AIDS Spending a Good Investment? Maybe Not

Video of the debate may be viewed here.Yesterday was an exciting day for me. In a debate at the World Bank timed to coincide with the International AIDS Conference a colleague and I took an unpopular position against two development celebrities in front of a potentially hostile audience and changed some minds. The proposition was:“Continued AIDS investment by donors and governments is a sound investment, even in a resource constrained environment”This was the line-up:- Richard Horton | Editor, The Lancet (moderator)- Charles Holmes | Chief Medical Officer and Director of Research & Science, Office of the U.S. Global AIDS Coordinator (debate introduction)- Jeffrey Sachs | Economist and Director, The Earth Institute, Columbia University (panelist FOR the motion)- Michel Sidibé | Executive Director, UNAIDS (panelist FOR the motion)- Roger England | Chair, Health Systems Workshop, Grenada (panelist AGAINST the motion)- Mead Over | Senior Fellow, Center for Global Development (panelist AGAINST the motion)For those who missed it, the LiveBlog Twitter roll, as well as a video of the event, is here:Here’s my take:Roger England and I seemed to fare OK. We benefited, I think, from Richard Horton’s well-informed and high-spirited introductions and interventions and especially from his decision to depart from past practice by asking for a show of hands at the beginning of the debate and at the end. The waving hands revealed to all just how lop-sided the support for the proposition was and probably gained a bit of sympathy for Roger and me. To the surprise, I think of the moderator and all four of us debaters, a sizable minority of people changed their views from supporting the proposition at the beginning to opposing it at the end, a fact that would not have been apparent without Richard’s poll.Why were Roger and I able to change more peoples’ minds? The audience seemed to be moved by Michel Sidibé’s argument that AIDS spending had engendered and subsequently fueled global social progress and tempted by Jeff Sach’s assertion that resources can be cajoled or wrested from the rich to meet all possible health needs. But neither of them adduced evidence to support the proposition at hand. In fact, both argued, Michel implicitly and Jeff explicitly, that the proposition be discarded so that the debate could be held on different premises and with different metrics.I suspect that many in the audience, especially those who at the outset were less firmly committed to the proposition, were a bit put off by Jeff and Michel’s decision not to play by the rules. This left an opening for Roger and me, which we had luckily prepared for: An evidence based argument. If Michel and Jeff had bombarded the audience with impressive statistics, like ART’s 96% prevention rate of HIV-negative partners from the HPTH 052 trial or the Granich et al finding that AIDS could be eliminated in South Africa within “only” 40 years by a $100 billon test-and-treat program, the proponents would have held onto, and perhaps gained, adherents. We could have fired back our own statistics, which in many ways would dominate a logical argument. But given an equal number of competing and impressive-sounding statistics on both sides, it’s possible that the philosophical positions adopted by Michel and Jeff would have tipped the undecided more towards their side. However, by sticking to their “high road” and leaving out the numbers and specifics, I believe that Michel and Jeff left themselves open to our guerilla offensive – and lost credibility.In adopting the negative side of this debate, I was forced to put aside my skeptical persona and deliver the best impressive statistics I could with as much authority as I could muster. It was fun. But in this blog space I now have time to go back over some of the arguments that were advanced on both sides and compare their “truthiness” to what I believe can actually be said based on a more contemplative and nuanced overview of the evidence. While I can’t predict how I will come out a few blogs from now on whether “HIV/AIDS spending is a sound investment, even in a resource constrained environment,” I can tell you one thing: I will be less certain of my position than I appeared in the debate.And, hey, call me a class warrior, but I do kind of like Jeff’s idea of a financial transaction tax on movements of cash from the Cayman Islands to Mitt Romney’s Boston checking account – earmarked of course for global health spending.