Politics of International Health in the Bush Administration.

Henry A. Waxman reviews the politicization of international health by the Bush Administration in three areas: tobacco control, nutrition, and reproductive health. He discusses how politics may threaten the President's primary international health commitment on HIV/AIDS. Taken as a whole, these and other actions have frequently left the United States isolated in its positions and have undermined public health progress across the globe. © Society for International Development 2004.

Introduction

As a member of the U.S. Congress since 1975, I am proud of my country's record in international health. From the eradication of smallpox to the identification of the SARS virus, from the volunteers of the Peace Corps to the disease detectives of the Epidemiologic Intelligence Service, the United States has invested resources and scientific expertise to save millions of lives across the globe.

Today's enormous global health challenges provide new opportunities for the United States to cooperate and to lead. The Administration of President George W. Bush, however, has often failed to do so. On several key issues, the Bush Administration appears to be basing international health policy on the wishes of its ideological and corporate supporters, not on evidence of what works.

Tobacco Control

By the year 2020, tobacco-related diseases will kill an estimated 8. 4 million people annually, more than two-thirds of whom live in developing countries. If current trends continue, more people will die annually from tobacco-related illnesses than from any single disease (Murray, 1997).

Despite these dire public health facts, the Bush Administration sided with cigarette manufacturers in negotiations over the world's first public health treaty, the Framework Convention on Tobacco Control (FCTC). Over two years of talks, the Bush Administration opposed proposals for mandatory tobacco taxes, fought provisions mandating secondhand smoke protections, attempted to weaken proposals to restrict tobacco advertising, and rejected prohibitions on the use of deceptive terms such as ‘light’ and ‘low’ (Waxman, 2002). At one point, the Administration supported ten of eleven deletions that U.S. tobacco company Philip Morris wanted made to the draft treaty text (Waxman, 2001; http://www.house.gov/reform/min/inves_tobacco/index_accord.htm, accessed 20 February 2004). When challenged on the science behind its positions, the Administration made several dubious legal arguments, including the false claim that the United States could not accept any treaty provision requiring additional legislation from Congress (Waxman, 2003b; http://www.house.gov/reform/min/inves_tobacco/index_accord.htm, accessed 20 February, 2004).

These efforts to weaken the treaty continued throughout the process. Indeed, the Bush Administration sent confidential cables around the world on the eve of the final negotiating session urging that public health considerations not be allowed to trump trade interests in the treaty (Waxman, 2003a; http://www.house.gov/reform/min/inves_tobacco/index_accord.htm, accessed 20 February 2004).1 U.S. pressure contributed to a number of changes that weakened the treaty. Even with these changes, and with Secretary of Health and Human Services Tommy G. Thompson's eventual support for the treaty, the President may refuse to sign and send it to the Senate for ratification.

An internal company e-mail from Philip Morris provides a revealing commentary on the role of the Bush Administration, stating that by the end of the negotiations, the company's positions on the FCTC were actually ‘to the left’ of those advanced by the United States (Berlind, 2001; http://www.pmdocs.com using document ID 2085780145D, accessed 20 February 2004). The company has contributed more than US $6 million to President Bush and his political party since his election campaign (Center for Responsive Politics, 2004).

Nutrition policy

It is estimated that over 1 billion adults around the world are overweight, and 300 million are obese (WHO, 2003b; http://www.who.int/hpr/NPH/docs/gs_obesity.pdf, accessed February 20, 2004). Rising obesity rates are causing increases in diabetes, heart disease, and other chronic illnesses in developed and developing countries.

For two years, the World Health Organization (WHO) has sought to develop a strategy to tackle this problem. Working with the Food and Agriculture Organization of the United Nations, WHO led an expert consultation on diet and nutrition, which was completed in April 2003 (WHO, 2003a). The consultation report recommends a variety of interventions – including diet modification, exercise, and social policies such as advertising restrictions and taxes – to fight obesity around the world. The Bush Administration, however, has sought to interfere with the report's adoption.

Most recently, in comments to WHO, the Administration urged major changes in the report (US Department of Health and Human Services, and US Department of Agriculture, 2004). According to the Administration;

the report should not say that fruit and vegetable consumption is associated with less weight gain (despite evidence of such an association) (Epstein, 2001);

the report should not suggest that advertising of junk food to children may contribute to obesity (despite evidence that preschool children respond to such advertisements) (Borzekowski, 2001);

the report should not find that excessive soft drink consumption is linked with obesity (despite evidence of such a link) (Tordoff, 1990; Ludwig, 2001; Mrdjenovic, 2003).

The Bush Administration has also tried to circumscribe the extent to which WHO can address obesity at all. According to the Administration, WHO's role is to provide technical descriptions of scientific evidence, not to recommend social policies such as taxes or advertising restrictions (US Department of Health and Human Services, and US Department of Agriculture, 2004; Steiger, 2004). These positions are similar to stances taken by the food industry. This industry has contributed more than US $21 million to the President's political party since his election campaign (Center for Responsive Politics, 2004; http://www.opensecrets.org, accessed 20 February 2004).

Reproductive health

Women's lack of access to education and healthcare contribute to maternal illness and death and high infant mortality rates. Despite extensive scientific evidence in support of comprehensive community-based interventions in reproductive health, the Bush Administration's policy has become fixated on two goals shared by the President's right-wing ideological supporters: (1) opposition to abortion; and (2) promotion of ‘abstinence only’ education in lieu of comprehensive sex education.

The Bush Administration has sought to defund and undermine organizations that provides abortion services. Soon after taking office, President Bush reinstated the so-called Mexico City policy blocking overseas nongovernmental organizations from receiving U.S. Agency for International Development (USAID) funds if the organization either directly or indirectly supports abortion (Global Gag Rule Impact Project, 2003; http://64.2245.182.238/globalgagrule/pdfs/executive_summary/GGR_exec_summary.pdf, accessed 20 February 2004). The impact of this policy has been devastating. Across the world, previously funded clinics lack supplies, are unable to provide screenings and treatments for sexually transmitted diseases (including HIV), and can no longer deliver HIV/AIDS education to youth. (Global Gag Rule Impact Project, 2003).

In July 2002, the Administration withdrew U.S. support for the United Nations Population Fund (UNFPA) because of unsubstantiated allegations that the fund supported forced abortions in China (Boucher, 2002; http://www.state.gov/r/pa/prs/ps/2002/12035.htm, accessed 20 February 2004 Ephron, 2002). It then stripped funding from organizations affiliated with UNFPA, cutting off essential health services in Angola, Congo, and Rwanda (Swarns, 2003). During the United Nations General Assembly Special Session on Children in May 2002, the Bush Administration joined with Iran, Iraq, Libya, Sudan, and the Vatican to argue that the term ‘reproductive health services’ should not include legal abortion services (International Women's Health Coalition, 2002, http://www.iwhc.org/index.cfm?fuseaction=page&pageID=385, accessed 20 February 2004; Sengupta, 2002).

Domestically, the Bush Administration has consistently argued that teaching ‘abstinence only’ to teenagers is the most effective way to prevent pregnancy and sexually transmitted disease, despite scientific evidence to the contrary (Starkman, 2002). Now the Administration is seeking to export this ideology abroad. In December 2002, at the U.N.-sponsored Asian and Pacific Population Conference, the Bush Administration proposed deleting ‘consistent condom use’ from a list of methods to prevent the spread of HIV/AIDS (Joshi, 2002). This position contradicts extensive scientific evidence and international consensus supporting the effectiveness of condoms against HIV/AIDS (Centers for Disease Control and Prevention, 2002; http:www.cdc.gov/nchstp/od/latex.htm, accessed 20 February 2004). USAID, 2003). The Administration's representatives later explained their fear that such a statement might encourage underage sexual activity, a concern that is similarly unsupported by science (Kirby, 2001).

HIV/AIDS

Over 40 million people globally are living with HIV/AIDS, with nearly 30 million in sub-Saharan Africa (UNAIDS, 2003; http://www.usaid.gov/our_work/global_health/aids/TechAreas/condoms/condomfactsheet.html, accessed 20 February 2004).

In response to the global HIV/AIDS crisis, President Bush announced in his January 2003 State of the Union address the ‘President's Emergency Plan for AIDS Relief’ (White House, 2003; http://www.whitehouse.gov/news/releases/2003/01/20030129-1.html, accessed 20 February, 2004). The Plan was described as a five-year initiative to provide US $15 billion, including US $10 billion in new funding, for AIDS treatment, prevention, care, and related activities in the developing world, focusing on twelve African and two Caribbean nations (White House, 2003).

The President's attention to HIV in Africa is welcome. However, there are troubling signs that the Administration's commitment may be waning. First, the Administration has not followed through on its funding promises. Despite congressional authorization for US $3 billion to implement the President's plan, the Administration asked the Congress to appropriate not more than US $2 billion (O’Neill, 2003; http://www.globalaidsalliance.org/oneillmemo.html, accessed on 20 February 2004). Only a small fraction of the funding is going to the Global Fund to Fight AIDS, Tuberculosis and Malaria, threatening the Fund's effectiveness.

Second, the Administration has been promoting abstinence as a major component of the President's Plan, diverting focus and funding from comprehensive approaches that have been demonstrated to work. The budget for the plan, as approved by Congress and signed by the President, sets aside one-third of all prevention funds (representing more than US $1 billion) for ‘abstinence-until-marriage’ programs. This includes one-third of all prevention activities, including those that address routes of transmission other than sexual, such as mother-to-child or needle sharing.

Third, there are concerns that the Administration may continue to interfere with the ability of poor nations to purchase inexpensive generic HIV/AIDS drugs (Waxman, 2004). The result could be a needless transfer of funds from AIDS victims to the pharmaceutical industry, a longtime ally of the President. Since the 2000 election cycle, this industry gave over US $40 million to the President's political party (Center for Responsive Politics, 2004).

Conclusion

The Bush Administration is abandoning the long tradition of U. S. leadership on international health issues. On tobacco, nutrition, and reproductive health, the Administration is failing to provide global leadership against scourges that claim millions of lives every year. The President's HIV/AIDS Initiative is at similar risk.

Pushing the Bush Administration to change course will not be easy. It will require strong stands by U.S. allies, an outcry from public health professionals in the United States, and a growing public awareness that America's scientific credibility and moral authority hang in the balance. But this change is essential if the United States is to play a constructive role in international public health.