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Holbrooke is famous among high-level diplomats for his penchant to engage in reality-speak. He fashioned the Dayton Peace Accords by dishing plain-spoken bons mots to intransigent politicians of the former Yugoslavia. And late last month, Holbrooke offered a dose of reality to San Francisco. He is now the chief executive of a group called Global Business Coalition on HIV/AIDS, an alliance of multinational firms dedicated to recruiting other corporations to help combat the disease.
Holbrooke has been trying to bring attention to a disheartening fact: Worldwide, 95 percent of people infected with HIV don't know it, thanks to the failure of global testing programs.
When he spoke last month, Holbrooke linked the absence of routine HIV testing, which has rendered the world's greatest scourge invisible, to social struggles emanating from San Francisco in the early 1980s.
"It is my conviction now, based on having worked on this problem for five years, that testing is the weak link in the chain to defeat HIV/AIDS. And it is a weak link for – because, not to put too fine a point on it, the United States, in an extreme example of ethnocentrism, exported to the rest of the world a battle that was waged in the streets of San Francisco in the mid-1980s. It was the Angels in America period. And the Reagan administration – and not just the Reagan administration, but President Reagan himself and members of his administration and people in public life at that time – said very publicly, and you all remember this, that the disease was God's punishment for people of a certain sexual orientation.
"And the result was that the gay community in San Francisco and New York went into the streets and went ballistic. And they won the war. Because they were right," said Holbrooke, who represents 140 companies in his new role. "As a result of that bizarre cultural event in American life, testing was going to henceforth always be confidential and, in most cases, voluntary."
At its most basic, Holbrooke's goal can be summed up as inserting the term "routine testing" where international HIV protocol now uses the term "voluntary testing." In a recent New York Times editorial, Holbrooke denounced the focus on voluntary testing as "ethnocentric Western rhetoric, born in the 1980's in the United States under different circumstances."
HIV testing, Holbrooke believes, should be required at marriage, before childbirth, and during any hospital visit.
There exist two extremes in the world of public-health approaches to HIV. There's the U.S. approach, evolved from the 1980s San Francisco human rights struggles, in which a large network of public and nongovernmental AIDS organizations seeks ways to combat the disease that are mindful of privacy, individual freedom of choice, and the potential for discrimination. The San Francisco AIDS Foundation, for instance, does not directly recommend on its Web site that individuals submit to HIV testing. Rather, the foundation recommends that people make an informed choice, considering the advantages and disadvantages of being tested, which, the group informs readers, include possible discrimination by insurance companies.
The other extreme is Cuba, where, a decade ago, I researched and wrote a series of stories on the country's health care system. I remember dining with a Swiss physician who worked with an international health-related nonprofit group and the director of cancer surgery at a Havana hospital, at the surgery director's home.
The two doctors discussed the pros and cons of the Cuban approach to HIV, which involved widespread, compulsory testing of people deemed at risk of HIV exposure due to their travel or sexual histories. The government then quarantined those who tested positive; once quarantined, physicians interrogated patients about their previous sexual partners, who were in turn tested.
According to a 2003 article in the Journal of the American Medical Association, Cuba's approach was also different from America's in a more palatable way: In 1986 alone, the government invested $3 million in testing equipment. By 1993, 12 million tests had been conducted in a country with 11 million citizens. By the 1990s, the country was devoting $15 million to $20 million a year to anti-viral drug therapy, intensive medical care, and food and housing for quarantined patients. In 2002 the Cuban government reported an HIV infection rate of .03 percent, less than one-tenth the level of the United States; it was a figure the JAMA article said international health organizations had endorsed.
Cuba has held the line on the spread of HIV despite its global renown as a sex tourism destination. The world's other sex-tourism capital, Thailand, is rife with HIV/AIDS. Cuba is the only country with this kind of success. It's the only country in the world to take such draconian steps. Yet it's not held up in AIDS forums as a global model for HIV containment.
I should emphasize that neither Holbrooke nor his organization advocates a Cuban approach. Nor would I advocate totalitarianism of the Cuban stripe. But Holbrooke is attempting to draw attention to the possibility of a praiseworthy third way, in which saving lives in countries where millions of people are threatened by HIV takes precedence over a preoccupation with individual choice.
To get a better sense of San Francisco's historical role in the current global AIDS testing crisis, I called Trevor Neilson, executive director of Holbrooke's Global Business Coalition on HIV/AIDS, and asked him if the San Francisco legacy of the insistence that AIDS tests be confidential and voluntary is really as bad as Holbrooke says. Neilson noted that I was calling on the 14th anniversary of the death of Ryan White, the 13-year-old who contracted HIV from a blood transfusion, then had to sue officials in Kokomo, Ind., to be able to attend public school.