Megatrends and Maximizing Impact

31 May 2017 by Mark Dybul

On 31 May, Mark Dybul completed a four-year term as Executive Director of the Global Fund to Fight AIDS, Tuberculosis and Malaria. The following is adapted from remarks he recently made to the Global Fund Board.  

It is now 15 years since global health leaders came together to form the Global Fund partnership. We have made incredible progress toward the vision of a world free from the burden of HIV, tuberculosis and malaria, and investing in resilient and sustainable systems for health. The countries we serve have saved more than 20 million lives and reinvigorated communities and countries all over the world. More broadly, what seemed impossible 15 years ago has been achieved. We are at the tipping point of ending the HIV, tuberculosis and malaria epidemics.

But tipping points can go either way – success or failure. New and urgent challenges confront us. The last stages of a battle are often the toughest. Every inch of progress we make from here will be harder and costlier than the last. If we fail, the epidemics will rebound in aggressive, drug-resistant forms that we do not have the science or resources to control.

We need to address a real break point with young people. We can either have a demographic dividend, or we can have a demographic disaster. That’s true across the portfolio of development, but it’s especially true for HIV. In past years, the data have become very clear on the driver of the HIV epidemic in southern Africa: It’s adolescent girls and young women. We didn’t really understand the dynamics until a group called Caprisa showed, by tracing the virus genetically, how infections occur. We see it in a cycle of sexual relations, and we now know that 15-to-25 year-old adolescent girls and young women in some places in sub-Saharan Africa are 14 times more likely to be infected with HIV than boys and young men. They become vulnerable to infection by 25-to-35 year-old men.

Who are these people, as human beings? Why are they the most vulnerable, not just to HIV, but in general? What are the social and economic pressures that influence their behaviors and circumscribe their choices? The data show that we are flat out missing the young people most at risk. They are not even getting tested. If they do not seek testing, we can’t get them to services, and we will perpetuate the cycle. If we don’t start to reach these people, the cycle will become unbreakable. It’s breakable if we can understand who these people are, and cater prevention and treatment services to their needs.

We must find better and faster ways to engage young people about HIV. The choices are stark. If we stay the current course – with high infection rates and the current youth bulge in sub-Saharan Africa – we will have more HIV infections in 2030 than in the 2000s. If we invest vigorously and innovatively in responding to the challenges they face, we can end HIV as an epidemic for good. If we get it right, it can be a huge opportunity. If we don’t, it’s a massive cost. 

The mobility of ideas and people is equally urgent. We live in an age of unprecedented connectivity, and we must do more to leverage the tools at our disposal to share ideas. In the development community, we’re not sharing ideas as quickly as we should be. As we develop mechanisms and tools, we need to create open source tools that can be shared on line. Ideas are moving so quickly. If we catch up, and share those ideas, we can do better in development. People are moving more than ever before. In 2015, there were 244 million people moving across borders, up by 71 million from 2000. Only 20 million of the 244 million, less than 10 percent, were refugees. Movement is about economic mobility. If we are to tackle the challenges that come from movement of people, we must broaden the issue beyond refugees. 

To achieve global health security and end epidemics, we have to create models that reach people with prevention and treatment services wherever they go. The Maldives are an instructive example. They set up TB treatment programs for international workers, who account for 44 percent of professional workers and 76 percent of manual laborers. When these workers come into the country with TB, they receive comprehensive treatment, allowing them to be cured and to work. The alternative – turning away a person with TB at the border – risks losing that person to treatment entirely and potentially fueling the spread. Thailand provides its national health insurance to documented migrant workers and is trying to extend those services to undocumented workers. This is the future. How we take care of people who cross a border, from a health perspective, is something we must engage in, supporting countries to deliver such health care services.

If there is an infectious disease outbreak anywhere, all of us are threatened. When people move, we must reach them with good health services wherever they to choose go. The new threat of antimicrobial resistance can hit the world from many corners. Fighting malaria resistance in the Mekong or drug resistant TB anywhere in the world should be the responsibility of all of us. In today’s interconnected world, we cannot be safe if others are unsafe.

It’s a hugely exciting time, and a challenging time, in global health. If we do things the same way, we’ll do good work but we will never get where we need to go. To actually end the epidemics of HIV, tuberculosis and malaria, the Global Fund partnership needs to act, innovate and evolve as it has for the last 15 years. We can tackle these problems and we will succeed. The challenges might seem daunting, but we’ve achieved what was thought impossible 15 years ago, and we can do it again.