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A Shot in the Arm Podcast
PEPFAR’s Dr. mike Reid Resigns on Substack: Equity, Authoritarianism, & the Future of Global Health
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- [00:01]
A
Welcome to this very special episode of A Shot in the Arm Podcast and the Global Health Diplomats Podcast, brought to you by A Shot in the ARM Media. I'm your host, Ben Plumbley. And of course, what we're interested in is equity and innovation in global health. And without equity, what is the point of innovation? Well, this special episode is covering a topic that is, I don't know, really quite extraordinary. Something very strange has happened this week. We've seen a devastating resignation announcement from one of our global health leaders working in pepfar, done through substack, of all things. Again making the point perhaps that substack is the Twitter of the future. Let's hope so. But the resignation statement was a powerful statement of opposition to what the US government is doing at the moment. I think honestly possibly the most powerful I've read since the administration has come into being in our field. And it comes from a deeply respected researcher, a physician, HIV physician and researcher, as well as an all around great guy and friend of the pod, Dr. Mike Reed. Now, Mike, and given that this is the Global Health Diplomats ambassador, Eric Guzmi, join me this afternoon to talk about the resignation, the context and where we go from here in more detail. Eric. Mike, welcome to the. Welcome to the show.
- [01:43]
B
Thank you. Lovely to be with you. Thanks for having me.
- [01:46]
A
You're looking remarkably well, Mike, is what I can say.
- [01:49]
B
Don't you think, Eric?
- [01:50]
C
Yes, yes.
- [01:51]
B
The weight off my shoulders.
- [01:53]
A
So, Mikey, if I could start with you first and sort of ask you to walk us through your decision. Well, and given the administration's proclivity for firing people at a whim, I guess the first big question is who got there first, you or the administration? Did you resign or were you fired?
- [02:16]
B
I had actually handed in my resignation. When I posted my resignation letter to Substack, the resignation process was accelerated. So by the end of the day, I was out of a job which was slightly earlier than I had planned to leave.
- [02:35]
A
That was a bit unexpected for you. Was.
- [02:41]
B
Was a little unexpected, but given what I'd put in my resignation letter, perhaps I should have anticipated that kind of reaction.
- [02:49]
A
Yeah, and we'll come on to that. I mean, really in just a second. I mean, there were. The second big question I think that comes to mind is why now? Because it's been really clear that incredible civil servants, career civil servants, experts in the field, have been working over the course again over the last year and a quarter, year and a half, to make the political changes work as best as they can. And I think many of us, looking from the outside in on leaders like yourself in pepfar thinking, well, they're holding it together. Things are still moving forward, perhaps not in the way that we would want. So why now?
- [03:38]
B
Well, maybe before I answer that, I will just say that working for PEPFAR was one of the greatest professional privileges of my life. Really thoroughly, thoroughly rewarding. And I greatly appreciated the opportunity to work with a group of dedicated mission oriented civil servants who continue to do very important work. I think I made the decision to leave now for a few reasons. Both reasons that are specific to the role and then reasons that are more relevant to sort of the broader political climate that we're in as it relates to petfar. I was concerned that there were settings where we were at risk of predicating our ongoing support for life giving HIV services on geopolitical and commercial interests and agreements with partner governments. And that was causing me a fair amount of moral dissonance and led me to make that final decision. But I will say that I think I've been struggling for some time with the trajectory that the administration has taken global programming on over the last couple of years. Insofar as we have seemingly deprioritized equity as a central focus of our work, we've under prioritized the importance of evidence based programming, certainly by comparison with how we used to implement our programs. And I think we've moved at such a fast pace to execute many of these changes that the normal deliberative approach to making strategic shifts in global health programming hasn't happened. So we haven't engaged partner governments or other important stakeholders in the way that we could have done. And all of that was causing me increasing amounts of anxiety. I will say, if I may, that much of the momentum that we have moved on towards country ownership away from donor dependency is something that philosophically I'm very aligned to. But how we are heading in that direction has caused me some ambivalence. So that's sort of the context for my decision. And then I think I've also just struggled more generally with where we're at in the US at this moment. It seems like we are, you know, we're being governed by an authoritarian regime. And I felt increasingly uncomfortable working for that regime and feeling like I am affiliated with it by the nature of the work that I'm doing.
- [06:32]
A
Eric, what do you make of Mike's decision and how he pulled it off? As a longtime US diplomat, how do
- [06:43]
B
you react to it?
- [06:45]
C
Well, I want to just acknowledge the sustained dissonance that it created in Dr. Reed's ability to do the work with the intellectual honesty that he approached it with and still feel he was true to an honest representation, reflection of the political decisions that the administration has made. And the growing kind of dissonance with that was obvious to everybody as he progressed. And I thought that Mike went to great lengths to accommodate those differences so he could still maintain a professional alignment and agenda with the ethics of his profession, which run deep and long and preceded the relationship with pepfar and dominate the decision making often. But reconciling that and working that through is what I've seen Mike struggle with over the, over the last bit, as I knew he would. And I understand coming to this decision, I think it's the correct decision.
- [07:51]
A
I mean, intrigued by the way this is obviously playing out in the sphere of public opinion. And there were a couple of things in your statement that really stood out to me. You used the words authoritarianism and you used, and correct me if I've not got this entirely right, you referred to global health as inherently anti fascistic. And I suppose the question I would ask you, again, I'm trying to approach this in a diplomatic way and not in a gotcha way. Your concerns about how the United States is approaching global health, can you talk us a bit more about those? There is obviously a, a link being much more publicly made, sort of a quid pro quo, which may actually be one of the fundamental things about both Trump presidencies. But the quid pro quo that was being asked in terms of economic arrangements with global health partner countries, what were the things that were beginning really to happen that felt very wrong to you?
- [09:12]
B
Okay, well, maybe I can respond to your preamble before I answer your question. I mean, I think I, when I'm referring to this administration as authoritarian, I think there are a few characteristics, right? You know, concentration of power into one individual or party, militarization of society, suppression of the rights of, you know, individual groups, suppression of dissent. And that, that feels like characteristic of where we're at right now. And so that's what I think I was trying to describe in articulating my ambivalence to the administration and the trajectory that it's going on in society, how that plays out in our global health work. Yeah, I think you've summarized some of that nicely. I think my concern is that we are at risk of predicating life saving programming on commercial interests and access to critical minerals. And that feels morally unsavory to me. And I don't want to endorse that by my affiliation I don't think it's cut and dry. I think that hasn't happened across the board. I don't think all of the MOUs have any explicit prerequisite on, you know, commercial deals being made. So I certainly don't want to mismessage that.
- [10:38]
A
Just as a point of clarity, the MOUs that you're referring to are the bilateral agreements between the US government and countries that are PEPFAR partners. And now it's sort of really getting into the weeds that quid pro quo. Yeah, yeah, but sorry to.
- [10:57]
B
Well, I think worth drilling down on just the nature of global health and I think Eric is, and probably both of you have described this well previously. It's an opportunity to exert soft power influence in partner governments. And insofar as the US does that, I think we should acknowledge that there is some self interest in global health and that's just the reality of how things are. And I don't have any moral quandary about that. I think that the issue that causes me concern is when we impose expectations on countries that will limit access to life giving treatments that we've already made available to them previously. And that was certainly my concern in one of the settings that I was working in.
- [11:55]
A
Because you could argue that the, the broader economic interests that the United States has in the continent, you know, now they've finally woken up to the fact that China has done so exceptionally well in building relationships around access to raw materials, but you know, also some, you know, early stage manufacturing that the US is just finally waking up to the need to play catch up. But Eric, as I think about what you did when you were in charge of pepfar, when you were driving the field, yours was one of approach of partnerships. You could argue that some of those were transactional in nature, but this sense that you weren't receiving American largess and therefore you needed to do everything that we tell you to do, but rather this attempt to build some kind of symbiosis in the relationship, you know, it
- [13:09]
C
was, it was really the, the articulation and definition of a shared responsibility that we focused on because we saw a shared responsibility in the population that we were targeting, that was in country and in and of the country. We as the United States were coming into another country with a population that was already impacted by the disease and trying to bring diagnostic and treatment and capability up to a global standard because it was the right thing to do because the people who needed it did not have access to it without that help. And we saw a partnership as possible to achieve, win wins for all entities concerned, country, patient and bilateral relationship. We never wanted to put a. Access to that service, to that diagnostic or that treatment juxtapositioned against you having to comply with anything. So a quid pro quo relationship was created. The ethics of that are not medical ethics, and we would not have anything to do with that. And the administration that we work in at the time completely embraced that philosophy, talked about it, understood it, and wanted to avoid it. So it was a different context. In a context where the government is taking and allowing that to come into play to get what you want. To introduce a coercive element like that is unnecessary and, I think, not productive, but it erodes the future relationship that we need for a sustained, resilient system to continue after we all recede to our corners. And that was the vision that I know Michael's awareness of was high when he entered pepfar, but it's the. It's the song he beat repeatedly in all of his interactions. From my perspective, watching what he was doing while he was there, and a heroic fight, without a doubt, in a different fight than what I was in front of.
- [15:20]
A
So it's really, I mean, from what both of you are saying, it's. It's really the nature of the transactional relationship that is now so fundamentally different. I mean, Eric, it struck me when you were speaking that when people go back to their corners, many in the United States, and I know I get no end of comments on our. Yes, on our substack, but our YouTube and Spotify particularly, why should we care about Africa? We need to care about at home. Why should we bother? And that again, gets me, Mike, to this description that you had of solidarity, and that solidarity is of itself an invaluable strategic imperative.
- [16:09]
B
Yeah, yeah. I mean, I think that's certainly true for global health and infectious diseases in particular. Right. We saw that with COVID that the disease spread around the planet at ridiculously fast pace. And. And I, I think we. We see that in. In the teachings of Nelson Mandela, you know, and the Ubuntu philosophy that he endorsed. Right. I am. Because we are like this, this sort of interconnectedness that is crucial to global health and awareness of it. And when we fail to appreciate that, then, yeah, we. We risk undermining the potential impact that global health can have. I mean, to that ends, I will say that. And I think Pete Morocco said this when he took over, when he assumed control of PEPFAR at the beginning of the Trump second administration.
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A
For the first five minutes, for the first Five minutes.
- [17:13]
B
But global health has to make sense for the guy who works in McDonald's in Michigan. It has to make sense for members of Pete Morocco's mom's Bible study group. And if we as a global health community fail to articulate to US Citizens why this matters, the interconnectedness, the importance of solidarity, then that's our failing. And so I think we do have to do a better job of helping people understand why global health is really important and why addressing these diseases in partner governments, partner countries, is important for our own health, for the economic prosperity of US Citizens. And as Eric alluded to, I think when it just becomes transactional and our investments are only in service of our own commercial interests rather than a true understanding of what solidarity should entail, then I think our ability to do things effectively diminishes rapidly.
- [18:13]
A
It sort of brings us to this second point that was in your substack statement, which you essentially put your decision in a sort of, in a broader perspective of the administration's domestic and international policy approach. Can you talk a bit more about that?
- [18:38]
B
Well, you know, I've sort of already mentioned my ambivalence towards some of the domestic policies. I think I'm increasingly reluctant to work in an administration that is willing to treat the most vulnerable within our communities in cruel and coercive ways, which we've seen over the last few months. But I think in the sort of broader global context, I just felt incredible dissonance about the fact that our global health programs are happening at the same time this administration is enacting other policies. A random fact that you may or not be aware of. But there are more children who have lost limbs in the last two years than at any point in human history. More children have died under the age of five in the last two years. At any point in the last 50 years, all of those lost limbs, all of those lost lives have happened in the Middle east because of policies that the US has supported through our military aid, through the munitions that we've sold to partner governments in the Middle east that has led to the genocide of people in Gaza. And that's just one example of a US foreign policy that has felt really odds with the stuff I care about, which is the health and well being of the underserved communities around the world. So I think that's the broadest sort of climate or context for where my ambivalence has come to come from. Yeah, and I guess that leads us
- [20:23]
A
onto a broader conversation actually about the program itself. Pepfar, the President's emergency Plan for AIDS relief. You were the chief scientific officer of that. And I guess what sort of state have you left it in? As you've, you know, you've. You've now left pepfar. Do you think it is. And I'm really struggling with the way of trying to say this in a diplomatic way. I mean, I would say it clearly isn't fit for purpose, notwithstanding some of the elements that are still very important that it's doing. But I would say that the manner in which all of the global health work was essentially terminated overnight demonstrated a real, well, lack of understanding and basic realpolitik of how to work with partners in the world. But also was, for those who watched Battlestar Galactica, they'll know this, this word that they had adopted, a frack you approach to our partners and fellow global citizens.
- [21:54]
B
I have no idea what frack you means. Sorry.
- [21:57]
A
That's probably good. Well, if you change the R and the.
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C
They use that term as their term in the movie.
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B
Yeah, I see. Yeah, I got you. Yeah.
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C
I was just going to say, just reacting to it.
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B
One of the
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C
messages, I think, that reverberates in the United States commitment to the PEPFAR portfolio and continued bilateral relationships is the contradiction it sustains in the lack of focus on underserved populations in the United States. It makes it indefensible for us to have a global agenda when we are willing and continuing to ignore our own. And to me, that's the biggest fear I would think this administration would have in how they are managing this moment. But the disregard for the relationship we've already made, as Mike alluded to, to the patient we've been with for 10, 15, 20 years playing a central role for the access to diagnostics, but mostly therapeutics, is. It's hard to understand how you reconcile that investment without the investment and with the receiving of the investment to those who are struggling in the United States, it's indefensible. And that hypocrisy, to me, volume is turned up when we move forward with this. That's part of the dissonance that a clinician feels in this work. You can't put that on the shelf and pretend it's not part of your understanding of what your work is about. That patient doctor relationship is where it starts for most doctors. And you can't reverse that and say we're going to put these other priorities in front of that commitment already made. Not for a month, but for years.
- [23:51]
A
For years.
- [23:52]
B
Yeah. Can I shift gears a little bit? No, no, no. I just wanted to also try and answer Ben's question and again highlight that this is not black and white. I think a lot of the moral outrage against the disruption that has happened over the last year, two years, has also from stakeholders who are very invested in the status quo, from civil society groups that are in, you know, who receive funding from pepfar, who were very happy with the way things were going, and perhaps even the relative inertia, inertia as it relates to transitioning programs to country government. And I will say one thing that has happened at incredible speed, which should be applauded, is this administration has said we want to ensure that programs are handed over to partner governments. And we want to do that now. And for the better part of the last decade, we've talked about doing that and not done it. And actually some of the agencies and some of our civil society partners have been some of the voices that have been articulating most resistance to that momentum. So there's something really good about the trajectory that we're going on. And I don't want to underplay the importance of that or even fail to sort of appreciate the management expertise of the political leadership at this moment to enable that, because we've moved very quickly now. That has also created a lot of risks, and those are risks I think previous administrations would have been aversive of taking. And this administration clearly is far less risk averse as it relates to some of those decisions. But it's not all bad.
- [25:42]
A
But given your sense of values, your emphasis on solidarity, I'm just playing devil's advocate here for a little bit. The idea that you can announce essentially overnight that we are not doing things this way anymore and you're on your own, and then we change our minds a little bit with some further clarifications that allow things to continue for a certain period of time with bridge funding and what have you. I mean, this is no way to manage things, is it?
- [26:21]
B
There's a. There's a public health response and a political response to that. I think politically and even legislatively, any administration who comes in is completely within their rights to take a pause and evaluate whether the current trajectory is in align with their strategic agenda. This administration chose to do that. Politically, they can do that. From a public health point of view. Does it make any sense? Probably not. Right? It certainly doesn't make sense if you care about those constituencies who are the most vulnerable, who have the least agency to advocate for themselves. And, and in that sense, I think you're absolutely right that this has been a decision or a set of decisions, the impact of which may be calamitous, but we might not fully appreciate for years to come. However, many partner governments have really appreciated this administration saying we want to hand programs over to you, we want to do things more efficiently. We want you to be able to receive the money directly that we're going to provide through donor assistance rather than through intermediary implementing partners. And some of that is good. Being responsive to the needs of countries and what they want, I think is good. And moving away from a sort of command and control approach to programs where we get to say where the money goes, we get to track what outcomes are being tracked, is its own form of paternalism that maybe we're moving away from. So as with many things, nothing is black and white. But for me, that moral compass of who is really looking out for the underserved, the folks on the margins, that's where I am most concerned that we may have lost our way. I think that's just good public health practice. You know, in any public health system, the US or overseas, typically your wealthy, well insured, well educated folks, they'll always be able to access services and we don't need to worry about them. But it's the folks that have the least money, who have the least political agency that are the ones that are most vulnerable. And it turns out that for hiv, those are communities that have been explicitly vilified by the current administration. Msm, transgender populations, female sex workers. And to leave them out of programming, not only is it morally questionable to me, it makes no public health sense because if we don't control the epidemic in those populations, we won't control it. And that just seems like bad, bad practice. It's not evidence based. And I think there's some sadness for me that we've let ideology get in the way of good public health practice.
- [29:25]
A
And many of the partner governments would say, of course, ideology was driving some of the past decisions, particularly as it relates to the most vilified communities. And frankly, that's where I'm most worried, because Secretary of State Rubio has explicitly said that services are for what, pregnant women and kids. And so what happens to the young gay man or the sex worker trying to get out of sex work, or a drug user trying to get access to services? Well, they won't be covered by the us the governments themselves in many contexts, and I don't wish to appear simplistic or offensive to sort of speak on their behalf, but these precisely are not priority populations. And yet they are crucial to Be reached, to be serviced if we are going to end this epidemic. So it feels, I don't know, a little, it makes complete sense to me that many governments in principle would like the idea of working this way, government to government, because it eases you out of all the nasty, messy stuff.
- [30:49]
C
Yeah, HIV is one of these diseases that forces you to deal with divergent realities whether you want to or not. The idea that if you can ignore the, the active seroconverting components in your society, the high risk groups and just focus on the groups that you like, how they got infected is not going to contain your epidemic. You will continue to have infections and deaths because of it in all populations, not just high risk populations, unless you have a rational approach that covers all of the access points of that virus to vulnerable people. And you've got to be smart and strategic about it. And I think that if our receiving of US government kind of top down oversight management changes does not harm that public health continuum that has been built over the last 25 years to identify, enter and retain people in care for the duration of their life, be applied to HIV and all diseases in the community and in the domestic sites in these high, highly developed countries like the United States too, we're going to continue to have expansion of, you know, infected people, the epidemic not contained people, morbidity and mortality continuing to rise. We're smart enough and have figured out how to stop all of that. But if we don't allow the science to be applied, we don't stop it. And that's the interface I'm hoping the receiving of US government oversight as abruptly as it was, and I'm skeptical that it'll, we'll be able to pull this off. But the great trick, the great magic trick would be that we don't decelerate the public health outcomes that we're looking at and have preserved, created now, but keep them and expand them with the country paying for it and managing and overseeing all of it. So that transition happens because that's a resilient, sustainable service that the United States can be proud of as a legacy the country can be proud of because it's responsive to the thing that's killing their population. That's always a good thing that they can raise their flag and say look at what we did about. But I believe that those are all ephemeral. In the fog of night we may not be able to get all of those precipitated out, fog of war or whatever. But you know, too much at play, too many moving parts without Control levers in place, and we decided not to do it the other way, where levers were defined and put in place and then pull the trigger. We just pulled the trigger. So it's going to be difficult to know how to keep track of everything that scatters.
- [33:43]
A
Yeah. And the idea of keeping track is still something in a sense that a part of these memoranda, of understanding in that what really matters actually of the transactional deals, the access to minerals, the access to basic manufactured goods that China has been able to, to access so effectively. So I, I sort of know the question, the answer to the question that I want to put to you both, and I'm not sure I'm going to agree with it, but let's see where this takes us. You, you, you see, what this administration has done is it's very good at breaking things. It has a sloppiness or a deficit in intellectual interest when it comes to what you do afterwards. And my question that I think so many people are concerned about. Pepfar feels really shaky now. Can it be repaired? Can it be saved?
- [34:58]
B
Would you like me to take a go for it?
- [35:00]
A
Yeah, you don't have to.
- [35:01]
B
No. So. So I don't know that I'm framing it as repaired or unsalvageable, which I think is how you're framing the question. I think it's too soon for us to say whether everything that has happened will have profoundly deleterious impacts. I think the way that you frame the question suggests that it will. And we have to wait and see. Right. Certainly, as we've discussed, there are grounds for pause because if we're not prioritizing equity as a key focus, then it's hard to imagine that we'll be able to close the gaps that need to close. But I think it's also worth stepping back and saying if it's salvageable, is that the fault of this administration or something that preceded this administration anyway? And here I would argue that
- [36:12]
C
over
- [36:13]
B
the last 13 years, we as the US government have created a dependency on our funding from partner governments. And so if us pulling away that funding now is anybody's fault, it's our fault for how we've done things over the last few years rather than just this administration. So I guess one point is just that I don't think we can put all of the blame on this administration. We do really need to think seriously about how do we do global health moving forward so that we don't prevent the neo dependency that led to this moment. And so that we articulate better to our own citizenry why global health is important so they don't choose political actors that will reject global health at the get go. But yeah, I think it's salvageable insofar as can we course. Correct. Yes, absolutely. And my hope is that if we do see that there are declines in epidemiological outcomes or that countries aren't able to pick up the tab, then we can correct in a way that both enables them to take agency and ownership and invest, but also that we can get alongside and support them as necessary. I think we'll just have to wait and see. I will say that this administration does seem pretty good at like holding to its threats and so I think that there may be near term consequences if countries don't meet their core investment expectations, etc.
- [37:50]
A
So wow, what do you mean by that? Because. So are you saying that if countries don't sign up to the bilateral agreements in the way that the US wants them to, that may be there may be fairly rapid negative consequences for them of doing that?
- [38:13]
B
Yeah, yeah. So I'll answer that question. Maybe I can just quickly go back to a point you made earlier, which is a reference to, you know, in the MoUs to sort of a transactional approach to commercial interest. To be clear, there, there are no MOUs that state that right now the MOUs are just a very clear commitment from both partner governments on their shared commitment to the HIV and the global health activities the US is supporting. There is only one scenario I'm aware of where there may be some linkage between a critical minerals agreement and the MO, but that's not across the board. But yet those MOUs stipulate very clearly that if partner governments don't honor their commitments, then the US is within its rights to reduce its funding or to remove funding from certain elements of the programming. So for example, there is an expectation that partner governments will use the electronic medical record systems that the US government has invested in and use it up to a certain percentage percentage of the HIV population. That's probably a really good target to hold governments to. But it's also clear in that agreement that if they don't meet that target, then funding for those programs will diminish. Similarly, there is an expectation that if they don't meet their co investment, their financial co investments, then that will have implications for further strategic investment from the US government. And again, if that's a way that can really ensure that there is greater domestic investment investment in their health programs, that might not be a bad thing. I will say Maybe Eric will disagree with me that we haven't really demanded partner governments to invest in their health programs to the extent that they could and should do over the last 20 years. And if we're serious about shared responsibility, then I think it's reasonable to say we'll continue to invest, but we want you to invest more. The Global Fund has had a co investment expectation in their agreements over the last 20 years, but there's no implications for countries if they don't meet it. So they often they don't meet it and there's no penalty. Whereas I think this administration at least is willing to say as part of these MOUs you are required to invest.
- [40:27]
A
Yes, but. And then shouldn't to you Eric, but you mentioned the electronic medical records. Countries have to use the U.S. system,
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B
not the U.S. system. The system in country.
- [40:38]
A
The system in country which let's be honest, has very often been what PEPFAR has required in the past. Right. So there's a continued. If we're not careful there is a continued dependency being. So there's that risk. The other is you're right about the actual text of the MOUS not making references to the broader transactional nature of the conversations that are happening, but those conversations are happening anyway, aren't they? So while the document may not require that agreement to be the broader agreement to be clearly identified, it's sitting within that context of access to minerals and other other commercial goods.
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B
Is that a question?
- [41:34]
A
No, I suppose from my side it's a clarification that or a perspective that so many folks are providing at the moment.
- [41:43]
B
Yeah. And I'm not sure to what extent that's actually true in reality. I don't think there are many countries where there where that express expectation is being made right now. There are certain circumstances.
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A
Yeah.
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C
It is such a programmatic kind of intellectual mistake to mix a public health outcome with a transactional need or agreement between a country and another country because they're. They have nothing to do with each other. You're looking at one to, to tell you whether or not you should do another. That's a setup for failure and you should not set your system up like that ever. But it's also the ethics suck with that completely. They're not there. So to justify that on an ethical level to mix a, a transactional kind of commercial outcome but with something that will give you access to a life sustaining or saving medical treatment is completely out of the blue Zoo. No one does that in a civilized society, truly. So if they do do would be called Foul in every society I'm aware of and should be, but people do it in the private sector all the time. But I mean, you don't have access to, you know, drugs that you. That are invented and on the shelf because of. You don't have the insurance to cover it. We're doing it only with that every day. So it's. We've been kind of brainwashed to not think of it that way, as I hear myself talk. But I do think it's something that we need to police in the, in this PEPFAR bilateral discussion. Yeah. Not to let them get away with that without really an engagement.
- [43:38]
B
Maybe one thing just to reflect on the bilaterals is just pivoting back to when Eric was the Global AIDS coordinator. Some of these discussions were had then there was consensus that at that point we needed to engage countries and expect countries to take on more of a shared responsibility. One of the differences Eric should speak to this is that at that time there was a really deliberative approach to engaging other stakeholders to thinking in a really thoughtful way about what domestic resource mobilization might look like, how we might hold countries to that. How could we ensure that equity was prioritized in this process? I think we've moved so fast in these MOUs that that process, which I believe took. It was more than a year. Right.
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A
It was.
- [44:23]
B
A lot of planning hasn't happened. And so it's sort of too bad that we, we failed to learn some of those lessons from your tenure, but nonetheless speaks to the fact that there is a core, you know, theme of truth that sort of extends from that point to where they are now.
- [44:40]
A
Yeah, absolutely. And Eric, I'd love for you to sort of comment on how we do that going forward.
- [44:47]
C
I do think that we are smart enough to know what elements are needed to identify, enter and retain HIV positive patients. Patients with any disease. We know how to do it for any disease and we don't. We choose not to do things that we know how to do and let alone take to scale in a country so it's available to everybody. So when we do do it, we do it in one or two pristine, you know, sites that are exceptional and not reflective of what is available everywhere and call that a day. And that's a demonstration project. But to take that capability and make it available to everybody who needs it is what a government should do. And we're in that dialogue with the government, says pepfar. That should be the dialogue we're in with the government that is going to take the full responsibility to deliver the thing we started, but want them to finish. And we're smart enough to put together a dialogue that builds a process around what have to be locally started, stopped and started and funded projects in country for this disease has to be there. That's the sustainable model. We need to be building that. But we need to be ready to come into a technical assistance deficit that may be present in one country and have the country be able to mobilize a rapid response to get them the information and knowledge they need to complete and fix the problem. They're smart enough to do that after 27 years of TA already going into them with Bevfar. They have those people closer than San Francisco to that problem. Certainly. Let's mobilize those lines that are already islands of capability untapped and match that with a funding reality that is generated out of models that are country specific and sustainable, that create an investment force that comes out of them. There's nothing in the world that we have to replace that. It's gotta figure out how to pay for itself. We don't build other things in this world. I mean, we just have to admit it and stop pretending like we do. The number of countries that have done national health insurance, you can count them on one hand when you get right down to it. And they're all shitty systems except for a few, but really they're not exemplary systems that are covering the need, but too much unmet need. Are we smart? Do we know how to do what we do? That's what's so strange about this whole discussion to me, is we know the science to do it, but we have failed to do it even in one country. That is the challenge that this profession needs to own.
- [47:34]
A
And it's not just this profession, this field. I mean, you can imagine a conversation that climate scientists would be having right now with a frustration that we know what to do, but we're not doing it. You mentioned budgets. And this is key because we will be in a situation where countries very explicitly now are being expected to provide much more of the overall health budget or the overall HIV budget, let's say, specifically for this conversation. That means that really tough choices are going to have to be made. And it means that countries may not be able to provide services at the same comprehensive level that they might have been able to do in the past with the support of the us. And of course, let's not forget that Europeans and other donors are reducing their contributions and partnerships as well. It seems to me that this is a sort of a conversation for the future. But how do we do more with less?
- [48:42]
C
Yeah, I hear you. It is the task. It's a challenge. We need to stop pretending like there's a fix out there that brings in external resources into your country to fix it. I don't see that happening anywhere. Have never really seen it happen anywhere in the past, but we've talked about it as if it's a reality. It's not a reality. We need to start a conversation. But that puts the entire onus of medical diagnosis and treatment on the country that we're in. Not any external funding. Really expected. Gravy on the potato if it comes, but not expected. And can you build a system that you want and can fund at the same time in your country? We'll help where we can, but you're going to have to pay for the continuum of care and services that you define, Period. That's the relationship. We are not your delivery system. And we got to stop being that. What is more honest and good for the country is that we stop being that and become a partner that helps them do what they need to do with their work and stop trying to take it away from them and be the implementer and act like that's good enough. It's not good enough. It creates an inferior product that is unresponsive to an expanding needle. And that's what we've built everywhere. My feeling is we can create a process that feeds into local rapid response capability to define and fix the problem in the continuum of care that they define. But to have an international capability that can come in from outside when those resources are exceeded and give you the information and help you work through the areas that are preventing you from continuing your completion of your continuum of care that comes in as a partner, not a savior, to implement it for you. But as we're going to figure this out kind of approach, what they've often talked about but rarely put in place. We've talked about it for 40 years, really, since World War II.
- [50:51]
B
Maybe I can add to Eric's comment, just a reflection on where there are opportunities for getting more juice for our squeeze in the near term. So first of all, even if there are more scarce U.S. resources, if those resources go directly to governments rather than through implementing partners, there may be efficiencies afforded because those hefty indirects, those big US salaries that get paid through those implementing partners won't be part of the equation. That's certainly a goal for this administration. Secondly, I think again, another goal for this administration that should be commended is a Very clear desire to integrate programs. So there are efficiencies that can be afforded by thinking about how do we deliver HIV as part of an integrated primary care infrastructure. We haven't done that for much of the last 20 years because we were worried about the quality of our programs being diminished by being delivered in lower quality primary care programs. I think that nonetheless is an area where if we can support governments to do more integrated service delivery, they may be able to provide services a lot more affordably than we have been paying for them. Thirdly, I think that there is an opportunity to better use technology. I do not think AI is the silver bullet. It's not going to solve all of our problems, but it may well have really important use cases in the HIV response, for example, enabling self care or self management for some patients. They may don't, maybe they don't need to see a provider as frequently if they can, if they can consult an AI agent for their questions. And I think that might be a really important way to offload an otherwise overwhelmed healthcare system. And then fourthly, sort of builds off of one of Eric's last point points is I think even as we invest less, we will have a continuingly important role to promulgate new tools. And some of those tools, whilst they might be expensive in the near term, could afford efficiencies and impact in the long term and that might help us to get closer to ending the epidemic even with less resources. Clearly, right now the tool that we're really excited about is Lena Kaffervir and one of the roles that us is playing is, is, is, is market shaping for learning. US government is procuring at high enough volumes that hopefully the generics can enter at a price that is affordable for partner governments and then they'll have access to a transformative tool, a low cost that will accelerate their trajectory towards ending the epidemic. There are other equally exciting tools on the near and medium term horizon that I think us science and tech stakeholders are pushing forward that could have a really important role even in a scenario where governments have less resources to spend on those tools.
- [53:49]
A
So this last part of the conversation is actually quite inspiring because it looks at where we go from here and that there are concrete things that we can do right now, whether it's in 2026 or whether we have to wait till 2029. My question for you, Mike, is are you going to be a part of this? What happens to you now? What are you going to do?
- [54:17]
B
Yeah, I mean, I hope I'm going to be part of this. I'm looking forward to returning to academic life at UCSF and noodling on some of these big questions, trying to think about what are the policy priorities for the coming few years. But yeah, I want to, I want to stay in the mix and just to, you know, close out where I started. Part of what was so inspiring about working at PEPFAR was working alongside incredibly mission driven individuals who are very talented and contrary to some of the propaganda that was put out by Doge, you know, all those months ago, are in this field because they care about it, not because they're making any money about out of it. And it was a real privilege to work alongside those people. So I hope that I get to work alongside them again.
- [55:05]
A
Yeah, well, and of course, for Doge, the idea of, of wanting to work in this field was itself a problem. Well, look, we, we're sort of coming up to the top of the hour. I, I do think, Mike, that, you know, this has been an interesting conversation because you, you, you started describing what was a very articulate, articulate, very shocking statements, an announcement of resignation, and have sort of pulled the conversation back to where the administration and the folks working within PEPFAR and the State Department are continuing to make contributions and how we can grow on that. Is there anything that we've missed? Anything that at least at this juncture, our viewers and listeners ought really to be aware of?
- [56:01]
B
Well, maybe I can jump in. I mean, so shameless plug here.
- [56:05]
A
All for it.
- [56:06]
B
Eric and I have a book coming out soon on redefining global health for the 21st century. And part of that book is to actually try and present a compelling vision for where we go from here. Part of it is also saying where we got to is not just the fault of the administration. Over the last 18 months, there are a lot of things that have happened that got us to this point. But looking forward, how can we think about doing things differently? I'm happy to unpack what that looks like in more detail, perhaps on a future podcast.
- [56:39]
A
Consider yourself invited.
- [56:42]
B
But I think one key thing for me that I'm sad about is one thing that we have lost. That Eric brought and colleagues like Dr. Fauci and even George W. Bush brought was just a very elevated sense of moral ambition, a collective sense for what we could achieve if we cared enough about it and put resources into it. Excuse me. And that's what we've seen with PEPFAR over the last 20 years. When you have enough moral ambition, you can have tremendous impact. And I think that's what I'm Sad about is that we've seen that shrivel. I think when commercial interests are the thing that you elevate as the most important thing then moral ambition maybe does sort of pay the price. So I think my hope for the future is that we capture that again and there's plenty of things to get excited about that could be really transformative both in the HIV space and in global health more generally. I mean we mentioned Elena Capaveir that the other prevention tools coming down the pike like MK8527, hugely exciting tool that I'm even more excited about than Lena Capavir. It's going to be super cheap, widely accessible and potentially have a massive impact above and beyond Lena Cap of it.
- [57:58]
A
And this is another long acting that is in research.
- [58:02]
B
That's right, development in phase three trials. Right now it's going to be a tiny pill.
- [58:07]
A
Oh a pill.
- [58:09]
B
It works, has a one month time of action. It's. Its time to action is 60 minutes. And the hope is that it prevents HIV at a very high level. Some of the things that are going to be concerning about Lena Capavir is the need for medical infrastructure to administer injections. That won't be an issue for MK8527. Super exciting. That's the near term, I think the possibility for AI to transform the HIV ecosystem. Very exciting. I've sort of alluded to that. And then in the further off horizon I think the possibility of curative interventions, the possibility to make long acting, long acting treatment options available is very exciting. So I think, you know, for the global health community writ large in the HIV community more generally whilst we're in a moment of
- [59:04]
A
crisis, crisis but like,
- [59:07]
B
you know, Phoenix will rise again from the ashes and if there's one thing that can be learned from the HIV community is that they are really good at leading in these moments of crisis. And that's my hope, is that as we think about the application of AI tools, as we think about how do you mobilize more domestic resources for the HIV response. The HIV community can lead in ways that are normative or informed. How we address these issues more generally
- [59:39]
A
and I would totally agree with that assuming we have a change of administration in 2029, but that's a, that's another matter.
- [59:47]
C
But Eric, final words, I would just not want to end without an optimistic point on the horizon. I, I think all of the elements needed to move forward to a, a better outcome where there's an expansion of capability services and a disparity, narrowing of disparities so equity is more evident, is in front of us. We have the tools to do it. We need to put a political context around it that creates political platforms where these this knowledge can really be fully expressed. I believe a change in the way an administration prioritizes how information and resources flow through them to have the impact on program that we're talking about is the change that is needed. When there's an alignment with that, the potential goes way up. And I still see that all as possible.
- [60:51]
A
Well, thank you both very much and Mike, again, I mean, real kudos to you for how you have, I don't know, handled yourself not just in these last few days, but through really the last month and a year and a quarter, year and a half. And it's really, really wonderful to hear that you'll still be playing a major role in driving our response to HIV forward. So thank you. Well, that's it for this episode. Thank you to Mike Reed and to Eric Goosby from ucsf, both of them for joining us in this episode. Thanks also to Eric Espera, our director and producer from A Shot in the ARM Media. And finally, a big thanks to you. Now, of course, you can download this and all our other episodes on whatever audio podcast platform is your preferred, but we'd also invite you to visit our YouTube channel and ask you to subscribe like this episode and encourage friends and colleagues also to subscribe and follow us. So with that, have a great week and a safe week, everyone.