The Next Generation

by David Carel:

It was barely 8:00 in the morning on Saturday, Oct. 30, 2010. I stood in line with a group of other Yale and Harvard students for President Obama’s afternoon speech in Bridgeport, Connecticut. Before proceeding through the wall of metal detectors and into the stadium, we stuffed banners into our pants  and jammed signs and chant lyrics into our jackets, wallets, shoes, and anywhere else we could hide them.

Following several speeches by Representative Himes, Senator Blumenthal, and a host of other politicians, Obama took the stage, galvanizing an energy and applause which thundered throughout the arena. In two separate groups on either side of the stage, we slowly unfurled the banners beneath our feet, stood up, and began shouting, “Broken promises kill, fund global AIDS. Broken promises kill, fund global AIDS.”

“Excuse me! Excuse me, young people!” the president responded. “We’re funding global AIDS, and the other side is not. So I don’t know why you think this is a useful strategy to take.”

“You promised more! Fifty billion.” We shot back in perfect unison, anticipating his evasion, drawing attention back to the promises he had made in 2008.

After several more minutes of back and forth with the president, we were spat on, kicked, and shoved. The signs were ripped from our hands as we were escorted out by security.

The decision to protest the president was not an easy one. Most of us were and continue to be staunch Obama supporters and cringed at the thought of harming his public image. But after fierce debates andcareful calculation, we found ourselves protesting the administration’s waning health equity to new heights.

In a twist of fate, merely two weeks later, the architect of Obama’s global health policy, Dr. Ezekiel Emanuel, paid a visit to Yale for a guest lecture on global health ethics. At the heart of Emanuel’s plan for Obama’s global health policy lay the belief that AIDS occupies too much of our national attention and budget. He emphasized that there are a host of other ailments and concerns, such as childhood respiratory and diarrheal diseases, which affect more lives in the developing world and can be treated more cheaply than fighting HIV/AIDS. Over the course of the day, I met face to face with Emanuel, along with Jared Augenstein and Nick DeVito, two students at the Yale School of Public Health and co-founders of the Student Global Health and AIDS Coalition on campus.

Over breakfast, Emanuel shared a few nasty words about AIDS activists, including many whom I had worked with or befriended over the preceding months. He chastised me for joining an outdated  movement that had selfishly hijacked U.S. global health policy.

“It’s always AIDS, AIDS, AIDS. Why do you guys all waste your time yelling at me about my AIDS funding? Why aren’t you out there fighting for maternal and child health and neglected diseases?”

His brow furrowed in contempt as he embarked on a verbal tirade mocking my criticisms of his policy agenda. He scoffed at my accusations in a self-confident and smug tone well-known throughout Washington.

The truth was, I was immensely uncomfortable with Emanuel’s accusations. I still fundamentally disagreed with his claims that AIDS treatment was too expensive and cost-ineffective, but I, too, began to wonder why AIDS activists weren’t doing more for other diseases. The AIDS movement had become so prominent in the United States largely because the disease affected Americans on a scale that  malaria, tuberculosis, and other infectious diseases simply do not. As part of the new generation of AIDS activists divorced from any personal history of HIV, why wasn’t I doing more for global health equity  broadly?

Even within the AIDS activism movement, there was considerable divergence. In conference calls with AIDS activists around the country, meetings in D.C., and mass list-serve emails, we, the new, younger generation, often struggle with the title “AIDS activists.” We come from a different world than the older generation of activists, who fought for their own lives and the lives of their loved ones as HIV/AIDS tore through the nation in the ‘80s and ‘90s. The vast majority of us have never truly known HIV. We were barely infants at a time when the epidemic was sweeping violently through this country, a dismal era when HIV was a death sentence and entire communities—homosexuals, African Americans, drug users, and others—were being decimated. Our generation, having learned about global health largely through travelling and working in the developing world, is less HIV focused and more interested in the broad issue of global health.


This past summer I found myself replaying my debate with Emanuel in my head. I was in the U.S. embassy in Maseru, Lesotho, on a short vacation after two and half months working on a Zulu youth empowerment project in South Africa. During the trip, I had the opportunity to meet with the President’s Emergency Plan for AIDS Relief (PEPFAR) and Center for Disease Control (CDC) teams in

Lesotho that coordinate the United States’ AIDS treatment and prevention programming in the country. As we sat down in the board room, the first thing they began telling me about was a new “mother-baby pack,” a kit of maternal and child services for pregnant women in remote Lesotho who have no access to any obstetric or post-natal care. The pack, they explained, allowed community health workers to provide comprehensive pre- and post-natal care in the women’s homes, offering a wide range of both diagnostics and treatments for these women.

“And who pays for these?” I asked, confused as to why a PEPFAR official, rather than a maternal and child health expert, was proudly showing this kit to me.

“PEPFAR does!” she shot back, equally confused about why I was asking such an obvious question.

As it turns out, among the cohort of tests and diagnostic tools included in the mother and child kit is a rapid HIV test. This HIV test was enough, the PEPFAR official explained, for PEPFAR to cover the entire cost of the kit and visit to the woman. An AIDS relief program was shouldering the entire cost of what was at most 10 percent HIV/AIDS and 90 percent maternal and child health.

The real question, however, was: Why was PEPFAR, an AIDS program, funding the mother-baby pack in the first place? Why is there no President’s Emergency Plan for Maternal Health Relief?


For years, ever since President Bush announced PEPFAR in his 2003 State of the Union Address, the U.S. government has been captivated by the narrative that AIDS funding is a vital part of American foreign policy, a crucial program not only for humanitarian reasons but also for national security. As the narrative went, AIDS was decimating a generation of young adults in Africa, many of them in the prime of their lives, and it was leaving a vacuum of social unrest in its wake which terrorism was primed to fill. If nothing was done to stop AIDS, millions of children would be left without parents or stable economies; governments would deteriorate, and organizations like al-Qaeda would capitalize on the social unrest to recruit from the dregs of a desperate African population.

This argument still reigns today. Last December I found myself face to face with Senator Pat Toomey’s (R-PA) national security advisor, a man of military background. I entered the meeting with apprehension, convinced that my calls for global health funding—40 cents for a day of antiretrovirals and pennies for neglected tropical disease treatment—would be trounced by $150 million fighter jets and over $3 billion in monthly spending in Afghanistan. I sat down and began my well-rehearsed AIDS lobbyist script, calling on Senator Toomey to promote the extremely bipartisan cause of PEPFAR for its public health, humanitarian, and national security benefits.

Before I could continue, his national security advisor interrupted, “You know, people just don’t realize that this PEPFAR is so important for our national security. Without it, AIDS is gonna leave a vacuum  which the terrorists are gonna fill.”

Just months prior, at the Wild Irish Breakfast in New Hampshire, I had a remarkably similar conversation with Newt Gingrich while calling on him to include strong AIDS policy in his presidential campaign platform.

“People just don’t realize that fighting AIDS is important for our national security,” Gingrich lectured me. “I actually have a call tomorrow morning with Bono to discuss just this point.” Friends, others from the Yale Global Health and AIDS Coalition, and fellow global health political activists at colleges across the country have reported similar comments from senior Republican Congressmen, Mitt Romney, Rick Santorum, and others.

Over the last decade, AIDS has captured the imagination of Washington, particularly Republican political leadership, in a way that childhood diarrheal diseases and women’s health have not. Emanuel was right––AIDS has received a disproportionate amount of funding and attention from the United States. Advocates and activists have two broad-stroke options to rectify this imbalance: withdraw from our AIDS activism and demand that our politicians support neglected global health priorities, or ride the wave of AIDS sympathy to expand the funding and opportunities for global health more broadly. If PEPFAR can mobilize bipartisan support for a pro- gram which supports global health efforts everywhere from antiretroviral treatment for AIDS patients to mother and child kits, the global health activist movement would be foolish not to capitalize and latch onto it.

Tragically, there may never be U.S. funding for neglected tropical diseases, maternal and child health, or basic primary health at a level anywhere near that of AIDS. Obama’s and Emanuel’s efforts to increase funding across the board for global health, though noble, have fallen tragically short in the face of our current political reality. Until we learn to embrace this reality, one where AIDS funding not only garners immense political support but also funds mother-baby packs and other areas of global health, global health funding may continue to suffer.


Are you HIV positive?” someone asked from across the circle.

“No…actually…I’m not,” I was barely able to reply before the young African-American man sitting to my right politely chastised my interrogator for his intrusive comment.

“We don’t put people in that kind of position, O.K.?”

I was sitting in the basement of St. Luke’s Church in downtown Philadelphia at the weekly meeting of ACT UP Philly, an organization that advocates for people living with AIDS through direct political action. I sat among young, openly lesbian white women covered in piercings, tattooed African Americans, ex-cons, and homeless men. As the meeting progressed and some openly discussed their perilous histories of drug abuse and the circumstances under which they had contracted HIV, the group advanced their plans to sway Philadelphia’s Mayor Nutter on the city’s HIV/AIDS policies and efforts to start a low income AIDS housing project.

As a 20-year-old male from the suburbs, white, Jewish, heterosexual, and HIV negative, I was the demographic elephant in the room. It was these individuals sitting around St. Luke’s church and all those around the nation that they rep- resent who put HIV/AIDS on our nation’s radar. Though it began as a fight literally between life and death to secure access to AIDS treatment in the U.S., an unparalleled international solidarity began to form with individuals in the developing world who faced the very same battle. This movement grew into the AIDS activists that we see today.

It is far from coincidental that it is AIDS that has dominated our nation’s global health funding. Modern America has been spared the massive burdens of malaria, tuberculosis, hookworm, and the challenges to maternal care faced by the poor in the developing world. AIDS is unique in this regard, spanning oceans and national borders in both the developed and developing world. As much as Emanuel and I may wish otherwise, the United States likely will never produce a childhood diarrhea or maternal health activist movement with the same force and urgency as the AIDS movement.

Whether because of the national security-oriented political landscape or the story of the HIV epidemic in the U.S., our foreign policy is inextricably bound by its history. The AIDS activists of a generation ago, like the group in that church basement, with whom Emanuel disapprovingly lumped me during our debate, laid the foundation for a much broader global health equity movement than Emanuel gives them credit, and perhaps than they ever imagined. It is on their shoulders that I and the rest of our generation of AIDS global health activists proudly stand. It is time not to halt that momentum of AIDS activism but to nurture it, inching the world closer and closer to global health equity.

David Carel ’13 is an Economics major in Pierson College. Contact him at