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American Journal of Public Health logoLink to American Journal of Public Health
. 2018 Oct;108(10):1272–1273. doi: 10.2105/AJPH.2018.304653

The World Health Organization’s Momentous Struggle to Respond to the AIDS Pandemic

Reviewed by: Matthew M Kavanagh 1,, Lawrence O Gostin 1
PMCID: PMC6137778

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The AIDS Pandemic: Searching for a Global Response By Michael Merson and Stephen Inrig

Cham, Switzerland: Springer; 2017 445 pages; $59.00 ISBN 978-3-319-47132-7

The world spends $48 billion every year to achieve something that’s never been done: ending a global pandemic for which there is neither cure nor vaccine.1 The plan entails identifying most of the 37 million people living with HIV/AIDS; affording universal access to newly designed drugs; providing preexposure prophylaxis to those at highest risk; supporting individuals in taking medication indefinitely; and deploying interventions to prevent transmission through sex and drug injection. Stepping back, perhaps it is not surprising that global health leaders generally labeled such an ambitious project in the AIDS pandemic’s first decade infeasible.

Yet as we enter the pandemic’s fourth decade there is remarkable progress. Access to antiretroviral drugs in the hardest-hit countries has risen from a few thousand to 21 million people.2 Incidence and deaths have fallen dramatically in much of the world. A total of 193 United Nations member states pledged to end the pandemic by 2030.3 Despite hard-earned progress, the international community has consistently failed to turn vision into reality and get ahead of the pandemic. The lesson learned again and again is that if we delay responding and then fail to act decisively, the epidemic grows quickly beyond our grasp.

METICULOUS HISTORICAL ACCOUNT

The AIDS Pandemic: Searching for a Global Response vividly illuminates this history of both unprecedented political will and unconscionable prevarication. Michael Merson, who directed the World Health Organization (WHO) Global Program on AIDS (GPA) from 1990 to 1995, and medical historian Stephen Inrig offer a meticulous account of the WHO response. The unique product of their collaboration is part memoire, told in the Merson’s voice, and part historical inquiry that “documents the formulation and dissolution of the GPA, the launch and subsequent course of UNAIDS, and the subsequent global response to the pandemic since the turn of the last century” (p. ix). Their book captures international institutions grappling with a monumental crisis for which they were ill-prepared and helps explain why the UN bureaucracy found the challenge overwhelming. Several themes emerged that provide vital lessons in reforming contemporary global health institutions.

Perhaps the greatest lesson lies in the repeated failure of the international community to provide ample, sustainable resources for the AIDS response—undercutting each effort to halt the virus. As early as 1986, Jonathan Mann, then-head of the GPA, identified 20 countries in urgent need of support. The price tag: $10 million. Only the United States, Sweden, United Kingdom, and Norway stepped up, pledging just $4.5 million (p. 36). The year Mann put forward his request, WHO reported 31 000 AIDS deaths—a tiny fraction of the 35 million deaths to come (p. 40). This book documents the repeated opportunities squandered as the world waited until the crisis spun out of control, a pattern we saw again as recently as the West African Ebola epidemic.4

Sadly, the lessons have not been learned. Trump administration proposals to cut AIDS and health security funding in the wake of Ebola and Zika and withdrawal from the Human Rights Council echo Reagan administration actions in this book. Meanwhile, international HIV funding is falling, just as the global plan to “end” AIDS by 2030 is being implemented.5 Donors remain “impulsive (when launching new programs) and impatient (when demanding results), and they tend to shift strategies to pursue short-term solutions for complex problems” (p. 397).

WHO’S FAILURES

At its heart, this is a study of an international institution struggling under the weight of an unprecedented challenge. It vividly details how WHO first ignored HIV as a “rich man’s disease” with moral complexities it felt ill-suited to address and how shifting course proved fraught even after global leaders came to understand the magnitude of the threat. The personality clashes and cronyism of WHO Director-General Hiroshi Nakajima’s administration are striking. Merson and Inrig describe, in painful detail, how WHO, the United Nations Development Programme, UNICEF, and the UN Secretariat each vied for control, openly competing with one another as the pandemic grew virtually unchecked. The creation of the Joint United Nations Program on HIV/AIDS (UNAIDS) and the dismantling of WHO’s GPA was thought to be the solution—the apex of Merson and Inrig’s story. Yet they explain how WHO leaders immediately sought to undermine the new agency, determined to see it fail. Although one might view this level of dysfunction as a relic of history, the tensions between WHO and UNAIDS continue, albeit at considerably lower levels.

SEARCHING FOR LEADERSHIP

Amid this dysfunction, the authors’ deeply personal account names the (often young) leaders who acted with vision and integrity. One especially poignant part of the book describes the late Jonathan Mann’s remarkable evolution from New Mexico’s epidemiologist to global AIDS and human rights pioneer. When Mann first took over the CDC’s Project SIDA in then-Zaire in 1984, he had never been on the African continent—but found himself directing WHO’s AIDS response barely two years later. Yet the choice proved inspired as, during these darkest days, Mann pioneered a new paradigm for public health—built on his vision that disease prevention and human rights were fundamentally complementary.6

The authors detail Mann’s leadership and clashes with Nakajima on matters large (the human rights strategy) and small (squabbles over travel requests), leading to Mann’s departure and Merson’s appointment as the GPA’s director. In a major contribution to global health history, the book catalogs the work of many who struggled behind the scenes, from Fakhry Assaad—WHO’s communicable diseases director, who championed the GPA—to leaders inside the GPA such as Daniel Tarantola, Purnima Mane, Stefano Bertozzi, and Gunilla Ernberg.

Merson is a central actor, and the book presents a reflective, personal study in management, describing his successes and shortcomings. Having helped build key components of the global health architecture, Merson’s decision not to stand for UNAIDS director is worthy of contemplation, including his struggles with “how to provide a longer, more stabilized, and less infernally contentious transition” (p. 329).

ABSENT ACTIVISTS

Merson and Inrig’s story takes place largely in WHO meeting rooms and hallways. Yet the critical ingredients of the greatest story in global health history are largely absent—the social movements and bottom-up mobilization that swept aside the dysfunction of governments and international organizations. Activists living with HIV, like Winston Zulu in Zambia and Prudence Mabele in South Africa, helped mobilize a movement. Physicians like Peter Mugyenyi in Uganda or Médecins Sans Frontières’ Eric Goemaere refused to accept the received wisdom that antiretroviral drugs could not be rolled out in Africa. An unlikely alliance of activists, lawyers, and generic drug companies made HIV treatment affordable where WHO negotiations failed. WHO’s work was disconnected from this powerful movement, however, to the detriment of the response and agency. UNAIDS’ broader mandate has helped bridge this gap between Geneva and the globe, albeit imperfectly, which is a significant driver of the AIDS response’s remarkable progress. Merson and Inrig’s deep insights are underappreciated, however, in discussions of bureaucratic reform inside the UN, in which critics cast doubt on UNAIDS’ future.

A MOMENTOUS STRUGGLE

The struggles that Merson and Inrig detail remain in the global health architecture: the interconnectivity of human rights and public health in HIV alongside drug-resistant tuberculosis and severe acute respiratory syndrome (SARS); questions of institutional coordination with the rise of bilateral programs (President’s Emergency Plan for AIDS Relief), public–private partnerships (the Global Fund and Gavi, the Vaccine Alliance) and philanthropies (Gates Foundation); realities of weakness in global political capacities in the context of climate change; and WHO reform in the wake of the West African Ebola epidemic.7 Yet for all the ways AIDS illustrates broader issues, it remains exceptional—where contested social norms on sex and drugs collide with cutting-edge medicine alongside basic questions of law, ethics, politics, and economics. With this book, Merson and Inrig remind us that the history of this defining pandemic is still being written.

REFERENCES

  • 1.Global Burden of Disease Health Financing Collaborator Network. Spending on health and HIV/AIDS: domestic health spending and development assistance in 188 countries, 1995–2015. Lancet. 2018;391(10132):1799–1829. doi: 10.1016/S0140-6736(18)30698-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Secretary General of the United Nations. Report on the Implementation of the Declaration of Commitment on HIV/AIDS and the Political Declarations on HIV/AIDS. New York, NY: United Nations; 2018. [Google Scholar]
  • 3.United Nations. Political Declaration on HIV and AIDS: On the Fast-Track to Accelerate the Fight against HIV and to End the AIDS Epidemic by 2030. Vol A. 2016;70(L):52. Available at: http://www.unaids.org/en/resources/documents/2016/2016-political-declaration-HIV-AIDS. Accessed August 9, 2018.
  • 4.Gostin LO, Cathaoir KE. Lurching from complacency to panic in the fight against dangerous microbes: a blueprint for a common secure future. Emory Law J. 2017;67:337. [Google Scholar]
  • 5.Kates J, Wexler A. Donor Governments Funding for HIV in Low- and Middle-Income Countries in 2016. Washington, DC: Kaiser Family Foundation & UNAIDS; 2017. [Google Scholar]
  • 6.Mann JM, Gostin LO, Gruskin S, Brennan T, Lazzarini Z, Fineberg HV. Health and human rights. Health Hum Rights. 1994;1(1):6–23. [PubMed] [Google Scholar]
  • 7.Gostin LO. New Ebola outbreak in Africa is a major test for the WHO. JAMA Forum. May 2018. Available at: https://newsatjama.jama.com/2018/05/29/jama-forum-new-ebola-outbreak-in-africa-is-a-major-test-for-the-who. Accessed August 9, 2018. [Google Scholar]

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