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A Shot in the Arm Podcast
Global Health Diplomats: The 2024 US Election
00:50:09
In this special episode of the Global Health Diplomats, hosted by Ben Plumley and Professor Eric Goosby, the focus is on the upcoming US presidential election and its implications for global health diplomacy.
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- [00:01]
A
And so I would say, I mean, to anybody involved in healthcare, whether they are service providers, whether they are patients, whether they are providers of private providers of insurance, if they are even our friends in the pharmaceutical industry and the biotech industries, you can't ignore this election. And in many ways, for those of us who perhaps might take a dim view of a growing federalization of services or, you know, that the private sector doesn't have enough say and, you know, anxieties, perhaps that there's, you know, an excessive reach of mission creep with the Affordable Care act. This is not the election to fight those issues right now. The issue is that the benefits to society from investment and sensible regulation of innovation is on the line. We all have to get to our balance. We're not stupid. We know what we've got to do.
- [01:26]
Welcome to this very special episode of the Global Health Diplomats, brought to you by a Shot in the Arm podcast. It is our special US Election broadcast coming out just before everyone goes to the polls, if they haven't already. And of course, I'm joined by my partner in crime, Professor Ambassador Eric Goosby. Eric, hi.
- [01:52]
B
How are you? I am always good.
- [01:54]
A
I'm good. How are you? You've just come back from Brazil.
- [01:57]
B
I did fine. A little foggy brained, but happy to be here.
- [02:01]
A
Yeah, well, I don't think you're. I don't think you're foggy brained. I'm the foggy brained one. This podcast going out just before the US Presidential election. In this episode, we're going to look at how we think global health diplomacy has been played out during a very extraordinary campaign. We are going to think about what happens next in 2025 for whatever administration.
- [02:32]
Comes into being. And then we're going to talk a little bit about aids. Is that okay?
- [02:36]
B
Sounds good.
- [02:37]
A
So the US Election campaign to date, without making it a loaded question, how much attention do you think the campaigns have put on to global health diplomacy?
- [02:51]
B
Oh, well, I can think long and hard about that and the answer is very little, if any. And I'm surprised at the lack of attention that this topic has not generated being so deafening as opposed to. Usually there's a little discourse that goes back and forth because it plays such a large role in kind of global perception of, of need. And the United States has always played such a large role in that response. But the times are such that there are many factors that have pulled both donor and governments into thinking locally and more prescriptively about their resources, to the point where I'm concerned that we're not in a situation where it's going to expand.
- [03:37]
A
I think you're right. And I think.
- [03:42]
You know, we don't tend to be a political podcast. There are elements about where we are at that has to be political. But I think, you know, there's failings on all sides. I think the biggest thing that worries me in this debate is that we are repeating what happened in the United states in the 1920s, this return to normalcy and the idea that post Covid. Well, that was then, but this is now and we go back to creating the world that we thought we had. Yeah, sure, that is absolutely a polite way of criticizing make America great again. But I think it's also.
- [04:27]
The fact that we are not being serious about the kind of investments that have to happen globally in order to protect ourselves, protect the security of the U.S. so you touched on it in your opening remarks. Local is global. Global is local. I've been sort of a bit disappointed that we as a movement have been at the table saying, sure, we need to have these security conversations, but as I think was coming up a little bit at the UN General assembly, we need to be thinking about pandemics, about climate and about conflict and these three things together and how it affects, as dear old Richard Holbrook used to say, as much as the miner in South Africa, the steel worker in Ohio.
- [05:16]
B
Yes, I think that it is a remarkable time where the global kind of self expectation to continue to create a response that is donor driven has waned. And I think it comes out of the 2008 recession that we really have not recovered from our European colleagues. The countries in Europe really were hit hard with that and have never. And withdrew kind of global health support, understandably, but it's never returned, not even to a reflection of what it was.
- [05:50]
A
Now, I know you're going to press me on this, so I'll just dive in and deal with it up front. Okay. You know, like a good British Labour politician ought to do, one would hope.
- [05:59]
B
Yeah.
- [06:00]
A
Britain's investment in overseas development since Brexit has been absolutely appalling. It has gone from 0.7 to between 0.3 and 0.5 of GNI of the total.
- [06:16]
Wealth, if you like, of. Of. Of the British country. And we've just had, yes, we've just had the first budget from Britain's first woman chancellor. But unfortunately, global health overseas development.
- [06:31]
Only sees a tiny, tiny increase. So it is actually at 0.3 of our total income. And of course a very significant proportion of that is on management of refugees. So it's domestic money, not. Not international money. So thought I'd head you off on the.
- [06:51]
B
Well, you're an honest broker of the truth. That is the truth. And I know how our colleagues really in the UK have struggled with this. No one feels good about it, but it nevertheless remains. And I think it is reflective of other democratic legislative discourse that's going on in Europe, the United States, Canada. The same reflection is true that people have gotten in their mind that this is a waste of resources for taxpayer dollars to basically go abroad away from their own, perceived as away from their own populations. And either or you're funding them and not us as in the home country population. But I do think that the awareness of the role that the global health diseases play as a threat has waxed and waned as legislative membership recedes and goes away and never comes back. The number of individuals in the House and the Senate and the United States who know the narrative in the last 15 years about what the Global Fund for HIV, TB and Malaria has done and how that's related to the President's Emergency Plan for AIDS relief. PEPFAR, which started at a $7 billion funding level in the United States and is now around 4.3, 4.2 and it was dropping ever since its peak funding with Bush. So it was never going up after that has been a blessing and a curse in the way I would say our legislative leadership has perceived it. Coming from President Bush inception, there was strong Republican support and that support has largely gone out of office now, especially in the Senate, but also in the House. There are very few who know the narrative about what HIV was. They're all younger than people who would have been alive during the beginning of that epidemic on any continent. And as a result, the ability to conjure up support that comes from a shared experience is not there. So I think we as a global health community, and specifically looking at these infectious diseases, have an obligation to keep the legislative layer, President, Foreign Service, but also ministers of finance aware of what the burden of disease is doing economically in their country and to their own populations. Bringing it home for them, I think, is the way it doesn't become something that feels that they're wasting their resource, but they're responding to a problem that is already home.
- [09:39]
A
Can I share a really dark thought with you? And it is about the way some of us in the US Global health community are presenting things like we, we have got to reinforce and defend the bipartisan approach.
- [10:02]
What you're saying and what I'm feeling is that, yeah, whatever happens in 2025, there is no bipartisan approach anymore. We have to recreate it. We have to recreate something that is fit for purpose now, whatever happens a the main, one of the two main political parties does not believe in international development. To your point, it does not have experience of, of living with hiv, living with the three diseases, aids, TB and malaria, in the way that even someone like Lindsey Graham used to have. And the people.
- [10:45]
Who are coming in for that party are people who would have supported what the first Trump administration wanted to do with overseas development budgets, as in remove them.
- [11:01]
So I think we, I mean, whatever happens, it's clear that we have a split.
- [11:09]
A big divide in attitudes in the United States, building consensus, building areas where we do agree, I think is going to be really difficult in global health and particularly for global health diplomacy. Please tell me I'm wrong.
- [11:24]
B
No, I think you're right. I think that is the challenge, and I think it's going to be a serious one that we need to take seriously in understanding that we need to define and engage a strategy that moves hearts and minds, keeps the ones that are there as few as there are, but engages with the new blood that's coming in and all the legislative bodies and make sure they understand the threat to their own populations and, and the global threat as well and how they're related. I think that the pandemic, COVID 19 came across at a time where you think that that learning curve for what the threat means, how it plays out globally, would be fresh in their minds. Everyone is trying to forget Covid. In the legislative discussions I've been in and out of, they're trying to act like they're getting ready for the next one, but at the same time, they want to push it in the rearview mirror in how they run their campaigns and what they tell their constituencies they're going to do.
- [12:29]
A
Get ready for the next pandemic by not getting ready for it.
- [12:34]
So we could have, when we were originally planning to do this episode, we could have been doing something that I think a number on, certainly the never Trump and the progressive wings agree on, which is we'd upset them by taking a fairly neutral approach, on the one hand, the Harris campaign, on the other hand, the Trump campaign. But something has happened in the last few days that I think blows that out of the water, and that is, let's get it from the horse's mouth, Mr. Trump himself saying that he wants to put Robert Kennedy Jr. In charge of health, women's health, God help us. But the CDC the nih, hhs. And that's like putting Dracula in charge of a blood bank. I mean, not to put too fine a point on it, this is someone who doesn't believe in evidence based medicine.
- [13:34]
B
I think that any president elect is of course obligated to think about their cabinet seriously and to get the best people they can attract into government, which is difficult and you want the top of the talent ladder for it. And that for this particular job, Secretary of Health and Human Services optimally would require someone who understood your point of evidence based engagement to decide to fund and deploy resources for which problems of a list of many that HHS secretary has to be able to prioritize and and with a limited pot, allocate 1 through 110 or long or larger and a constituency behind each one of those asks that is going to watch and continue to monitor what that final decision is and that accountability is important in a democratic system to nurture and support. I'm afraid that a choice such as that with a person who has been so aggressive in fighting basic science principles around.
- [14:45]
Vaccine safety and it's associated with really autism and mental types of associations has been looked at repeatedly with prospective studies by NIH after being challenged that have consistently shown there is no association that can be proven. And I know what it's like to be in front of parents who have an autistic child who did get vaccinated. And it's the causal relationship that we're talking about because many things happen to the child, but it's impossible almost to talk someone out of this. I've just been there too many times. You work with them and you try to get them to understand why it's important that that child still needs to be vaccinated and what it looks like when they aren't. But in a country where people are allowed to make decisions that are bad for them.
- [15:41]
Still is the case. You as a medical community have to embrace the whole group and respond to their needs as they emerge and they'll be different than the needs of the vaccinated.
- [15:52]
A
So it's okay, I think, to live in a country where you can make bad decisions.
- [15:59]
That's the price of democracy. The issue is when the people who are making bad decisions are insisting that those are the decisions that everybody makes.
- [16:10]
B
Yes.
- [16:11]
A
And so I would say, I mean to anybody involved in healthcare, whether they are service providers, whether they are patients, whether they are providers of private providers of insurance, if they are even our friends in the pharmaceutical industry and the biotech industries, you can't ignore this election. And in many ways, for those of us who perhaps might take a dim view of a growing federalization of services, or that the private sector doesn't have enough say and anxieties, perhaps that there's an excess of reach of mission creep with the Affordable Care act. This is not the election to fight those issues right now. The issue is that the benefits to society from investment and sensible regulation of innovation is on the line. We all have to get to our balance. We're not stupid. We know what we've got to do.
- [17:24]
B
I think we really do. And this is one of those elections where I think you must vote for all the reasons that you've said. And I would also say that we're at a point where deciding on how a government plays in your life seems to be on the front burner. In a medical community understanding that a elected official needs to be able to understand the burden of disease just to get very concrete about it. And in that understanding understand that the disease does not distribute equally to every aspect of your population. There are differences and there are groups within that population that rise to higher risk than lower risk. And that you have to have a delivery system both in the private and public sector that understands those differences. So the needs and barriers that are presented to populations trying to access and be retained in care are understood and addressed and easily relatively eliminated. And that requires someone who allows evidence based data to lead their decision making. When that isn't there, random decisions get made that you can't be accountable for. If they're right, no one really speaks about it, but if they're wrong, everyone will accuse them. And the ability to understand the mistake, to not do it forward as you now re engage is critical in these bureaucratic type jobs. And the Secretary of Health and Human Services is definitely that person. You don't have to have a medical understanding. You have to have a sophistication of your own awareness of your strengths and weaknesses in your understanding. And, and you need to staff yourself to balance it because you can really make wrong decisions with an imbalance of and you with that lack of knowledge. It's a knowledge gap. Your staff in HHS is good at keeping a secretary informed and an inquiring mind. It doesn't have to be a medical one. There have been, you know, people without a medical background who've done HHS infrequently, but it's happened and they can do a good job if they're staffed properly. But this is such a moment of, I would say, difficult conflict Decisions around domestic versus international. The same challenges that are occurring globally with lack of accountability in a New York or a Geneva decision, deciding what services are available in Kampala, Uganda, and not having the outcome of those decisions. How well people do get fed back to the people who are making the budget for the next year. Not for a year, not for five years down the road, but the next year. A rapid turnaround of resources going up or down, supporting or not supporting the vision that was initially funded. That kind of feedback loop is something that I think we are losing in lines of accountability at the international level, but also domestically. Well, the HHS secretary sits in the vortex of both and needs to balance both of those.
- [20:43]
A
Well, I'm not even thinking HHS. I'm thinking the FDA.
- [20:47]
B
All of they're all in HHS.
- [20:49]
A
Oh, okay, okay.
- [20:50]
B
HHS is over. FDA, NIH, CDC and HRSA, all of the service organizations. There are 12 public health agencies that they're called for.
- [21:01]
A
So I hope our listeners and viewers in Bucks County, Pennsylvania are listening right now and picking that up because that decision will fundamentally affect their income, their livelihoods and their futures.
- [21:18]
B
They will. HHS is Social Security and it's Medi Cal, Medicaid. All of that comes through hhs. It's an extraordinary agency.
- [21:27]
A
So if we try and you know, it's all 50, 50, it's all flip of a coin. It feels like the other administration that might emerge in January, that is an evolution of Obamas, of Bidens and potentially now Harris's. What would you look for there? What would you like to see from a global health diplomacy perspective?
- [21:56]
B
Yes.
- [21:58]
I think that we are at an inflection moment in the United States contribution to the global burden of disease. We have taken a leadership role for 25 years and more in being part of the solution at country level with the most impacted individuals in HIV in particular and TB and to a lesser degree, malaria and that. But all of those have responded to what I would say have been central funding lines that have originated from the United States. The other global democracies have not come back since the 2008 recession and does not look like they're going to in the near future. And the dialogue in the United States has shifted from seeing the vision that Ben was talking about in the beginning of the need for and why it's important that those who can do respond indeed have a responsibility to respond that that idea is receding. And a why are we funding this? Is what you're being met with. Is this an entitlement? Is what you're being met with. When you go to legislative bodies in the United States and try to argue for sustained or increased funding, that argument and the adamance in that argument has gotten harder. And.
- [23:22]
I believe that the Democratic Party's candidates, Harrison Waltz's vision that they've articulated so far includes a vision of healthcare expansion, the Affordable Care act, not receding, but being more relevant to the needs of the populations we've already embraced and responding to them in a proactive way to understand the needs as how they have changed and change with them. That has been very clearly articulated. It's difficult to roll out without a sustained, at the highest level vision that says this is important to me and we want you to complete this. I believe that that's the choice this time. It's that stark. Never been this stark in my lifetime, but it is this time. And I think that I would say that we are looking at a vision of receding involvement and the receding of the self expectation as a country that you are responsible in part for this and trying to close your eyes to the outcomes that would tell you you've made a mistake by not engaging.
- [24:38]
A
So both of us are California based. Both of us have been involved in campaigns for Congresswoman Barbara Lee, who continues to speak for me even though I live in Sacramento.
- [24:55]
And of course Vice President Harris. And I think both you and I were involved in her first campaign.
- [25:03]
For president. By the way, do you know that she made me cry? And it's on tape at a fundraising, small fundraising event in San Francisco where I was asking her about her continued commitment to the global fund. And I don't know, just something about her just made me cry. I was in tears at the end of it. Yeah. I mean, pathetic. But she said yes, absolutely.
- [25:25]
B
Oh, yeah, yeah.
- [25:26]
A
But I got to ask you, what you've just described about what a Harris administration has done, have you had the chance to tell her that?
- [25:34]
B
You know, not in the way I should. You're absolutely right to say that. You never talk to, you know, people in, in that type of a position and tell them how good they're doing or all the wonderful things that you've thought or said and it's, it's a mistake. They need to hear that and we need to make an effort to close that loop. It's the feedback they need to get up and do it again. And I think if anything is pushing them in any direction, it's still more and more isolation. As a person who's an elected official, there's no one you talk to who isn't asking you for something and upset when you don't give it to them. So it's this strange message that you get as a person and I've seen that play out in many political people at all levels. Presidents that write down, secretaries of state and the whole thing. People are people and they absorb it and they don't have anywhere else to put it. But we don't do that and we should. So I think it's a good point. I have to own it.
- [26:36]
A
So let's imagine and it's very possible that there is a Harris administration. I've got another sort of slightly cheeky thought that I'd like to test out with you. She has said that she wants this to be a.
- [26:54]
A coalition of different views and even saying that she would have Republicans in her cabinet. What about putting a Republican in charge of pepfar?
- [27:06]
B
You know, I wouldn't care what political party you came from, but I would hold whoever is put up for that position. They've got to be able to understand the medical challenge and to me the complexity of the moment we're in, in the response to HIV globally and our ability to pivot into longer acting formulations that really afford preventative and treatment options that we don't have right now. There's also a vaccine hovering around for HIV and for TB that is good enough to start talking about it. And I think over the next, you know, whoever's in the next administration, certainly over an eight year period, they'll have that to deal with as well.
- [27:52]
A
Just listen to, you are the consummate politician. You answered that by not answering it brilliantly.
- [27:57]
B
Oh, I didn't mean to.
- [27:58]
A
No, no, no, no, it's fine. I think it's an interesting one. But I do think you're right that it's, it's dependent on the character of the individual. It's not a token. And of course I am not proposing in any way that our good friend John Nkengasong is marginalized by any stretch of the. But I'm just thinking about how we bring the Never Trumpers.
- [28:25]
All of these politicians who have put their essentially their careers on the line by saying we support Kamala Harris into the. Whether it's the Cheney's, whoever it is, whether it's the Tim Millers from the Bulwark, whoever it is.
- [28:45]
I'd also really like to know. We haven't spoken about her for a while. I'd really like to know what Debbie Burks is thinking. I mean, sort of slightly cheekily. I would like to know which way her neck scarf is pointing at the moment.
- [28:58]
B
Well, Dr. Birx is wonderful and still contributing out there, so there's no doubt that she should be in consideration for all of the positions if there is a need. I don't know if Deppy is actually thinking a republic.
- [29:12]
A
As a Republican, I think she would probably shoot me for saying that she.
- [29:17]
B
But if that is indeed the case, she would be embraced on a multiplicity of levels. And we should just say that it would be a smart thing for the new administration on the Democratic side to look at those types of bridging people who can come in with high competency in the content and the topics but are also acceptable in a different way to the Republican Party for the sole reason that we need both parties and the individuals in them to have the country that we've envisioned and to try to exclude 50% of the population is a mistake. We should look for every opportunity, as I think Kamala has verbalized in her speeches, that this is a moment to bring in and accept conversations that may be difficult but are necessary to continue to understand what the greater good is for the populations we've already assumed responsibility for.
- [30:19]
A
I mean, I can't wait for us to get back to conversations where we differ on policy, but we are aligned in wanting to save lives. The two other things that we haven't touched on in this conversation, obviously the woman's right to choose. Abortion is a really crucial element of this. And I've also been horrified at the way in which both the presidential campaign but also local campaigns from Republicans are trying to push the anti trans button to scare people into voting Republican.
- [30:58]
B
We're in a country where that works and it saddens me deeply, but the truth of it is they're doing it because it works. People need to unpack in their own hearts and minds why this is an issue for them and why they feel they need to impose their standards, whatever they are, on another human being. Why that has become the acceptable norm is, I think, something that people individually need to engage with. One of the sorrows that I keep with the whole reproductive rights issue is the fact that physicians, when confronted with a patient who needs a procedure, have actually been confounded about what their ethical obligation is to do. It's not confusing. The doctors are not confused about what they're supposed to do. It's clear what they're supposed to do, and in most instances it was done, but it's being reported as if the person was turned away to go travel across states that I Hope is the exception and that there were others, that the physician in the emergency room or wherever it was responded to the immediate needs of the patient and did not worry about a legal threat that would stop them for their ethical medical responsibility to carry it out. And that is something the medical community has not engaged around in a debate. If it indeed is a barrier to care, let me help you think through that. This should not be a barrier to care. You've already taken an oath that says you will respond to a need of anybody in front of you, no matter what their political party, race, color, creed or sexual preferences. Doctors don't need to do that and shouldn't start doing that. We treat it all well.
- [32:51]
A
Absolutely. But. But you really do have a situation where the politician, where the government is now saying, yeah, but only within these parameters. And if you stray from your Hippocratic. Oh no. If you stray in order to meet your Hippocratic Hippocratic, then it's legal response.
- [33:16]
B
And we need to let it happen and go to court and work it out because the ethics of that are non existent. And you did not go into the medical profession to do that. And if you start doing that, you're doing something else. And that just needs to be discussed. I don't know anybody, Dr. Wise, who's practicing in front of real patients who feels that way. And I think everyone I know and have grown up with medically would never do that. But it apparently is happening. It's happening.
- [33:44]
A
Apparently.
- [33:45]
B
Yeah.
- [33:46]
A
So two other points for us to cover in this podcast.
- [33:53]
Let's go back to being agnostic for a second. What do you think either administration is going to face from a global health perspective? Pandemics, climate related diseases. What do you think is on the radar that people have to be thinking about?
- [34:13]
B
Climate is going to get worse. We've already lived through a summer that we've never experienced in the Bay Area. And the United States in general, on every level, in every sector of the United States is seeing things that are unprecedented, that fosters different types of fungal infections. I'm just going to go right to it. That can live in environments that are warmer that couldn't before. Yeah, we're going to see an emergence of fungal infections that's going to move from the south to the north. And those fungal infections are the type that are invasive and often get into the meninges and to the brain and are chronic. So the other part of that is the drugs that are going to be needed to effectively treat those.
- [34:58]
Deeply seated, embedded, especially central, central nervous system infections. Are not available in the settings where these are going to emerge. And that is going to be the next kind of challenge for our global community.
- [35:11]
A
So we need a good rigorous FDA.
- [35:13]
B
That can get us and get and position this understanding so formularies can evolve and change to the needs of the.
- [35:23]
A
Population changes rather than Dr. X or Dr. Truth Social.
- [35:28]
B
Yes. I just have to say that it's all doable within the technology we have now. And for us to make this an insurmountable problem gets to the larger issue that we talk about with global health. Are we as a planet going to ever reach the point where we can say there are enough resources that we can cover the health needs of the population, the 7 to 8 billion people on the planet? Can we, with the resources already on the table that we're aware of, can we reconfigure how those resources are made available so everybody gets the basic basement of healthcare needs that go through your basic child, adolescent and young adult, old adult, adult, et cetera. Needs for healthcare maintenance, immunizations, preventative care covered. Sanitation type issues should be covered. Why we as a global community cannot say that's worth the investment. Let's figure out how to make that base investment and then think about the emergence of how the private sector of healthcare comes into public sector delivery system and bowls them over. Usually we're smart enough to do this more logically, more humanely. So we cover things uncovered together and embrace that effort. When we rolled Covid out and the response to it in the United States, every healthcare third party payer in the United States in the San Francisco Bay area, I sat with the committee that met three times a week in the first six months of that outbreak to say how we should distribute resources with the Director of Health. That discussion did not have any third party payers in it because they didn't feel they were responsible for a public health outbreak. Didn't want to put any money into testing or treatments, period. Until they got so sick they had to be admitted to the hospital. We're ready for that third party payers. But we are not doing any of this. That's the Department of Health in the city. It required lawyers to talk to each other to get them and embarrass them into. You better tee up some support for this. Your population who's covered by your health plan is getting Covid and you shouldn't wait to have your response only be when they're at the point of needing to be admitted. Yeah, and they saw that. But it took them a ridiculous number of conversations to do it. That same hesitancy is everywhere. And the managed care.
- [38:08]
Kind of carrot of enormous wealth coming in that somebody in the society can make has confounded the basic charge that a government has to protect its people. Protect should include the health of its people. They usually think education is something they should do, but health is something they can wobble on. And saying that there's a private sector has always been the out for the public sector to say, well, the private sector, but it's not. But are we not smart enough to figure out how to define the needs of a population so they're covered?
- [38:43]
A
So when you welcomed me into the world of global health diplomacy, say in the early 2000s, I think that sense of optimism, which I sense you still very much have, that we could do this. We could got to get all the stars to align, but we could do this. I got to say, I'm not so sure. I'm not so sure. I don't know that we have either the willingness or the attention span to be able to do that. And it leads me, I think, to the final question for this podcast about what the hell do we do with the AIDS response after 2025 and after 2020? 2030.
- [39:26]
B
Yeah, after.
- [39:27]
A
Yeah, because, you know, the community.
- [39:32]
The broad community, the AIDS community of all of us, this messy family of doctors, politicians, activists, we signed up to ending AIDS as a public health crisis by 2030.
- [39:48]
Eric, are we going to end AIDS by 2030?
- [39:51]
B
Not. We are not. And I think that with all of the wonderful, dedicated work that has gone back 25 years in the global sector with serious investment being made, has resulted in a profound impact on morbidity and mortality. But the influx of new cases is still overwhelming us, even though I take great pride in the people that have been stopped dead in the tracks of progression and are not going to die from hiv, but will die from something else. So taking that population that we for 23 years have been giving antiretrovirals to and putting systems around them that identify them, enter and retain them in care over time. We don't let them get lost to follow up. We bring them back in. Those things need to continue. But we need to look at what that same group is dying from. What are they dying from now in 2024? And is our delivery system responding to those needs or not? If not, why not? And is it an impossible concept to think of shifting the needs, the services of a delivery system that has been HIV dedicated to also include the big diseases that are killing that same HIV positive patient that you've been responsible for for 25 years from strokes, heart attacks and end stage renal disease untreated, with relatively easy, non expensive interventions early, we will prevent the bulk of those or at least significantly so. And to not do that is criminal in our own ethical relationship right now. To me, we should evolve with the needs of the people we're responsible for as the impetus to why we're doing it. We're not moving away from an HIV response. We are continuing in an HIV response with the people that we have been in a relationship with for 20 years. And that is responsible because we jumped over countries and started delivery systems that were not part of the public health delivery system. Clinics and hospital system that largely has shifted back with over the last 10 years is shifting back to a more public sector. But that difference puts us in a primary provider responsibility engagement with the patient that still needs to be honored until we transfer that care to the entity that's going to pick it up formally for the rest of the patient's life. And until that transfer occurs, it's an abandonment of care threat if we don't do it correctly. And I would say we need to ask ourselves, why are we not responding to the needs of the patient as we see they're dying from stroke, heart attack, et cetera. Is there not a responsibility for us as the providers of their HIV care to do something about that?
- [42:48]
A
Well, I think we have to pull the blanket back from what policymakers primarily are saying about that, because.
- [43:01]
NDAs by 2030 basically means, if we're being really honest about it, ending the entitlement funding for HIV that has happened globally. As you've pointed out, the Europeans have pretty much stepped away from it. The US will.
- [43:18]
And it means telling countries with the highest burden to pick it all up. And we have to ask ourselves the question, will they? And do they have the ability to continue to pay for people's treatment? Because if they don't, they will die. And pulling the blanket back, and I'm sure you've heard this, some policymakers will say, oh, these folk have had a good 10, 15 years that they weren't otherwise going to have.
- [43:46]
So they're going to die. It's time for us to invest in the people who were good enough not to get hiv.
- [43:53]
B
Yeah, well, the ethics of that are zero, flat out zero. You have a responsibility to that person still, whether you think it's appropriate or not. There were 10 great years, but you've set them on a trajectory that you're now abandoning and that is an abandonment of care. So that to me is not an option that you can justify. People can do it and people will do it. We've seen countries do it where they withdraw support. That was doing that and they convinced themselves that it was so many clicks away from the person that it really doesn't have anything to do with it. Well that is just not true. And the ability to embrace the added service needs of those NCD diseases is non communicable. Non communicable diseases is not going to necessarily take away resources that go for hiv. If as we withdraw donor funding we work with countries to define local resources as narrow as they are, most countries will absolutely not have the money in the short or long term to pay for the antiretrovirals that they're currently using in their populations. And they're going to need help. Our help needs to be creative in a way it's never been. But we can't and we can't take the money away without a replacement is what I'm trying to say. And we're smart enough to do that. It's not rocket science to fill something up as you receive something. And that needs to do it. That needs to be what happens. And we need to keep the surveillance system in place enough so we know that we haven't missed this and dropped that care. But the transfer of care, when it occurs, that person is tucked. And also if you use the system that the country has invested in, the primary care healthcare system, you support it to be robust enough to take care of the HIV community that now is coming into their system. But to think that we are going to continue an outside funding line indefinitely has got to get out of the thinking long term. And the short term funding from donors United States will stop if there isn't movement toward expanding local donor money, dropping local money going up from any source. But that it not be. But that it be as sustainable as possible. Looking for that sustainability is what PEPFAR is starting to do and the Global Fund. And it's the correct thing to do. The handoff needs to start. But we need to help them build the resource structure from the countries coffers and resource portfolio that they haven't yet. That they may not be aware of. No.
- [46:47]
A
Because PEPFAR on an annual appropriation now.
- [46:52]
B
Yeah.
- [46:52]
A
It may not be around. Not five years from now. Next year.
- [46:56]
B
Yeah.
- [46:56]
A
So putting you on the spot, would you be willing to work with me over the coming months in sort of.
- [47:07]
Articulating what the, the next phase of the AIDS response needs to be for international policymakers? For donor policymakers. But really what we think's got to happen.
- [47:20]
B
Yeah, I, I, Yes, I would love to bring people in for you to interview. We can interview together to kind of talk about the elements of that, because they're there and I don't have the answer, but I do know what the elements are, and I think that is half of it.
- [47:36]
A
I think you know what the questions are.
- [47:39]
B
Yeah, I mean, that's a better way to say it.
- [47:41]
A
Yeah, I'll, I'll hold you to that. Okay, so look, we've come to the top of the hour of this episode. Anything that we've missed that we want our viewers and listeners to.
- [47:52]
B
No, I think we've covered a lot of things. I guess my only thing with the domestic versus global is the same issues that we have. Our hesitancy to embrace a primary care.
- [48:09]
Platform with the HIV patients in our global health portfolio as the United States. That same dilemma of appropriateness is domestically fraught. So I see it strangely as the same issue, but in different sectors of how resources come into states and get to municipalities, et cetera. And we, I think, globally, have an opportunity to really do it right in a way that we have never done successfully. But I believe there are, I do hold an optimism that is real based on the realities that I think can converge to make this happen. Is still a belief, but we'll see.
- [48:56]
A
The only thing that I would add is if you haven't already.
- [49:02]
Voted, make a plan to vote and make sure your friends vote and your family vote, assuming you are US Citizens and have the obligation, not just the right, to vote.
- [49:17]
Eric, thank you so much for a terrific Global Health diplomats discussion.
- [49:24]
B
Pleasure. Pleasure, always.
- [49:26]
A
So it just remains for me to thank Eric Espera, our director and producer. Thanks also to Aisha Rafael, our production coordinator and assistant producer. And finally, a big thank you to you. You know what to do on this coming Tuesday if you're a citizen of the United States and you're entitled to vote. And we'll be back very shortly with what has to happen next. Have a great week and a safe week, everyone.
- [49:57]
B
Everybody be safe. Vot.