At the end of the original edition, Whiteside compared HIV/AIDS with other global equity issues: “AIDS is a harbinger, the first of many new and alarming challenges, and has given us the opportunity to learn. Only time will tell if we did.”

The global AIDS response as a harbinger, a frontrunner, a pioneer of addressing global challenges with global responses: that is exactly how I felt about it at the time. Almost 17 years after the International AIDS Conference in Durban – where Justice Cameron compared the attitude of affluent countries observing how poorer countries in Africa were unable to provide antiretroviral treatment, with the attitude of watching the Holocaust unfold or accepting the persistence of Apartheid – we seem to have forgotten how innovative the global AIDS response was. For the first time in the history of global public health, the international community accepted long-term responsibility for a global health policy: a policy that was contingent on humanity being accountable for it. If that was possible for HIV/AIDS, it should be possible for other health policies as well. At least to some extent, that is what happened: international assistance for health increased dramatically, from $12 billion in 2000 to $38 billion in 2013. The global AIDS response took a big share of that increase, but even if we subtract all funding earmarked for the global AIDS response from the total, the increase remains impressive (from $10 billion in 2000 to $26 billion in 2013).

In 2012, the Institute of Health Metrics and Evaluation already predicted the end of the golden age of global health, way before Donald Trump had political ambitions. Since 2013, international assistance for health has been shrinking. The global AIDS response is starting to adapt, emphasising national responsibility, and trying to fit into universal health coverage (UHC). As Whiteside describes it:

“HIV and AIDS have been the exception. The global trend is towards universal health care (UHC) in various forms. This is more appropriate for mainstreaming and normalizing AIDS. UHC would be expected to include ART [antiretroviral therapies] and possibly prevention activities.”

Conceptually, I agree, on one condition: that the international community accepts shared responsibility for UHC, as it once did for the global AIDS response. However, despite the ‘universal’ in its name, UHC seems to be understood under the old terms of ‘sustainability’: adapted to what countries can afford, in the long run, without international assistance. That does not bode well for the mainstreaming of the (no longer) global AIDS response. Even with the cheaper generic versions of antiretroviral medicines, and even if many poorer countries are less poor than they were in the year 2000, many of them are still too poor for an appropriate domestic response. Neither does it bode well for global health in general. International assistance for other global health programmes is likely to shrink too, but far more important than that (in my opinion): we seem to be returning to the ‘Westphalian’ era, in which all countries, supposed to be equal and sovereign, are also expected to take care of their own problems.

In a different paper, David Wilson and Alan Whiteside describe “AIDS at 35” (35 years after the first medical report about the syndrome that was called AIDS later) as “a midlife crisis”. Humanity knows, much better than 35 years ago, what HIV and AIDS are, how they spread and what can be done about it. At the same time, (a big part of) humanity is retrenching behind state borders, leaving countries to their own devices. I wonder if this is indeed a ‘midlife crisis’, or rather a kind of ‘early retirement’: the job of the global response is only half done, but it is leaving the remaining tasks to a system that was unable to start the job in the first place.

I prefer to see the present situation of the global AIDS response as ‘growing pains’. The global AIDS response did lead to “a lack of local ownership and dependency mind-set”, as explained in HIV/AIDS: A Very Short Introduction: 2nd Edition, instead of a correct allocation of national and international responsibility. The global AIDS response did not sufficiently spread to other areas of global health and global social policy. Unless we correct these flaws, the global AIDS response will go into (an inappropriately) early retirement. However, our window of opportunity is not closed yet. Even President Donald “I’m Not Representing the Globe” Trump seems reluctant to cut USA programmes to fight AIDS. The exceptionality of the global AIDS response appears to be more robust than we believed it was, at least for the time being. All in all, however, the election of this US President, together with the ‘Brexit’ and other political events in other parts of the world, seem to signal a deep fatigue with globalisation itself, not only with shared responsibility for global challenges.

Globalisation is not ‘motherhood and apple-pie’, as some wanted us to believe, it is tough and mostly unfair. Yet I cannot see a viable path towards a pre-globalisation era. How can we deal with global challenges such as global warming, increasing inequality due to tax competition, and global health security, if every country is supposed (and allowed) to decide on its own? Globalisation is here to stay, and we have to manage it. It is difficult, we do not yet have the appropriate tools for it, and we do not even know exactly what global equity would look like. We must discover and learn it, step by step, issue by issue, through trial and error. HIV/AIDS: A Very Short Introduction: 2nd Edition documents one of these important trials. Read it (and keep it, to compare with the 3^rd edition of 2024).

Our essential argument was and remains the realization of the right to health for everyone. But it is not the only argument. The 2007 World Health Report added ‘global public health security’ to the equation and warned that at least “57 countries, most of them in sub-Saharan Africa and South-East Asia, are struggling to provide even basic health security to their populations”. The authors of the report asked rhetorically: “How, then, can they be expected to become a part of an unbroken line of defense, employing the most up-to-date technologies, upon which global public health security depends?”

According to our estimates, high-income countries should have contributed around $7 billion in total to these countries (to allow the $80 expenditure level) to build health systems strong enough to prevent the present Ebola disaster. As you probably read in a recent WB study, the two-year regional financial impact of Ebola could already reach US$32.6 billion by the end of 2015. A rather unwise underinvestment, it seems.

However, the real cost, in our opinion, is not the economic loss, but the enormous human cost of – what economists like to call – the “externalities”  of an economic and political world order that seems unable to get a grip on rising income inequality or to show even the petty solidarity required – 10 cents out of every $100 – to maintain a minimum of dignity for humanity. On top of that, it would be silly to think that this Ebola outbreak is and will be the only global public health disaster that could have been prevented, or that could be prevented in the future. It is merely the tip of an iceberg of (re)-emerging infectious diseases. While the world rightly focuses on the containment of Ebola, these already fragile ‘post-recovery’ (in the case of Sierra Leone and Liberia)  health systems in the affected countries are further collapsing. Many health centers have closed as people avoid these centers out of fear of becoming infected with the virus. Last week UNFPA warned that “120.000 women could die in childbirth within the next year in Sierra Leone, Liberia and Guinea”. The three countries rank at the bottom of the Human Development Index and their maternal mortality and infant mortality rates remain amongst the highest in the world, and recent progress will be reversed.

The engagement of the global health community in developing and advocating for a long term response matters not just for preventing  future similar disasters, but, unlike most would think, also determines how we can deal (more) effectively with the one raging in front of our eyes. Government health expenditure stands at $7 per person per year in Guinea, at $18 per person per year in Liberia, and at $13 per person per year in Sierra Leone, according to the 2014 World Health Statistics report (estimates for 2011). Are we really going to build a ‘state of the art’ emergency response assuming that government health expenditure (including international assistance) will return to these (low) levels after the crisis? Or will the international community make sure that these levels increase to $50 or even $80 per person per year, and never again decrease to unacceptable levels?

The answer to this question – and everyone involved will have to answer this question, one way or another – will be decisive for the design of the ongoing emergency response and its aftermath. It is hard to imagine an effective response with 2.7 nurses (Liberia) or 1.7 nurses (Sierra Leone) per 10,000 people. It is striking that the 57 countries which lack basic health security are the same 57 countries lacking minimum access to a skilled health workforce (see World Health report 2006).

Additional caregivers will have to be trained on the spot. But how to find volunteers for this task, if short-term prospects are hazardous, and unemployment might ensue in the longer term? Over the last decade many health workers have migrated from countries in West-Africa, now affected by Ebola, fleeing the war, looking for employment elsewhere. They are direly missed now.

After the crisis, lessons will be learned, or not. For this Ebola outbreak, we cannot wait until the crisis will be over. The international community has to decide now whether it will provide the caregivers of Guinea, Liberia, and Sierra Leone  the bare minimum to protect themselves while risking their lives to save others – decent training and quality protective wear for a start – and the perspective of a job in a functioning  health system after the crisis.  Someday, this Ebola outbreak will be over, and the international health community, together with the governments of the affected countries, will have to face up to the arduous and long overdue task of restoring people’s trust in the health system.

Other viral outbreaks, such as SARS, have taught us  that we are dealing with “post-Westphalian” pathogens,  i.e. “transcending the idea of independent nation-states established by the Peace of Westphalia in 1648”. As Richard Horton noted last week, Ebola shows that the WHO and its member states-funders seem to have forgotten some of the lessons of the SARS crisis: “In its pursuit of “reform”, precipitated by member-state reluctance to invest in WHO’s core activities, the agency implemented cuts that fatally weakened its ability to respond to a global health crisis.”  Admittedly, WHO has been chronically underfunded the last decade, with tied funding to programs that restricted the organization in its efforts to build an autonomous response program to a global health crisis, so the blame is to be shared. Member States should seriously consider to re-invest in the WHO and/ or consider the development of a separate global (“health systems” see infra) contingency fund and mechanism to address future outbreaks of (re)emerging infectious diseases in an equitable and accountable manner.

The global health community, and decision makers, could continue neglecting transnational epidemics such as Ebola, and fail to adjust to “post-Westphalian public health” . It appears ever more likely though that sooner or later, the world will be forced to deal with “the Great Stink of the 21^st Century’” in a more serious way.