PEPFAR Is Worth It: Ezekiel Emanuel Is Wrong on AIDS Funding

The idea that differing global health initiatives must compete with each other lacks not only ethical legitimacy but also scientific merit.
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The diminishing commitment by donor nations, including the United States, to fund AIDS treatment initiatives such as the President's Emergency Plan for AIDS Relief (PEPFAR) will be a major topic this July in Washington, D.C., at the XIX International AIDS Conference. The global economic recession and the de-emphasizing of HIV/AIDS in favor of other global health initiatives threatens to undermine the impressive results achieved thus far in treating HIV in the resource-limited settings.

Dr. Ezekiel Emanuel, an eminent bioethicist and former Obama administration health policy adviser, argues in an editorial in a recent The Journal of the American Medical Association (JAMA) that AIDS funds are not the best use of international health funding. Dr. Emanuel wrote:

"Is PEPFAR worth it? Many other global health programs are improving the health of poor people worldwide but are not funded anywhere near the level of PEPFAR. The fundamental ethical, economic, and policy question is not whether PEPFAR is doing good, but rather whether other programs would do even more good in terms of saving life and improving health."

Dr. Emanuel is no stranger to this debate. He co-authored a JAMA commentary in 2008, stating: "PEPFAR is not the best use of international health funding," and "fails to address many of the developing world's most serious health issues." Fortunately, AIDS researchers and activists refuted Dr. Emanuel's claims with data affirming that AIDS funds can actually advance and synergistically reinforce the overall primary healthcare infrastructure in recipient countries beyond just HIV/AIDS. It is surprising that Dr. Emanuel is resurrecting his discredited critique of PEPFAR.

Dr. Emanuel wrote, "It is unethical and irresponsible not to ask how global health assistance should be directed to produce the most good." However, the issue should not be if global health donor funding should focus on AIDS versus diarrheal diseases versus neglected tropical diseases. We must focus on all of these diseases.

The real issue is the inadequate financial resources committed to global health in toto. In an ideal world, we would commit the $60 billion per year needed to treat the essential health burdens around the globe. We would treat every essential disease and need not make judgments on rationing treatment based on flawed metrics such as disability-adjusted life-years. Yet we continue to make the unethical argument that an "ideal world does not exist." Instead of arguing about funding allocations that pit diseases against each other, as Dr. Emanuel tacitly proposes, we should be thinking about new ways to fund global health initiatives such as enacting a global financial speculation tax or expanding the pool of donor nations to include China and the oil states of the Middle East.

The idea that differing global health initiatives must compete with each other lacks not only ethical legitimacy but also scientific merit. Confronting illness in isolation -- whether by funding AIDS at the expense of programs that target other diseases or vice versa -- cannot be our way forward.

--- Anand Reddi is at the University of Colorado School of Medicine

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