Healthy world

I must admit I haven't used my constitutional right to vote in a while. I suppose you could say that I have been hiding my voter apathy behind the rather flimsy excuse of living abroad. On top of that, the Dutch political landscape is just so depressing these days with parties such as the ominously titled "Trots op Nederland" (Proud of the Netherlands) and "Partij voor de Vrijheid" (Party for Freedom) that I'd rather run for the hills than participate in this sham. Not the way to go, I know. I'll try to do better in future. You've got to practice what you preach after all, and I'm certainly no stranger to a bit of political preaching. One of my former flatmates once sighed in desperation "Are all you Dutch so political?!".

A lot of my preaching takes places in the international rather than the domestic arena, probably in part the result of my line of work these days. Like so many across the world, I have been keeping a very close eye on the US presidential elections. And like so many outside of the US, I have had no trouble picking my favourite. Of course, healthcare is a topic close to my heart in this election. The American healthcare system represents both some of the best and worst in the world. Top class medicine for some but unattainable for many. In international aid and development on health, the Americans have also imposed an at times rather controversial agenda. It is interesting to see where the candidates stand on these issues. If I hadn't made up my mind already, this article just published in The Lancet might have done it for me:

Obama vs McCain on global health
by: Nellie Bristol
The Lancet (2008), 372:9638, p.521-522

In the run-up to the presidential election, US health care continues to dominate the debate. But where do the candidates stand on global-health issues? Nellie Bristol reviews Obama and McCain's pledges in this area, including their views on HIV/AIDS and international development.

When asked by a reporter last year if he supported the spending of US tax dollars on contraceptives in Africa to slow the spread of HIV/AIDS, John McCain, the Republican US presidential hopeful, seemed unsure and confused. "I haven't thought about it before", he said. "Before I give you an answer, let me think about it a little bit because I never got a question about it before. I don't know if I would use taxpayer money for it."

The scene illustrates what global-health experts say is the key difference between McCain and Democratic contender Barack Obama in the area of global health: that of particular investment in the issue. "Obama has a personal knowledge and interest that is not insignificant", said J Stephen Morrison, executive director of the HIV/AIDS task force and of the Africa programme for the Center for Strategic & International Studies, based in Washington, DC. "He made sure he was smart around the issues of global health." Morrison cited Obama's Kenyan father and his August, 2006, visit to Africa where Obama and his wife Michelle were publicly tested for HIV/AIDS in an attempt to reduce stigma attached to the procedure. "I do not think McCain is indifferent, but I do not think he has the same level of personal knowledge or passion", Morrison said. "[McCain has] said much less both about development issues and global health so it's hard to infer from silence", said Ruth Levine, vice president for programmes and operations and senior fellow at the Center for Global Development (CGD). "It does not feel like a core part of the agenda he would bring in."

That difference is evident in the candidates' campaign literature and in their statements about global health. Although McCain is a vocal supporter of the US global AIDS programme—the President's Emergency Plan for AIDS Relief (PEPFAR)—and has pledged to combat malaria in Africa, his campaign documents are thin on the subject of global health. Meanwhile, Obama's campaign promotes proposals to confront HIV/AIDS globally and has a multiple page list of sweeping reforms in international development. "He is really reading the play book of many of the strongest voices in development and in global health", Levine commented. Obama supports and calls for changes in PEPFAR, including an additional $1 billion over 5 years to fight the epidemic in southeast Asia, India, and eastern Europe. He also calls for increasing the capacity of health systems to deliver HIV/AIDS treatment. In a move likely to cost him support among pharmaceutical manufacturers, Obama also pledges to "break the stranglehold that a few big drug and insurance companies have" on HIV/AIDS drugs. "Obama supports the rights of sovereign nations to access quality-assured low-cost generic medication to meet their pressing public health needs", his campaign literature says.

Although supporting US bilateral HIV/AIDS efforts, Obama also advocates more US funding for multilateral programmes and the Global Fund to Fight AIDS, Tuberculosis and Malaria. US support for the Fund has been a partisan issue; some conservatives are concerned that the organisation does not reflect US policies on issues like sexual abstinence and needle exchange. Obama also pledges US support to meet the UN Millennium Development Goals. In 2005, he cosponsored the International Cooperation to Meet the Millennium Development Goals Act.
Some Americans view the UN suspiciously, and even hostilely, claiming its aim is to usurp US power and channel money to corrupt dictators. The USA is behind in its payments to the organisation and many, including Obama, are pushing for UN reforms. Nonetheless, development experts say his endorsement of the goals and of other multilateral efforts is substantial, indicating a change from the go-it alone strategy now used by the USA. "It is quite a profound departure from what we have seen up to this point", said Levine. "I think it will really bring US development policy into alignment with where Canada and the Europeans have been."

Another key piece of Obama's development platform is his Health Infrastructure 2020 plan. "Barack Obama will take the lead at the G8 working with and leveraging the engagement of the private sector and private philanthropy, to launch…a global effort to work with developing countries to invest in the full range of infrastructure needed to improve and protect both American and global health", campaign documents say. Among issues addressed by the plan is the migration of health-care workers from developing to rich countries. Obama also advances sweeping reforms for US foreign assistance—a move favoured by the development community and some members of Congress. He advocates doubling yearly foreign assistance to $50 billion by 2012 and endorses a $2 billion fund to support primary education globally. He also calls for 100% debt cancellation for the world's heavily indebted poor countries and programmes to advance commerce and democracy in struggling countries.

Add it all up and the dream plan of Obama's development experts costs a substantial amount of money, so much so that some question its feasibility. "It is not entirely clear to me that everyone has done their homework on how this could possibly be paid for in what is sure to be a real food fight around priorities in a tight economy", said CGD's Levine. In addition to fiscal constraints, because he is so engaged with the global development community in the USA, Obama is also likely to be buffeted by the tensions that exist within it, Morrison added. One major point of contention is the degree to which PEPFAR will become the whole of the USA's global-health policy for the foreseeable future. "What he [Obama] has is a very active and divided debate" with one side arguing that PEPFAR has had "hugely distorting impact on development commitment", he said. Those advocates will be "arguing for a rebalancing" against the constituency that believes PEPFAR can be tweaked sufficiently to serve a broader purpose. "I would anticipate that early in an Obama administration you are going to have some serious battles around these issues", Morrison commented.

Nils Daulaire, president of the Global Health Council, although a strong PEPFAR supporter, is among those who think that the USA should widen its focus. "The reality is that HIV/AIDS is a large, but by no means the predominate piece of the global-health puzzle", he said. The Global Health Council and others, he said, are "really focused on getting the next Presidential Administration and the next Congress to look at the larger issues of global-health infrastructure and basic health services and, in particular, bring back attention to the pretty severely neglected areas of maternal and child health and family planning."

Although global-health experts call for increased access to primary health care, specific diseases still tend to attract the most attention from candidates. On Malaria Awareness Day, McCain pledged as President to "end malaria in Africa". He said that the USA will spend $1 billion a year on the disease in the next few years and added, "I call upon the private sector to meet its obligation to serve a cause greater than its self-interest by matching the federal commitment dollar for dollar". Laurie Rubiner, executive director of the Malaria No More Policy Center, said eliminating deaths from malaria in Africa, would cost an estimated $2·2 billion a year over 5 years. The disease currently kills more children in Africa than AIDS and tuberculosis combined, she added. McCain's malaria pledge illustrates his commitment to "soft power" in US foreign policy, Rubiner commented. Another example of that approach is McCain's proposed "League of Democracies", which he refers to as "the core of an international order of peace based on freedom". In explaining the proposal, McCain said, "Our great power does not mean we can do whatever we want whenever we want, nor should we assume we have all the wisdom, knowledge, and resources necessary to succeed". He added: "We need to listen to the views and respect the collective will of our democratic allies."

Experts agree that both candidates support a more collaborative relationship with other countries, which could be a boon for global health generally. "Both Obama and McCain from quite different perspectives have an appreciation for the US in the broader context of the world", said Daulaire. "I think this is the most internationally savvy pair of candidates that we have ever had running for president."