December 1 is World AIDS Day, and January 2023 marks 20 years of the President’s Emergency Plan for AIDS Relief (PEPFAR), which provides for groundbreaking AIDS treatment, prevention, and research. In this episode of Big World, SIS dean Shannon Hader, an expert in infectious diseases and epidemiology and a global leader in the fight against HIV/AIDS, joins us to explore how the AIDS response informed policies during the outbreak of COVID-19 and how politics impacts the public perception of public health crises.
Dean Hader discusses how PEPFAR’s monumental achievements have influenced public health policy (3:22) and how PEPFAR continues to garner bipartisan, bicameral support from Congress, even throughout a time of intense political division (5:43). She explains how blame and shame are not sustainable or effective responses to an infectious disease (11:30). She also talks about the dangers of putting the goals of disease prevention and treatment in opposition to one another (13:23).
How did the HIV community respond to the emergence of the COVID-19 virus (17:07)? While with UNAIDS, how did Hader help advise public health officials on how to protect human rights amid a crisis (18:51)? Hader answers these questions and discusses the importance of data in making sound decisions and targeting resources (21:01). The episode concludes as Hader shares how her impressive career in public health prepared her to lead a top-10 international relations school (27:17) and what she hopes to accomplish while at SIS (31:20).
During our “Take Five” segment, Hader shares the five steps she would recommend to governments around the world to create and sustain positive forward momentum on AIDS research, prevention, and treatment (22:29).
0:07 Kay Summers: From the School of International Service at American University in Washington, this is Big World, where we talk about something in the world that truly matters. In June of 1981, public health officials first noted the appearance of a rare lung infection in five previously healthy, young, gay men. These men were the first identified victims of the disease we came to know as AIDS. It was nearly two years later in May 1983 that French scientists first identified the virus that causes AIDS, the human immunodeficiency virus, or HIV. As history shows, the world was slow to mobilize, to understand and fight the spread of HIV for reasons that had everything to do with the negative perceptions of the people who initially tended to contract the virus, gay men and IV drug users. It was not until so-called "innocent victims" of AIDS, like teenage hemophiliac Ryan White, got sick that then President Ronald Reagan publicly mentioned the disease by name.
1:07 KS: But while this tragic inaction was occurring, public health officials and researchers were scrambling to identify the scientific causes of AIDS and to slow transmission of the virus. And their efforts bore fruit with the advent of safe sex and safe needle campaigns. And most crucially, the development of antiretroviral drugs introduced in the '90s that have allowed people with HIV to live more normal lives without an inescapable death sentence hanging over them. However, in the mid to late '90s, the nexus of the HIV/AIDS epidemic shifted to Africa where it has remained ever since. And for the most part, the Western world's attention has long since turned away. So, today, we're talking about global HIV/AIDS policy since the early 2000s, and we're also going to touch on global infectious disease policy in the time of COVID.
1:55 KS: I'm Kay Summers and I'm joined by Shannon Hader. Shannon is Dean of the School of International Service. She's a medical doctor who served as former Assistant Secretary General of the United Nations, and Deputy Executive Director of Programs at the Joint United Nations Program on HIV/AIDS, or UNAIDS, Director of the Division of Global HIV and TB at the Centers for Disease Control and Prevention, Senior Deputy Director of the HIV/AIDS, Hepatitis, STD, and TB Administration at the District of Columbia Department of Health, and Senior Scientific Advisor to the President's Emergency Plan for AIDS Relief at the US Department of State. Shannon Hader, Dean of the School of International Service, thanks for joining Big World.
2:38 Shannon Hader: Thank you for having me.
2:40 KS: In January 2003, then-President George W. Bush launched the President's Emergency Plan for AIDS Relief, or PEPFAR, for short. Since its inception, PEPFAR has provided more than $100 billion for AIDS treatment, prevention, and research. And PEPFAR was the largest mustering of global health resources focused on a single disease until the COVID-19 pandemic. You are someone who's worked with PEPFAR in many different roles in your career. So I wonder, as we approach the 20th anniversary of this monumental effort, would you tell me briefly about PEPFAR's achievements and put those in the context of global public health efforts?
3:22 SH: Sure. So many. We can start with the most concrete and stark, so what are some of the impacts by the numbers, right? PEPFAR alone has led to over 21 million lives being saved over its almost 20 years of existence. More than 2 million babies being born HIV-free, who otherwise would be HIV-positive. But more than that, PEPFAR really helped push an entire movement globally for a global response. And along with the founding of PEPFAR was the founding of the Global Fund for AIDS, TB, and Malaria, which the US also directly supports. It came along with the movement started by the World Health Organization, WHO, to have this three by five initiative, 3 million people on HIV treatment by 2005. And this was this whole mobilization coming together of both money, and as you said, money that hadn't been seen at this level before in a dedicated way, but also super huge aspirational goals. Goals that people said were impossible.
4:32 SH: That 3 million people on HIV treatment by 2005, that was starting from a starting point of fewer than 40,000 people, particularly in developing countries, which was the bulk of people living with HIV, fewer than 40,000 people on lifesaving HIV treatment at that point. And yet, where have we gotten to from that? We've gotten from that fewer than 40,000 people on lifesaving HIV treatment to 29 million people on lifesaving HIV treatment right now. And everything that went into achieving these sort of big, almost unimaginable goals that got a lot of criticism for being too bold, had to do with political commitment, had to do with financial commitment. But it had a lot to do with also saying, "We're going to do things in a different way."
5:28 SH: And so when I look at some of the things that allowed PEPFAR to be hugely impactful and to be different and to be not business as usual, there are some really important things. PEPFAR was founded based on congressional authorizing language. And that sounds sort of really boring, but what it meant is it laid out the parameters in five-year cycles, essentially for our US commitments to these programs. And what it's meant is we've had bipartisan, bicameral approval of each five-year authorization through unanimous consent, even in this time when we're seeing so little bipartisanship, so that's one thing that was distinctive. Second thing that was distinctive that was laid out in this sort of, "How we're going to do business differently?" In the authorizing language, was this idea of all of US government coordination. They actually made a Global AIDS Coordinator sitting in the Department of State, Ambassador-at-large level, which not everybody likes, right? Who are these czars? Why do we need them? Is it undercutting the organizations of experts we have?
6:46 SH: But in this case, they also gave that position through Congress fiscal authorities, made them responsible for saying, okay, not only do all of the US government agencies who spend money on HIV abroad have to sit down with you and coordinate, but you get to approve their budgets for HIV for how they're spending their HIV dollars, even if that money is going directly to their agency. And so it's really based on almost like, in terms of planning and strategy, more of like a Joint Chiefs of Staff model, this idea that you're going to have different expertise, different insights, and you're going to be stronger when you're coordinated and when you're together on that. But it was also really based on getting the most out of cohesive investment.
7:35 SH: And what then followed from that, and was also in this authorizing language, was a set of expectations for results, for transparency and reporting on results, for accountability. So that in fact, and a granularity of accountability for results on this that hasn't typically been seen in our global health or development work, but was so unique that I'm very convinced that's part of the reason PEPFAR continued to get bipartisan, bicameral support and raised budget over the years because folks could see what was and wasn't happening, what results were coming out and being successful and what weren't, so that things had to change.
8:25 SH: It wasn't just about having perfect results, it was about having results that were transparent, that you could see where the bang for your buck was, and you could see where you had more work to do. And I think all that together really layered into an entire approach that was about iteration, and update, and what's next. The original launch of the PEPFAR program, the strategy in part was cheekily, but actually verbally said it was a point, shoot, aim. So there was a fear that a bunch of the experts would just sort sit around and do research and figure out what the perfect solutions were and not actually fulfill the mission of PEPFAR, which was to get money out there that would save people's lives and decrease the HIV epidemic.
9:17 SH: And so I think this issue of rapid iteration, of evaluation and reset of what's turned out to be incorporation of new science, new technologies, new approaches, new understandings of service delivery, and what works and what doesn't work, new understanding of participation, and who needs to be at the table and how those decisions get made if you really want them to take off, all of those together have continued to drive a dynamic program that looks very different today than it looks 20 years ago.
9:56 KS: We're going to talk a little more about HIV, but I do want to talk for a few minutes about the global COVID-19 pandemic. We know that COVID-19 isn't ending. The virus isn't going away, but the world has emerged from the acute crippling crisis that typified the first two years of the pandemic. I think that especially in this country, the US, there has always been, at least from my observations, a tendency to see infectious disease crises as something that only happens among "those people" who make different sexual choices or who have the poor judgment to live in the developing world as though that's something that people get to decide.
10:34 KS: It's not a great viewpoint. Now, with the benefit of not being paralyzed by fear and also a tiny bit of hindsight for all of us, I wonder, do you think that the airborne nature of the COVID virus and perhaps even this inescapably visible tragedy of widespread casualties that we have had, seeing that viruses don't pick and choose people, has done anything to lessen this reflexive western reaction about disease being the fault of the person who caught it? It's a long question, but I'm wondering if, I guess the short question is, has COVID-19 helped grow our empathy for disease and people who contract them?
11:22 SH: Yeah, I'm not sure I agree with everything that's in the prelude of that question, but let me jump to some of the things that I think are really important take home points on that. What is the role of blame and shame in a public health response? And this isn't just about global work, it's also about domestic work, and it always has been. I'll say as a doctor and a public health scientist, almost as an across-the-board finding, blame or shame are not sustainable nor effective modes of disease prevention or survival. They just don't work. You can talk about on every single level, scare tactics, even if they help in a short-term, they do not sustain. And so it has been disappointing to see how much of that has raised its head again, as it is like to do in the COVID epidemic.
12:29 SH: And it has created a lot of the riffs that we are still dealing with in the COVID response. I think we could unpack vaccine hesitancy and anti-vaccine positions, but beyond those specific unpackings, a lot of the tenor around interventions became so politicized, I think, because it really was couched in blame and shame, was not necessarily couched in protection, in civic respect, in doing what you can to help not just yourself, but also your family, also your community. And so I don't know that we've escaped that blame and shame with the COVID response. In fact, I think we reverted to it way too much or let it get out of control. But a second part of the challenge that also we had the opportunity to escape, but I don't think we escaped it again, is there has oftentimes in public health been this perceived tension between prevention versus treatment. And now, before we have treatment for a disease, all you have is prevention and mitigation, and you have to do what you can with that.
13:54 SH: But this idea that you would put prevention and treatment, especially for any infectious disease, in opposition and add, we've somehow routinely added some sort of moral value superiority on prevention, which drives me crazy because it doesn't work. And I just don't think it's right. And so I think that I was hopeful when the COVID pandemic started that, yeah, we would have people more understand some of these complexities. Complexities of who gets disease, who suffers from it the most, who doesn't, how that takes off. Certainly what was highlighted and people got very familiar with were disparities in who's getting COVID and who dies from COVID, whether that's because of comorbidities, other medical diseases. And we certainly know in the United States, you can track severity and presence of some of these comorbidities by zip code because there are so many influences of structural policies on the longstanding health of people. With disparities and who is being hurt by a disease, who has access to health services for it, such huge illustrations about how many of those factors aren't about individual choices or reactions or health.
15:27 SH: The fact is, if you are a frontline service worker, be it a bus driver, or a school lunch lady, or a nurse, or a doctor, you're going to be more likely to be exposed to COVID when it's out there. All these different structural factors. Yet at the same time, I didn't see us fully respond to those in ways that didn't repeat our mistakes of the past. I'm not giving up. I do hope we will be investing more in these non-shame, non-blame strategies in this idea that for a holistic response to any disease, you want prevention, you want care, you want treatment, you want to address the social factors surrounding the disease that help people benefit from prevention, mitigation, and treatment, whether it's your jobs, your education, your safety, your security. And I hope that we'll invest more and more in addressing some of these structural factors that drive disparities across communities as well. But I don't think we got it figured out with COVID.
16:39 KS: Shannon, as I said in the opening, HIV/AIDS first emerged in 1981, so we're looking at more than 40 years of HIV/AIDS as a public health crisis. Looking at this intersection with COVID again, how do you think lessons from the AIDS response informed how public and government officials responded, discussed, and treated COVID-19, especially in those early days?
17:08 SH: I think there was a lot that we've learned in the HIV response as well as TB responses that was directly relevant to especially the early days of COVID where we had some things that were known. We had this really, at the time, very unimaginable level of transmissibility and severity and not a lot of tools. And so I think across the HIV community, there was a really active response of, "we can help." We don't know everything, but we know some things that should really rise to the top of the response. And we also have a lot of mistakes we made that we would hope that you don't need to make again. It's the lessons learned, including the unfinished business that had a lot to do with COVID-19. How did this rise up?
18:01 SH: What do we see on this? Well, worldwide actually, you saw that a lot of the national leaders on a nation's COVID response actually stepped in from the HIV community. We saw that here in the US with Tony Fauci and Debbie Birx. They came from an HIV background and were contributing. That happened all over the world to be huge parts of the initial mobilization of the response. So, the leadership and the experience really mattered. We brought examples of how to think about getting services, services like testing to large volumes of people very quickly in ways that were acceptable, that would work for them, that would help you then decide what to do. We also brought some of the, I think, broader wraparound social experiences that if they're set up right, they help, and if they're set up wrong, you dig yourself into a hole.
19:07 SH: One of the first reports we put out as UNAIDS was essentially a "How to Have Rights in an Epidemic" portfolio platform that says, this is what we've learned about the HIV response. And it essentially highlighted ways in which in a public health emergency, you can absolutely have restrictions, take policies and measures that put burdens on people to have to comply and change some of their day-to-day activities. However, you need to do that in a way, if you're going to be effective and sustained, that actually protects human rights. And you can do that if your policies are evidence-based, not capricious, if they are subject to review and change, subject to external review and change, if they make accommodations for the most vulnerable people versus persecuting and exacerbating impact on the most vulnerable people.
20:07 SH: These are all things that can allow you to have sometimes very aggressive public health policies, but in a way that actually helps protect people's rights and helps you evolve and change them as your knowledge of the epidemic change and as the epidemic itself changes. I'm not sure we saw that holistically around the world. We saw countries where having some of the lockdown policies and some of the public health policies were in fact used as excuses to go and do, let's say, raids on houses of young, gay men who live together under the excuse that, "Oh, that's not a real family, and so we're going to arrest you." So, we didn't fully learn all of those, not only how to have rights in an epidemic, but how to, as part of that, change your options as you learn more and as you have more tools.
21:02 SH: One of the things that I was hopeful and do think we landed in a better place that became so clear in this epidemic that we've spent years building in the HIV response is this idea of, to make sound decisions, to target resources, to those who need them most and will benefit most, you need data, data, data. You need data in real time so that you can intensify in places that need more intensified support so you can back off when you don't need them anymore. And the second is this issue of disparities, being able to look below the surface, to get away from just the tyranny, the average, and differentiate, in more granular data, who's being left behind so that you can then supplement, enhance. So, I think, again, that became very visible, including our gaps in it during the COVID response, but I'd say it remains unfinished business.
22:07 KS: Shannon Hader, it's time to Take Five. You get to reorder or maybe just put your spin on the world. This podcast is scheduled to release on December 1st, which is World AIDS Day. What five steps do you think governments around the world should take to create and sustain positive forward momentum on AIDS research, prevention, and treatment?
22:28 SH: Take Five. Top five things. All right, let's do this. One, keep their commitments. Nearly every country in the world has committed to bold new targets for 2025 in their HIV response, and those commitments include differentiating their response, going from one-size-fits-all that have delivered some really good services, and buckling down on what the people who haven't benefited yet need now. So, differentiating the response, intensifying it for those who haven't been reached yet, and keeping their commitments. Second, make sure we continue to put and do a better job of putting communities in the leap. We need to not just make community leadership a slogan or a mantra, but we've got to fund community-led organizations to be at the core of many different parts of the responses from policies and decision making to service deliveries to that accountability of, is what's been promised actually being delivered in your neighborhood at ground-level?
23:39 SH: Third, I would say invest in the social factors that are going to change the course of the disease. So, there is a huge evidence base that you can actually change some of these social and structural factors with investments, with interventions, but they don't happen necessarily organically, or at least not on a timeframe that is sufficient for what we need. So, invest in the political will and the policy changes that will help decriminalize people and behaviors and lay the groundwork for an expansion of harm reduction modalities that reduce harm for the people who are most vulnerable to HIV. Invest in decreasing violence. Violence against women, violence based on gender, violence towards people living with HIV. Safety and security is critical for any of us to have our health and wellbeing at the forefront. And continue to battle stigma. Stigma is not something that goes away on its own. And if you're not actively investing in programs to counter stigma, it has this tendency to resurface.
24:50 SH: Number four, I would say, continue our fabulous biomedical innovation. The fact that we are so much better off now than we were 20 years ago has to do with the many different interventions we've talked about and the many different political commitments. But going from 25 pills a day that are unforgiving if you miss even one, that make you nauseous, that have huge side effects to one pill a day for most people, which might be now one shot every two months for other people, that just makes everything easier. And I think there's all sorts of innovation that we still are hoping for and counting on, including innovation for a vaccine and innovation for a cure, not giving up on those. And then I think finally, got to continue the funding. Money matters. If we think about the billions we spend on everything in the world, even the big numbers on the HIV epidemic are a sheer rounding error to everything else we spend money on. And yet the value of what we've gotten out so far, our commitment to showing results, showing what that money has bought has been really tremendously successful.
26:09 SH: And so I think even as the world is in a time of economic uncertainty, even as the value of different currencies and dollars is fluctuating all over, which makes it harder for some of our countries to move forward on what they had planned, now's not the time to back off on funding, either for HIV specifically or public health writ large. We got to double down on investments so that we can get to that end that we have in sight.
26:41 KS: Shannon, I want to talk about you for a moment. I know you don't want to, you'd rather talk about health policy, but I do want to talk about you for a moment. After an impressive career in public health, both on the science side and the policy side, you've had positions at the local, national, and global level, you're now the Dean for the School of International Service. What drew you to academia? And how do you think your career as a pediatrician, an internist, an infectious disease specialist and an epidemiologist have prepared you to lead a top-10 international relations school like SIS?
27:17 SH: Yeah, so as you know, I am thrilled to be here, and I feel like a kid in the candy shop just getting to learn about all the phenomenal scholarship and programs and projects that are going on across SIS, much less meeting the students and meeting the alumnis who all bring their own stories and experiences to the table as well. Hopefully from our conversation so far, you get the sense of what, to me, it's meant to be an AIDS doctor, which is, and a health diplomat who is part of embassies out there in a bilateral mold or a multilateral mold trying to negotiate, work with stakeholders to achieve certain outcomes that aren't happening yet. But an element of the HIV response is, yes, HIV is a virus, but it's always been much more than being about a virus, right?
28:13 KS: Right.
28:13 SH: It's been about the social factors that have to do with who gets infected, who doesn't, who gets resources, who doesn't. Has to do with the political factors and the political will of, who counts and who we're going to pay for and who we're going to empower in our political decisions and investments. Has to do with education and poverty and so many intersecting issues on social justice and structural determinants. To me, that's a whole lot of what SIS does writ large. That's the whole essence of a multidisciplinary, interdisciplinary, and even transdisciplinary school, is that we bring people together. We bring experts together, and we bring community members together who come from different perspectives and different expertise and different disciplines, and we pull them together to say, "You know what we want? We want to solve the world's most complex problems," and there is no way that is going to happen coming from just one discipline or perspectives.
29:19 SH: And so I feel like that background, not just as a pediatrician or an internist, but really part and parcel of a global and local HIV response, of a global and local social medicine, social justice understanding of disease, of how your policies and programs and research need to be driven by what's going to matter to communities. I feel like that fits in really well at SIS. And part of the reason the SIS appealed to me so much really.
30:00 SH: It captured my attention from our name to begin with, School of International Service, not just the School of International Studies. And that service, which to me resonates as a scholarship informing practice, and that practice informing cutting-edge scholarship that recognizes there's so many different angles of service that you can come at. That when I scratch below the surface and convinced myself it wasn't just like a branding mantra that had no substance, and I found out, no, it's not just some substance, it is generations of substance. And it is a mission drive and a pride of members of our community, from students to faculty and staff to alumni that I find completely resonating with me. And I do hope that my professional experience resonates with SIS, has something to offer.
30:58 KS: And you mentioned trying to solve the world's most complex problems, which is always something that the people who come here to study are trying to build the skills to go out and try and do that, but it's a bit of a to-do list. So in kind of framing that a little bit more, what do you hope to accomplish while leading SIS?
31:19 SH: Yeah, so many things. How to distill a few down? I think there are a few buckets that, of course, get my attention right away. The student experience, how do we not only continue to deliver on the student experience we've had, but continue to push ourselves to make sure all student experiences, including overseas studies, including internships, are available to all of our students? Reducing any barriers that limit access. How do we make sure our students are learning not just what was important in the last 10 years, but what's going to be important to the next 10 years as we come through? How do we make sure that they are problem solvers and diplomats and creative thinkers and leave SIS confident in their ability to reach out to alumni and network, to sit at tables of power and have insights and influence and ideas to share?
32:21 SH: I think a second important bucket that I think about is: How can I as Dean really help to support and boost our mission of big ideas and big solutions? How do I make sure our faculty and with our students are empowered to be developing some of these cutting-edge solutions, identifying the policy insights that we need to apply if things are going to change? So how do we strengthen the ability for our faculty to do research and to have high impact with the research we do? How do we make sure students can be part of that if that's where their interests lie? How do we convene and make sure we are bringing together special people on interesting and innovative angles of unpacking these big topics and these big solutions and in ways that frankly reflect our unique values and perspectives, our unique commitment to interdisciplinary, not always in agreement perspectives that reflect a commitment to service, to waging peace, to positively impacting humanity?
33:41 SH: And then I think the third bucket really that crosses over with the other two is partnerships. How can I help strengthen partnerships that we do have and reach out for additional and new and important partnerships for the future of our community? We still are one of the top drivers of young people to the Peace Corps, so that's a sustained partnership we've had over the years. Over the years, we have been through our intercultural communications experts and through our peace and conflict resolution experts, we have been some of the trainers of everything from government agencies to Fortune 500 companies on some of these techniques that we know are important to coming to better solutions together. With COVID, I think we have a time to reboost some of that. And then in addition, I think we do have the ability to form even more partnerships, particularly through some of our lifelong learning, or how do we share some of our expertise and training with organizations it matters to so that not only are our ideas getting out in the world, but frankly those partners know that our students come armed with those skills and techniques?
35:08 SH: We've got these great programs in political risk analysis. Think of the organizations in DC that act globally that could benefit in these increasingly politically complex times. There are all sorts of opportunities like that that I think feed back and benefit the entire community.
35:27 KS: Dr. Shannon Hader, Dean of the School of International Service. Thank you for joining Big World to discuss global HIV/AIDS policy, global health policy. It's been great to speak with you.
35:37 SH: Thank you so much.
35:39 KS: Big World is a production of the School of International Service at American University. Our podcast is available on our website, on iTunes, Spotify, SoundCloud, wherever you listen to podcasts. If you leave us a good rating or review, it'll be like getting something you actually like in the office Secret Santa. Our theme music is, "It Was Just Cold" by Andrew Codeman. Until next time.