How HIV, SARS, and Ebola Put Global Health on the Agenda

An Essay by Ambassador Mark Dybul, Professor of Medicine at Georgetown University School of Medicine, and former United States Global AIDS Coordinator

America often has to choose between two paths: looking inward with fear or looking outward with compassion.  Fighting disease in Africa is one of America's greatest successes --  beyond saving the lives of millions, American-led compassion helped lay the groundwork for more than just foreign aid.

President Bush carries Baron Mosima Loyiso Tantoh, 4, back to the White House after making a statement about the President's Emergency Program for AIDS Relief (PEPFAR) in the Rose Garden, May 30, 2007. (Eric Draper / White House) President Bush carries Baron Mosima Loyiso Tantoh, 4, back to the White House after making a statement about the President's Emergency Program for AIDS Relief (PEPFAR) in the Rose Garden, May 30, 2007. (Eric Draper / White House)

In 2000, there was no coherent concept of “global health.” Today it is on nearly every major agenda, including for the first time, the G-20.  What happened? 

It is a complex story, but several key factors are clear.  In 2000, for the first time a disease, HIV, was discussed at the U.N. Security Council.  That helped to change the paradigm and move health from the domain of medical researchers and caregivers to the global policy stage. 

The SARS, Ebola, Zika, and anti-microbial resistance outbreaks have completed what was started with HIV.  Global health is now firmly, and perhaps irrevocably, an issue of global security and stability. 

The Millennium Development Goals (MDGs) were important. The Goals were the first expression of global solidarity to envision a better world. Health got a big boost from the MDGs because of their recognition of the key role health plays in development, clear targets were set and many were met. In fact, when the MDGs’ successor, the Sustainable Development Goals (SDGs), was being debated, there was frequent reference to global health as the model for other areas. 

Global health is now firmly, and perhaps irrevocably, an issue of global security and stability.

How global health became part of the agenda 

While hugely important, global health security and the MDGs and SDGs were concepts, documents, and commitments.  What made them real and planted them so firmly on the global agenda? 

In my view, the game changer was the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), the largest international health initiative in history for a single disease.  Launched by President George W. Bush, it has garnered strong bipartisan support across three administrations, committing an astounding $70 billion and supporting countries to achieve breathtaking results. As the former head of UNAIDS, Peter Piot, said: “PEPFAR changed the conversation from millions to billions.”  

PEPFAR was followed by the President’s Malaria Initiative (PMI), the world’s largest bilateral malaria program.  The fact that an American president put global health on his agenda put it on the global agenda.  

Sir Elton John, Dr. Mark Dybul, and Ambassador Deborah L. Birx, M.D. testify before a U.S. Senate subcommittee hearing on global health programs, May 6, 2015 in Washington, D.C. (Paul Morigi/Getty Images Sir Elton John, Dr. Mark Dybul, and Ambassador Deborah L. Birx, M.D. testify before a U.S. Senate subcommittee hearing on global health programs, May 6, 2015 in Washington, D.C. (Paul Morigi/Getty Images

There were also major multilateral initiatives.  Gavi, the global vaccine alliance, and then The Global Fund to Fight HIV, Tuberculosis and Malaria were created as public- private partnerships to address some of the most significant, preventable, and treatable diseases in the world.  

Both receive strong financial and advocacy support from Bill and Melinda Gates and their foundation.  President Bush gave the first, and the first second, donation to the Global Fund.  

The Global Fund is the largest multilateral funder of health programs, raising $25 billion for six years at two replenishments hosted by President Barack Obama and Prime Minister Justin Trudeau. With strong bipartisan support, the U.S. government is the largest funder and ensures global engagement by leveraging $2 for every $1 contributed. 

Those huge sums – nearly $100 billion since 2003 for HIV, tuberculosis, and malaria - were unthinkable 15 years ago.  They were unthinkable because the yardstick by which any area of development was measured was how much money was being spent. 

Launched by President George W. Bush, it has garnered strong bipartisan support across three administrations, committing an astounding $70 billion and supporting countries to achieve breathtaking results. As the former head of UNAIDS, Peter Piot, said: “PEPFAR changed the conversation from millions to billions.”

A new focus on results and partnerships 

If that were still the case, there would be no field of global health. In many ways, global health, led by the response to HIV, drove a philosophical revolution in development that changed everything.  

The revolution began with the Monterrey Consensus, in which President Bush and his administration played a pivotal role. It shifted the mindset from how much money was being spent to results, accountability, and partnership.   

These principles became the lifeblood of the surge in funding for, and centrality of, health on the global agenda. Soon after PEPFAR was announced, President Paul Kagame succinctly summarized the sea change: “This is the first time someone has respected us enough to hold us accountable.” 

The shift from counting money to tracking results drove accountability. But who was to be accountable? A shift to shared responsibility, from paternalism to partnership, ensured that everyone would be accountable, but with a particular emphasis on the countries.  

The massive increase in resources and focus on achieving results meant that pilot projects driven from distant capitals were obsolete. National scale-up was required, and that meant countries had the lead and so had to be accountable.  

"This is the first time someone has respected us enough to hold us accountable.” 
- President Paul Kagame of Rwanda on PEPFAR

The accountability expanded from results to significantly increased domestic finance. In the Bush administration, country compacts created a five-year agreement on increased domestic finance and service delivery coupled with a commitment of support from the U.S. government. 

 President Bush and local community members at the Ngungu Health Center, which was renovated as part of Pink Ribbon Red Ribbon, July 3, 2012. (Shealah Craighead/George W. Bush Presidential Center) President Bush and local community members at the Ngungu Health Center, which was renovated as part of Pink Ribbon Red Ribbon, July 3, 2012. (Shealah Craighead/George W. Bush Presidential Center)

The Obama administration picked the ball up and took it further down field. In the past few years, the Global Fund initiated co-financing requirements with penalties for non-compliance that leveraged $6 billion in new commitments over three years.  When all is said and done, one of the greatest legacies of PEPFAR, the Global Fund, PMI, Gavi, and other initiatives will be the massive change in the paradigm, from money spent to results, accountability, and partnership. 

When all is said and done, one of the greatest legacies of PEPFAR, the Global Fund, PMI, Gavi, and other initiatives will be the massive change in the paradigm, from money spent to results, accountability, and partnership.

Supporting national disease specific programs also created technical expertise and infrastructure for health more broadly.  The response to HIV has played a disproportionate role because it requires lifelong therapy and prevention efforts. 

So another remarkable legacy of the HIV response is that for the first time development financing support the creation of a chronic care delivery system. That set the foundation for Pink Ribbon Red Ribbon (PRRR) to combat cervical, which is highly linked to HIV, and breast and prostate cancer in Africa. 

PRRR is the first international initiative to explicitly link the fight against cancer with the fight against infectious diseases. PRRR was conceived of by the George W. Bush Institute in partnership with  Susan G. Komen®, and co-sponsored by the U.S. government – then-Secretary of State Hillary Clinton joined the launch – and UNAIDS.  This public-private partnership now has many partners and has achieved significant results. 

All of which brings us back to where the journey started – HIV being recognized as a threat to security. As PRRR demonstrates, the systems that have been built to combat specific diseases provide the foundation to build a strong and resilient system for health that can prevent, detect, and respond to current and new health threats.  

For example, there is, appropriately, focus on the three countries that experienced the Ebola epidemic. But those were post-conflict countries with weak systems.  Several neighboring countries were able to mount rapid and effective responses, and even prevent its spread across porous borders. The systems they used to achieve that had been significantly strengthened by the massive investments in global health. 

As PRRR demonstrates, the systems that have been built to combat specific diseases provide the foundation to build a strong and resilient system for health that can prevent, detect, and respond to current and new health threats.

The risks of not investing in global health care 

More broadly, investments in health will help determine if there is a global demographic dividend or demographic disaster.  The population of Africa is projected to double by 2050. By investing today in health and education, the engines of economic growth, we can help secure a future of increased markets for all, and a stable, prosperous world.  

A member of the medical staff at the Ngungu Health Center in Kabwe, Zambia, is assisting with the check-in process for the women who are waiting to receive a cervical cancer screening in the renovated facility on July 3, 2012. (Shealah Craighead/George W. Bush Presidential Center) A member of the medical staff at the Ngungu Health Center in Kabwe, Zambia, is assisting with the check-in process for the women who are waiting to receive a cervical cancer screening in the renovated facility on July 3, 2012. (Shealah Craighead/George W. Bush Presidential Center)

But if we do not, the appropriate concern about migration today will seem like child’s play. In that regard, in 2015 nearly 250 million people migrated; only 20 million were refugees. Normal migratory patterns are good, in fact necessary, for global economic growth.  

However, there are associated health risks including the spread of tuberculosis and a frightening increase in multi-drug resistant tuberculosis. Because of these stark realities, business and military leaders have strongly endorsed continued investment in global health and development. 

Tremendous progress has been made. The intellectual and implementation foundations have been laid to solve some of the greatest health challenges in history.  

But if we blink, all can be lost. The world is in massive flux. Geopolitical end economic power is shifting. People and ideas are on the move in ways that was unimaginable at the turn of the 21st century. Significant change can lead to a sense of insecurity. 

History has taught us that during such times there are two paths. We can look backward and inward with fear and its constant companion, hate. Or we can look outward and forward with hope. 

The second path is who we are as Americans, and when we have been the greatest throughout our history.  Now is the time to give flight to “the better angels of our nature” and the birth and advance of global health can be our guiding light. 

We can look backward and inward with fear and its constant companion, hate. Or we can look outward and forward with hope.  The second path is who we are as Americans, and when we have been the greatest throughout our history.
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