On February 18, Dr. Wafaa El-Sadr, the director of ICAP at the Mailman School of Public Health, presented on the HIV epidemic and its lasting effects on global and public health for the annual John Lindenbaum lecture hosted by the Columbia Vagelos College of Physicians and Surgeons.

Dr. Wafaa El-Sadr doesn’t believe in a magic bullet. As she traced the trajectory of the HIV/AIDS epidemic from the 80s to the present, she emphasized the role of the communities that make the delivery, healthcare providers, laboratories, and financing that allow treatments to get to the people who need them. As important as innovations such as PrEP and HIV rapid testing are, they mean nothing if they don’t reach the people who need them most. As director of ICAP at the Mailman School of Health, an organization operating in over 40 countries specializing in improving health services, Dr. El-Sadr is well-positioned to take a holistic perspective on global and public health. Her talk seamlessly integrated HIV with its impact on health systems, which in turn fundamentally altered how the world handled future epidemics and pandemics such as COVID-19. 

She began her talk with what she called “The Dark Years.” Just as many countries in sub-Saharan Africa began making strides in life expectancy, the HIV/AIDS epidemic hit in the ‘80s, undoing their progress. Life expectancy plummeted in the most severely impacted countries, such as Zimbabwe, South Africa, and Botswana. Health experts began to talk about a “lost generation” of young people lost to HIV/AIDS. The healthcare systems were equipped to provide acute care, or short-term treatment, but not the chronic care that treating HIV/AIDS infections required. Hospital beds housed multiple occupants, and unlucky patients didn’t get a bed at all. Death tolls continued climbing, and economies and health systems were left ravaged. Even with the introduction of antiretroviral therapy, a cocktail of medications that prevent HIV from reproducing, low-income countries still suffered from a lack of access to such treatment.

In response to this economic injustice, affected communities mobilized, precipitating what Dr. El-Sadr called one of the “most remarkable” turnarounds in the history of global health. Price decreases and foreign aid allowed sub-Saharan African countries to access treatment, leading to dramatic rebounds in life expectancy from 2002 to 2011. These countries used aid to invest in their health systems, a comprehensive term that includes the healthcare providers, service delivery systems, and financing. ICAP at Columbia University, which Dr. El-Sadr heads and helped found in 2002, was a vital part of revolutionizing these health systems. 

While foreign doctors were integral to ICAP’s operations, Dr. El-Sadr emphasized local communities’ roles: “They know the culture and the language.” Furthermore, reforming health systems involved task shifting, or changing who delivers and administers services. Due to a shortage of doctors, nurses and community members became more involved in providing and administering HIV treatment. 

This reform process fundamentally altered how much of sub-Saharan Africa approached future infectious disease outbreaks. As much of the world struggled to administer lifesaving treatment during the pandemic, countries such as Uganda and Eswatini benefited from the differentiated service delivery model they had been using for over a decade. Furthermore, many of these countries had invested in laboratory systems and strengthened their workforce. 

Dr. El-Sadr’s talk comes at a critical juncture in public health history. In terms of HIV, there are more than one million cases annually, higher than the global target. Nearly 40 million live with HIV globally (Dr. El-Sadr was careful to emphasize that the AIDS epidemic stretched far beyond sub-Saharan Africa), and around a quarter are not receiving treatment. But there are implications beyond the HIV/AIDS epidemic as well. As the global population ages, the threat of non-communicable diseases, such as cancer, cardiovascular diseases, diabetes, and chronic lung illnesses, will only increase. The infrastructure used for HIV/AIDS, another chronic condition, will be vital to tackling these threats. Dr. El-Sadr also mentioned climate change and human displacement. These issues are often not thought of in the context of global health. However, they both can increase rates of infectious diseases and cause death in and of themselves. “We need to use the same principles for [these] other threats,” Dr. El-Sadr said. 

Dr. El-Sadr did not shy away from discussing how President Trump’s policies will negatively impact global health. Nor were the implications lost on the audience. When Dr. El-Sadr discussed lessons learned from the HIV/AIDS epidemic, she talked about the importance of “political will, both positive and negative.” Sardonic laughter immediately followed. 

On January 20th, Trump signed an executive order withdrawing the US from the World Health Organization (WHO). WHO operations are integral to coordinating international disease responses, and the US was its biggest funding contributor.  Dr. El-Sadr emphasized the United States’s normative role in the WHO–the withdrawal may erode the organization’s structural foundation. Another executive order paused foreign aid from the United States Agency for International Development (UNSAID). Part of UNSAID operations is PEPFAR, an initiative that has donated over $100 billion to HIV/AIDS prevention and treatment in over 50 countries. PEPFAR is estimated to have saved at least 26 million lives. Secretary of State Marco Rubio has resumed some of UNSAID’s initiatives, but the state of foreign aid remains uncertain. 

Dr. El-Sadr did not underestimate the impact of the executive orders. Calling the predictions “quite dire,” she cited a study from South Africa that found that up to 600,000 more people could die in South Africa alone if the US withdrew PEPFAR funding completely. 

The executive orders regarding the WHO and UNSAID reflect a broader political climate of isolationism promoted by President Trump. The US has also withdrawn from the Paris Climate Agreement and the United Nations Human Rights Council, indicating an “America first” mindset. Despite US attempts to retreat from the international stage, the US cannot so easily extricate itself from the global community, Dr. Sadr argued. She referenced the COVID-19 pandemic as an example of the necessity of international cooperation to tackle global health issues.  “You can’t build walls around countries anymore,” she said, possibly referencing Trump’s border wall plan. As the world faces an uncertain future in the face of climate change, international cooperation will only become more important. Failing to do so could put everyone at risk. 

Still, more research is needed. Dr. El-Sadr and her colleagues are currently attempting to secure more funding for studies on the political climate’s effect on health outcomes. When an audience member asked what health professionals can do to combat political resistance to global health initiatives, Dr. El-Sadr cited the historical importance of coalition building and institutional support. She later stated that she wakes up and thinks about what she can do every day–the future remains uncertain, and it is impossible to answer such a question with absolute certainty. 

Amidst all the doom and gloom, Dr. El-Sadr remains optimistic. “I’m a believer that people can come together and make change.”

Header image via Flickr