Why AIDS First?

In 2003, George W. Bush launched the largest international health initiative ever directed at a single disease: the President's Emergency Plan for AIDS Relief (PEPFAR). According to a recent Stanford study, the program was responsible for saving the lives of more than a million Africans in just its first three years. More than five million people in poorer countries are now receiving lifesaving drugs, mostly through support from PEPFAR, the Global Fund and budget contributions of the countries themselves.

The effectiveness of this global fight against AIDS is well established. But its cost effectiveness is still debated. Some claim this money might have been better spent on less complex interventions such as clean water, or on broader priorities such as health infrastructure. Has putting AIDS first actually diverted attention and resources from more urgent goals? The implicit challenge of this question is that more lives might have been saved by other, less costly methods.

Confronting HIV/AIDS through prevention and treatment is a relatively expensive, long-term commitment. But in Sub-Saharan Africa, it was not merely one option among many. With the cohesion of whole societies at stake, confronting AIDS first was the prerequisite for all other progress.

In the last five decades, despite weak health systems, unchecked malaria and unclean water, life expectancy in much of Sub-Saharan Africa increased by almost 30 years and infant mortality decreased. But one aggressive pandemic changed all that. As HIV/AIDS swiftly spread in the 1980s and 1990s, life expectancy began to fall -- in some cases by more than 30 percent -- and infant mortality began to climb. In some countries, nearly 50 years of public health gains were wiped out in less than a decade. In the hardest hit nations more than one-third of the adult population was HIV-positive, and in some areas more than 75 percent of pregnant women were infected.

Unlike plagues of the past, HIV is a discriminate killer. It targets the most productive and reproductive part of society -- those who are 15 to 49 years old. HIV is not a disease of the poorest of the poor. Studies from India, Russia and Africa show that HIV disproportionately affects those who have climbed a few rungs on the socioeconomic ladder, including factory and mineworkers, the military, and those who are more educated, including teachers and health-care workers.

At the height of the AIDS pandemic, four percent of nurses in Swaziland died from HIV every year. In Zambia, 38 percent of all departures from the health workforce were HIV-related. In Kenya, health workers were twice as likely to be HIV-positive as the general population. And the number of HIV cases was overwhelming already strained health-care systems. The disease accounted for 50 percent of all hospitalizations in hard-hit countries. Without first addressing the effects of HIV, there was no chance to build strong health systems.

The crisis reached further. In Zambia, for example, HIV was killing two-thirds of newly trained teachers, making progress on education impossible. The disease was undermining economic growth on the continent. HIV disproportionately affected militaries, significantly limiting the strength of African peacekeepers -- 40 percent of all global such forces. But the largest effect was psychological -- the hopelessness and despair that came from a sense that death from HIV was every person's destiny. Men and women living in the shadow of death are less likely to invest in education, plant for the next season or start a business, and more likely to embrace radicalism and violence.

HIV was not just another disease to be coldly calculated by cost per life saved. It was taking the people, and undermining the attitudes, that make modern society possible. Early in this decade, Africa had many other needs, but the threat of this disease was overwhelming. Issues such as health infrastructure are important -- but they become less urgent during the Black Death. It was necessary, even unavoidable, to put AIDS first.

With the worst of the emergency confronted -- AIDS deaths declined in the world for the first time in 2008 -- it is now appropriate to begin taking a broader view. The response to HIV demonstrated that massive investments in global health could achieve results and shattered the paternalistic myth that poor countries could not manage complicated health delivery. It is because of the response to HIV, not despite it, that we can discuss significant investments in other areas of global health. More than a third of PEPFAR and Global Fund budgets now support the building of health systems. The principles of President Obama's Global Health Initiative -- dedicated to better coordinating efforts on an array of health challenges -- are a natural evolution of PEPFAR and deserve broad support.

But on this World AIDS Day, we should not minimize the work that remains. HIV remains the leading killer of young Africans and is the leading cause of death of women of reproductive age in low- and middle-income countries. Were it not for HIV, deaths around childbirth would have declined an additional 20 percent.

It remains as true today as it was in 2003: Unless HIV is controlled in Sub-Saharan Africa, there is little hope for progress in any area of health or development. For seeing the future so clearly and taking decisive, compassionate action on HIV, President Bush deserves the Nobel Prize. The irony is that he might be one of the few not to care if he ever receives it.

Mark Dybul is Distinguished Scholar at Georgetown University's O'Neill Institute for National and Global Health Law, the Global Health Fellow at the George W. Bush Institute and was the Global AIDS Coordinator from 2006 to 2009. Michael Gerson is a senior adviser at the ONE Campaign and served as a policy adviser to President George W. Bush.