Global fund’s woes bad news for TB; is U.S. to blame?

Stingy pledge puts lid on contributions, critics say

The Global Fund to Fight HIV/AIDS, TB, and Malaria is in big trouble, and will be bankrupt if more money doesn’t come in by the time the next round of grant applications are due three months from now, says Paul Zeitz, MD, executive director of the Global AIDS Alliance, an advocacy group based in the nation’s capitol.

The fund was launched a year and a half ago by United Nations Secretary-General Kofi Annan as a means to way to marshal more resources for fighting the HIV/AIDS pandemic, as well as fight the "Big Three" diseases, which historically have plagued developing countries.

The fund’s difficulties spell big trouble for TB, says Joanne Carter, legislative coordinator for RESULTS, a grass-roots advocacy organization that has taken up the cause of global TB. The U.S. intelligence community predicts that HIV infections the world over will triple by 2010, and will probably grow fastest in the same five countries — China, Russia, India, Nigeria, and Ethiopia — that already account for half the world’s TB burden. When the two epidemics collide head-on in those populous countries, "TB rates will absolutely skyrocket," says Carter. "Can we really afford to just sit around and wait for that to happen?"

In what may have signaled uncertainty about how to deal with the budget crisis, the fund’s board of directors postponed action last month on a financial prospectus it had been expected to approve. The prospectus maps out a budget for the coming years, and by doing so highlights the enormous gap between what’s needed, and what the fund actually has on hand.

Next proposal round in jeopardy?

Based on needs projected by extrapolating from requests that have already come in, the prospectus calculates the fund will need $4.25 billion in 2003 (about a billion of which would go to TB). So far, only $650 million has been pledged. In 2004, the need will grow to $4.6 billion — but a mere $300 million of that amount has been pledged.

The crisis has grown so urgent that looking ahead to 2004 is almost beside the point, says Carter: "What I’m most worried about isn’t 2004 — it’s whether the fund will have enough money on hand to even fund the next round of proposals," she says.

A big part of the problem is that when U.S. pledged only modest amounts to the fund. America’s pledge for 2003 is just $250 million, a sum Columbia University economist Jeff Sachs calls "derisively small. "Other potential donor countries took the cue, and followed suit with even smaller pledges of their own.

When Congress, trying to undo the damage, attempted to pass a bill last summer that would have put up another $500 million in emergency funding, the White House blocked the move. The Bush administration’s reluctance "has definitely had a dampening effect on other countries," says Alexander Soucy, MD, national coordinator for RESULTS/Canada. "It’s very important for the U.S. to take a stronger stance." So far, Canada has pledged just $150 million, he adds.

A donor formula proposed

In an effort to loosen the U.S. stranglehold on the fund, the Global AIDS Alliance recently released its reckoning of what each country’s equitable contribution should be, based on the country’s world economic output. According to the Alliance’s Equitable Contributions Framework, the 47 wealthiest countries ought to provide about 90% of the money for the fund. By economic output measures, that would put the U.S. tab at $1.488 billion for 2003 — seven times the amount pledged so far. "When you consider that the U.S. is about to embark on a war that may cost as much as $150 billon, that’s not an unmanageable sum of money," notes Sachs.

It’s worth noting that according to Sachs and other public health experts, the $4.25 billion the fund needs for 2003 is only half the amount it will take to get a handle on the AIDS epidemic. That is, along with the money spent by the fund, an equal amount should be spent in bilateral aid, bringing the total to somewhere in the neighborhood of $8 to $10 billion a year.

Mitchell Daniels, director of the U.S. Office of Management and Budget (OMB) and point man for the White House stance on the AIDS fund, counters that the U.S. has given more than its fair share to the fund — more than twice as much as the next highest donor — and that U.S. contributions make up only a fraction of what America spends overseas on HIV, TB, and malaria.

Nonsense, says Sachs. "We may be doing more than our share, but it’s more than our share of a wholly inadequate effort," he says. "It’s as if there is a raging wildfire out West, and we’re congratulating ourselves for sending a single firefighter to work on it."

Sachs is convinced that "the administration hasn’t focused at all on the AIDS epidemic, and they simply have no plan at all to deal with it." In an exchange of letters this past summer with the OMB’s Daniels, Sachs adds that he was struck by the fact that White House estimates of projected need didn’t take into account the money needed to ramp up infrastructure in poor countries. The OMB didn’t even appear to understand that the fund is intended to benefit not just HIV/AIDS programs, but also programs that fight TB and malaria, he adds.

Zeitz says there’s still a chance that his organization’s equitable-contributions framework will be picked up and approved by some influential group — perhaps the G-7 countries as a whole, he says, or maybe the Organization for Economic Cooperation and Development.

That had better happen soon, say Sachs and Carter. Otherwise, what Carol Bellamy of UNICEF calls "the perfect storm" — a deadly convergence of drought, famine, and AIDS — will continue to rage unabated, and the costs needed to contain it will continue to soar.