On January 6-7, PEPFAR convened a legally constituted Scientific Advisory Board and just yesterday, posted a web site dedicated to it. The web site includes several PowerPoint presentations which provide an excellent overview of PEPFAR’s perceived research needs and of the meetings’ concluding recommendations.
I accepted the invitation to attend this meeting and join the group without fully appreciating the gravitas of the event. I had thought that Ambassador Goosby and Paul Bouey would just be gathering a handful of people to shoot the breeze and offer some suggestions about research priorities. I should have looked more closely at the materials I was sent before the meeting. PEPFAR has gathered some of the most distinguished people from the medical research community, as well as representatives from other government agencies and partners such as the Global Fund for AIDS, TB and Malaria. The list includes the former head of NIH, Harold Varmus, along with Peter Piot, former head of UNAIDS. The membership of 48 folks posted here reads like the bibliography for a course on the biology, epidemiology, social science and research methods of HIV/AIDS. I was one of only two Ph.D. economists on the list. If I had known more, I would have looked in the back of the closet for one of my suits from my days at the World Bank instead of showing up in my usual think-tank-casual. Why were we all there? And why in particular was I there?
First, what IS a Scientific Advisory Board? It turns out that this group is a legal entity created under the authority of the U.S. Congress through the Federal Advisory Committee Act (FACA). The U.S. General Services Administration maintains a portal to a set of web sites here which provide explicit guidelines on the establishment, the objectives, the management and the performance measurement of a Federal Advisory Committee. Furthermore, there is a database to keep track of the 1,000 or so U.S. government-established advisory boards in operation at any point in time. *
But PEPFAR’s advisory committee is a bit special. While foreign assistance in general has previously benefited from only one federal advisory committee (for details, see my recent post here), there are seven such committees related to HIV/AIDS. These, committees, along with the U.S. government agency that sponsors them are listed here:
- AIDS Research Advisory Committee, NIAID -- HHS
- Microbiology, Infectious Diseases and AIDS Initial Review Group -- HHS
- AIDS and Related Research Integrated Review Group -- HHS
- Office of AIDS Research Advisory Council -- HHS
- Presidential Advisory Council on HIV/AIDS -- HHS
- CDC/HRSA Advisory Committee on HIV and STD Prevention and Treatment -- HHS
- HIV/AIDS Prevention of Mother to Child Transmission Expert Panel – DOS
Of these seven, the first five support the U.S. domestic AIDS effort or the research programs at the National Institute of Health. The sixth supports the Center for Disease Control’s efforts in the prevention and treatment of sexually transmitted diseases, primarily in the United States.
The seventh of the committees dealing with HIV/AIDS, that called the “HIV/AIDS Prevention of Mother to Child Transmission Expert Panel,” is a previous creation of PEPFAR. According to its justification in the FACA database, “the purpose of the Expert Panel is to provide an objective review of PEPFAR’s PMTCT activities, and provide recommendations to the U.S. Global AIDS Coordinator and the appropriate Congressional committees for scale-up of services to achieve the ambitious target of reaching 80 percent of pregnant women in countries most affected by HIV/AIDS in which the U.S. has HIV/AIDS programs.” PEPFAR says that this committee met once on January 9, 2009, with no subsequent meetings, nor do any seem to be planned.
So how long will PEPFAR’s new “scientific advisory board” last? For only one meeting, as has PEPFAR’s PMTCT panel? Or for decades like USAID’s advisory committee? I guess the lifespan of this committee will depend on why PEPFAR established it in the first place, whether the committee can effectively advance those objectives and also on the more general question of whether combatting AIDS epidemic retains its importance on the list of US foreign assistance objectives.
Paul Bouey, Deputy Coordinator of PEPFAR, writes on the web site that, “members of the Board are tasked with providing insight on the latest developments in HIV science and research and advising as to how PEPFAR can use this information to plan for the future. The Board's input will also help to feed into the broader research agenda of the Global Health Initiative.” He says that we members of the new board are charged with providing advice, which PEPFAR is of course free to ignore, on how PEPFAR can best “contribute to the evidence base around HIV interventions, as well as broader health systems strengthening and integration.”
So our purpose is to advise on the evidence base and the broader research agenda, but to what end? Paul restates the overall objective in terms similar to those I have heard from Ambassador Goosby on several occasions, terms that were somewhat bizarrely reflected in Secretary Clinton’s remarks last year: PEPFAR’s overriding objective is “[T]ransition from emergency response to sustainable country-led programs [emphasis added].”
Despite good intentions, AIDS programs cannot be “sustainable” in poor or even in middle-income countries unless they meet one or both of two criteria: new infections should be rare and high quality AIDS treatment should be much less costly than it is now. PEPFAR seems to realize that it does not currently know how to do this. They hope to gather evidence in order to have a better idea, and our job on the committee is to advise PEPFAR how best to proceed in gathering and analyzing this new information.
To me, a “sustainable” public program is one that places a low fiscal burden on its tax-paying constituency relative to the benefits they perceive and one that is broadly “incentive-compatible,” meaning that most of the stakeholders in the program have something to gain from its continued success – or something to lose from its failure. Since the topics of fiscal burden, public service benefits and incentive compatibility are all within the domain of economics, maybe there is indeed a place for an economist or two on PEPFAR’s new panel. In fact, perhaps it should include some names who are as prestigious in the economics world as many of the panel’s members are in the medical realm. Someone like Joseph Stiglitz, Lawrence Summers, Amartya Sen, or Alice Rivlin would augment the prestige of PEPFAR’s new advisory panel and enhance the policy impact of its recommendations.
* - To see the posted information on PEPFAR’s new scientific advisory board, navigate your browser to the FACA database here. You don’t need to log on. Just click on the underlined word “Search” at the top of this page. Then in the space designated “Search for Committee by Name or Number”, enter the number 76050, which is the identifier for this PEPFAR committee. You will see a menu of items specific to this particular committee. Clicking on the “Justification” or the “Members” menu choices will bring up the information I refer to in the text of this blog.