How Smallpox Eradication Led to a Tragedy: Interview with Laurie Garrett
This is Part II of an interview with Laurie Garrett, Pulitzer Prize-winning author and senior fellow for global health at the Council on Foreign Relations. Ms. Garrett has written widely — and passionately — about the importance of health systems development, both in the United States and around the world. Here, I talk with her about why the U.S. can and should support global health infrastructure growth — even if it doesn’t generate quite as a compelling fund-raising campaign as HIV or malaria-targeted projects.
For Part I, please click here.
Mara Gordon: A Kaiser Family Foundation survey that came out earlier in November on American public support for global health had some interesting – and somewhat surprising -- findings, specifically about the way many Americans want to see aid dollars for global health spent. Most Americans support U.S. funding for health programs in poor countries despite the economic recession and agree that it promotes American health and security; 58% of Americans support infrastructure development rather than disease-specific funding. Does this surprise you? Do you think it is a shift away from what Americans favored a decade ago? What is responsible for the change?
Laurie Garrett: I was, indeed, surprised. It has long been assumed by the entire public health field that Americans did NOT support foreign assistance, in general, and were swayed towards backing global health via the targeted initiatives that captured the political imaginations of millions of people. Surely HIV treatment has benefited from that sort of appeal, and I earnestly believe that the surge in support of HIV care has helped pull American eyes -- and dollars -- towards larger health issues. But the poll revealed that Americans have become more sophisticated in their views of overseas problems than global health leaders had given them credit for. I think political leaders on the Hill have taken note of this, and feel wind in their sails regarding funding priorities.
There is a feud going on inside the global health "movement", if you can call it that. Those who have backed the initiative approach to health, and the medically-targeted prioritization of aid feel threatened by this larger, health systems and infrastructure targeting. They shouldn't. I think all boats can lift together. The only thing in the way of rising success on all fronts is the disunity and bickering within the global health community, especially in the USA.
I honestly think the overall approach the Obama Administration is aspiring to take makes good sense. Rather than screaming, or giving President Obama a D+ score, as some AIDS activists have done, everybody should recognize that Congress, the general public and development leadership inside the Administration share a growing sense of disdain for the squabbling among health advocates -- the "my disease is more important than your disease" stuff. One key official in the Administration told me that it seemed like one set of activists were saying the Administration should let people die in poor countries from illness A, B and C -- just stop illness D. That is sick. We can and should find ways to integrate our approaches so that everything we do targets more causes of death and morbidity, and improves the lives of billions of people. The obvious example is creating stronger links between HIV and TB care, as TB is the leading cause of death for HIV+ people in Africa. Another is to broaden the prenatal care package so that every woman worked up for routine pregnancy checkups is also worked up for HIV, and vice versa.
I always try to remind people of one of the big tragedies of the recent past: smallpox eradication. Tragedy? Well, eradicating smallpox was certainly one of the single greatest achievements in human history, saving far more lives in the 20th C than were lost in all wars, combined. BUT, the tragic mistake was in building a vast infrastructure worldwide to tackle the disease, training millions of community health workers and funding enormous surveillance and statistics operations in the poorest countries on earth...and then dismantling it all the day eradication was officially declared. I will fight my hardest to ensure that such a mistake is never repeated.
Initiatives are fabulous -- and I ardently support expansion of HIV treatment to achieve to universal access targets -- but let's be clear about something: If a cure or vaccine for HIV were found tomorrow, it would be criminal to walk away from the HIV treatment and prevention infrastructure worldwide. If everybody could focus on that notion, it would help a great deal in mollifying disputes. Consider this: As we further increase support for Ministries of Health and the worldwide network of NGOs that target HIV issues, can we do so with that goal of "cure" and "vaccination" in mind? Isn't the REAL goal to stop HIV? I hope you are nodding you head. OK, so if you share that goal, doesn't it make sense to build the HIV, TB, malaria, maternal health -- all the initiatives -- in such a way that the great tragedy of smallpox eradication cannot be repeated, and every program leaves countries' health systems and capacities stronger than they were, capable of addressing all the needs of their people?
MG: I was interested to read in a recent interview with Dr. Eric Goosby, the U.S. Global AIDS Coordinator, that PEPFAR may be headed in this direction. He told Global Health Magazine that he sees developing human resources for health as a key part of PEPFAR's strategy for the next five years. He was quoted as saying, "Countries need support and have the courage to engage in something that could be disruptive and cause radical transformations under their social services." Do you think this is the beginning of a positive change for PEPFAR?
LG: I think I have answered this above. Fighting HIV is about a hell of a lot more than access to ARVs. Yes, everybody who needs them, deserves ARVs -- including Russia's IV drug users, India's prostitutes, Brazil's transvestites, South Africa's infected babies -- everybody. But we cannot treat our way out of this pandemic. Treatment is a stopgap measure, buying the world time, and individual's time, to a cure or vaccine.
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