Four leadership decisions in 2017 that could rock the (global health) world

The coming year holds a series of major leadership changes that will determine the trajectory of the global HIV response for the foreseeable future. Given the size and scope of the global response, how much do individual leaders matter? We need only to look to the past to see the outsize influence strong leadership can have – and the vacuum created in its absence.

In 1986, in the midst of widespread fear, hysteria and denial among world leaders about the spread of a deadly new disease, a lone doctor and epidemiologist – Dr. Jonathan Mann – arrived in Geneva to establish and lead the World Health Organization’s (WHO) Global Program on AIDS (GPA). Over the next four years, Mann traveled the globe several times over calling on leaders to acknowledge what he was by then convinced was a global crisis, mobilizing funding for the response, and promoting a plan of action to address the social and economic injustices that he strongly felt were at the root of the epidemic’s spread.

Under Mann’s relentless and almost evangelical leadership, attention for the WHO’s call for urgent action to address the global AIDS crisis was on a meteoric rise. The World Health Assembly declared AIDS to be a worldwide emergency and adopted a global strategy for the prevention and control of AIDS (1987), the U.N. General assembly passed its first ever resolution on a particular disease (1988), and world leaders began to wake up to their responsibility to take action to stop the global AIDS crisis. By 1989, the Global Program on AIDS seemed poised for even greater impact and had grown from a staff of two and a budget of less than $500,000 into the WHO’s largest program with 280 staff and an annual budget of almost U.S. $110 million.

Just as GPA was rising in power, a new WHO Director-General — Hiroshi Nakajima — took the helm. Nakajima felt that the AIDS program had grown too large, infamously saying: “Don’t talk to me about AIDS; I have malaria, which is a much bigger killer of people, on my hands.” Frustrated by new institutional roadblocks at every turn, Jonathan Mann resigned from this post in 1990. It would be another six years, before the U.N. system would establish the United Nations Joint Program on HIV/AIDS (UNAIDS) and almost a decade before political attention and resources for the fight against AIDS would significantly increase once again.

Twenty years after Mann pioneered the global AIDS response, and in the wake of the recent election of Donald Trump as President of the United States and the installment of Teresa May as Prime Minister in the days following the referendum on the United Kingdom’s membership to the European Union earlier this year, few people would argue with the claim that leaders matter.

In 2017, the World Health Organization and the Global Fund to Fight AIDS, Tuberculosis and Malaria will select new leadership. In addition, the change of administration in the United States and the recent appointment of a new United Nations Secretary General, have introduced a great deal of uncertainty about whether the current leaders of the United States’ bilateral AIDS program (the President’s Emergency Plan for AIDS Relief or PEPFAR), and UNAIDS will continue in their posts.

Leadership change at all four of these institutions will undoubtedly have significant effects on the lives of people living with and affected by HIV. Together, these global health institutions are responsible for defining evidence-based and human rights-centered international norms and standards that guide the HIV response. They comprise more than 64 percent of all donor funding for AIDS programs, influence the scope and content of programs for people living with and affected by HIV in communities around the globe, and hold the mandate of mobilizing the necessary financial resources and political action to address the AIDS crisis.

These leadership transitions are also happening at a critical moment in the trajectory of the epidemic and the response. A growing number of experts now believe that it is possible to end AIDS as a major public health threat by 2030, and scientific evidence shows that starting HIV treatment immediately upon diagnosis enables people to live longer, healthier lives and is among the most effective ways to prevent HIV transmission. Yet, less than half of all people living with HIV have access to lifesaving treatment and over the past two years there have been record declines in donor funding for the AIDS response.

In October, instead of increasing funding to bridge this gap, a Global Fund replenishment target was set well short of what world leaders had agreed would be needed to adequately scale up the response. A new exchange rate formula used by the Fund for the first time to report the total amount pledged means that even less funding is available for allocation than previously announced at the time of the replenishment conference. This shortfall will mean that countries are able to put fewer people on treatment at precisely the moment the world should be aggressively implementing treatment for all. The next leader of the Fund must be a fierce and fearless fundraiser who is ready to call for a mid-term supplemental pledging opportunity to mobilize donors to bridge the gap that still remains.

The next WHO leader faces the responsibility of a similar opportunity. The recent High Level Panel on Access to Medicines report makes plain the need for aggressive, pro-health intellectual property reform in countries and globally going beyond the more limited mandate of the WHO Global Strategy and Plan of Action on Public Health, Innovation and Intellectual Property. The next WHO Director-General should make it a priority to implement the Panel’s recommendations, and to go even further and lead the way on advancing near automatic issuance of compulsory licenses on essential health technologies — allowing generic producers to manufacture and market generic equivalents premised on payment of adequate remuneration to patent right-holders. This kind of bold leadership will be necessary if we are to end AIDS as a major public health threat by 2030.

As the world seems to shift its gaze from an AIDS crisis that still looms large, it is more critical than ever that we have highly competent, mission-minded health justice warriors at the helm of each of these institutions.

In the coming years, audacious leaders must mobilize the funding needed, chart forward bold initiatives based on evidence about what works, devote themselves to systematically dismantling the policies and practices of marginalization and criminalization that fuel the epidemic, and must work hand in hand with an increasingly diverse array of private and public actors. They must be ambitious, principled, politically savvy and unrelenting in their drive toward the goal of ensuring quality treatment and prevention for all. Above all, because the epidemic rages on and threatens resurgence in the face of inaction, the world needs global health leaders who refuse to accept the false premise that the world’s response to the AIDS crisis has passed its peak.

The stakes are high. These leadership changes will have serious worldwide consequences. Whoever ends up running the global health world, activists will be watching and we stand ready to hold them accountable.