Catastrophe. That was the word Dr. Herbert Betancourt used when I asked him Tuesday what impact the shortfall in Global Fund donations may have on the effort to reduce the AIDS and TB burden in El Salvador.
“The most negative impact will be on prevention (efforts), followed later by treatment,” says Betancourt, country officer for the Joint United Nations Program on AIDS, or UNAIDS, in El Salvador. Together, he says, cutbacks on these two fronts will allow AIDS and TB (which often accompanies advanced HIV infection) to surge back. This, he says, would be tragic and potentially catastrophic.
Middle-income countries like El Salvador, Betancourt says, are at great risk of losing support from the Global Fund to Fight AIDS, Tuberculosis and Malaria. When funding gets tight, he says, the international community will look for places to cut and programs in middle-income countries will appear more expendable than those in poor countries.
This neglects the reality that middle-income countries still have a lot of poor people (actually, most of the world’s poor now live in middle-income countries) who, when times get tight, fall through the cracks.
When those falling through the cracks are infected with tuberculosis or HIV, disease spreads more rapidly. Infectious disease knows no borders. As Kofi Annan said in a recent plea for support of the Global Fund: “If we’re all in the same boat, a hole in one end of the boat puts us all at risk.”
At the conclusion of this week’s Global Fund “replenishment” talks at the UN, the international community has donated just $11.7 billion to this initiative for fighting AIDS, TB and malaria over the next three years.
I was surprised to see some news accounts and pundits initially report this as if it was something to be celebrated, given that it was less than the minimum amount the Global Fund needs to maintain programs — and much less than the requested $20 billion aimed at reaching more of those in need.
I’ll note again (I just can’t get over this fact) that this amount — less than $4 billion per year to fight the world’s three great killers — should be compared to the $20 billion our military spends every year air-conditioning tents in Iraq and Afghanistan. That might help put the numbers in perspective.
But why focus on this particular hole in the boat? Why El Salvador? Well, why not?
It’s a neighboring nation with strong links to the U.S. (we helped fund its horrific civil war, after all, which ended in 1992 after some 75,000 deaths). American dollars are the official currency. I met Betancourt on a visit to San Salvador in April, along with a gang of other journalists invited to see the Global Fund at work.
El Salvador isn’t ground zero in the fight against AIDS or TB. It’s not the worst (or the best) when it comes to battling AIDS and TB (not much malaria there). It’s also not the poorest country in Central America.
It’s just kind of in the middle, when it comes these kinds of measures.
But middle-income is still pretty poor and El Salvador has only in the last few years started to get a handle on its still-increasing rates of HIV infection. HIV/AIDS had been concentrated among urban sex workers and especially among the “men who have sex with men,” or MSM in public health lingo.
Surveys (again, prompted and funded largely by the Global Fund) have revealed HIV is now increasingly spreading into rural areas, heterosexually, and is a much bigger problem within the prison population than had been previously thought.
El Salvador has a big prison population, thanks to a fairly large gang problem (which, arguably, the U.S. helped foster … long story). Here’s a good story done for Slate by one of the journalists on our trip about dealing with HIV/AIDS in a women’s prison.
Prior to the Global Fund’s involvement in El Salvador, much of the disease burden was hidden due to problems with discrimination based on sexual orientation, the typical disenfranchisement of the poor and the lack of much commitment by the government to seriously engage with civil society on these issues.
To receive funding for help combating these diseases, governments must work together with affected groups to form a “country coordinating mechanism.” It gets pretty bureaucratic, but the gist is the Global Fund forces the government to demonstrate it can work with all of those affected — the poor, sex workers, prison inmates — to reduce disease.
El Salvador is predominantly Catholic, and would be expected not too keen talking about sex for purposes other than procreation. But on the media tour, we met with organizations representing sex workers as well as transsexuals who, though still stigmatized, feel like they are now part of the discussion.
We visited community clinics, schools where teenagers were actively involved in AIDS prevention education and hospitals where people with HIV or TB were getting the kind of treatment and care that saves live and also prevents further spread of disease.
“We have come a long way, but there is still much more to do,” Betancourt said.
El Salvador is a country that has made great progress against these diseases, thanks in large part to the Global Fund. Now, the global economic downturn has caused many wealthy nations of the world to pull back from donating to this initiative, threatening to undermine the progress already made.
For photos from my trip to El Salvador, see the slide show.