By Gregg Gonsalves
Yale University and the International Treatment Preparedness Coalition

Comments at
The Future of Development:
Human Rights and International Aid Beyond the Economic Crisis
Robert L. Bernstein International Human Rights Fellowship Symposium
April 8-9, 2010
Orville H. Schell, Jr. Center for International Human Rights
Yale Law School, 127 Wall Street, New Haven, CT

* * *
Good afternoon. Greetings from up on Science Hill, where I just got out of a
class on evolutionary biology. Permit me to use one analogy today–only because it seems so apt.  A new book by a fairly well-known philosopher named Jerry Fodor has just come out. It’s called What
Darwin Got Wrong. This isn’t some creationist tract. Dr. Fodor apparently believes in evolution, but he thinks Darwin erred by claiming natural selection is responsible for it.  The book hasn’t been well-received among scientists–not because we have a vested interest in this 150-year-old theory, but because the evidence supports natural selection and Dr. Fodor’s description of it only remotely resembles the phenomenon.

You have Bill Easterly here today to give you a keynote. He is
well-known for his 2006 book, The White
Man’s Burden: Why the West’s
Efforts to Aid the Rest Have Done So Much Ill and So Little Good. It
could have just as well have been subtitled What
the West Got Wrong.
Dr. Easterly’s effort was greeted with a kinder reception than Dr.
Fodor’s and it is a much better book. When it came out in 2006, I read
it and liked it. Until I got to the part about HIV/AIDS. Then Dr.
Easterly had a Dr. Fodor problem–he missed the mark through some
fundamental misunderstandings of the history of the epidemic, the
complexities of the forces at work in global health.  I don’t
blame him. He’s an economist, not a health expert, as Dr. Fodor is a
philosopher, not a scientist.

As Amartya Sen said in his review of Dr. Easterly’s book in Foreign
Affairs, there is a strong case for judging a book by its best
contributions, not its weakest points.  I would have been willing to
do so, but Dr. Easterly has doubled-down on the comments on HIV/AIDS
in book since then and been in the fore-front of what I call the AIDS
backlash, a move to walk the fight against AIDS backwards, as one more
misplaced development priority, a folly of the West’s good intentions.
Dr. Easterly and his fellow travelers’ mistakes will have deadly
consequences for many of the people I work with, millions around the
world.

Let’s start with the history.  One of the key contrasts in The White
Man’s Burden is between planners and searchers.  The planners are the
big, white men with big plans often residing at big institutions–think
Jeffrey Sachs and economic shock therapy–, while searchers are the
local people looking for specific solutions to problems in their own
backyards.  Dr. Easterly likes searchers–planners, not so much.   In
reading Dr. Easterly’s book and his subsequent writings on HIV/AIDS,
one would have thought that if it wasn’t for Bill Gates, Bill Clinton
and yes, Jeffrey Sachs, the AIDS epidemic would have gone
unnoticed–these big men raised the profile of the disease, set up
things like the Global Fund to Fight AIDS, TB and Malaria, and pushed for
the provision of antiretroviral therapy to millions in the developing
world.

Except it isn’t quite true.  The big men around the world ignored AIDS
for a very long time and when they came to the table it was late.
Since the beginning of the epidemic, the big problem was getting big
men to take notice, to care about a disease that was killing fags, whores
and junkies and the poor.  We marched to
the White House to confront
Presidents, on the FDA, on the NIH in the 1980s and 1990s to get them
to listen.  In the interim, we built community-based organizations to
do what the big men wouldn’t–help stem new infections in our
communities, teach people how to take care of themselves, while we
buried our own dead week after week.  We were the searchers trying to
do our best in the most difficult of circumstances on the ground, on
the frontlines.

And this wasn’t just an American phenomenon. The same thing happened,
is happening now in Brazil, Thailand, South Africa, Russia, China,
Lesotho, Nepal–communities responded to an epidemic in their midst
with local knowledge and local efforts.  When the new drugs came out,
we marched again, in the USA, in Brazil, in Thailand, in South Africa
to demand that our governments, our big men give us the drugs we
needed to stay alive.  That’s the history that Dr. Easterly so
conveniently erases, so that the fight against AIDS can be a proof for
his general theorem about foreign aid and development.

Dr. Easterly maintains that his criticisms about the fight against
AIDS are really about AIDS treatment, the provision of expensive drugs
to the poor, since with the money that costs, we could do more on HIV
prevention, provide malaria bed nets, etc.  Let’s talk about that. Dr.
Easterly believes AIDS prevention is separable from HIV treatment and
that we should emphasize the former and de-emphasize the latter.
Except things are not that simple.  HIV transmission takes
two-to-tango.  A key feature of HIV prevention is what we call
“prevention for positives,” in which the idea is reduce the number of
HIV+ people transmitting the virus.  Antiretroviral therapy is the
single most effective intervention we have in reducing infectivity,
transmissibility of the virus, full stop.  AIDS treatment also is the
key to getting people to get tested for HIV.  People who know their
status are far less likely to engage in unsafe sexual practices and
treatment is critical to getting people to come forward to get tested.
If AIDS is a death sentence, who really would want to know whether
one carries the virus or not? Why would someone who is HIV+
participate in “HIV prevention,” if their government’s official policy
is to deny treatment to those who need it? Finally, changing
individual behavior is a difficult thing.  If it were easy, as my
friend Ted White at the public health school says, he’d be thin.

Our greatest successes in HIV prevention have been when communities
rallied together to confront AIDS–Helen Epstein documents this in
Uganda in her book The Invisible Cure
and we’ve seen it here in the
USA in the early days of the epidemic when infection rates plummeted
in New York and San Francisco among gay men because the collective
threat inspired collective action that was able to shift community
norms.  I don’t think we’ll be able to mobilize around the abject fear
that drove the early responses to AIDS, but we can mobilize around
treatment.  And there is a worldwide movement of searchers, little
people, not big men, who have found access to medicines as something
they want to fight for.  And this movement isn’t just about treatment,
it’s about access to clean needles and methadone in St. Petersburg,
about the right of a woman to walk home at night in a township in Cape
Town without getting raped or harassed, about the salaries of health
workers in Lusaka, the right of a gold miner in Lesotho not to take
home multi-drug resistant TB to his wife and family as a Christmas
present.

We need more money for global health overall and we need to spend that
money wisely, more efficiently–I have no arguments with that and we
can discuss it.  I am began my work as AIDS activist 20 years ago–my
life and those of people I loved were at stake and I went searching
for answers, but it didn’t take long to put two-and-two together to
quickly realize my fate was linked to the broader struggle for health
and human rights.  We’ve invested in access to AIDS treatment for 4
million people now in what is the most ambitious public health effort
in history, but we still need to do more in AIDS AND in all areas of
health.  No one should die from any preventable or treatable disease,
when we have the resources globally to do far more than we’re doing
now.  But punishing successes in AIDS is not the way towards a better
future.

Before AIDS as my colleague Paul Farmer says, the idea of “health for
all” was a joke: “As the year 2000 approached, the Alma Ata slogan
became the butt of ridicule in international health circles. The
slogan contained a typographical error, went the joke: the rallying
cry was in fact ‘health care for all by the year 3000.’ ” AIDS has
revived the fight for the right to health.  As Jonny Steinberg a South
African journalist has said: “The idea of demanding that a drug be put
on a shelf, or that a doctor arrive at his appointed time, is without
precedent. The social movement to which AIDS medicine has given birth
is utterly novel in this part of the world, the relationship between
its members and state institutions previously unheard of”.  And it’s
happening all over the planet.

We are the searchers.  We are the heirs to Alma Ata. This is the
movement that Dr. Easterly finds so objectionable, so misguided.  You
know I hate to be the skunk at your garden party.  But I’ve tried to
talk some sense into Dr. Easterly as have others, we’ve trotted out
the evidence, corrected the mistakes, but he has a big plan and he’s
sticking to it.  After all, he has a book to sell and a new movie to
promote. Nothing sells like the sizzle of the sex of controversy and
contrarianism in certain circles.  And hey, it looks like the
out-of-town tryout in New Haven is packing them in.