Part of this funding shortfall can be attributed to the wealthy world’s lack of commitment. EU countries, as well as the United States, have failed to meet their responsibilities to the Fund. The Bush Administration argues that it has given more money to the Fund than any other country—US$683 million since 2001—and has indicated willingness to give more so long as the United States does not donate more than one-third of all contributions in a given year. In contrasting US contributions to the Fund with those of other nations, the US Department of Health and Human Services recently insisted that a US twelve-month fiscal year’s worth of donating be compared with just nine calendar-year months’ worth of EU contributions, drawing the ire of Europeans.

The United States prefers to focus on its own bilateral HIV/AIDS programs. As currently conceived, PEPFAR will treat two million people and provide other types of care to ten million by the end of 2008. As of September 2004, PEPFAR has actually spent 1.2 percent of its funds, directly providing treatment to 18,800 people.

For much of its existence, PEPFAR has been mired in fights over whether its dollars could be spent buying cheap generic drugs versus US-patented products, over condom promotion versus abstinence, and over how best to mete out funds through a laundry list of competing federal agencies (among them the CDC, the US Agency for International Development (USAID), the National Institutes of Health, and the Department of Defense). In a sense, PEPFAR is a global treatment access entitlement program. To the degree the United States continues to go it alone, the burden for maintaining the health of hundreds of thousands of people around the world will rest on US taxpayers for years, quite possibly decades, to come—a burden born, moreover, by a US populace that is decreasingly likely to have health insurance or be able to afford medications for itself. The foreign policy implications of stopping funding—in essence, committing medical murder—are obviously profound.

Congressional whims aside, should there be regime change in a recipient country, the United States would face a critical moral and political dilemma. The appropriations bill allocating FY2004 PEPFAR money stipulated that a third of prevention and education funds had to be spent on abstinence-promoting programs, none of the money could buy sterile syringes or needles for IV drug users, and faith-based organizations should receive special priority for receipt of treatment funds. Any organization or US program thought to promote access to abortions, or to chiefly promote birth control and condom use, has lost US government funding and support. In Uganda, for instance, the government claims HIV “prevalence” dropped from 30 percent in 1990 to 5 percent today. President Yuweri Museveni, signaling his allegiance to the Bush Administration, told the 2004 International AIDS Conference that the key to success was a campaign that pushed abstinence before marriage and fidelity after marriage. That no doubt helped, but the country’s only long-term study shows the number of new infections in southern Uganda dropped by about 40 percent between 1990 and 2002 without any significant changes in general sexual behavior. The only factor that changed, according to the study, was the increase to an 80 percent rate of condom use between casual sex partners.

Even the US Congressional General Accounting Office’s recently released report cites the Bush Administration’s programmatic restraints as an obstacle to PEPFAR’s success. Politicians may not like the idea of handing out sterile needles to heroin users, for example, but such a program in New York City pushed HIV among drug injectors down from a 1990 high of 50 percent to 15 percent in 2002.

Though PEPFAR funds are meant also to address tuberculosis and malaria, USAID cannot explain how it spends most of its tuberculosis and malaria money. In September 2004 testimony to the House Committee on International Relations, USAID representatives indicated US$65 million was spent in FY2003 for malaria efforts but could specify only US$4.2 million in purchases of anti-malaria bednets. The remainder was unaccounted for.

All the while, new infectious diseases, such as Severe Acute Respiratory Syndrome (SARS) and “Mad Cow,” continue to surface. Globalization ensures many more microbial surprises lurk in the future. The emergence of humanly transmissible strains of avian influenza, or “bird flu,” poses the very real possibility of a 1918-type flu pandemic, which killed between 20 and 50 million people in 18 months, including nearly 700,000 in the United States, and circumnavigated the globe in four months, infecting one-fifth of the global population. Although pharmaceutical improvements in treatment and vaccine possibilities offer hope that such a deadly flu strain might be controllable, grave concerns remain: the drugs have limited efficacy even under conditions of ideal use and supplies are limited. Worse, the United States can manufacture only enough vaccine, even under emergency conditions, to protect some citizens, and most of the world lacks any capacity to manufacture vaccine. In a pandemic, the United States would face the foreign policy implications of denying vaccines to billions of people while saving the lives of some of its own. WHO conservatively estimates, even with widespread vaccine and drug use, this pandemic could potentially infect up to 30 percent of the world’s population of six billion people, with approximately seven million deaths.

The Next Steps

The international community does not have its eyes on the right ball. HIV/AIDS is a devastating pandemic that requires a massive global campaign to reverse its course of societal destruction. But HIV/AIDS does not exist in a vacuum. It is impossible merely to reverse the course of the HIV/AIDS pandemic without addressing its companion epidemics of malaria, hepatitis, tuberculosis, and pediatric illnesses associated with orphans exposed to HIV.

One way forward is to integrate the prevention, diagnosis, and care of these interconnected diseases. The diagnosis and testing for all of these diseases would be matters of life-saving routine. Basic research would go hand-in-hand with treatment programs, not shoved to the side as an inconvenient impediment. Prevention and treatment of any particular disease would not be segmented off from others because of jurisdictional boundaries of a certain UN agency, US federal bureaucracy, or international program. Buttressing these efforts must be an infectious disease surveillance system that can synthesize well-founded data from around the world to stem potential scourges (such as SARS and avian flu) before they escalate to overwhelming, not to mention expensive, epidemics. The only way truly to achieve this is through comprehensive integration and communication.