Emily Mendenhall, a professor of global health at Georgetown University’s Edmund A. Walsh School of Foreign Service, has developed an idea that she hopes will help solve an ongoing health crisis in Sub-Saharan Africa. Mendenhall proposes that the President’s Emergency Plan for AIDS Relief (PEPFAR) fund treatment for noncommunicable diseases—such as diabetes and hypertension—in addition to antiretroviral treatment, which PEPFAR has provided for more than 10 years. I recently spoke with Mendenhall, who has conducted research on poverty, depression, and diabetes in vulnerable populations in Sub-Saharan Africa. Our exchange has been edited and condensed. (Maria Fabrizio)
What specific problem does your proposal try to solve? In 2004, George Bush created the President’s Emergency Plan for AIDS Relief to address the global HIV/AIDS epidemic, primarily in Africa. At that time, HIV/AIDS in Sub-Saharan Africa and in low- and middle-income countries was a clear emergency. These funds delivered antiretroviral treatment and absolutely transformed the landscape. Through this incredible amount of funding for HIV treatment, many people walked away from their deathbed.
A decade later, HIV has changed from an emergency to a chronic infectious disease, largely because people are now able to live longer and healthier lives on antiretroviral treatment. But many are starting to suffer from infectious and noncommunicable diseases, such as stroke, heart disease, diabetes, and mental-health issues, in addition to HIV. There has been an increase in noncommunicable disease among the poor in low- and middle-income countries, especially among the HIV-infected and HIV-affected, because as these countries become more economically advanced and people live longer and come out of poverty, people’s lifestyles change significantly. For example, many people who transition from working in the field to the city may have to travel an hour across the city, and will often find themselves eating on the go and consuming fried fatty foods along the streets. This is a common narrative that leads to widespread obesity, from which emerges hypertension and diabetes, as well as mental-health issues.
Having chronic illness, especially two severe chronic illnesses, can be really complicated. These diseases require consistent management. So if you have HIV, you are going to have to go to the hospital quite often for testing. But let’s say you have diabetes as well. Diabetes also requires going to the hospital a lot. The problem is that in a lot of health systems, you don’t just go to one doctor to test all of your diseases; you go to different clinics for every disease.
What are PEPFAR’s current policies? The legislation and funding have not kept pace with the epidemiology. PEPFAR says they’re trying to bring comprehensive HIV treatment, but they’re not considering co-morbidities or multi-morbidities. The international policy is currently exclusively focused on disease-specific programs. There is a lot of political recognition of the impact of overlooking noncommunicable diseases, but the global health funding doesn’t recognize this.
How Do you propose that PEPFAR change? The best thing that PEPFAR could do for this changing epidemiological landscape would be to provide care for all the diseases that people who are HIV-positive have. Although its legislation doesn’t currently allow for this, PEPFAR needs to care for people as people, not simply as people with HIV disease. If someone who’s HIV positive also has diabetes, hypertension, and depression, they should get care for all of their problems, not just their CD4 count. Overlooking those diseases is a death sentence in the long term. Their untreated diabetes is going to affect their HIV disease.
We need to fund health systems to provide comprehensive health care to the poor. If everyone who commits to global health could transform their funding into building health systems, there would probably be fewer short-term advances and successes, but there would be many more long-term successes. You want to bring extraordinary success to the immediate need as well as the long-term need.