New Report from UC Berkeley and Johns Hopkins: "The Gathering Storm"

Burma junta faulted for rampant diseases
By Yasmin Anwar, Media Relations 28 June 2007

BERKELEY – As Congress debates extending political and economic sanctions against Burma's military regime, a new report from the University of California, Berkeley, and Johns Hopkins University documents how decades of repressive rule, civil war and poor governance in the Southeast Asian country have contributed to the spread of HIV/AIDS, tuberculosis, malaria and other infectious diseases there.

Extreme travel restrictions imposed by the Burmese government have forced Médecins San Frontières (Doctors without Borders) in France and the multinational Global Fund to Fight AIDS, Tuberculosis, and Malaria to pull out of the country, and have severely curtailed the work of the International Committee of the Red Cross, according to the report co-authored by researchers from UC Berkeley's Human Rights Center and The Johns Hopkins Bloomberg School of Public Health.

The report was released today (Thursday, June 28), and can be viewed online.

U.S. Senators Dianne Feinstein (D-Calif.) and Mitch McConnell (R-Ky.) introduced a bill on June 15 that would extend the U.S. sanctions, set to expire July 26, against Burma because of continued human rights violations. The sanctions include a ban on imports from Burma and visa restrictions for members of the government.

While 40 percent of Burma's annual spending goes to the military, only 3 percent goes to health care, according to the report. The Burmese military junta spends 40 cents per citizen each year on health care, compared to the government of neighboring Thailand, which spends $61 per citizen a year, the report says.

"Military expenditures should be reallocated to support health care delivery," said Eric Stover, faculty director of UC Berkeley's Human Rights Center. "Burma is not at war with its neighbors, and its security is more profoundly threatened by the rise of drug-resistant malaria and tuberculosis, and by emerging infectious diseases such as avian influenza, than from external military threats."

Stover and fellow researchers from the Human Rights Center and Johns Hopkins launched the project last year to discover the roots of Burma's dire disease epidemics and to determine whether international aid could be delivered in a way that is responsible and effective.

For the report, researchers traveled to the large Burmese city of Yangon, formerly known as Rangoon, and to Burma's borders with China, Thailand, Bangladesh and India. From health clinics in those regions, they gathered data on HIV/AIDS, tuberculosis, malaria and lymphatic filariasis, and interviewed aid officials and health care workers.

The researchers found that the widespread distribution of counterfeit antimalarial drugs, coupled with the rise of drug-resistant malaria and tuberculosis, pose a major health threat to the Burmese people, especially those living in border areas where health care is scarce, if available at all.

Burma has one of the world's highest tuberculosis rates and is home to more than half of Asia's malaria deaths. Those most vulnerable to disease epidemics there are ethnic and religious minorities, displaced farmers, commercial sex workers and intravenous drug users.

Drug trafficking has also played a major role in the spread of HIV/AIDS among intravenous drug users and commercial sex workers, the report says. In addition, aggressive campaigns by the Burmese government and the United Nations Office on Drugs and Crime to eradicate poppy cultivation and heroin production have led to the displacement of tens of thousands of families who have no alternative source of livelihood. Many have relocated to the Thailand border, where communicable diseases are thriving. Meanwhile, methamphetamine production in Burma's border regions is rising.

"Decades of neglect by Burma's military government have turned the country into an incubator of infectious diseases," said Chris Beyrer, a co-author of the report and professor of epidemiology at The Johns Hopkins Bloomberg School of Public Health. "While the health situation deteriorates, the junta continues to limit the ability of international relief organizations to reach those most in need."

In 1990, Burmese voters elected Aung San Suu Kyi, 62, as their democratic leader. But the military rejected the election results and placed her under house arrest, where she has remained for most of the last 17 years. During the 1990s, international relief organizations began responding to Burma's neglect of its citizens' health. By 2004, 41 aid organizations were operating in Burma with a combined budget of about $30 million, and tens of millions of dollars more aimed at fighting infectious diseases, according to the report.

But that changed in 2005 when Burmese government authorities imposed travel restrictions on international organizations. In October 2006, the European Union, along with Australia, Britain, the Netherlands, Norway and Sweden, launched the "Three Diseases Fund" to fight infectious diseases in Burma. Yet the fund, now worth $99.5 million, faces formidable challenges, including the critical task of ensuring that aid reaches Burma's border regions and other areas where infectious diseases are rampant and severe.

The report recommends that:

• The Burmese government develop a national health care system in which care is distributed effectively, equitably and transparently
• The Burmese government increase its spending on health and education to confront the country's long-standing health problems, especially the rise of drug-resistant malaria and tuberculosis
• The Burmese government rescind guidelines issued last year by the country's Ministry of National Planning and Economic Development because these guidelines have restricted organizations such as the International Committee of the Red Cross (ICRC) from providing relief in Burma
• The Burmese government allow the ICRC to resume visits to political prisoners without the requirement that ICRC doctors be accompanied by members of Burma's Union Solidarity and Development Association or by other junta representatives
• The Burmese government take immediate steps to halt in eastern Burma the conflicts and human rights violations that are displacing an unprecedented number of people and facilitating the spread of infectious diseases in the region
• Foreign aid organizations and donors monitor and evaluate how aid to combat infectious diseases in Burma is affecting domestic expenditures on health and education
• Relevant national and local government agencies, United Nations agencies and non-governmental organizations establish a regional narcotics working group that would assess drug trends in the region and monitor the impact of poppy eradication programs on farming communities
• These agencies also collaborate more closely, sharing information, to lessen the burden of infectious diseases in Burma and its border regions, and to develop a regional response to the growing problem of counterfeit antimalarial drugs.

Op-ed Trifecta

by Clara Presler

(New York City, June 18, 2007)--Three articles over the weekend cover a range of themes within the AIDS crisis—global aid, government sanctions, clean needle exchange—and converge in their call for increased government responsibility in the global effort to curb the epidemic.

Looking towards the fiscal 2008 appropriations bill, the New York Times calculates that the G8 pledge of $60 billion is actually a “retreat from previous goals”. Past G8 meetings have resulted in a declaration for universal access to treatment; this year, the group set its goal at treating only 5 million individuals in Africa. The editorial calls on the US government to increase its spending: “Congress should set the nation—and, by its example, the world—on course towards universal access to AIDS treatment by 2010.”

Considering whether the US should continue its sanctions against the Burmese military junta for its human rights abuses, or address the deterioration of its citizens’ health—and increase of HIV/AIDS prevalence—with humanitarian aid, the Boston Globe looks at how the Burmese government has spent its own money. While the rulers claim that there is not money to address health care, they have spent extravagant amounts on buildings, weapons, and nuclear agreements. The editorial says enough is enough: “Increases in humanitarian assistance are clearly necessary—but so are increases in political pressure…Now is not the time to reward the generals for their brutality [and] mismanagement…Bush is right to continue sanctions against the generals, and Congress should support this position.”

On the domestic front, the Chicago Tribune looks at a bill in the House of Representatives that would let the people of Washington, DC decide whether to sponsor clean needle programs. At the moment, DC cannot use their own local funds for such programs; no federal funds can go to them either. Such regulations cost money and lives; a sterile syringe costs a quarter, while supporting someone with AIDS costs about $25,000 a year. Numerous scientific institutions have affirmed that needle-exchange programs work without negative consequences. The commentary has a message for Congress—look at the evidence: “Restrictions on the sale and possession of injecting equipment, like the funding bans, make it harder for drug users to take basic self-preservation measures. If you like throwing away money, preventing addicts from getting access to sterile syringes is an excellent strategy. If you like squandering lives, it’s even better.”

Lately, much celebration has been paid to the Bush administration for pledging more money to PEPFAR. These 3 articles look beyond those headlines towards sustainability. Raising the bar, they call for an increase of governmental responsibility. Here are three ways that the US government can begin to meet the bar, both domestically and internationally.

World Bank: Not one approach, but many

The World Bank released a report yesterday entitled The Africa Multi-Country AIDS Program 2000-2006: Results of the World Bank’s Response to a Development Crisis. Advocating locally approapriate approaches to tackling the AIDS epidemic, it says, "the mobilization of empowered 'grassroots' communities, along with delivering condoms and life-saving treatments, are beginning to slow the pace of the continent's epidemic."

The articulated goals of the World Bank's Multi-Country AIDS Program have been to:
(1) to build strong political and government commitment to responding to HIV;
(2) to create a conducive institutional and resource-appropriate environment in which successful HIV/AIDS interventions could be scaled up to a national level;
(3) to make the HIV/AIDS response local—increasing community participation and ownership in HIV/AIDS interventions by providing financial resources and capacity building; and
(4) to move to a multisectoral approach involving all government sectors, with improved coordination at the national level and decentralization to subnational government structures.

Michel Kazatchkine said of the program, "It (MAP) was a precursor because of its specific objective of supporting civil society, which we know is a key component of the response against HIV/AIDS. In addition, the World Bank is in a privileged position to bring in the fight against HIV/ADS within the frame work of the fight against poverty and the fight for development and for promoting health in development."

Read the report and press release.

The Basics on PEPFAR

by Clara Presler
Recent developments on the President's Emergency Plan for AIDS Relief (PEPFAR)
(New York City, June 12, 2007)--In 2003, President Bush introduced the President's Emergency Plan for AIDS Relief (PEPFAR), a plan that allocated $15 billion over 5 years to AIDS relief in 15 countries hardest hit by the epidemic. Last Wednesday, May 30th, Bush announced that he would reauthorize this spending and boost the amount to $30 billion over the next 5 years starting in September 2008.

While PEPFAR has been instrumental in providing treatment to some 1.1 million people since 2003, heavy controversy surrounds the myriad restrictions that are placed on the funds and the specific earmarks. Additionally, increases in the number of people on treatment are being far outstripped by those becoming infected. For example, in sub-Saharan Africa for each 1 person put on treatment in 2005, 5 became infected. This means that, while Bush has doubled the overall funds, per capita spending on HIV-positive individuals will likely remain flat or even decline.

Currently under PEPFAR, 55 percent of funds must go to treatment and 10 percent must go to programs targeting orphans. Twenty percent of the funds go towards for HIV prevention and Congress requires that 33 percent of prevention funds be spent on abstinence-until-marriage programs (the remaining 15 percent goes to palliative care). As a percentage of money spent specifically on prevention of sexual transmission, close to two-thirds is spent on abstinence-only education. This requirement has been shown to divert finds away from other methods of HIV-transmission prevention, for example prevention of maternal-to-child transmission and prevention targeting injecting drug users.

Looking ahead to the next years of PEPFAR, advocacy organizations are working to see that the restrictions on prevention programs will be lifted and replaced by programs that are evidenced-based and fulfill the right to information, and that better respond to the factors making women vulnerable to HIV infection. Such programs include prevention of mother-to-child transmission, comprehensive sex education, and programs addressing property rights and domestic violence.

Another area of advocacy relates to US government policy which does not allow funding for clean needle exchange programs. These are needed in much of Asia and Eastern/Central Europe and specifically in places like Vietnam (a PEPFAR country) where the majority of HIV-transmission occurs through injection drug use. Other groups, including HealthGap and Physicians for Human Rights are pushing for attention to increasing health personnel (training and retention). Jose DeMarco of HealthGAP said, "Fighting AIDS in Africa without addressing the health worker crisis is like treating a massive hemorrhage with a handful of bandaids. PEPFAR must spend money to train and deploy new health workers and pay the providers who are at the heart of any successful AIDS response."

One step towards these goals is the bipartisan PATHWAY Act of 2007 (Protection Against Transmission of HIV for Women and Youth Act of 2007), introduced by Congresswoman Barbara Lee and Congressman Chris Shays that is currently up for consideration. This act would strike the abstinence-only earmark and further require the President and the Office of the Global AIDS Coordinator (OGAC) to establish a comprehensive and integrated HIV prevention strategy to address the vulnerabilities of all women and girls to HIV infection.

Decisions around PEPFAR are moving quickly: just last week, the 5th of June, The House State and Foreign Operations Subcommittee marked up the appropriations bill in a manner that reflects our concerns with US foreign aid, including the recommendation that an option to waive the abstinence-until-marriage earmark be included. The next vote on this will take place this week.

MORE INFORMATION:

President Bush’s announcement of May 30th
New York Times: Bush Seeks to Double Spending for AIDS Program
Washington Post: Bush to Seek Extension of AIDS Effort

Analysis
The Government Accountability Office (GAO) April 2006 report,
The Institute of Medicine (IOM) March 2007 report
PEPFAR Watch