Princeton Lyman Interview (2006): Conversations with History; Institute of International Studies, UC Berkeley

A Strategic U.S. Approach to Africa: Conversation with Princeton N. Lyman, Ralph Bunche Senior Fellow, Council on Foreign Relations; by Harry Kreisler; February 16, 2006

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Public Health

Let's talk about some of these problems one by one and give our audience a feel for the problem and a feel to the obstacles that lie in the way of possible solutions. Of course, the first thing is the public health agenda and the problem of AIDS. Why is this such an important topic for anybody looking at the problems of Africa?

It's an important topic because HIV/AIDS is now a worldwide phenomenon. The epicenter is in Africa. If we don't know and learn how to address it in Africa, we're not going to be very effective -- and I say we, the international community -- in addressing it as it spreads through China, where it's now spreading; in India; up through central Asia and into Russia.

We're at a very, very critical time in this pandemic because most of the infections took place in the nineties, and the timeline of this disease is roughly ten years from infection to full-blown AIDS. Last year, more than two million people died of AIDS, but we're at the beginning of a rising death rate, and it's going to have impact not just in the health field but on the social and economic and political dimensions. We're running behind the pandemic, even though there's been a lot more resources put into it. We've got to do more, if we are going to learn how to contain this here. The lessons will be learned for the rest of the world.

When you have a problem of this magnitude and begin thinking about solutions, you run into a hornet's nest of issues. For example, is the response multilateral or does it come from one or two major powers?

Right now, the United States provides roughly half of all the resources going into the HIV/AIDS pandemic. The U.S. and President Bush deserves a lot of credit for his initiative, called the President's Emergency Program on AIDS Relief, pledging $15 billion over five years. That galvanized much more international attention.

There is a question of how much should be done bilaterally and how much should be done through the new Global Fund for HIV/AIDS, TB, and Malaria, and what the Congress has said is, "We should do a lot for the Global Fund but never do more than one-third." That has pushed the Europeans and Japanese, and others, to put more into the Global Fund. But it raises lots of problems of coordination on the ground for countries as to matching these funds and addressing how you buy generics, or you don't buy generics, etc. The Europeans also do a lot of bilateral programs, as well as the Global Fund.

There are also issues of prevention versus treatment that set off a nerve in the American debate about public policy.

A change has taken place. At the beginning when people were looking at this, and there weren't the kind of treatments available that there are today, the overwhelming emphasis was on prevention. But treatment has become a human rights issue, and it also relates in part to prevention because you can't get people to come in to be tested if there's nothing you can do for them. So, there is a synergy there.

What the world has done is made an extraordinary commitment, first under the president's program and then under the WHO program, to say two to three million people will be brought under treatment. But at the G-8 meeting last year there was a pledge to bring in everybody in the world who needs treatment, to provide it. This is treatment you have to give for life, and most of it's in the very poorest countries. We're only beginning to realize what that commitment can mean, and what it can cost, and what it takes to do that. So, this is one of the major areas that we're going to be dealing with for a very long time.

You have a lot of experience as an American ambassador in the AID program, and as you reflect back on what the U.S. did in earlier periods, did we lay the groundwork for coming up with adequate solutions in terms of the kinds of aid we gave for health in the past?

One of the problems and one of the themes of the report is that if you treat Africa largely as a humanitarian case, you veer off into treating it as a charity. You don't even take account of what Africans themselves are doing. Changes are going on in Africa, and we talk a lot about that. The result in the AID program is that while there have been increases in foreign aid to Africa over the last ten years, about half of it is emergency aid -- we respond to droughts and emergencies.

I'll give you an example of exactly the issue you're talking about. There's a report that's just come out recently from a think tank in Washington called the International Food Policy Research Institute on what it would take to push food self-sufficiency in Africa. I read that report, and from my days in AID in the 1970s and 1980s I said, "That's what we used to do." But in the 1990s the World Bank and the United States reduced our aid to agriculture by 90 percent. So we're in agriculture for a while, then another fad comes along.

What we're saying in the report is, if we're serious about this, if this is really important to us, we've got to take a few key sectors and be prepared to stay with them for ten, twenty years with new technology and training. That we haven't been doing.

Is there a role for the private sector, both in the West or other parts of the world, and then the private sector in Africa? Is there a synergy that we can find, say in health, that reflects this new synergy that the world is recognizing?

One of the changes taking place in Africa is a major change in economic policy away from statist economist policies to opening up for the private sector and much broader economic openings. It's still very hard. There are still a lot of bureaucratic obstacles to entrepreneurial development. But the private sector is going to be key, because Africa isn't going to make it just on foreign aid -- in fact, shouldn't make it on foreign aid. It should open up investment opportunities and grow. In some areas it's striking. The growth of the cell phone market in Africa is faster than anywhere else in the world. American companies haven't been so heavily involved, but the South African companies are expanding like crazy in places like Nigeria, Kenya, Mozambique, etc. So, there are these opportunities now for the private sector that are going to be very important.

What changes have to occur in the African governing class? AIDS is a good example where there was quite a debate in South Africa about the proper course to take. How does that piece fit into this problem, namely, convincing the African elites that this is the way to go?

It's varied across countries; it's hard to generalize. South Africa, for a lot of reasons that we can go into, was very ambivalent (the leadership) about devoting so much attention to HIV/AIDS, because Thabo Mbeki felt it was going to take away from all his other objectives. It led the government to be very slow in responding. But you have countries like Uganda, Zambia, Senegal, and now Kenya taking it quite seriously, the leadership of the country making a major effort, and we're beginning to see real progress in those countries because the governments take it seriously. But they're a little worried. The international communities say you've got to put a lot of people on treatment. They're saying, "Fine, but are you going to be here five years, ten years, fifteen years from now, when these treatment costs are going to be massive for many years to come?"

Is there a way to make known the implications of the problem on the ground? A recent guest here was Sir David King, the science advisor to Tony Blair, and he was talking about how computers empowered the scientific community to understand where mad cow disease was going, and that it became a political challenge to make the farmers aware of the problem. Is this something we have to look for in Africa, not necessarily with computers but elevating the consciousness of the leadership?

I think communications in Africa, through the Internet and elsewhere, are [making] a difference. The Africa Union, which is a different organization than its predecessor, the Organization of Africa Unity, is bringing countries together around problems that they didn't deal with before. The Africa Union has created a Peace and Security Council, saying, "Conflicts are our responsibility, [whether] they're internal or external," and they're sending African peacekeepers into a whole variety of places. You have civil societies flourishing in Africa much more than before, and they're communicating with each other, and that's having an impact. And you see reactions against leaders that try to extend their time in power, you see much more pressure for democratization, you see women's groups communicating around the continent. So, this kind of thing is taking place.

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