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USA/Africa: Images and Issues

AfricaFocus Bulletin
Feb 21, 2008 (080221)
(Reposted from sources cited below)

Editor's Note

As President Bush winds up his 5-day trip to Africa, the initial focus on his legacy in the fight against AIDS and malaria has been enlivened with debate on the new and highly controversial AFRICOM military command (See, for example, http://www.nytimes.com/2008/02/21/world/africa/21prexy.html), Commentators have also highlighted the contrast between Bush's itinerary (Benin, Tanzania, Rwanda, Ghana, and Liberia) and unresolved crises in Kenya and Sudan. But from AIDS to AFRICOM, coverage of the trip was also revealing for points hardly mentioned by either Bush boosters or critics.

On PEPFAR (President's Emergency Plan for AIDS Relief), the coverage has focused on how much credit President Bush should get, and secondarily on current issues such as levels of funding and abstinence-only policies. In historical perspective, however, the most striking development is the dramatic change over eight years. In Bush's first year, USAID administrator Andrew Natsios rejected the option of AIDS treatment for Africans claiming they couldn't tell time (see http://www.africaaction.org/docs01/nat0106.htm). Now it is assumed across the political spectrum not only that addressing AIDS and other health issues in Africa is essential, but also that it is something for which politicians are eager to claim credit.

The change was the result of mobilization by activists in Africa, the United States, and around the world. In the United States, Congress, and then the administration as well, responded to popular pressure to address the issue, coming not only from "liberals" but also from many in Bush's conservative Republican base. The result, albeit not satisfactory to activists in either quantity or quality, was a significant shift from previous administrations. Ironically, President Clinton's own significant contributions to the fight against AIDS came not when he was in office, but in his postpresidential incarnation.

The debate about AFRICOM, with President Bush forced to deny that the United States is seeking new military bases, nevertheless ignored the extent to which the U.S. focus on anti-terrorism has already shaped U.S. military intervention, such as its encouragement for the Ethiopian invasion of Somalia in 2006-2007 and support for highly disruptive counter-insurgency operations in the Sahel in 2004 (see http://www.africafocus.org/docs07/sah0701.php and sources cited there).

More generally, on the fundamental issues of security, democratization, and economic development, the Bush administration has given more rhetorical attention to Africa than did the administration of his predecessor President Bill Clinton. But neither administration systematically prioritized peacemaking over sporadic diplomacy nor met African development issues with responses going beyond the conventional economic policies of freemarket fundamentalism.

This AfricaFocus Bulletin contains brief editorial notes and links to relevant AfricaFocus Bulletins on a range of issues in USA/Africa relations. Given the prominence of President Bush's AIDS program in coverage of the trip, also included are a set of recommendations for improvement of that program, coming from a meeting of African civil society organizations in December 2007.

A new page on the AfricaFocus website ( http://www.africafocus.org/country/usa-africa.php) highlights previous AfricaFocus Bulletins with a focus on bilateral relations, as well as other links to background information. AfricaFocus welcomes suggestions for additional links for this page, particularly to substantive analyses exploring the options for a new post-Bush agenda.

For the official White House site on President Bush's trip, visit http://www.whitehouse.gov/infocus/africa/trip2008

For a special collection of critical articles, see Pambazuka News, 346 for February 18, 2008 ( http://www.pambazuka.org/en/issue/346

For historical perspective, see the annual Africa Policy Outlooks, from 1995 to 2008, from Africa Action and its predecessor the Africa Policy Information Center (http://www.africaaction.org/resources/page.php?type=18)

For AfricaFocusPlus, providing a custom search of AfricaFocus, Pambazuka, Africa Action, and other selected partner sites. visit http://www.africafocus.org/plus/search1.php

++++++++++++++++++++++end editor's note+++++++++++++++++++++++

HEALTH

The shift in assumptions and funding levels for HIV/AIDS since the year 2000, at both multilateral and bilateral levels, represents significant change. This gives a political starting point for further advances, and for consolidating the perspective that global health is not an issue of charity or party politics but of fundamental human rights. But neither the fight against AIDS and other pandemic diseases nor the effort to foster Africa's health more generally are yet close to meeting the need.

Brief Issue Checklist

• Funding levels - current U.S. congressional proposal includes $50 billion over 5 years for PEPFAR, increasing President Bush's flatrate funding proposal of $30 billion over years.
• Restrictions - current U.S. congressional proposal eliminate current restriction that 1/3 of prevention funds be spent on abstinence-until-marriage programs. President Bush opposes lifting the restriction..
• Overall levels of funding for programs, including PEPFAR, the U.S. malaria initiative, the multilateral Global Fund to Fight AIDS, TB, and Malaria
• A comprehensive approach to global health, including building capacity of health services and the supply of health professionals

Links for more background

See http://www.africafocus.org/healthexp.php and http://www.africafocus.org/country/usa-africa.php

For a summary of the positions of U.S. presidential candidates on global health issues, see http://www.health08.org/issue_globalheath_hivaids.cfm

Document

African Civil-Society Recommendations on the Next Phase of U.S. Global AIDS Assistance

December 11, 2007

http://www.globalaidsalliance.org/index.php/803

On December 10-11, 2007, representatives of 21 civil-society organizations, including representatives of PLHA organizations as well as large PEPFAR AIDS treatment providers, met in Nairobi to provide feedback and recommendations on the future of U.S. global AIDS policy. The meeting was hosted by the Kenyan AIDS Treatment Access Movement, Global AIDS Alliance, and Health GAP. In light of the upcoming debates on PEPFAR reauthorization, we respectfully submit the following recommendations from people living with HIV/AIDS and working on the front lines of the AIDS pandemic. The following summarizes our prioritized recommendations, and a full report will be made available shortly.

1. Numbers on treatment versus measuring healthy patients: PEPFAR is doing a historic and important job of getting people on ARV treatment. However, counting a person who is receiving AIDS drugs is not the same as supporting health for people with HIV. The urgent and important work of attempting to meet treatment targets is not integrated with more comprehensive support for actual patient health. When patients are only provided one part of what we need to survive, however important, the end result is poor health outcomes, questionable accounting practices, and unacceptable loss to follow up.
   • The second five years of U.S. global AIDS initiatives should measure longer-term patient health outcomes in addition to simple numbers of people on ARV treatment. This should be backed up by independent patient satisfaction surveys and spot audits of PEPFAR-supported medical facilities.
2. Opportunistic infection drugs are not available: Many programs provide free ARVs, which are urgently required and profoundly appreciated. However, efforts to scale up access to AIDS treatment is taking place without an eye toward actually increasing patient survival. While anti-AIDS medicines are almost always free, medicines to treat the opportunistic infections that accelerate our death are often unavailable from clinics and too costly for patients to purchase from pharmacies. Stock-outs at medical facilities and dispensaries are also common and very harmful to patient health.
   • PEPFAR should provide free and accessible OI treatment and services at all health facilities.
3. Unequal standards of care: Powerful new antiretroviral drugs are transforming the lives of people with HIV in the United States, producing much more durable viral suppression, greatly reduced toxicity and side effects, and improved prospects for long-term adherence. With few exceptions, these new drugs are not available through PEPFAR-supported ART sites or other treatment support programs. We recognize that drug regimen decisions are largely made at the country level, but guidance from PEPFAR strongly influences treatment formularies.
   • Support provision of quality regimens that are less toxic and more accessible, affordable, and manageable for people living with HIV/AIDS.
   • The U.S. should work with countries, generic drug manufacturers, and PEPFAR recipient programs to ensure that there are equitable standards of medical care between the North and South.
4. Services for young adults: HIV prevalence is mostly impacting children and young people between the ages of 9 and 24.
   • Funding and programs should specifically target children and young people, and meet the needs of the increasing number of orphans and other vulnerable children. The age bracket receiving support from the OVC earmark should be increased to include young adults, and the percentage of funding for orphans, vulnerable children, and youth should be increased.
5. Efforts to reach marginalized populations should be expanded: Programs should be designed and implemented with respect for the human rights of marginalized groups, such as people living with HIV/AIDS, orphans and other vulnerable children, women, prisoners, commercial sex workers, men who have sex with men, people with disabilities, migrants, people living in conflict or post-conflict situations, pastoralists, rural populations, ethnic minorities and the elderly. PTMCT services are the privilege of a few, and many poor mothers cannot afford recommended services, such as alternatives to breast milk. There is a new wave of stigma due to existing PEPFAR prevention policies, and current programs are insensitive to age, culture, and gender-specific needs. The abstinence-only earmark is a distraction from meaningful work to reduce rates of new infections in our countries.
   • Services should be tailored to meet the needs of vulnerable populations and be accessible, affordable, and within reach.
   • Prevention programs should invest in evidence-based preventive strategies that strengthen communitybased and peer-led awareness creation and behavior change programs, placing vulnerable populations at the center of prevention responses, and addressing the social, economic, and cultural issues that drive new infections.
   • Prevention program should be context-specific, include prevention services for people living with HIV/AIDS, and step up efforts to address AIDS-related stigma and gender-based violence.
   • New efforts should be launched to support active outreach to underserved, high-risk groups such as prisoners and people in post-conflict areas.
   • PMTCT services should be scaled up to provide nutritional support, alternative infant nutrition, and affordable Cesarean sections for pregnant HIV-positive women.
   • PMTCT programs should be linked to AIDS treatment and sexual and reproductive health programs, including family planning, pre-, post- and antenatal services, and socioeconomic support for mothers.
6. Lack of medical equipment: Many health facilities especially in rural areas are poorly equipped in terms of equipment and supplies. In particular, countries urgently need CD4 machines and reagents as well as x-ray machines. People with HIV are required to show CD4 results or x-rays in order to medically qualify for AIDS or tuberculosis treatment and to monitor therapies. Too often, the machines are not available in any accessible medical facility, or the tests are prohibitively expensive.
   • Procure and maintain medical equipment needed to provide AIDS care, including x-ray and CD4 machines and necessary reagents.
7. Shortages of trained health workers and facilities: There is a shortage of health care providers in our countries, and provision of primary health care suffers when PEPFAR-supported programs hire away scarce health professionals from public sector primary care facilities. Training of existing health professionals has not kept pace with the scale-up of AIDS programs at the country level, and improved quality assurance measures are necessary. Women and people with HIV serving as community health workers and home-based care providers bear the brunt of providing care and services to people living with HIV/AIDS, but are not recognized, supported, or paid. Additionally, access to functioning care facilities can be very difficult outside of urban centers, and too many rural clinics are understaffed, inadequately equipped, and inconsistently supplied.
   • U.S. AIDS initiatives should invest to substantially increase the supply of health professionals, support preand ongoing in-service training of all cadres of new and existing health workers, and work with countries and professional associations to develop HIV care provider accreditation standards and monitoring.
   • Much more should be done to retain existing health workers, including increased remuneration and improved working conditions.
   • Community health workers should be trained, certified, equipped, and supported by a functioning referral systems and increased number of health professionals. Community health workers should be paid a wage sufficient to support a family and be integrated into the mainstream health system.
   • More health facilities are needed in rural areas, as well as transportation support for patients.
8. PEPFAR country plans are not aligned with national plans or accountable to civil society: U.S. programs are too often operated as parallel systems duplicating, undermining, or even weakening country-level capacity to respond effectively to health issues. While civil-society organizations have been at the forefront of the fight against AIDS, we are not consulted or meaningfully able to contribute to U.S. efforts, policies, plans, and priorities.
   • Broader and transparent consultation is needed to ensure that PEPFAR programs are more responsive to country contexts, complement country plans and priorities, and strengthen the country ownership necessary to ensure sustainability.
   • PEPFAR should prioritize integrating services into existing programs, especially in public-sector health facilities, rather than running parallel services. Parallel efforts such as the Supply Chain Management System (SCMS) should be required to work with in-country partners to transfer operations over time.
   • PEPFAR programs should be developed in consultation with civil-society organizations, including networks of people living with HIV/AIDS and other vulnerable groups, to ensure community ownership, leadership, and sustainability. Future U.S. AIDS initiatives should adopt a bottom-up approach to empower communities to take leadership in policy design and implementation.

The following organizations developed these recommendations, and thank you for considering their inclusion as the U.S. global AIDS initiative is reauthorized, reformed, and renewed:

Alex Margery, Tanzanian Network of People Living with HIV/AIDS (TANEPHA)
Alice Tusiime, National Coalition of Women with AIDS in Uganda (NACOA)
Ambrose Agweyu, Health Workforce Action Initiative, and Kenya Health Rights Advocacy Forum (HERAF)
Ann Wanjiru, GROOTS Kenya
Beatrice Were, Global AIDS Alliance (Africa)
Carol Bunga Idembe, Uganda Women's Network (UWONET)
Caroline A. Sande, UNAIDS Consultant
Elizabeth Akinyi, International Community of Women Living with HIV/AIDS (ICW)
Everlyne Nairesicie, GROOTS Kenya
Flavia Kyomukama, National Forum of PLWHAs Networks in Uganda (NAFOPHANU)
James Kamau, Kenyan AIDS Treatment Access Movement (KETAM)
Joan Chamungu, TNW+ and Tanzanian National Council of People Living with HIV/AIDS (NACOPHA)
Linda Aduda, Kenyan AIDS Treatment Access Movement (KETAM)
Paddy Masembe, Uganda Network of Young People Living with HIV/AIDS (UNYPA Positive)
Maureen Ochillo, ICW
Micheal Onyango, Men Against AIDS in Kenya
Nick Were, East Africa AIDS Treatment Access Movement (EATAM)
Prisca Mashengyero, Positive Women Leaders, Uganda
Rose Kaberia, EATAM

Plus two additional individuals representing large AIDS treatment programs supported largely by PEPFAR, who wish to remain anonymous to protect their ability to offer candid assessments.

Sponsors:

James Kamau, Kenyan AIDS Treatment Access Movement (KETAM)
Alia Khan, Global AIDS Alliance (DC)
Paul Davis, Health GAP (Global Access Project)

PEACE AND SECURITY

In his visit to Rwanda, President Bush visited commemorative sites of the 1994 genocide, and pledged an additional $100 million for African peacekeeping forces in Darfur. But he failed to answer critics who say that his policy on Darfur can be characterized as "Walking Loudly and Carrying a Toothpick,"
(http://www.africafocus.org/docs07/sud0704b.php).

The President should be congratulated for refusing the call by some for direct intervention of U.S. troops in Darfur, which would have been not only ineffective but also counterproductive. But it is also true that both diplomatic engagement and pressure on Sudan's government have been sporadic and weak. In effect, crying "genocide" has served as a substitute for effective action rather than an incentive for it. Meanwhile close intelligence cooperation with the Sudanese authorities has continued on the "anti-terrorism" front, and the U.S. is still over one billion dollars in arrears on payments for United Nations peacekeeping operations.

The formation of AFRICOM, as noted by Gerald LeMelle of Africa Action in the latest Africa Policy Outlook (http://www.fpif.org/fpiftxt/4949), is only one indicator of stepped-up U.S. military involvement. While this involvement is presented as promoting security, and even cast in humanitarian terms, the lack of accountability for alliances with repressive regimes should raise doubts even among those most trustful of U.S. motives.

Links for more background

See http://www.africafocus.org/peaceexp.php and
http://www.africafocus.org/country/usa-africa.php

On Sudan, Somalia, and the Democratic Republic of the Congo in particular, see
http://www.africafocus.org/country/sudan.php,
http://www.africafocus.org/country/somalia.php, and http://www.africafocus.org/country/congokin.php

POLITICS AND DEMOCRATIZATION

It is the crisis in Kenya that raises most pointedly the question of U.S. commitment to democratization and to building political systems that can manage conflict without disintegration into civil war. Although U.S. diplomats have joined in voicing support for African peace-making mediation, it remains to be seen whether this will be accompanied by sustained pressure on the Kenyan government, which has been a key military ally.

The tendency to prioritize strategic alliances and economic interests such as oil over rhetorical commitment to democracy is certainly not original with the Bush administration. But in an era in which popular demands for democracy continue to increase, the gap between democratic rhetoric and de facto policy is going to be repeatedly challenged. It remains to be seen to what extent, as in the cases of South Africa in the 1980s and Nigeria in the 1990s, U.S. and African activists can bring enough pressure to bear to provide an alternative guide to policy.

Links for more background

See http://www.africafocus.org/polexp.php and
http://www.africafocus.org/country/usa-africa.php

On Kenya and Nigeria in particular, see
http://www.africafocus.org/country/sudan.php and
http://www.africafocus.org/country/nigeria.php,

ECONOMY AND DEVELOPMENT

Although President Bush has taken credit for an increase in aid to Africa over his time in office, the latest international statistics (from the Development Assistance Committee of the OECD) show that in 2006 the United States still ranked next to last (at only 0.18 percent) in percentage of GDP provided for official development assistance. Only Greece was lower, at 0.17 percent. while the average for European Union countries was 0.27 percent.

On the issue that has seen the most substantial international mobilization by activists, the United States has joined in debt cancellation efforts with other creditors. But the debts of African countries are still far from sustainable. On issues of the quality, predictability, and accountability of aid, changes in recent years are either marginal or highly debatable. In international trade negotiations, the United States has paid lip service at best to the interests of developing countries.

See http://www.africafocus.org/econexp.php and
http://www.africafocus.org/country/usa-africa.php

On specific economic issues - trade, debt, agriculture, and ICT (information and communication technology) - see
http://www.africafocus.org/tradexp.php,
http://www.africafocus.org/debtexp.php,
http://www.africafocus.org/agexp.php,
http://www.africafocus.org/ictexp.php, and
http://www.africafocus.org/aidexp.php

AfricaFocus Bulletin can be reached at [email protected]. Please write to this address to subscribe or unsubscribe to the bulletin, or to suggest material for inclusion. For more information about reposted material, please contact directly the original source mentioned. For a full archive and other resources, see http://www.africafocus.org