PEPFAR, Entitlements, and the Implications for U.S. Foreign Policy

When you’ve had enough light summer reading about the unintended consequences of relaxing regulations of the offshore drilling industry or of the U.S. financial sector, you can turn to an article in the July/August issue of Foreign Affairs on the unintended consequences of a program you thought was doing fairly well – the President’s Emergency Program for AIDS Relief or PEPFAR, which since 2003 has prolonged the lives of almost three million AIDS patients in the developing world.  In the article, entitled “No Good Deed Goes Unpunished:  The Unintended Consequences of Washington’s HIV/AIDS Programs,” (gated) Princeton Lyman and Stephen Wittels of the Council on Foreign Relations follow me in using the term “entitlement” to describe the implicit commitment the U.S. has made to each person to whom it provides a daily dose of antiretroviral therapy (ART) under PEPFAR.  As I argue here, here and here, once a patient has been started on ART, withholding that person’s treatment will condemn an identified patient to death, an action which would expose the U.S. to more reputational risk than I believe it will be willing to accept.  Lyman and Wittels say that “Because [ART] needs to be provided over a lifetime, treating HIV/AIDS patients is a serious long-term commitment. … [This kind of aid] will create a sense of entitlement in recipient countries and make patients directly dependent on the annual U.S. foreign aid appropriations process…”  [Emphasis added.]I argued that providing individuals with a life-sustaining drug on which they will thenceforth be dependent effectively constitutes a kind of “post-modern colonialism.”  Similarly, Lyman and Wittels suspect that this kind of aid “could spawn as much resentment as gratitude.”  They say that with continued expansion of the numbers of HIV/AIDS patients supported by the U.S., “[t]he effort might well produce gratitude among the patients benefiting from the aid, but as with other dependencies, it might also breed resentment, and African governments may be ambivalent, too.”We also agree that a growing AIDS treatment entitlement will likely squeeze other health programs. Lyman and Wittels go even further and argue that AIDS treatment entitlements are likely to squeeze all of foreign aid.   They concur that by channeling AIDS treatment assistance through the Global Fund for AIDS TB and Malaria, the U.S. could shift the entitlement burden to this international agency, which might then be able to share both the dependency and the fiscal burden among contributors.Despite these important commonalities, Lyman and Wittels’ analysis differs from mine in two respects:  (a) while I fear that the increasing dependency of PEPFAR countries on the U.S. government for the daily life-sustaining doses of ART would give the U.S. too much influence over recipient countries’ policies, they  believe to the contrary that the humanitarian aspect of AIDS treatment actually ties the hands of the U.S. State Department, reducing their leverage over recipient policies; and (2) while I argue that donors should shift their objective from universal access to AIDS treatment to the achievement of an “AIDS transition,” they support the universal AIDS treatment objective.  (See my recent Policy Forum piece in Science Magazine, which my colleague Bill Savedoff blogged here.)On our first point of difference, Lyman and Wittels have changed my mind, persuading me with their tales from Ethiopia, Uganda and Zimbabwe that the U.S. will not threaten the withdrawal of PEPFAR and other humanitarian programs to influence the recipient’s policies, even when other democratic or humanitarian objectives are at issue.  In fact, this commendable U.S. reticence is further evidence of the extent to which the patients on ART have an effective “entitlement”.  Lyman and Wittels go on to say that “The Obama administration will need to recognize the paradox that in the absence of increases in other forms of aid, more humanitarian assistance will mean less leverage.” [Emphasis added.]  And they point out that this fact casts doubt on “[t]he notion that development and diplomacy will always reinforce each other, one of the principles of Secretary of State Hillary Clinton’s plan to make them `twin pillars’ of U.S. foreign policy. … For one thing, [they say,] development efforts typically last much longer than the more immediate demands of diplomacy, a disconnect that is particularly acute in the case of PEPFAR.”  This is pretty compelling stuff – with far-reaching implications for U.S. foreign assistance policy.On the donor commitment to universal access, I believe that Lyman and Wittels are wrong to assert “None of these issues should be allowed to undermine the commitment to treat all HIV/AIDS patients.”  As I argue in a podcast and this new essay, universal access to ART is a self-defeating goal which will perpetually recede as more patients are placed on treatment.  Donors should instead commit to assisting recipient governments attain an “AIDS transition,” defined as enrolling enough additional ART patients to hold down AIDS mortality, while improving HIV prevention efforts until the verified number of new cases is pushed below the annual number of AIDS deaths.  I am convinced that the secret to achieving an AIDS transition, either within a single severely affected country or globally, will be to enhance the incentives for HIV prevention at every level of HIV/AIDS policy.  (See this essay.)  When the AIDS transition has been achieved, and the total number of patients begins to shrink, universal treatment access will reemerge as an attainable goal.