A few weeks ago, I was reading another [18] in a long series of articles about the fight between Obama and Clinton over whether words matter. The story played out the same as it has for the past few months - Obama makes a compelling, inspiring speech that lacks much policy substance, and Clinton responds that it takes more than great oratory to run a country. Hyperbolic rhetoric ensues.This seemingly theoretical argument reminded me that, in some cases, a few words could mean the difference between life and death for people, and success or failure for a vital program. Eight little words in the US Leadership Against HIV/AIDS, Tuberculosis and Malaria Reauthorization Act of 2008 [19] that will be voted on in the House this week will severely limit the US's ability to respond to the AIDS crisis which needlessly claims the lives of over two million people each year.
The first six words are found in the sections on family planning, and have been discussed [20] frequently on this blog. The President's Emergency Plan for AIDS Relief (PEPFAR) is currently able to provide funding for HIV counseling and testing in family planning settings. Many women enter the health care system through family planning clinics. It is critical that we ensure HIV prevention and treatment efforts are integrated with family planning clinics to reach the most number of women with HIV services. While it may seem innocuous, the phrase "supported by the United States Government" in the sections on linkages to family planning programs[1] may be a major step backward in efforts to prevent HIV infection. It is absolutely insane that the House PEPFAR legislation, by including six small words, could completely eliminate funding for HIV/family planning integration.
The last two words that may mean life or death for thousands of people are found in the section on training additional health workers [21] to fight AIDS, TB and malaria. Over the past five years, dozens of reputable sources, from the World Health Organization to the Global AIDS Coordinator, have pointed out that the lack of trained health professionals represents the greatest obstacle to scaling up access to HIV treatment, prevention and care in Africa. The WHO recommends 2.3 health professionals per 1,000 country residents, but thirty-six African countries do not even meet this minimum standard. The reality is that we simply will not be able to reach any of the goals set by PEPFAR reauthorization, whether they are to treat one-third of people in need, or prevent millions of HIV infections, unless we train and retain more doctors, nurses and other health professionals.
The House PEPFAR legislation calls for training "at least 140,000 new health care professionals and workers for HIV prevention, care and treatment"[2]. They key here is the use of two words - and workers. Everyone knows it is costly and time-consuming to train new doctors and improve working conditions so those who are trained want to stay. By including "and workers" in the bill language, the House leadership has given the Global AIDS Coordinator an easy option for quickly and cheaply meeting the goal - give 139,999 people a two-day course on how to administer AIDS medication, or test someone for HIV, then pay them marginal wages for a few hours of work each week, and train one new doctor.
There is one big problem with this strategy. While community health workers are needed, we will not be able to meet our other goals unless we train doctors, nurses and other health professionals to provide care and treatment. Instead of taking the easy and cheap way out, we need to train 140,000 new health professionals, plus additional community health workers and paraprofessionals as needed.
So why are those eight words in the bill? Maybe it's because House leadership didn't want to stand up to far-right ideologues like the Family Research Council who praised the House bill for addressing "some, if not all, of the social responsibility concerns"? Maybe it's because fighting AIDS the right way is more expensive than doing it the easy way?
Millions of lives depend on whether this legislation passes, and House leaders should do everything they can to make sure the best possible bill, one that does not compromise on key issues and hamper our efforts to fight AIDS, is passed this year. Whatever their reason for including these eight words, there is still a chance to fix it with amendments before the bill becomes law and we have to deal with these words for five years.
[1] "supported by the United States Government"- Henry J. Hyde and Tom Lantos United States Leadership Against HIV/AIDS, Tuberculosis and Malaria Reauthorization Act of 2008, p. 21, lines 13-14, p. 66, lines 1-5, p. 108, lines 1-5, p. 111, lines 8-16
[2] "and workers" - Henry J. Hyde and Tom Lantos United States Leadership Against HIV/AIDS, Tuberculosis and Malaria Reauthorization Act of 2008, p. 52, line 2