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What's Next: Our recommendations
- Congress should continue to support and full fund PEPFAR and the Global Fund to Fight AIDS, Tuberculosis, and Malaria
- Congress should continue to support integrated approaches to health care that include HIV/AIDS, women's health, and other communicable and noncommunicable diseases (NCDS)
- PEPFAR should focus on youth
- Policymakers should champion local solutions
- Policymakers should continue to strengthen health systems to respond to new and emerging epidemics
The world continues to make advancements on key indicators of global health, with the United States leading the charge. American investments in the health and well-being of their fellow citizens, coupled with political will and hard work from partner country leadership and engaged stakeholders, have reached achievements that may have been thought impossible just a few decades ago. Approximately 21.7 million people living with HIV are receiving treatment as of June 2018, two-thirds of those due to the President’s Emergency Plan For AIDS Relief (PEPFAR), and incidence rates have fallen by 47 percent since 1996. Mortality rates for children under five have also declined from approximately 9.1 percent in 1990 to 3.8 percent in 2017.
As we celebrate the success of these efforts, we must pay attention to possible threats to the gains we have made, and emerging new trends. The growing younger population is especially at risk. In sub-Saharan Africa, where the HIV/AIDS epidemic has taken its highest toll, incidence of HIV is rising in young populations, specifically in girls and young women aged 15 to 24 and men aged 25 to 35, which could fuel a resurgence in the epidemic if not appropriately engaged. Sustained high rates of infectious disease coupled with an increase in noncommunicable diseases (NCDs), such as cardiovascular disease, cancers, respiratory disease, and diabetes, represent a double burden of disease, faced disproportionately by low- and middle-income countries. In 2017, an estimated 73.4 percent of worldwide deaths were caused by NCDs.
Even highly preventable NCDs such as cervical cancer remain a challenge, especially in low-resource settings. Each day in 2018, over 1,600 women were newly diagnosed with cervical cancer, even though it is preventable with the HPV vaccine and easily treatable if detected early. Sub-Saharan Africa bears approximately 20 percent of new diagnoses, and estimates suggest that more women will die from cervical cancer this year than will die during and following pregnancy and childbirth. Emerging diseases and new epidemics also threaten global health security if health systems are not appropriately strengthened to respond.
The American people should continue to support foreign assistance because we understand it is not only our moral duty as a prosperous nation to help our fellow global citizens, but as President George W. Bush reminds us, “The human condition elsewhere matters to our national security.”
Studies indicate that U.S. engagement in global health strengthens democracies, reinvigorates economies, and encourages friendlier and more-productive diplomatic relations. To continue the United States’ leadership role in global health, we put forth the following five recommendations.
CONGRESS SHOULD CONTINUE TO SUPPORT AND FULLY FUND PEPFAR AND THE GLOBAL FUND TO FIGHT AIDS, TUBERCULOSIS AND MALARIA
Congress should reauthorize PEPFAR, and the Administration should fully support and fund this successful bipartisan program that has spanned three presidencies. Using data to drive decision-making, PEPFAR has been able to each year increase the number of people on treatment and drive results. Despite this incredible progress, threats exist that could undo these gains. We must continue to get ahead of the HIV epidemic by committing appropriate resources to this program.
PEPFAR is a smart investment that has not only saved millions of lives but is good for Americans. It has facilitated better governance and accountability, more-responsive health care systems, and stimulated economies. Congress should also continue to support U.S. participation in the Global Fund to Fight AIDS, Tuberculosis and Malaria, which increases the overall pool of funding to fight infectious disease and galvanizes support from other countries.
CONGRESS SHOULD CONTINUE TO SUPPORT INTEGRATED APPROACHES TO HEALTH CARE THAT INCLUDE HIV/AIDS, WOMEN’S HEALTH, AND OTHER COMMUNICABLE DISEASES AND NCDS
The health care infrastructures enhanced by PEPFAR have laid the groundwork on which additional comprehensive services can be provided. For example, the George W. Bush Institute has partnered with PEPFAR and UNAIDS through the Partnership to End AIDS and Cervical Cancer to build on the PEPFAR platform and provide services for screening and treating cervical cancer. Women living with HIV are up to five times more likely to develop cervical cancer. Because sub-Saharan Africa has a high prevalence of HIV, women in the region disproportionately face an increased risk for cervical cancer. As part of this initiative, PEPFAR is committing $30 million to address cervical cancer in eight countries in sub-Saharan Africa that face a combined high prevalence of HIV with a high incidence of cervical cancer. These types of integrated programs should continue to be supported.
PEPFAR SHOULD FOCUS ON YOUTH
Africa has the youngest population in the world; 60 percent of Africans are under age 25 and the median age on the continent is 18. By 2020, the youth population in Africa is expected to have doubled from the beginning of the HIV pandemic in 1990. Young people in sub-Saharan Africa represent great potential, but this generation could pose a challenge to the progress made on HIV unless effectively engaged.
Adolescent girls and young women (AGYW) are at the greatest risk of new HIV cases — among 15 to 19 year olds, girls represent 75 percent of new cases of HIV. At the same time, more than half of men under age 35 in sub-Saharan Africa do not know their HIV status and are not on treatment. These men then pass HIV to their partners who too often are AGYW.
PEPFAR has worked to engage AGYW though its DREAMS partnership and to reach men through its recently announced MenStar Coalition. Through DREAMS, PEPFAR has seen a 25 percent to 40 percent reduction in new HIV diagnoses among young women in nearly two-thirds of DREAMS-supported districts since 2015. MenStar aims to reach an additional 1 million men with treatment, leading to viral suppression in 90 percent of men aged 24 to 35, which will significantly reduce transmission rates. These programs should be sustained and scaled up.
POLICYMAKERS SHOULD CHAMPION LOCAL SOLUTIONS
Leading public health theory stresses the necessity of early and continued inclusion of community representation when planning and implementing public health programs. PEPFAR is already working toward this objective by planning to contract 70 percent of funding to indigenous organizations by the end of 2020. In addition to what is already underway at PEPFAR, other implementing agencies of U.S.-funded global health programs should include community representatives when identifying problems, designing solutions, and implementing responses, and increasingly fund indigenous organizations as primary grant recipients.
Not only does this approach ensure local solutions to local problems, but it emboldens community leadership, builds capacity for sustained solutions and represents cost savings for the United States.
POLICYMAKERS SHOULD CONTINUE TO STRENGTHEN HEALTH SYSTEMS TO RESPOND TO NEW AND EMERGING EPIDEMICS
Leading scientists and public health experts warn of disease outbreaks and other public health emergencies, such as antimicrobial resistance, that could threaten global health security. Ebola continues to remind us of this threat. The best way to prepare for new and emerging public health epidemics is to strengthen health systems to respond before outbreaks become widespread, including improving structures such as health information and disease surveillance systems, laboratory systems, human resources, and physical and sanitation infrastructure. PEPFAR invests in whole system strengthening, and has been credited with preventing widespread outbreak of Ebola in Nigeria during 2014, although surrounding countries suffered grave loss. The importance of horizontal investments in health system strengthening is a priority for averting widespread outbreak and protecting the health security of Americans.
The United States’ unrelenting leadership on global health remains important, and the benefits of our commitment to global health are undeniable. Congress and the Administration should set an agenda of strong, continued engagement in global health, but also invite other partners to join the effort. Our investments have saved the lives of millions around the world, but there is still work to do. We cannot quit now.
Holly Kuzmich serves as Executive Director of the George W. Bush Institute and Senior Vice President at the George W. Bush Presidential Center. She oversees the strategy and management of the Bush Institute, an action-oriented policy organization that cultivates leaders, fosters policies to solve today’s most pressing challenges, and takes action to save and change lives. Specific areas of focus within the Institute include education reform, economic growth, human freedom and democracy, global health, the military service initiative, the women’s initiative, and the Presidential Leadership Scholars program. Holly also serves as a member of the management team of the Bush Center, leading strategic planning and budgeting and board relations.
Previously, she was Vice President and COO of Margaret Spellings & Company, a public policy consulting firm with a specialty in education and workforce issues at the national, state, and local levels. Holly also served as the Assistant Secretary for Legislation and Congressional Affairs and Deputy Chief of Staff at the U.S. Department of Education. In those roles, she served as the main liaison with Congress, the White House, and the Office of Management and Budget on education policy issues including the No Child Left Behind Act and the Higher Education Act and oversaw policy development within the agency.
Holly came to the Department from the White House Domestic Policy Council, where she served as Associate Director for Education. Prior to that, she spent five years working in the U.S. Senate on domestic policy issues.
A native of South Bend, Indiana, she received her bachelor's degree from Northwestern University.Full Bio
Crystal Cazier serves as an Associate at the George W. Bush Institute. In this role, she helps coordinate the Bush Institute’s involvement in The Partnership to End AIDS and Cervical Cancer, a collaboration of the Bush Institute, PEPFAR, and UNAIDS that works with eight countries in sub-Saharan Africa to prioritize HIV-positive women in national cervical cancer prevention and control programs. She also serves on the research and evaluation team which supports programming across the Bush Institute.
Before joining the Bush Institute, Crystal worked as a Clinical Research Associate at Carle Cancer Center in Urbana, Illinois where she managed budgetary and contractual negotiations for both pharmaceutical and government-sponsored clinical trials.
Crystal received her undergraduate degree from the University of Illinois in Urbana-Champaign and is currently pursuing a Master of Public Health at the University of Texas Health Science Center.Full Bio
Questioning the continued relevance of PEPFAR is dangerous thinking
17 million lives have been saved thanks to the resolve of national governments, investments by PEPFAR, and support of many. But this is not time to quit.
A Reflection from My Summer in Zambia
Bush Institute Global Health Associate Crystal Cazier has worked in the cancer space for eight years but says she didn’t fully understand the extent of the disease’s severity and gravity until she observed cervical cancer screening in Zambia this summer. Crystal explains how a better world where women do not succumb to horrific, preventable, and treatable diseases like cervical cancer is within reach.