Crisis of Command
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The George W. Bush administration increased annual U.S. assistance to Africa almost sixfold, from $1.3 billion in fiscal year 2001 to $7.3 billion in fiscal year 2009. One-time debt forgiveness and emergency humanitarian assistance contributed to this increase, but it was primarily driven by the President's Emergency Plan for AIDS Relief (PEPFAR), the United States' single largest continuing commitment to Africa. PEPFAR, which was originally expected to disburse some $15 billion over its first five years, actually spent $25 billion between 2003 and 2008. The program also kick-started a sharp increase in AIDS-related assistance worldwide and laid the foundation for the G-8's announcement, in 2005, that it would provide all those infected with HIV with access to life-saving antiretroviral (ARV) treatment.
This commitment will become staggeringly large. There are currently just over 33 million people infected with HIV, more than 22 million of whom are in sub-Saharan Africa. In 1998, only a few hundred thousand people with the virus received ARV treatment. By 2009, over four million were receiving treatment, with PEPFAR providing it for two million of them, according to the Kaiser Family Foundation. But UNAIDS, the Joint United Nations Program on HIV/AIDS, estimates that that year nearly ten million people needed treatment. If new infections continue to outpace AIDS-related deaths by 35 percent, as they did in 2009, this number will inevitably increase.
Because ARV therapy needs to be provided over a lifetime, treating HIV/AIDS patients is a serious long-term commitment. If universal treatment is to be achieved, some 30 million people worldwide will have to be kept on ARV treatment for three or four decades. Some countries may be able to shoulder the cost of such care for their own citizens, but those in sub-Saharan Africa -- the world's poorest region -- will not. If the United States continues to lead the international community in filling this "treatment gap," the magnitude of the commitment will steadily grow.
And so, too, will the foreign policy problems this kind of aid creates. More aid will limit Washington's influence on issues other than HIV/AIDS in recipient countries. It will create a sense of entitlement in recipient countries and make patients directly dependent on the annual U.S. foreign aid appropriations process, which could spawn as much resentment as gratitude. Eventually, the U.S. government (and other donors) may grow disillusioned with the commitment. Its growing claim on the U.S. foreign aid budget is already sparking arguments over priorities within the development community. In reaction, the Obama administration is now trying to shift more of the cost of treating HIV/AIDS patients to African governments, but few, if any, of these governments will be able to pick up the slack. And these challenges are arising just as the Obama administration is seeking to make development and diplomacy "twin pillars" of U.S. foreign policy.
MORE AID, LESS LEVERAGE
The United States' dramatic increase in humanitarian and life-saving AIDS assistance creates an acute paradox: it diminishes Washington's leverage over the governments that get the aid. Aid that is so closely linked to individuals' survival cannot reasonably be curtailed, even if serious differences arise between the donors and the recipients. And now, this kind of irrevocable medical assistance, along with emergency food aid, makes up the bulk of U.S. aid to Africa. Ten years ago, humanitarian aid to Africa accounted for 40 percent of all U.S. assistance to the continent; in fiscal year 2008, some 80 percent of U.S. support to Africa came in the form of food and medical assistance, mostly to combat HIV/AIDS and to promote child survival. According to the U.S. State Department, the figure was even higher in some of Africa's most populous and geopolitically important countries: 91 percent of U.S. aid to Nigeria, 90 percent of U.S. aid to Uganda, 84 percent of U.S. aid to Ethiopia. U.S. security assistance, in theory a more flexible instrument, is minimal in Africa -- just seven percent of total U.S. aid there -- and most of it is committed to peacekeeping, another area in which it is difficult to scale back.
Relations with Ethiopia and Uganda, two of the largest recipients of U.S. aid in Africa, illustrate the limits of Washington's leverage. The Ethiopian government is a close ally of the United States on security issues in the Horn of Africa. But it has cracked down hard on political opponents since a disputed election in 2005. In the run-up to national elections this May, it arrested a prominent opposition leader, put tight restrictions on the press, limited the role of international election monitors, and took other repressive steps. Ethiopian and international human rights organizations are charging that the government has also been committing serious human rights violations in an ongoing campaign against dissidents in the province of Ogaden, which borders Somalia. Washington has expressed its concern about these issues to the Ethiopian government, and the Ethiopian government has reacted not only negatively but also insultingly -- despite receiving $533 million in U.S. assistance in fiscal year 2010 (some 77 percent of it, almost $411 million, in the form of health and humanitarian assistance), according to the U.S. State Department. In March, Prime Minister Meles Zenawi compared the Voice of America's Amharic-language service to the radio station Radio Mille Collines, an instigator of the 1994 genocide in Rwanda, and ordered that its broadcasts be jammed. The U.S. State Department called the accusation "baseless and inflammatory," but the decision has stood. Meles also rejected outright the findings of the State Department's 2009 human rights report on Ethiopia. Whatever problems Washington has with the state of democracy in Ethiopia, it is not prepared to reduce its humanitarian aid to Addis Ababa. Neither those invested in the HIV/AIDS programs nor the American public would countenance doing so if it meant letting Ethiopians die.
The situation is similar in Uganda. In 2006, President Bush personally urged Ugandan President Yoweri Museveni, who has been in power since 1986, not to run in that year's election and to make way for a democratic transition. Museveni refused and won another term, and he is now contemplating running for reelection again this year. Although Museveni has done much to improve Uganda's economy and has played an important role in regional diplomacy, there is serious concern that instability could rock Uganda in the future. In over 20 years in power, Museveni's government has not developed any basic democratic institutions. Journalists who have criticized his regime have been charged with sedition, opposition parties have been systematically dismantled, and the country's military forces have frequently committed human rights abuses. Despite the $456 million in U.S. aid it has allotted to Uganda for fiscal year 2010 (the vast majority of it for health and emergency assistance), Washington has little ability to spur democratization there.
There are more examples. In Zimbabwe, where current U.S. assistance, almost all of it PEPFAR and emergency aid, now reaches $500 million a year, U.S. influence over Robert Mugabe's autocratic and economically destructive policies is negligible.
The steady increase in spending on HIV/AIDS treatment presents a second problem for Washington: it creates competition for many other development objectives. In his first year in office, President Barack Obama promised to double aid to Africa over the next four years. But deficits and rising political concern about them have already put that goal in doubt. For fiscal year 2011, the U.S. State Department has reported a proposed increase in aid to Africa of only about eight percent and an increase in PEPFAR funding of only two percent. And it has offered to contribute only $1 billion -- $50 million short of the U.S. contribution for fiscal year 2010 -- to the Global Fund to Fight AIDS, Tuberculosis and Malaria, a much-touted multilateral prevention and treatment program.
To better address the president's health priorities, the administration has introduced the Global Health Initiative (GHI), a broader approach to global health that includes PEPFAR but focuses more on AIDS prevention and on investments in health-care infrastructure. Most experts have applauded the GHI's priorities, but these are now competing with the growing demand for ARV treatment. The Obama administration has promised to keep to its commitment to increase the number of patients receiving ARV treatment under PEPFAR to four million by 2014. Yet bowing to budgetary constraints, it has planned for virtually no increase in 2011. This decision has prompted HIV/AIDS advocates to accuse the U.S. government of condemning people to death and has set the stage for disputes between proponents of HIV/AIDS relief and supporters of broader health and development programs.
In Africa, the reaction to the cap proposed for 2011 was almost immediate. The Office of the U.S. Global AIDS Coordinator announced the news to field missions in June 2009 in a message noting that treatment and other care costs accounted for more than half of PEPFAR program resources. Offices in the field were advised to "exercise great care and deliberation in planning support (especially direct support) for further treatment scale-up in FY 2010" because "the overall PEPFAR budget does not provide additional resources to address such situations." This was understood as a prohibition on enrolling new patients, and it prompted a sharp retort. International research and health professional organizations from 30 countries issued a statement warning that "shifting funding from HIV [to other health programs] will not fill the yawning gaps in resources for health -- this move is a cheap diversionary tactic that offers no genuine or long-lasting solutions for health." According to Peter Mugyenyi, the director of the Joint Clinical Research Center, which is in charge of AIDS relief in Uganda, halting the increase in PEPFAR funds for ARV treatment has already caused new AIDS patients to be turned away. This, in turn, has forced current patients to share their medication with family members who also are infected, a practice that could worsen the epidemic by diluting the effectiveness of the treatment and thereby lead to the development of more treatment-resistant strains of HIV.
The U.S. global AIDS coordinator, Eric Goosby, has responded by reiterating the Obama administration's commitment to treating four million persons under PEPFAR by 2014. The administration may be able to achieve that goal, but not without more competition between PEPFAR and other GHI initiatives. PEPFAR already accounts for $51 billion of GHI's $63 billion budget. In fiscal year 2009, about 45 percent of PEPFAR's budget was spent on treatment. That percentage will only rise in the years ahead as more people are treated and as those who have already begun treatment develop a resistance to first-line drugs and start needing more expensive second-line therapies. Thus, unless overall aid to Africa grows substantially -- which is unlikely in these times of deficits and budget stress -- PEPFAR, and especially PEPFAR's treatment programs, will increasingly crowd out other health efforts. The Obama administration's nonhealth initiatives, such as the Global Hunger and Food Security Initiative and programs to combat climate change, will also feel the pressure as PEPFAR consumes a steadily larger share of total aid.
SHIFTING THE BURDEN
Washington is looking for ways out of this dilemma. Various guideline documents, including PEPFAR's FY 2010 Country Operational Plan (COP) Guidance, issued by the Office of the U.S. Global AIDS Coordinator, suggest that Washington may soon ask governments that receive U.S. aid to shoulder more of the cost of HIV/AIDS programs. In Uganda and many other sub-Saharan countries in which the U.S. government covers as much as 75 percent of funding for national HIV/AIDS programs, this approach will surely meet resistance. Many sub-Saharan African countries depend heavily on foreign aid, not only for their HIV/AIDS programs but also for their entire health budgets. Having to assume a significant share of the ever-rising cost of treating AIDS would be a severe shock. Ongoing talks about such a shift are causing alarm even in South Africa, the wealthiest country in sub-Saharan Africa: half of its HIV/AIDS program is financed by outside sources.
South Africa's situation may be a harbinger of things to come elsewhere. President Jacob Zuma has reversed his predecessor's resistance to the public provision of ARV drugs, made it easier for South Africans with HIV/AIDS to become eligible for treatment, and set out to treat 80 percent of those now eligible by 2011. To pay for these measures, the South African government increased its spending on HIV/AIDS by one-third in its 2009-10 budget. But if the government successfully meets its 2011 treatment target, the number of people receiving ARV drugs from the state will more than double, to 1.5 million, in just one year. The projected five-year cost of this increase is $6.4 billion, a sum that South Africa's health minister claims would prevent the funding of any other health programs. As the bioethicists Theodore Fleischer, Sebastian Kevany, and Solomon Benatar wrote in the South African Medical Journal, "It would be medically, politically and morally -- and probably legally -- unacceptable for expanded treatment of the HIV population to come at an unacceptable cost to patients who bear the burden of other chronic diseases and health conditions and could also benefit significantly from appropriate treatment." South Africans in the government and in the health community are now seeking even more donor assistance from other governments and from nongovernmental organizations. In light of this, it is difficult to imagine how poorer African states could take on the cost of HIV/AIDS treatment anytime soon.
THE WAGES OF AID
However commendable the commitment to address the HIV/AIDS pandemic, there is no doubt that the rising number of people in need of treatment and the rising expense of treating them will produce more concern, more debate, and more problems.
As the steep cost of treating all HIV/AIDS patients becomes clear, donors may begin to question the wisdom of the G-8's 2005 commitment to do so. This is especially likely if the number of new HIV infections continues to outrun the number of people newly placed on treatment. Faced with a never-ending and constantly increasing need for funds, donors might put severe pressure on aid recipients to improve prevention, perhaps going so far as to cap the funding for new patients in those countries where the rate of new infections does not start to fall. At some point, the commitment to universal treatment itself could be abandoned.
As the demand for treatment keeps rising, an uncomfortable debate will also likely intensify within the U.S. development community. The U.S. government designed the GHI to respond to criticism that PEPFAR put too much emphasis on HIV/AIDS, and especially on treatment, to the detriment of other health needs. But the controversy sparked by the Obama administration's decision to not increase treatment spending under the GHI in 2011 demonstrates just how sensitive the issue of HIV/AIDS treatment is when the demand for access to ARV drugs is pitted against other health needs. Africa's need for infrastructure, agricultural development, improved trade capacity, and environmental protection -- all issues on the Obama administration's agenda -- may fuel an even nastier debate and cause deep splits among members of the development community and the members of Congress in charge of foreign aid appropriations.
Another disturbing possibility is that those who live with HIV/AIDS may come to be resented by their compatriots. A key strategy of HIV/AIDS programs has been to combat the stigma associated with the disease and encourage those who are infected to call for more attention and better access to treatment. But as the cost of HIV/AIDS programs account for an ever-increasing share of U.S. aid, and perhaps also of the health budgets of the recipient countries, the growing appreciation of the plight of HIV/AIDS patients could give way to resentment. South Africa has the largest number of people infected with HIV -- 5.7 million -- in the world. But that figure represents only about 11 percent of the country's total population, the vast majority of which suffer from poverty, unemployment, poor education, and inadequate health services. Impatience with the special treatment that people with HIV/AIDS in South Africa receive could rise. Things might even turn ugly, as with the riots against immigrants two years ago.
The United States, too, might suffer a backlash. The surge in Washington's assistance to Africa, particularly PEPFAR funds, has contributed to its strikingly favorable image in Africa in recent years, an image held even during the Iraq war, when the United States' popularity was plummeting elsewhere. But if the percentage of total aid tied to HIV/AIDS increases or if the U.S. government insists on shifting more of the burden of treating AIDS to other governments, those attitudes could turn. During the early years of this century, then South African President Thabo Mbeki accused the West of focusing on the HIV/AIDS pandemic in order to hook patients in African countries on expensive drugs produced largely by Western pharmaceutical companies. The West would then shift this obligation to African governments, Mbeki argued, crippling their efforts to reduce poverty or meet other development needs. At the time, Mbeki's argument was dismissed as an expression of his deep-seated resistance to recognizing the seriousness of the pandemic. Soon, African governments may begin to wonder if he was right.
Perhaps the most significant problem is that the G-8's commitment to universal treatment is making the survival of millions of people, mostly in Africa, directly dependent on annual aid appropriations by the U.S. Congress. If universal treatment is achieved and the U.S. government continues to finance half the effort, as it does now, by 2030 there could be as many as 11 million people in Africa alone whose lives would depend on the annual provision of U.S. aid. Another 11 million people in Africa would be dependent on other AIDS-related programs, such as the Global Fund to Fight AIDS, Tuberculosis and Malaria, to which the U.S. government is also a major contributor.
Support of this magnitude could create an unprecedented sense of entitlement. The implications are unclear. The 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. This dependence, moreover, will severely limit the flexibility of the U.S. Congress, with future aid appropriations already irrevocably committed to this single issue. Congress' underlying commitment to universal treatment could sour. These are unchartered waters.
LIVING WITH PEPFAR
None of these issues should be allowed to undermine the commitment to treat all HIV/AIDS patients. This undertaking is one of the greatest humanitarian gestures in history and a statement by the developed countries that they refuse to deny life-saving treatments readily available in rich states to the millions elsewhere who need them. But the full implications of this commitment need to be addressed before they become more serious problems.
One useful step would be to recognize the aid's effects on Washington's leverage over recipient countries. Washington's influence derives not only from its aid programs, of course; the United States is the world's leading military and economic power and a beacon of freedom and democracy. Instruments other than aid, such as trade policy and public diplomacy, as well as commitments to humanitarian causes, also provide Washington with influence. But the American public and Congress, especially advocates of democracy and human rights, tend to assume that aid is a greater instrument of influence than it actually is.
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. The 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, is questionable on many fronts. For one thing, development efforts typically last much longer than the more immediate demands of diplomacy, a disconnect that is particularly acute in the case of PEPFAR. Thus, Washington will need to develop a diplomatic strategy to advertise humanitarian commitments such as PEPFAR as evidence of U.S. goodwill, without hoping to use them to pressure recipient governments on unrelated issues. In order to exert that kind of pressure, other tools need to be strengthened: trade policy, other forms of assistance (insofar as these can be increased), and support for regional and continent-wide institutions in Africa and African civil-society organizations that advocate for democracy and human rights.
Second, the United States should not allow the dependence of millions of people who rely on U.S. foreign aid to grow indefinitely. It should seek to internationalize the implementation of direct HIV/AIDS treatment programs before its support for such programs becomes too great a financial burden and too sensitive a political issue. The U.S. government should begin to build the capacity of the Global Fund to Fight AIDS, Tuberculosis and Malaria to take on this job. Placing the procurement of drugs and the task of distributing them under one international organization may also be more cost-effective. The global program to combat HIV/AIDS will continue to require international support, much of it from the United States, as will the effort to strengthen health institutions in poor countries, one of the GHI's major goals. But internationalizing treatment programs would attenuate the link between the sources of aid and the survival of its recipients, thereby limiting some of the uneasy dynamics of the United States' responsibility today.
Third, work must continue on the search for alternative means to combat HIV/AIDS. With no vaccine or cure for the disease at present, the only ways to tackle it are by preventing its spread through changes in social behavior and providing lifelong treatment for those who are infected. The prospects of developing a safe and effective vaccine are slim, and the chances of finding a cure are even smaller. Yet given the scale of the pandemic and of the commitment required to contain it, these searches must persist. The International AIDS Vaccine Initiative, a public-private partnership dedicated to developing an HIV vaccine, states on its Web site, "While there will never be a single solution to HIV and AIDS, we know from history that no major viral epidemic has ever been defeated without a vaccine." The Web site of UNAIDS does not even discuss the prospect of a cure, but that, too, must be on today's research agenda. Without a vaccine or a cure, the HIV/AIDS problem will, in just a few decades, be even greater than was ever imagined.
Taking these steps will not solve all the problems created by the developed world's commitment to providing all HIV/AIDS patients with access to ARV treatment. But acknowledging what the implications of it are and adopting measures that anticipate the problems it creates will attenuate the risks and help sustain this major undertaking.