Can AIDS Be Stopped?

During the past two decades, while virtually all Western countries experienced more or less constant economic growth, much of the rest of the world suffered a series of financial catastrophes—from the international debt crisis of 1982, to the Mexican peso crisis of 1994, to the Asian financial crisis of 1997, to the Russian default of 1998. The social consequences of these economic disasters—including impoverishment, mass unemployment, and ill health—have been felt almost entirely outside the West: in Africa, much of Asia, Latin America and the Caribbean, and the former Soviet Bloc.

While the causes of these crises were complex, much public criticism has been directed at some of the institutions that are attempting to estab-lish rules for economic globalization—the World Trade Organization, the World Bank, and the International Monetary Fund. Protest movements have emerged, involving many different, sometimes conflicting, constituencies—from labor unions to environmentalists to college students to non- governmental organizations involved in health, social justice, and human rights. Their grievances more or less converge on a common theme: as Western governments, backed by multinational banks and corporations, push economic liberalization to extremes, they are exacerbating, and even exploiting, the vast social and economic inequalities that exist in the world.

Recently, George Soros, the financier and philanthropist, seems to have joined this chorus. In his new book George Soros on Globalization, Soros concludes that international finance and trade have outstripped the capacity of sovereign states to manage the politics of globalization.¹ Especially neglected has been the provision of global public goods, things needed by everyone but not produced by the marketplace, such as clean air and disease control. Instead of proposing to dismantle the WTO, the World Bank, and the IMF, Soros would like to see them strengthened, and complemented by stronger global institutions in social fields like health, such as the World Health Organization, and labor standards, such as the International Labor Organization. Successful globalization, he argues, requires effective global institutions devoted not only to finance and trade, but also to public health, human rights, environmental protection, and other public goods.

At the top of Soros’s list of global social problems in need of attention is HIV/AIDS. Public concern over the global AIDS epidemic, particularly in Africa, has grown enormously in recent years, but there is considerable debate about what the international community can and should do about it. Especially controversial has been the high cost of antiretroviral drugs used to extend the lives of people with AIDS. The pharmaceutical companies that make these drugs price them beyond reach of the world’s poor, but in November 2001 at the WTO meeting in Doha, Qatar, these companies were forced to accede to pressure from developing country governments, nongovernmental organizations, and activists, and allow poor governments to adjust certain rigid patent rules applying to vaccines and drugs in order to protect public health. Despite this apparent triumph of international pressure, far more needs to be done. A coalition of governments and nongovernmental organizations, led by the UN, recently launched the Global Fund Against AIDS, Tuberculosis, and Malaria (referred to here as the Global Fund), and its performance will test how well such a global institution can confront the most serious health crises of our time, and perhaps in all of human history.

1.

To date, an estimated 50 million people have contracted HIV; about 25 million people in sub-Saharan Africa are infected, and about three million of these people die annually. In some countries, average life expectancy has fallen by more than a decade because of HIV/AIDS. Unfortunately, it has been only in the past two or three years that the gravity of the AIDS problem in Africa and other parts of the developing world has been fully recognized by those in the best position to do something about it, including many African presidents and prime ministers and such Western government leaders as Secretary of State Colin Powell, former President Bill Clinton, and the G8 heads of state at meetings in Okinawa and Genoa in 2000 and 2001.

Yet by 1985 many epidemiologists were already warning about the scale of the global AIDS epidemic.² Perhaps it should not surprise us that the AIDS crisis in Africa in particular has taken so long to become a matter of concern at such high political levels. In 1999, the UN Security Council declared AIDS in Africa an international security issue, because it further destabilizes already politically fragile African nations. But how much does this really matter to the West, particularly the US? The postwar history of the West’s relationship with Africa suggests that when millions of Africans die, or when African states collapse, Western leaders often look away.

Diseases like malaria, respiratory infections, measles, and diarrhea, all preventable or curable and largely controlled in the West, continue to kill millions of African children, and yet US overseas bilateral aid to Africa fell by half in the 1990s. During the cold war, the US actively supported regimes in Liberia, Zaire, and South Africa that were responsible for the deaths of thousands more. The US and Western Europe failed to intervene during the Rwandan genocide, and had it not been for a group of rock stars, Americans and Europeans might well have ignored the Ethiopian famine in the 1980s. Throughout the 1990s, US funding for HIV prevention in developing countries averaged some $70 million per year, about the same as the US military allocated for Viagra when this medication first became available.³ Why did AIDS in Africa at last grab the rich world’s attention? Why haven’t similar deadly scourges of the third world done the same? One possibility is that when Western leaders, activists, corporation heads, and the general public look at the problems of the developing world, they mainly see reflections of problems in their own societies.

For many reasons, the suffering of African AIDS patients may draw international sympathy in a way that the suffering of malaria and diarrhea victims do not. For one thing, AIDS is a manifestly “global” disease; by the time it was first recognized in the early 1980s, HIV had already spread to nearly every continent. It has killed people of all races and classes, from the economically flourishing gay neighborhoods of San Francisco and New York to the poorest slums in Africa, Asia, Latin America, and the Caribbean.

Other infectious diseases were once as widespread and devastating as AIDS. Five hundred years ago, measles and smallpox introduced by Old World explorers and settlers decimated indigenous people in the New World. In 1918, “Spanish flu” killed millions around the world. Until the early twentieth century, malaria and typhoid claimed lives not only in the tropics, but also in Minnesota, England, and Arkhangelsk, Russia. During the past half-century, however, deaths caused by infectious diseases, particularly those common in childhood, became increasingly rare in industrialized countries. This led epidemiologists to associate certain patterns of disease with different stages of economic development. They classified communicable, nutritional, and reproductive problems such as malaria, tuberculosis, malnutrition, and death in childbirth as “diseases of poverty.”

A second generation of diseases—which includes heart disease, stroke, diabetes, and cancer—were classified as “diseases of affluence,” common in industrialized countries (although many people in developing countries, especially the well-to-do and middle class, also suffer from these chronic and degenerative diseases).

AIDS is part of a “third wave” of infectious, environmental, and behavioral pathologies that have accelerated in recent years. Some of these may be seen as “diseases of globalization” because they affect all countries and their ultimate control will require unprecedented global cooperation. During the past two decades, more than two dozen new infectious agents have been identified, including the prions that cause new variant Creutzfeldt-Jakob disease and the measles-like virus that killed fourteen horses and their trainer in Australia in 1994—along with new environmental health problems like global warming and ozone depletion. In addition, health problems associated with hazardous behavior, such as drug abuse, unsafe sex, traffic accidents, and violence, have also increased, particularly in societies undergoing rapid social change. The global distribution of these emerging diseases may explain why AIDS in particular is no longer seen as just another “third world” problem that people in the West feel they can largely ignore.

AIDS also raises troubling issues surrounding the global influence of private markets and the spread of infectious diseases. The collision between these two trends has created a kind of moral riptide with momentum of its own. Since 1996, HIV-positive patients in rich countries have had access to “cocktails” of drugs called antiretrovirals that can slow the progression of AIDS. These drugs are designed to attack the HIV virus, allowing the patient’s immune system to repair itself and fight off opportunistic infections. Although the drugs do not cure AIDS, can have serious side effects, and do not work for all patients, their use has added many healthy years to the lives of thousands of people living with HIV in rich countries. There are now on the market around twenty antiretroviral drugs developed in the past fifteen years by pharmaceutical companies, the US National Institutes of Health, and university laboratories.

Partly because they are so expensive, these life-saving drugs are largely inaccessible to the world’s poor, especially the millions of HIV-positive people in Africa. One reason they are expensive is that international trade rules allow pharmaceutical companies a twenty-year patent, which effectively grants them a monopoly. During this time, the companies can charge whatever the market will bear. Until recently, patents on Western pharmaceuticals were valid only in a few countries, but that is now changing.

In 1994, Western governments concerned about protecting intellectual property pushed for an agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) linked to membership in the World Trade Organization. TRIPS aims to extend patent protection to all WTO members, so that someone who produces a new CD or computer program, or invents a new pharmaceutical drug, will have the rights to that invention protected not only in the country in which it was first developed, but also in every country that joins the WTO. TRIPS was partly a response to the accelerated globalization of information which has made it easy for music and video pirates in China and generic drug makers in India, Thailand, and Brazil to copy Western inventions and products. Not all countries have signed on to TRIPS, but most have or will do so within the next decade.

Patenting drugs that could, if they were cheaply available, extend the lives and postpone the suffering of thousands or even millions of poor people in developing countries raises serious ethical concerns. The development of antiretroviral drugs owes a great deal to gay HIV activists in rich countries, particularly in the US, who, beginning in the late 1980s, picketed the US National Institutes of Health (NIH) demanding that more money be spent on AIDS research. They also demanded that the Food and Drug Administration accelerate the regulatory approval process for promising drugs. In the late 1990s, many of these same activist groups, including Act Up, began to ally themselves with campaigns led by such international development organizations as Médecins sans Frontières, Oxfam, and CARE. They claimed the pharmaceutical industry set exorbitant prices to enrich their shareholders while ignoring the plight of the world’s poor. Why, they asked, were these life-saving drugs, now finally available, so expensive? Could they not be sold more cheaply to HIV-positive people in poor countries?

The debate over access to AIDS drugs in poor countries has taken place at the same time as an even larger debate about the mysteries of pharmaceutical pricing policies in general. There is some parallel between the AIDS drug debate and the debate over the high cost of prescription drugs for Americans, including Medicare patients. Drug companies are increasingly having to confront growing discontent among their customers in rich countries where they make most of their profits. These customers may be particularly sympathetic to poor Africans with AIDS because they share their concerns. Increasingly, Americans are asking: Why are drugs so expensive? How much profit is fair? Shouldn’t moral standards apply to drug pricing for all people, poor Af-ricans with AIDS as well as ourselves?

Concerns about the high cost of drugs in general have led to increased public scrutiny of the pharmaceutical industry, and this is beginning to pay off. Activists calling for greater use of generic drugs in poor countries with serious public health problems recently won a number of concessions. Generic drug companies in Brazil were already producing an antiretroviral cocktail before the country joined the WTO in 1996, and these drugs now form the basis of an exemplary treatment program, which offers free anti-retrovirals to all Brazilians who need them. However it is not clear how easily Brazil’s program could be reproduced in Africa, since Brazil’s per capita income is ten times that of most African countries affected by AIDS, and only 0.5 percent of its citizens are HIV-positive, compared to between 5 and 35 percent in most countries of sub-Saharan Africa. The obstacles to distributing AIDS drugs in much of Africa are therefore much greater than they are in Brazil. Nevertheless, last April, the government of South Africa won a court case allowing it to manufacture its own generic versions of some patented drugs, and if Thabo Mbeki, South Africa’s president, were to revise his idiosyncratic views on AIDS, a similar program could be launched there in the near future.⁴

At the recent WTO meeting in Doha, Qatar, poor governments were given permission to issue compulsory licenses, permitting local pharmaceutical manufacturers to produce generic versions of patented drugs for the local market in order to protect public health. Negotiations are underway to determine whether some countries might also be permitted to import patented drugs made by generic producers in other countries. In this way, a country such as Uganda that does not have the capacity to manufacture its own antiretrovirals might be permitted to purchase them from the Brazilian generics companies. To reduce the din of negative publicity, multinational pharmaceutical firms have been forced to offer AIDS drugs to a limited number of health institutions in developing countries at reduced prices under the Accelerated Access program, endorsed by the United Nations. However, this program offers only a limited number of drugs, and critics believe that only global generic competition will bring AIDS drug prices low enough so that they will reach a significant number of poor people in developing countries.

2.

Indignation over the high cost of AIDS drugs has helped focus international attention on the global AIDS epidemic and by the end of 2001, an antiretroviral drug cocktail could be obtained in some developing countries for $300 to $500 per year, many times less than the price in the West. However, for a variety of reasons, including the sluggishness of government bureaucracies, the stinginess of drug companies, and the fact that even at these low prices the drugs are still too expensive and difficult to distribute, few AIDS patients in developing countries are actually receiving these drugs or, for that matter, any modern medications at all beyond the cheapest antibiotics. With this larger dilemma in mind, the UN recently launched the Global Fund for AIDS, Tuberculosis, and Malaria. But despite the fact that it is greatly needed and holds great promise, the Global Fund still faces great challenges. Kofi Annan originally proposed that between $7 and $10 billion per year was needed, to be met by contributions from rich governments, corporations, and private donors. Thus far, however, the pledges total about $1.7 billion. Despite the rhetorical concern of Western donor governments, the commitments have been astonishingly stingy. The US government has promised only $500 million over three years,⁵ setting off a series of correspondingly disappointing commitments by other rich countries.

Difficult decisions will have to be made about how to allocate these limited resources to prevent and treat these three diseases. Opinions vary, for example, about how much of the Global Fund should go to pay for AIDS treatment. Last year, a group of Harvard academics proposed that some of the money be spent on buying discounted antiretrovirals from Western pharmaceutical firms. They cited various small-scale AIDS treatment programs including one based at the Clinique Bon Sauveur in Haiti and Médecins sans Frontières’ Khayelitsha Project near Cape Town, South Africa, as evidence that administering antiretroviral drugs to poor AIDS patients in developing countries is feasible.⁶ The greatest obstacle, say the directors of these programs, is the cost of antiretroviral drugs.

These small pilot projects are admirable and offer many practical lessons and hope, but there are grounds to question whether they could easily be extended throughout sub-Saharan Africa. Both the Bon Sauveur and Khayelitsha projects are currently administering antiretrovirals to only around one hundred patients each, while there are millions of people in Africa alone who might benefit from antiretrovirals. But experience shows that distributing even relatively simple drug regimens on such a large scale poses formidable obstacles. Programs in developing countries that aim to treat people with syphilis and tuberculosis, or even to distribute vitamin A supplements to children, show how difficult it is to deliver health care in such countries, even if the drugs are free or nearly so. An estimated 1.6 million women who give birth every year in those countries have syphilis, a disease that puts their newborns at high risk of deformity or death, even though the tests and drugs to treat it cost only about twenty-five cents. Hundreds of thousands of children go blind every year, and more than a million die, because they are deficient in Vitamin A. Vitamin A supplements, which need to be taken only twice a year, are virtually free. Of course some treatment and vaccination programs have been very successful, for example those for smallpox, polio, and onchocerciasis (“river blindness”), but vaccines for polio and smallpox need to be administered only a few times in a lifetime, while the oral dose to prevent the onset of onchocerciasis symptoms is taken once a year; and the recipients of such treatment, unlike AIDS patients, do not require ongoing care. And even these relatively simple programs have required enormous donor commitment and funding over long periods.

The failure to deliver some even very cheap, simple treatments in developing countries is largely owing to the lack of sufficient trained and motivated health personnel, inadequate management and administrative capacity, and insufficient supplies of vehicles, refrigerators, lab reagents, and other basic equipment. For example, syphilis screening and treatment in antenatal care requires adequate staffing, an efficient referral system, reliable supplies of testing materials and drugs, an on-site rudimentary laboratory with quality control, and other resources that a great many health centers in poor countries simply do not have.

Treating AIDS patients is far more complicated than testing for syphilis or administering Vitamin A drops. AIDS patients need counseling, laboratory tests, and ongoing clinical care to treat opportunistic infections and monitor drug side effects. Even if the drugs and other necessary supplies were available, and in most cases they aren’t, antiretroviral treatment programs require considerable effort on the part of public sector health workers. But because of political instability, economic stagnation, and misguided health sector reform policies mandated by donor institutions such as the World Bank, the health workforce throughout sub-Saharan Africa has been collapsing. Doctors are severely underpaid, earning sometimes as lit-tle as $100 a month. Nurses and other staff earn far less. Low staff morale and moonlighting by government workers already severely undermine health services. During the past year, frustrated health workers in Zimbabwe and Uganda went on strike, and throughout sub-Saharan Africa trained doctors and nurses are leaving the public sector to seek better pay in the private sector, or migrating to other continents.

Any effective AIDS treatment program must endeavor to strengthen the health care system generally, especially the human infrastructure of front-line health workers, as well as meet the concerns of people affected by AIDS. The Harvard group proposed spending an additional $150 per year for the extra clinical work associated with each patient on antiretrovirals; but this may not be sufficient because adequately trained and motivated staff and organized health systems require many years of sustained investment. The antiretroviral treatment program at Clinique Bon Sauveur in Haiti, like many similar small-scale antiretroviral treatment programs in developing countries, is carried on through a health center that has long been well funded by foreign donors. Since Clinique Bon Sauveur was established fifteen years ago, it has always provided a far higher standard of care than is generally available in the public sector in Haiti, even before it began dispensing antiretroviral drugs to people with AIDS. Staff are paid regularly and decently, and know they have the resources, in drugs and supplies (in addition to antiretrovirals), to do their jobs well.

While antiretroviral drugs are important, they are not a panacea for the AIDS crisis in Africa. Indeed the debate over the high cost of the drugs has made AIDS in Africa appear to many to be merely a medical problem, when it is in fact far more than this. When an American or European becomes ill with AIDS, it is often mainly a matter for the patient and his doctor. Friends and family may grieve, but the effect of AIDS on an African family is of an entirely different order. This is because AIDS kills and weakens the adults who grow the food and earn the money that supports everyone else. The dependency ratio in Africa is much higher than it is in the West, not only because there are so many young children, but also because there are so many unemployed people, and most countries have no social safety net. Most sub-Saharan African workers are farmers, but because of inequitable land distribution and declining prices for Africa’s agricultural products, farmers increasingly depend on relatives who are migrant workers or casual laborers in urban areas.

Migrant workers are particularly at risk of HIV, because of their youth and because of the loneliness and social anomie in the hostels and urban slums where many of them end up. When a South African mine worker, for example, becomes sick or dies of AIDS, he may leave behind in his rural home village as many as ten or twenty destitute dependents, including children, wives, in-laws, brothers and sisters, parents and grandparents. Antiretroviral drugs could help some of the mine workers stay healthy longer, but the drugs have side effects of their own, they don’t work for everyone, and they are certainly not a cure. Eventually, the family will need other kinds of help, including money for children’s school fees and seeds, small loans, or help finding jobs and business advice, so that survivors can start small enterprises.

Because the economies of so many African countries are in such a bad state, many small enterprises fail, so families affected by AIDS also require some sort of financial safety net to tide them over while they try again. In addition, families affected by HIV need education about their legal and human rights, especially regarding property rights and HIV-related employment discrimination, which is widespread in developing countries. Since laws protecting the rights of people with HIV currently exist almost nowhere in Africa, mechanisms must be found to create and enforce them at local and national levels. Communities affected by HIV also need information about how people can protect themselves from the virus, and they will also need reliable supplies of condoms, which are still, twenty years into the AIDS epidemic, not easily and cheaply available everywhere.

Overemphasis on the medical aspects of AIDS in Africa probably arises from the tendency to see the problems of the developing world as reflections of problems in the West. But many small African AIDS groups see AIDS quite differently. They provide a wide range of social support and HIV prevention services, in addition to rudimentary care for AIDS patients. Most of these projects rely at present on dedicated volunteers and shoestring budgets, and there are not nearly enough of them to help everyone. Emphasizing access to AIDS drugs alone risks bypassing much of the very good work that these groups are already doing.

A strong case can be made that the pharmaceutical companies should either donate their drugs to Africa entirely for free or permit the use of generics, in exchange for some guarantee that their markets in industrialized countries will be protected. The companies can well afford to do this. A similarly strong case can be made that projects like the Faraja Trust in Morogoro, Tanzania, or the Friends of Street Children Project in Kampala, Uganda—to name just two of thousands of such groups in East Africa alone—should get most of the support from the Global Fund. Antiretrovirals could then be part of such programs whenever feasible.

The governing board of the Global Fund seems to recognize the importance of both national health systems and nongovernmental programs that strive to meet the complex and spe-cific needs of particular communities. Under the fund’s guidelines made public at the end of January 2002, National AIDS Coordinating Councils, quasi-governmental bodies that include members from nongovernmental organizations, will submit proposals to the fund, and the money will be disbursed to the government, usually the Ministry of Health, which will then pass the money on to nongovernmental entities. However, there are already concerns that many groups will be overlooked. Cronyism and corruption, perennial problems with international aid in general, will also have to be addressed, but as yet, it is not clear how this will be done, or how the spending will be monitored.

Addressing the AIDS crisis in Africa will require an emphasis on more than antiretroviral drugs alone, important as they are. What sub-Saharan Africa seems to need even more than it needs AIDS drugs is the improvement of its health care systems, the creation of livelihoods for families impoverished by AIDS illnesses and deaths, and the alleviation of the loneliness, poverty, and despair that are likely to motivate risky sexual behavior. The Global Fund cannot deal with all this on its own. Until scientists discover an effective vaccine to prevent HIV infection, sustained relief from the African AIDS epidemic may depend on the subcontinent’s social and economic stability, which in turn will depend on better governance by Africa’s leaders. But it will also depend critically on greater support for Africa from the international community, which could begin by establishing fairer terms of trade for African farmers and debt relief programs that are not tied to the same harsh conditions—such as underinvestment in African institutions, especially those devoted to health and education, and reduced government support for nascent African business enterprises that need to be nurtured—that have combined with local corruption and mismanagement to undermine African development.

Nevertheless, it is of enormous importance that the Global Fund succeed, not only because it could reduce much human suffering, but also because it could advance the credibility of new mechanisms to manage the negative consequences of globalization. If the fund’s performance were to generate cynicism, it could undermine similar efforts in other areas. If successful, it could become a model for global governance in the future.