Toward facilitating a voice for politically marginalized minorities and enhancing presidential public accountability and transparency in foreign health policymaking.

• Author: Crimm, Nina J.

ABSTRACT

Residents of underdeveloped countries who belong to ethnic, racial, sexual, and political minorities usually endure relatively ineffective political voices. More than any other world population segment, these marginalized people are vulnerable to, and suffer from, compromised health and life expectancies. Their immense human tolls have spawned severe global humanitarian, economic, social, political, and security dilemmas contrary to the strategic interests of the United States. Despite recognition of these devastating harms here and abroad, the president as de facto primary U.S. foreign policymaker continues to formulate foreign health policy in an insular policymaking environment. The insularity enables the president to design policy without broad input, transparency, or public scrutiny. This Article suggests the alteration of the presidential policymaking apparatus. It proposes a concrete structure to facilitate a voice for politically marginalized minorities and to enhance public accountability and transparency in presidential foreign health policymaking, thereby collaterally imbuing the process with a new legitimacy.

TABLE OF CONTENTS I. INTRODUCTION II. THE HIV/AIDS PANDEMIC A. Overview B. The Story of HIV/AIDS 1. In the Beginning, Response Avoidance 2. The Mid- to Late-1980s 3. The Early- to the Mid-1990s 4. The Mid- to Late-1990s and the New Millennium 5. Summary III. FOREIGN POLICY DECISION-MAKING STRUCTURE-THE ACTORS A. The President as the Primary Foreign Policymaker B. Executive Branch Agencies C. Nonprofits as Nongovernmental Actors IV. PRACTICAL REASONS FOR A FORMAL POLICYMAKING ROLE FOR NONPROFITS A. Nonprofit Organizations as Unofficial Designers of Foreign Health Policy B. Limitations of Unofficial Role C. Practical Reasons for an Official Role V. CONSTRUCTING AN APPROPRIATE POLICYMAKING STRUCTURE A. Paradigms of Nongovernmental Organizations' Participation in International Bodies' Policymaking Processes 1. World Trade Organization 2. The NGO-World Bank Committee 3. U.N.'s World Health Organization 4. International Labor Organization 5. Organization for Economic Cooperation and Development 6. U.N.'s Economic and Social Council B. A Constitutionally Acceptable Revised Presidential Foreign Health Policymaking Structure 1. A Presidential Advisory Committee 2. A New Presidential Advisory Committee on U.S. Foreign Health Policy 3. An Assembly of Nonprofit Entities VI. CONCLUSION A popular government, without popular information, or the means for acquiring it, is but a Prologue to a Farce or a Tragedy; or perhaps both. Knowledge will forever govern ignorance: And a people who mean to be their own Governors, must arm themselves with the power which knowledge gives.--James Madison **

1. INTRODUCTION

   Residents of underdeveloped countries (1) who belong to ethnic, racial, sexual, and political minorities usually endure relatively ineffective or nonexistent political voices. More than any other world population segment, these people are vulnerable to, and suffer from, compromised health and life expectancies. These marginalized people have received increased international visibility since the onset of globalization and worldwide recognition that their immense human tolls have spawned enormous fractures in "critical infrastructures that sustain the security, stability, and viability of modern nation-states," (2) contrary to the strategic interests of developed countries, including the United States. (3) Nonetheless, in the de facto role of primary foreign policymaker, (4) U.S. presidents have failed to act adequately to forestall these groups' health crises and to avert consequential damaging global outcomes.

   Perhaps it should be no surprise that U.S. presidents have been mightily deficient in tackling the health needs of such Third World countries' marginalized residents. In the United States, it is well documented that even during the past fifty years, the overall health and life expectancies of politically under-represented ethnic, racial, and sexual groups--women, gays, African-Americans, Hispanic-Americans, Asian-Americans, Pacific-Americans, American Indians, and Native Alaskans--have been below those of the U.S. population as a whole. (5) Nonetheless, the medical hardships of these Americans pale in comparison to the substandard health status of underdeveloped countries' ethnic, racial, sexual, and political minorities.

   Statistical data regarding health conditions of Third World women and children confirms this disparity: despite the growth of gender-targeted healthcare programs available to some underprivileged women residing in underdeveloped countries, (6) these women continue to be particularly plagued by high levels of complications from pregnancy or delivery, many of which result in lifelong disabilities. Indeed, more than 80,000 women residing in poor countries annually develop fistula, which leaves them permanently incontinent and socially ostracized. (7) Women in the Third World also are particularly susceptible to death from disease and maternal difficulties. Reports reveal that around the world more than 500,000 women die every year--that is, one woman every minute--from pregnancy and childbirth complications, such as delays or failures in obtaining obstetrical care, unsafe abortions, and the lack of access to drugs. (8) Ninety-nine percent of these deaths occur in low-income countries. (9) The World Health Organization (WHO) reported in 2005 that more than 500,000 women in underdeveloped countries have demonstrated particular vulnerability to contagious diseases. (10) They contract malaria, tuberculosis, and HIV/AIDS in disproportionately elevated numbers. (11) As of 2005, women comprised 45% of all people (women, men, and children) worldwide living with HIV/AIDS. (12) Women's deaths from contagious diseases are notably high. For example, on a worldwide basis, tuberculosis accounts for 9% of women's deaths annually. (13)

   Children residing in Third World countries are another group sorely under-represented by political voice who disproportionately suffer from preventable or treatable health issues. (14) For example, each day approximately 6,000 girls, often between the ages of four and eight living in eastern, central, and western African communities, the Middle East, and in immigrant communities in Asia, the Pacific, Latin America, and Europe, are subject to female genital mutilation. (15) This practice has led to grave psychological and physical health problems such as organ damage, serious long-term infection, HIV/AIDS, infertility, and death for an estimated 135 million females. (16) Across the world, approximately 1,500 children contract HIV/AIDS every day, (17) and those living primarily in poor countries now account for one-half of all new HIV/AIDS sufferers worldwide. (18) At the end of 2005, more than 2.3 million children under age fifteen lived with HIV/AIDS, (19) and most of these children resided in the Third World. (20) Strikingly, HIV/AIDS afflicts young girls in certain countries to a larger measure than boys. For instance, 76% of youths with HIV/AIDS in Sub-Saharan Africa between ages fifteen and twenty-four are girls. (21) All of these youngsters are plagued by severe physical and emotional consequences of the disease.

   Children in underdeveloped countries also experience high mortality rates. (22) The Global Health Council reports that "[e]very minute of every day, 20 children die somewhere in the world, and two-thirds of these deaths could be readily averted by existing preventive and therapeutic strategies." (23) Moreover, of "the 10.8 million children under age five who die each year, 10 million (more than 92 percent) resided in the lower-income countries." (24) Childhood mortality from HIV/AIDS, largely acquired from mothers during birthing or breast feeding, (25) is exceedingly high. By 2000, about 4.3 million children younger than age fifteen had died from HIV/AIDS. (26) In 2005 alone, estimates reveal that between 290,000 and 500,000 children under fifteen years old died of HIV/AIDS. (27)

   These small glimpses into just two politically under-represented population segments living in underdeveloped countries suggest the magnitude of various health maladies that impact numerous such groups. They beg us to ask how our nation's leading foreign policymaker permits such tragedies to continue unabated despite U.S. strategic interests to the contrary. (28) The story of the HIV/AIDS pandemic is revealing.

   The HIV/AIDS pandemic reared its ugly head in Africa and the Caribbean more than two decades ago (29) before striking politically under-represented minorities of developing and developed countries, including the United States. (30) President Ronald Reagan was aware of the mounting HIV/AIDS problem at home and abroad as early as 1983. (31) Nonetheless, he and his administration discounted the evidence, denied the disease's potentialities, and failed to react. (32) For almost two decades thereafter, presidents (and other policymakers) largely ignored the rapidly growing HIV/AIDS crises. (33) The reasons for their inaction are based on attitudes, information, and politics. Initially, in the U.S. HIV/AIDS was viewed as a disease primarily affecting the domestic gay population, a minority affinity group with little political clout in the early 1980s. Moreover, the disease was then considered exclusively sexually transmitted. (34) Persons who contracted HIV/AIDS were viewed as foolishly having engaged in risky behavior preventable by sexual abstinence or precautionary measures. In other words, a prevalent attitude was that these individuals got what they deserved. As the drug-addicted population became victims of the disease as a result of their use of contaminated needles, stigmatization mounted. Superimposing these stigmas on top of racial and ethnic biases associated with the disease's probable African origin (35) further tainted perspectives of the...