Two Memos: Issues and Reminders

Every think tank and every policy wonk in the country is working on white papers, analyses, proposals, critiques, and plans in the hope that their ideas will be placed before the new president and the new Congress. The HIV/AIDS community is no different, and there will be many ideas specific to this epidemic proposed to our new government. Given the short space available for this issue's Policy Watch, the following 2 memos have been written to capture a few essential points for 2009 and beyond.

To: President Obama
From: Those concerned about HIV and AIDS

Mr. President, you have come to office with an enormous supply of good will from the people who elected you-people who hope deeply for change in a positive direction. Your postelection remarks make it clear that you understand the difference between campaigning and governing; we believe that the discipline and vision you brought to the former will also be evident in the latter. Your Cabinet choice for secretary of Health and Human Services (HHS) is an experienced legislator who has thought and written about problems in our "non-system" for health insurance and service delivery. Others you have named to Cabinet and other posts appear to be equally qualified for the assignments you have handed them.

On World AIDS Day, after recognizing the international AIDS issues, you said¹:

“But we must also recommit ourselves to addressing the AIDS crisis here in the United States with a strong national strategy of education, prevention, and treatment, focusing on the communities at greatest risk. This strategy must be based on the best available science and built on the foundation of a strong health care system."

A key question for you and HHS secretary-designee Thomas Daschle is the agenda for your first few months in office. There are a few critical issues that we would suggest you put at the top of the list.

1. Appoint an AIDS policy coordinator who has serious experience in the interdepartmental, executive/legislative, and White House worlds. [On this I speak from experience, knowing how easy it is for old-timers set in their ways to confuse, delay, or even derail the best of a newbie's intentions.] Back him or her up with a national advisory group who knows the epidemic and the history of our successes and failures and who will carry the administration's AIDS message to the community while challenging your agencies. Charge your AIDS czar with reenergizing the policy office and making sure that Cabinet policies and your own legislative liaison staff work together on such concerns as the following:

a. Allowing the District of Columbia to set its own policies for HIV prevention and services. The limitations put on the District regarding syringe and needle exchange fly in the face of science and of proven effective public policy.

b. Carefully examining any and all limitations not based in good HIV/AIDS science that were put on the use of PEPFAR (President's Emergency Plan for AIDS Relief) funding around the globe. As with the District of Columbia, each involved nation should be able to coordinate these funds and make use of all demonstrably effective approaches to prevention and treatment. This must include a full range of sex education, access to condoms, and access to treatment for all those infected.

c. Making HIV prevention research (including behavioral studies on sexuality and addiction) as important as treatment and vaccine research.

2. Energetically pursue a system for universal insurance coverage for all, with benefits that include prevention, diagnosis, and treatment. Let no advocate for an age-group, disease, treatment, business, or profession be allowed to capture the debate for a parochial agenda. We as a nation are a global embarrassment in our failure to use wisely the wealth of this country to ensure that all have the opportunity to receive the care that is needed. And do remember that care that is needed does not mean "anything I want" or "anything someone can invent and market."

3. Assure us that we will have federal leadership for a well-supported public health system that can monitor the health of the nation and provide the essential primary prevention services that will guarantee the conditions within which we can all remain healthy. Protection of the food supply, assurance of comprehensive health education, management of waste products, and identification of new threats to health are public health services that go beyond what a good personal medical care system provides and reduce the need for care. These benefits must be there for everyone.

Thank you for your leadership. Please let us know what we can do to help you make these essential changes happen.

To: Those concerned about HIV and AIDS
From: Me

As I watch this new administration get ready to take office-with our national health policy and, specifically, AIDS policy on my mind-the wish lists that have been accumulating over the past 8 years will probably become longer and longer. This memo is a reminder and a warning from one who inherited the overwhelming wish lists that have accumulated from before the beginning of the Clinton years and who-like many of you-has learned many hard lessons about how difficult it is to make change happen within any president's administration. Some things to keep in mind:

1. A White House policy coordinator who is successful will be more of an inside staff worker than a public figure. Let the chair of the president's HIV/AIDS advisory panel be the public face, and don't expect the coordinator to spend much time "out and about."

2. Please don't see health reform as a distraction from HIV/AIDS policy. Comprehensive health coverage is an essential underpinning for our response to any disease. The years of struggle to support medication, hospitalization, home care, and other health services for those living with HIV provide more than enough evidence that we need a better system. There will be the temptation, however, to let the particular concerns about HIV distract us from the central issue, which is "everyone in." Yes, the devil is in the details, but a focus on details helped derail the 1993-1994 reform debate. Once we get everyone included, we can (and will have to) clarify ways to deal with both chronic and acute conditions, long-term care and ambulatory care, and mental as well as physical health.

3. Be realistic about the pace of change. It's easy to talk about a president doing things with the stroke of a pen, but the translation of those pen strokes into real services at the local level, either domestically or globally, will take a while. Don't become discouraged, and don't blame the pen-wielder for the multiple steps needed in the hours and days after the signatures are in place.

I can see in the emerging Obama Administration the beginnings of so many changes that are critical to HIV/AIDS policy, practices, and programs. Continue to offer advice and support to each other and to our new government's leadership team.

References:

Reference1. Obama Addresses World AIDS Day. Washington Post. December 1, 2008. http://voices.washingtonpost.com/the-trail/2008/12/01/obama_addresses_world_aids_day.html. Accessed December 4, 2008.