Obama &amp; Global Health

The inauguration of Barak Obama as US President has largely been seen as a positive change around the world. But what Obama's Presidency will mean for the world's poorest and most vulnerable people is still somewhat ambiguous.

Two major breaks with previous policy have gone almost unnoticed by the outside world. The first was the forced resignation of Ambassador Mark Dybul, the controversial head of Bush's $48 billion President's Emergency Plan for AIDS Relief (PEPFAR) the day after Obama's inauguration.

The second came a couple of days later when Obama signed the Executive Order overturning the even more controversial so-called 'Mexico City Policy', originally passed under President Reagan, which prevents US aid to overseas organisations that provide or even discuss abortion related services.

PEPFAR has always courted controversy – for pumping billions of dollars in to programmes for just one disease, for promoting abstinence only prevention programmes, for not funding family planning services (or at least those with any abortion related agenda under the Mexico City Protocol), and for being seen by many lobbyists as being driven by a conservative, and evangelical Christian agenda. Others criticised it for being bi-lateral, arguing that the funds would have been better funnelled through the multilateral Global Fund for AIDS, TB & Malaria

Dybul's resignation was thus seen by some commentators as a symbolic head on a platter to many of these lobby groups, possibly at the instigation of Dybul's newly inaugurated boss, Hilary Clinton (or by those close to her).

But in reality, PEPFAR has been far more effective and broad based than many of its critics give it credit for. So far it has got 2.1 million HIV+ people in 15 countries on to antiretroviral therapy (ART), distributed 2.2 billion condoms (giving a lie to the charge that its prevention strategies were abstinence only focussed), and gave access to prevention of mother-to-child anti-HIV therapy (PMTCT) to 1.2 million women. And only 7.4% of its budget has gone to abstinence only programmes (indeed, new protocols agreed in December would mean more funding going to a wider range of sexual health and education initiatives geared at HIV prevention). It has made errors, but has learnt from them, has moved away from being top down to being more responsive to local needs.

Multilateral approaches may have suffered from less funding as a consequence, and there are other criticisms to make. But in Africa, many see PEPFAR as Bush's lasting and most valuable legacy.

Obama has committed to honour the December 2008 PEPFAR act which would pump nearly $50 billion in to HIV prevention, care and treatment over the next five years. And more of that money will now probably go to family planning services that will undoubtedly save lives – the link between good family planning services and reducing HIV rates among women and children in particular is strong. That some of those services will go to promoting and providing abortion is, however, a cause for concern, and may divert funding from initiatives that are proven to be effective.

And while national programmes that promote delayed sexual debut, partner reduction, fidelity, effective condom usage, voluntary testing and counselling, etc, continue to be effective in reducing rates of new HIV infections and increasing access to early ART interventions, we wait to see if the new head of PEPFAR (whoever she or he will be) will continue to prioritise effective, evidence based programmes, or will she/he succumb to the pressure of ideologues of either side to promote their own agendas.

We will watch Obama with interest, as will all of the developing world, especially Africa. If he can live up to and exceed Bush's legacy on HIV/AIDS (and other health issues - Bush also launched a major initiative combating malaria) in much of the developing world, it will be good news for many. But fears and uncertainties must abound about the other forces that may move his hand in less helpful ways. Let us uphold him, along with all our leaders, in prayer!