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USA/Africa: Images and Issues
Feb 21, 2008 (080221)
(Reposted from sources cited below)
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,
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
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
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
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 (
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
For a special collection of critical articles, see Pambazuka News,
346 for February 18, 2008 (
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
++++++++++++++++++++++end editor's note+++++++++++++++++++++++
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
- 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
For a summary of the positions of U.S. presidential candidates on
global health issues, see http://www.health08.org/issue_globalheath_hivaids.cfm
African Civil-Society Recommendations on the Next Phase of U.S.
Global AIDS Assistance
December 11, 2007
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.
- 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.
- 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
- PEPFAR should provide free and accessible OI treatment and
services at all health facilities.
- 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
- Support provision of quality regimens that are less toxic and
more accessible, affordable, and manageable for people living with
- 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.
- 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.
- 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
- 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
- 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
- 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.
- 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.
- 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
Alice Tusiime, National Coalition of Women with AIDS in Uganda
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
Everlyne Nairesicie, GROOTS Kenya
Flavia Kyomukama, National Forum of PLWHAs Networks in Uganda
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
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.
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,"
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.
Links for more background
See http://www.africafocus.org/peaceexp.php and
On Sudan, Somalia, and the Democratic Republic of the Congo in
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
On Kenya and Nigeria in particular, see
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
On specific economic issues - trade, debt, agriculture, and ICT
(information and communication technology) - see
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