My best, most vivid experiences in government concerned global health. I sat in the Oval Office and watched President George W. Bush approve the Emergency Plan for AIDS Relief—the largest program in history to fight a single disease. I watched the president give his go-ahead for the President's Malaria Initiative, designed to cut mortality rates in half in 15 highly endemic African countries.
Five or six years ago in a place such as Rwanda, about 4 percent of people who needed AIDS drugs received them. Today, that figure is above 70 percent. With American help, Rwanda cut its death rate from malaria by two-thirds in less than two years, mainly saving children under 5 years old.
These are some of the fastest, broadest achievements in the history of public health, and the progress is repeated across the continent. AIDS treatment in particular has not only saved lives—saved mothers to raise their children and teachers and nurses to serve their communities—it has also encouraged testing and decreased stigma. An infectious disease becomes less terrifying and more manageable when it is not a death sentence. Not all American foreign assistance is effective. But these two programs prove that overseas aid, under the right conditions, can be effective.
Six or seven years into a noble experiment, we have learned some lessons. We have learned that measuring outcomes matters. We have learned that boldness matters. National scale-ups and countrywide plans encourage real development, because they require the creation of supply, management, and human resource systems—the kind of accountability and transparency that can benefit an entire health system and society.
We have learned that, like an effective military, effective aid requires an integration of efforts in a central command structure. And we've learned that for development assistance to be broadly supported and aggressively funded, some political and moral argument must be suspended—particularly arguments on abortion.
But this momentum is now threatened. The U.S. federal government faces a crisis of competing fiscal priorities. We are entering an era of austerity. In this economic environment—particularly without the leadership of President Bush—it will be easy for Republicans to return to an anti-government default position on foreign assistance, adopting a kind of moral isolationism.
The consequences of retreat are serious. Even freezing the number of people currently receiving AIDS treatment would be destructive. In some countries, the word has gone out that putting large numbers of new patients on treatment is unlikely. Health officials already report pill splitting, which can increase drug resistance. Other patients resort to quack remedies. Without a serious prospect of treatment, the incentives for AIDS testing are weakened, making all prevention efforts more difficult.
So what is the response to these challenges?
First, there is an intellectual task: to assert that robust foreign assistance is a centerpiece of American foreign policy. While the political consensus for foreign aid is fragile in America, the intellectual consensus is broad and bipartisan. Conservative and liberal thinkers generally understand that the worst challenges of our world—terrorism, drug trafficking, human trafficking, criminal gangs, refugee flows, pandemic diseases—emerge from weak states, ungoverned regions, and hopeless parts of the planet.