Dear Fellow Advocates,

 

Surely all of us are scouring over the President’s budget released this week to answer the questions on all of our minds: did he listen when we spoke? Did he really mean what he said when he committed himself to increased funding for global health and foreign assistance programs—or were those just empty campaign promises? While our current President is a master of words, we recognize that the budget proposal speaks louder than words—it is the blueprint of his true priorities. And we want to know where we stand. 

 

In a briefing to our advocacy community on Tuesday, May 5, and in an official statement from the President, the Obama Administration introduced budget numbers for global health as part of a “six year strategy.” Many members and organizations in our community were quick to respond that the proposed $63 billion over six years amounts to a failure on behalf of this administration to both fulfill campaign promises and that millions of lives may be lost as a result. As a global health advocate, I share a deep sense of disappointment that these numbers are not higher. Global health is but a small slice of our governmental spending, yet its impact is proven to be so crucial in the protection of a right to a healthy life for so many people around the world. 

 

Yet a part of this story is untold when just looking at numbers. Even amidst our disappointment with the President’s numbers, there was an increase. And we must recognize that while we lead the world in funding and support for global health programs, we lag—to the detriment of those people we are trying to support—in our commitment to sound policy governing that funding. 

 

Well, fellow advocates, there was another, crucial part of the President’s statement on global health that somehow was overlooked by some members of our community who could utter nothing but words of contempt for the perceived stinginess of the six-year strategy. President Obama said in a written statement, “We cannot simply confront individual preventable illnesses in isolation. The world is interconnected, and that demands an integrated approach to global health.” 

 

Wow. Imagine that. An “integrated approach to global health.” What does that mean? They’re certainly words for which I’ve advocated. But in practice—what would this look like and why do I think this is much more monumental than some of our colleagues are recognizing?

 

Well, for so long, global health advocates have worked tirelessly to build up funding streams and programming for specific issue areas, be they family planning, maternaland child morbidity and mortality, HIV and AIDS, tuberculosis, malaria, other neglected tropical diseases, safe water and sanitation, food security, or others. With a limited amount of discretionary funding to appropriate, this has resulted in competition within our community for the same pots of funding and on-the-ground implementation that is manifest in segmented and disjointed health care services—reflective of the manner in which the funds were authorized and appropriated. 

 

Don’t get me wrong—U.S. global health programs are some of the best in the world. However, for a young woman in a low or middle income country in need of contraceptive commodities, she must visit the family planning clinic; if she also wants testing for HIV, she must go to another clinic miles away, and in the case she tests positive, she must access food to take her HIV medication at another source miles away from there. For that young woman, the current U.S. global health portfolio is simply not realistic. The lack of coordination does a disservice to both the people our global health programs try to serve and the ultimate public health and development results we seek to achieve. 

 

A Stanford University Medical School study recently found that the President’s Emergency Plan for AIDS Relief had reduced the death toll from HIV and AIDS by 10 percent. Ten percent. That’s a million lives. We were able to do that even though our clinics are miles apart and funding for one illness or condition cannot go to the other, etc., etc. And I understand that funding is what made that happen—money flowed and supported the rapid scale up of interventions that transformed HIV from a death sentence to a disease that when treated effectively can be managed indefinitely. All this in very low resource settings where many public health experts said it could not be done. 

 

I write this open letter to our community to ask us to take a step back amidst the budget analysis to imagine what we could do if those clinics were better coordinated and those services were better integrated. Imagine how many illnesses and conditions would be averted, how much more effective treatment would be, how many more lives would be saved—and most importantly—how much more empowered all the people accessing health care would be.  

 

The same Stanford study referenced above also found that PEPFAR “has had no appreciable effect on prevalence of the disease in those nations.” No appreciable effect on prevalence. If we do not integrate our global health programs, especially reproductive health (including comprehensive sex education, family planning, maternal health, among other emphases) with HIV, a disease that is primarily transmitted through unprotected sexual intercourse, will any amount of funding ever be enough? I don’t think so. And even if we were to fund treatment for every person living with HIV throughout the world, where are our priorities as a country if we are not equally as committed to empowering those persons to prevent the transmission in the first place? 

 

President Obama’s global health strategy, while it may not deliver on the numbers, indicates that the administration is ready to do the difficult task of adjusting and reconfiguring the way we do global health work. Moreover, Secretary Clinton’s recent testimony to the House Committee on Foreign Affairs unapologetically declared this administration’s support for healthcare and foreign aid investments that focus on the empowerment of individuals to make choices about their reproductive health despite the widespread politicization of those interventions. The Obama Administration is by no means perfect, and a “strategy” is nothing without implementation. But this is undeniably a step in the right direction.  

 

As advocates, I think we can all agree on one thing: we have a responsibility to our constituents, not our political representatives. Our government leaders are to be held accountable—decried when they make bad decisions and praised when they show bold leadership. In this instance, I must voice my strong disagreement with those who are choosing not to recognize the critical paradigm shift that has been introduced in the administration’s strategy: a focus on integration. I will be the first to challenge the administration if I believe it is falling short on following through with this strategy—but at this moment, integration is the bold and transformative change to global health policy on which the lives of millions depend for their health and wellbeing, and on which the future of the U.S. global health portfolio depends for its success. Money is an important part, but not the only part of the equation and we as advocates have a responsibility to our constituents to support this agenda. 

 

Sincerely,

Brian Ackerman