There's more to public health than pandemic preparedness. On an international scale, for example, there's HIV/AIDS, tuberculosis and malaria (being concerned about one thing doesn't mean ignoring the others). So, here's an interesting story.
President Bush’s program to fight HIV/AIDS is considered by Republicans and Democrats alike to be one of the unvarnished foreign policy successes of his presidency.
So why has broad bipartisan legislation seeking to more than triple the program’s funding to $50 billion caused such a rancorous fight?
Ask Sen. Tom Coburn, M.D.
Now, let's give some background. The Senate bill in question is S. 2731: Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008 and it's equivalent in the House is H.R. 5501: Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008. The House bill passed with 100% of Dems and 60% of Republicans supporting it. The Senate bill is considered "in committee" and not yet brought to a vote. That's because Tom Coburn and six other GOP Senators have blocked it from being voted on, or even discussed.
What the bill does is reauthorize the President's Emergency Plan for AIDS Relief (also known as PEPFAR), "a five-year, $15 billion American Government initiative to combat the global HIV/AIDS epidemic." That is the one foreign policy initiative that this administration has bipartisan backing on.
As Avenging Angel diaried on Friday
As Politico detailed, Coburn and a group of six other socially conservative GOP Senators have placed a hold on the reauthorization of one of President Bush's few popular initiatives, the Emergency Plan for AIDS Relief (PEPFAR). Enjoying broad bipartisan in Congress, the Senate has proposed boosting funding to $50 billion over five years. But the Senate bill would do away with the previous requirements "that 55 percent of the HIV/AIDS appropriation be spent on treatment and drugs and that about 30 percent of prevention funds be allocated to abstinence education."
In other words, the legislation would:
- Authorize $50 billion to combat HIV/AIDS, malaria and tuberculosis during the next five years.
- Provide treatment for at least three million AIDS patients.
- Prevent 12 million new HIV infections.
- Provide care for five million AIDS orphans.
- Train and support 140,000 new health professionals.
- Authorize $4 billion for the treatment and prevention of tuberculosis.
- Authorize $5 billion to fight malaria.
The Oklahoma Republican, along with six other social conservatives, has put a hold on the bill in the Senate, unless a provision is added to direct most of the spending toward treatment for HIV/AIDS rather than toward prevention and other priorities. Otherwise, Coburn said, "the vast majority of the money is going to get consumed by those wanting to help people with HIV, rather than [by] people with HIV."
Coburn argues that treatment of HIV/AIDS-affected individuals usually drops their viral load to the point where they will not infect other people, and thus, it’s "the No. 1 prevention protocol we have."
But many other Republicans and Democrats, as well as outside public health experts and AIDS charities, dispute Coburn’s math. With the program, called the President’s Emergency Plan for AIDS Relief, set to expire in September, they are very concerned.
"Most experts agree that treatment is only one small part of the prevention agenda," said Denis Nash, director of monitoring, evaluation and research at the International Center for AIDS Care and Treatment Programs at Columbia University.
Nash, whose work includes studying the efficacy of PEPFAR programs, said that while anti-retroviral medication does considerably reduce the viral load, fewer than 10 percent of the 33 million people infected with HIV are receiving treatment.
"The prevention effect of treatment is not likely to be anywhere near the magnitude of prevention through prevention," including safe-sex education and condom distribution, said Mead Over, senior fellow at the Center for Global Development.
It's that "safe-sex education and condom distribution thing" that has the conservative Republicans all screwed up. See, the conservatives don't like condom use, even though it has proven effectiveness. They like abstinence, even though it's incomplete by itself, and has been remarkably controversial when applied to PEPFAR. So, they gin up objections that have no grounding in science. Here's Lancet on the topic:
"Many more lives will be saved if condom use is heavily promoted alongside messages to abstain and be faithful."*
* "HIV prevention policy needs an urgent cure", The Lancet 367(9518), 15-21 April 2006
And that's where Tom Coburn comes in. He and his buddies are so far out on this they even have Republicans like Michael Gerson upset.
How much do seven members of the U.S. Senate weigh?
Eyeing them -- Tom Coburn, Jim DeMint, Jeff Sessions, Saxby Chambliss, David Vitter, Jim Bunning, Richard Burr -- I'd guess they probably come in at about 1,300 pounds. These are the Republicans who have signed a hold letter, preventing action on the reauthorization of the President's Emergency Plan for AIDS Relief (PEPFAR).
Now, how much do 3 million HIV-AIDS-infected people -- the treatment goal of a reauthorized PEPFAR -- weigh? This is a more difficult calculation. Adults with advanced forms of the disease can weigh about 60 pounds. Children with AIDS are like shadows falling on a scale. Maintaining weight becomes difficult with vomiting and diarrhea, with tuberculosis and fungal infections, with cancers such as Kaposi's sarcoma and lymphoma.
Part of Gerson's moral outrage is focused on my controversial stance that AIDS treatment dollars be spent on treatment. I want to preserve PEPFAR's original formula that sends at least 55 percent of all dollars to AIDS treatment so widows and orphans and actual patients, not program officers and consultants, will be the primary beneficiaries of the program.
It's not just Gerson that's ticked, it's also Richard Luger and 13 other Republicans who think this bill needs to get passed. There's are other consequences of not reauthorizing PEPFAR in a timely manner, including losing the ability to convince other nations in the G8 to cooperate and be generous with their own funding. More importantly, there are people who will die for lack of prevention and treatment.
What's scary about Coburn is not just how wrong he is (see the comments above from Denis Nash and Mead Over; they are public health experts, which Coburn is decidedly not), and how far out of the mainstream he is, it's that he's John McCain's chief medical adviser and functions as a medical adviser for Republicans (like Bill Frist on the Terri Schiavo debacle, Coburn is way over his head on this but Republicans turn to him anyway). John McCain in particular relies on Coburn to tell him what to do about medical issues (this reference is about condoms and AIDS):
Q: "But you would agree that condoms do stop the spread of sexually transmitted diseases. Would you say: ‘No, we’re not going to distribute them,’ knowing that?"
Mr. McCain: (Twelve-second pause) "Get me Coburn’s thing, ask Weaver to get me Coburn’s paper that he just gave me in the last couple of days. I’ve never gotten into these issues before."
and despite having a year to read "Coburn's thing", on this issue said:
"I'll be glad to assist. I'm sorry to tell you I'm not that familiar with the process of this legislation.
making Coburn's position – right or wrong – all the more influential.
Be that as it may, the issue on the table is reauthorizing PEPFAR and saving lives, millions of them. The Senate needs to do what's needed to get this bill to a vote (it will pass overwhelmingly, just like in the House where it passed 308-116).
This is a story we will continue to follow. And if you want to do something about it now, you can sign this petition. While we get to vote in November for people that understand public health and science, some things can't wait until November.
Update [2008-6-15 15:39:18 by DemFromCT]: For clarification, Coburn's main stated objection is removal of fixed allocation for funding treatment (55%) in favor of local flexibility. The Institute of Medicine has recommended against fixed allocation because it does not support sustainability. My own suspicions of conservative objections remain, but the public battle will be over the allocations provision.
Update [2008-6-16 0:20:15 by DemFromCT]: More on condoms.
The seven conservative Republicans are critical of the program's higher spending level and prevention programs that include condom promotion