenting over filing taxes, or mediating post-holiday-meal banter between family members, we all eventually end up on the topic. "Foreign Aid" inevitably weaves its way through many of our personal conversations about domestic affairs and national spending, because at the end of the day, it's our taxpayer dollars that are being sent overseas, and it is our business as Americans to make sure the investments are wise and productive. Whether you're watching Bono duke it out with G8 leaders in televised arenas, or calming granpda down as he criticizes 'those damn [Democrats/Republicans]', the issue of foreign aid is anything but foreign to Americans.

We are undisputably one of the richest nations in the world, fluctuating among the top ten highest GDP/capita nations. Only $2,200 in assets puts you in the top half of the world's wealthiest people, and with $61,000 in assets, you shoot up to joining the 2% of the world's wealthiest. CRAZY.

America is exponentially better off than the 53% who live on less than $2/day (yes even fathers and mothers with families to raise) and certainly luxurious living compared to the 20% of our global neighbors living on less than $1/day. Let that SOAK IN for a minute. That's reality.

As a non-isolationist nation we have a responsibility to attend to the needs of our fellow global citizens. Not only would neglect be inhumane, unjust, and heartless, but more pragmatically, it is foolish to discount the potential benefits one would reap from giving stability, security, and health to billions of our global neighbors. Productivity and innovation would increase, not to mention basic human dignity.

Few would realistically argue that the U.S. should not provide foreign aid. However, contentions abound when the discussion begins on how best to give foreign aid: to whom? for what programs? in what amounts? on what conditions?

In 2006, the U.S. gave 0.17% of her national budget to foreign aid. Fabulous folks like Bono and Jeff Sachs are pressuring for at least 1%, but how do we know that more is better? Is .17% a cowardly shame or a wise decision? What's our track record? Has our foreign aid in the past been effective at all in sparking economic growth in recipient nations?

Research on aid effectiveness to date has primarily analyzed the macroeconomic impacts of aid on recipient country economic growth, savings, and investment, and has consistently yielded inconclusive results. Aid-efficacy studies relate economic growth as a dependent variable to many causal independent variables including foreign aid - these other variables include everything from economic measures to human development indicators (infant mortality, primary school ratios, life expectancy). Researchers continue to try and find a relationship between aid and growth - what is is about some countries that aid is effective? Why has is been ineffective in so many places?

Among many significant contributions to the literature, one notable discovery of how aid can be effective was authored by Craig Burnside and David Dollar in 2000,(click here and scroll to bottom to download free from SSRN). They concluded contrary to common conclusions that aid actually could impact macroeconomic growth, but only when recipient nations endorse specific ‘good’ policies. They found that aid has a positive impact on growth in developing countries with good fiscal, monetary, and trade policies, but has no effect on growth in countries with poor policies. Most significantly, they introduced the idea that policies and institutions of the recipient nation matter if aid is to improve and not hamper development.

However the theory has been challenged, with particular efficacy by William Easterly et al (click and scroll again to DL) , who determined with the same model and expanded data (countries and years) that not even in countries with deemed ‘good policies’ could aid be proven to promote economic growth.

After all the running of regressions and number crunching and data analysis...the effects of foreign aid on a recipient country's economic growth presently remain inconclusive. But if we don't know how to give effectively, why should we keep dumping billions of our taxpayer dollars into the foreign aid system?

[As I have mentioned, my thesis falls out of the overarching foreign aid conundrum, focusing specifically on the relationship between AIDS-specific foreign aid and HIV rates (in parallel to general foreign aid and rates of economic growth). The same questions arise in this sub-section, as there is abundant speculation over the billions presently being spent on HIV/AIDS. Do we not give enough, or give too much? Are we spending it effectively?]

Funny how we get ahead of ourselves, though it feels quite natural to want to act urgently when the allocation of resources and wealth in the world is disproportionate to the point of disorientation. There is an enormous desire to tip the scale just for dignity's sake. But compassion is rarely what tips the scale and approves the budget requests. Strategic interests and need for political concessions predominantly determines who receives aid. So naturally, when aid is received by leaders who have made bilateral deals and arrangements, leaders who run systems where accountability to the general public is neither practiced nor enforced, the aid spills into personal accounts, and rarely reaches the people in need.

The intersection of power and resources, without a traffic light of coordination, quickly becomes a scene of collisions, destruction, and chaos. Especially when the police aren't enforcing, and when the drivers speed through, feeling accountable to no one else on the road. It's no surprise to see the gridlock and people waiting. Accidents and people dying. Frustration and people fighting.

Some people conclude that ineffective aid means we should stop giving. But many people continue to demand governments like the US give more, because we can. Personally, I am infuriated to my core watching people wait for promised aid who know in their hearts they are waiting for nothing (a clinic with no doctor, a line with no food at the end, a well queue with no clean water at the bottom). To suggest stopping aid seems as unjust as continuing our current, corrupted system: a guarantee that the poor will always be waiting, suffering, bearing injustice.

Rather, a diligently monitored and sufficiently financed reform effort of foreign aid systems seems to be a worthy global agenda item. In a world as rich as ours there is absolutely no reason, beyond pure human greed and insecurity, that anyone should have to raise a family on less than $1/day. And I don't believe it's a matter of not caring...if it didn't somehow effect the safety and security of Bono or grandpa, they wouldn't be bickering about it.

Whether this issue tears at your heart, concerns your reputation, or simply matters to your wallet, I encourage you to learn more about US Foreign Aid in the many links within this article. The situation is far from hopeless, but like most major issues, is merely a matter of political will and coordination of actors. If we want to help poor people, we should not give money to national governments. But if we want national governments to become less corrupt and likely to steal foreign aid, we need to seriously reverse our current track record of supporting corruption.

At the risk of concluding on useless vaguery, an example of reform's potential for progress:

The antiretroviral drug Nevirapine has been clinically proven to half the chance of an infected mother passing HIV to her child during pregnancy, birth, or breastfeeding. Nevirapine is an incredibly hopeful advance in the prevention of new cases of HIV in resource poor settings, because it is so simple that even mothers in rural areas, where many women give birth with just a midwife and no doctor, can easily receive the pill. Nevirapine is certainly not without its controversies and imperfections, but widely agreed upon as the best option for prevention of mother-child transmission in resource poor settings.

Imagine if we were able to prevent ALL mother to child transmission? No children born with AIDS! We wold need to responsibly 1. make the drug the safest it can be and 2. mass distribute. The simplicity of a single pill is easy enough to supply to doctors and midwives all over the world (or rather, simpler than complicated drug regimens that are difficult to adhere to or require refrigeration). Researching, perfecting, and producing the drug is possible. But the logistics of distribution are complicated. Dollars earmarked for HIV-prevention don't just transform into Nevirapine. In this example we need professional doctors to give the drug, hospitals and clinics at which woman can give birth and get the drug, clean water with which to take the drug. It's great to give a magic pill but it's cruel to give that if the surrounding necessities are not in place.

Nevirapine's potential to end the transmission from mother to child - a revolutionary advance - demonstrates the need for coordinated actors and shared responsibility. The pharmaceutical industry needs to recognize the emergency and the potential of the drug to respond, and invest more time and resources into AIDS drug research - make the drugs the best and easiest to take that they can be. Rich countries need to monitor massive aid to build hospitals and hire doctors in poor countries. Smaller organizations, social entrepreneurs, and innovative projects and programs can supplement this national-level reform that is not achievable by non-governmental actors. Effective, specific efforts would ensure and increase use of improved health systems: sponsoring patients at hospitals and clinics for their medication, providing cars to rural communities or district hospitals to allow drugs to be delivered (although the roads are often unnavigable!), or training community members to serve as health-care workers to do simple tasks like giving Nevirapine that don't require an M.D.

What emerges is a tier of primary and secondary concerns that we hate to admit exists, because it seems inhumane to categorize the provision of lifesaving drugs to be 'secondary'. But pragmatically, the drugs won't work without doctors and clinics and food and water. However we absolutely cannot wait until primary concerns are solved - they will never wholly be - before we attack the secondary. Rather we must agree internationally on who will conquer what, how, and when.

We need coordination - a much better traffic light - because even though our cars our bigger and safer and virtually indestructible, we are all driving on the same road. At the end of our American day, certainly our national security and economic stability are top concerns, and these are two major reasons that dictate who we give to and in what amounts. But the well-being and humane treatment of our global neighbors is not mutually exclusive. It's not one or the other. And if we can be innovative and visionary enough, we can design a system where each perpetuates the other.

And to give this our best most responsible effort, we need data, to be informed! Next time, further focus on HIV/AIDS: how is the disease progressing and has AIDS-specific foreign aid been effective?

All questions and comments are greatly appreciated!

Responsible Local Media!

Many thanks to The Valley Breeze, who recently published a letter I wrote in response to the passing of Joe Swanson. On local and global levels there truly are ways we can each invest our time, efforts, and money to alleviate the effects of AIDS...and The Breeze are doing their part to raise awareness on a local level!

http://www.valleybreeze.com/Free/7255807335172.php

Welcome to the Green Monstah

Welcome! The Green Monstah, as most know her, is the infamous 37-foot left field wall at Fenway Park, home of my beloved Boston Red Sox. In an effort to share my current research into global financing of the HIV/AIDS pandemic, I introduce to you another Green Monstah:

As many of you know, despite our existing medical technologies and abundant resources, HIV/AIDS continues to ravage our world, particularly in resource-poor communities where social and medical services are disturbingly absent.

The rich of our world have certainly been contributing to financing and end to AIDS. The most impressive contributions have come from bilateral aid, particularly through the U.S. President's Emergency Plan for AIDS Relief (PEPFAR). Multi-lateral donors like the Global Fund to Fight AIDS, Malaria, and Tuberculosis (Global Fund), and UN agencies, particularly the World Bank, have also contributed significantly.

But HIV - preventable and treatable - continues to infect and kill, and in many places, at increasing rates. Are we not spending enough, or are we spending on the wrong things? Why are we not reversing bad investments, trivial spending, poor monitoring and evaluation? Is AIDS really too difficult to defeat? Or are we just using too many dollars and not enough sense?

In my work in Ghana, Tanzania, and South Africa I have witnessed many successful localized programs that are eliminating AIDS against intimidating odds. For example, Keep a Child Alive funds the "Blue Roof Clinic", in alarmingly 41% infected Wentworth, Durban. KCA funds top-quality, comprehensive care for FREE including voluntary counseling and testing (VCT), anti-retroviral (ARV) treatment, adherence counseling for medications, home-based care, alcohol and drug abuse counseling, psychosocial support, nutritional counseling and food assistance. With 1,340 patients on file and 358 patients on comprehensive ARV treatment in one year, the success and popularity of the Blue Roof model is forecasting an additional 200 patients per quarter in 2008.

Not quite 'saving the world', but making significant progress in one community. Is scaling grassroots efforts up and out a more sensible option than 8-figure donations to national governments?

Many successful programs I have witnessed do not receive PEPFAR and Global Fund money, which are often (or exclusively, for PEPFAR) channelled through recipient national governments before disbursement, rather than given straight to actors on the ground. I will reference and reflect on more experiences as I work my way into new territory - exploring the origins, direction, and use of massive AIDS aid.

Many infected and affected people I have met in Africa and America have referred to AIDS as an absolute "monster". However I am tempted to think it is not AIDS that is the monster, but rather our foreign aid system; a Green Monstah that keeps our potential home-run efforts from making it over the wall.

I aim to follow 'the green' to figure out how to best use our resources to end AIDS. How can we break down the paradox of more aid not resulting in less AIDS. Should we be giving more money or less? To which countries? For what purposes? Where have we found success and where have we failed? Can my Millenial generation really end this pandemic? How?

I invite you to join me on my journey. I encourage you to respond to posts with questions and comments, to share relevant articles and research, and to take action in some way to participate in a solution.

Thanks for joining in - and Happy 2008!