Ezekiel J. Emanuel, head of the Department of Bioethics at The Clinical Center of the National Institutes of Health and a breast oncologist, is on extended detail as a special advisor for health policy to the director of the White House Office of Management and Budget.
But that doesn’t speak to his impact. He is one of the architects of the Obama administration’s Global Health Initiative, and he has been a lightning rod of criticism for activists who want a much more vigorous global AIDS response from the administration.
Emanuel spoke to John Donnelly on Saturday about how the Obama administration now needs better ideas for making global health programs more efficient, and how he won’t shy away from taking on AIDS activists. “I have two brothers and all we do is disagree,’’ he said.
Q: You haven’t been shy in pushing back on criticism from AIDS activists about the Obama administration’s smaller increases in the global AIDS budgets than under the Bush administration. What really upsets you?
A: We can have disagreements about the right policy, which way we are going forward, but we can’t have a disagreement about the facts – the facts of the budget. A number of advocates are saying we are cutting the PEPFAR budget. The fact is funding for HIV and our work on PEPFAR is going up – in 2009 2010 and 2011. That is matter of fact. You may not like the allocation we have made, or not like the pot we are putting it in, but (saying we are) cutting the budget is wrong.
The second thing is [the notion] that somehow I am `anti-HIV,’ or `anti-work-we-are-doing-on-HIV,’ is absolutely wrong. This development of the [Global Health Initiative (GHI)] is building on everything we have done, using what our work in HIV and malaria has shown us. One of the things that we have shown is that you can take complicated medical interventions, get them working in rural areas — including sophisticated techniques like measuring T cell and viral loads — and monitor people. A lot of what we have put into the GHI is built on the foundation of PEPFAR. We want to broaden it.
And (another thing) is that we have a moral obligation to the people we are trying to help that if we are spending money on things that are not efficient, we have to be more efficient. There is a moral obligation from the community (working in AIDS issues) not to just ask for more money, but to say, `We have this pot of money, how are we going to do the most with it?’
We’re not doing this because we are green-eyeshade, no-morals people. It’s because we want to save lives and spend money most efficiently.
Q: Still, Ambassador Eric Goosby told Science Speaks this week that even with efficiencies, there will be a `mismatch’ between funds and the need.
A: The United States has been a leader in the global HIV fight. President Obama is dedicated to that fight. He said there has to be a freeze in our spending and for everything that gets an increase, there has to be a decreases. In the 2011 budget, he increased global health funding by 8 percent. That should speak volumes to his dedication.
Q: But back to the Ambassador Goosby’s statement …
A: This is a shared responsibility. It’s not for the US alone to do everything for the world. It’s too big a problem. There are some numbers from UNAIDS (to be released Sunday) that show of all money for AIDS globally, (more than 50 percent) is American dollars, dwarfing by fivefold the next country. We are not shirking out duty. Everyone has to contribute, developing countries and developed countries.
Q: You challenged an audience in Vienna yesterday to identify cost-effective programs as well as inefficient ones. But what have you and others in the administration already identified as both winners and losers?
A: I am too distant from particular projects or programs to tell you what is working and what isn’t. When I ran a research group at the NIH, we would look at projects we were spinning our wheels on, and we would say, `Let’s kill it now.’ We have to do the same thing on the HIV implementation side. What’s going well, great. But what’s not going well, let’s cut it.
I have been told of some examples that we are thinking about, but this is really far beyond my expertise. One thing, on monitoring patients on antiretrovirals, instead of monitoring them every month to stretching it out to four months, then checking on that, and perhaps then stretching it out to six months.
The reason I issued my challenge is I am not the expert on the ground. I want to know what the community knows. I got a very loud non-answer (Friday) about what is effective and what isn’t effective. I do expect the community to come back and be frank. This is a collective effort, this isn’t one person and their judgment alone deciding things.
Q: Evidence-based recommendations are now putting more pressure on AIDS budgets – for instance, the WHO recommendation to start treatment when a person’s CD4 count falls below 350, instead of 200. Even with efficiencies, how are you going to meet that need with small percentage increases in budget?
A: In the whole area of global health, you have to recognize that we have millions upon millions of preventable deaths each year – not just in HIV, but in pneumonia, malaria, in maternal health. Every single one of those deaths is a tragedy. We have 2.2 million children die each year because of pneumonia. We have a vaccine for pneumonia, and it costs $1 — doesn’t that eat away at you? That eats away at me. The fact we have 2.5 million people die of HIV. That doesn’t eat away at you? It does me. The need clearly outstrips what the world is willing to contribute to this area. All of it is a tragedy. It’s why we want GHI to make a bigger impact than we have so far. We have to keep out eye on the ball. From 2003 to 2008, we spent $19 billion on HIV – for the five years. Now we are spending $6.9 billion a year – roughly one third that total.
Q: What area of PEPFAR’s work most easily translates into GHI? Where do you expect results?
A: Two things. One is prevention of maternal-child transmission. If transmission at birth is not zero, (it should be.) We have an intervention that works. Two, we want to integrate HIV/TB treatment. So many people with HIV have TB, and vice versa. Integrating those programs are going to be critical. But I am not a good micromanager. Eric (Goosby) and I discuss strategy, directions, but I don’t tell him what programs to do. It’s just like I don’t tell Raj Shah (USAID administrator) what programs to support. You are not going to see me designing particular programs.
Q: After an update on GHI recently at Kaiser Family Foundation, a leader in the US government on global health programs turned to me and whispered, `This is all fine, but PEPFAR is where the money is. GHI has no money — relatively.’ How are you going to manage this transition to GHI when nearly all the money is in PEPFAR?
A: There is no doubt that PEPFAR retains 70 to 75 percent of the funding. That is just the case. My point to the community has been to get off the dollars as a measure of success, or off dollars as a major scorecard. Our assessment has to be on impact on health. Are we decreasing mortality and morbidity, are we saving people’s lives. We have set goals on GHI … are we doing all we can with the funding that is projected?
One of the things I’m preoccupied by now, quite reasonably, is that there is a vaccine out there for pneumonia, and for rotavirus, and we have to make sure they are implemented. We are not the only game in town on this. We are working with Gates Foundation and with GAVI to make sure it works, to save the hundreds of thousands of lives we know we can save with these vaccines.
Underlying your question, I think, is the thought that since we have come to office, we haven’t done anything in the last 18 months. That is completely false. One of the things we’ve done is change how business is being done. We’ve pushed the notion of integration. Ambassador Goosby, Raj Shah and Tom Friedan at CDC meet regularly. Their deputies meet weekly, there’s better coordination on programs. A lot of this is less about the money and how are we going to do this in better fashion.
Q: How are things going at Vienna?
A: Oh, we had a few protestors yesterday — five out of 150 people or so. I don’t mind people disagreeing with me. I have two brothers and all we do is disagree. I’m used to argument, vigorous discussion. I think it is quite healthy. I do object to two things. One is disagreement not being fact based. The second is the HIV community has its own responsibility here. They need to be responsible, too. They have to come up with some positive ideas. How can we be more efficient? How can we integrate our programs with other ones so that everyone benefits? Activists did not come to their positions of power just by whining. They did because they were creative.