2004
Stopping mass murder: action against AIDS

The UNDP Human Development Report 2003[4] states “China, India and the Russian Federation – all with large populations and at risk of seeing HIV infection rates soar – are of particular concern. About seven million people are infected in these countries, and in sub-Saharan Africa seven million cases exploded to 25 million in a decade.

…[E]ven in a moderate scenario, by 2025 almost 200 million people could be infected in these three countries alone.”

There are areas where even now too little is known about the extent of infection, denial and stigma retard effective surveillance and treatment as well. There is the potential for a considerable rise in infections in the Middle East and North Africa, but in a number of countries the data is scant. UNAIDS states that speedy action on prevention is urgently required, particularly among groups that could be drawn into the next phase of spread of the disease. Reluctance to deal with men who have sex with men, sex workers and injection drug users has hampered response. Condom promotion is largely absent in the region, but some countries are developing more substantial prevention programmes. These must be extended to deal with migrant workers, young people, refugees and displaced persons and transport route workers, among others.[5]

Where AIDS is highly prevalent, the impact goes far beyond the already incredible suffering and loss of life, undermining human security in many dimensions. In such countries the prospect of achieving the Millennium Development Goals is faint, in fact life expectancy, economic and social security are moving backward.

• Economic security: the UNDP Human Development Report 2003 notes that AIDS “can through development off course.”[6] A World Bank study indicates that an adult HIV prevalence rate of 10 percent can reduce the growth of national income by up to one third.[7] The United Nations Children’s Fund (UNICEF) estimates that by 2010, the South African economy will be 20 percent smaller than it would have been without HIV/AIDS.[8]
• Food security: As 2002 ended, some 14.4 million people in six southern African countries were at risk of starvation. Agricultural production and food supply have become tenuous. The United Nations Food and Agriculture Organization (FAO) estimates that seven million agricultural workers in 25 severely affected African countries have died from AIDS. Some 16 million more could die in the coming 20 years unless the impact of the disease is reversed.[9]
• Families and social structure: HIV/AIDS not only destroys “human capital” but threatens societal collapse because the function of the family by which knowledge and abilities are transmitted from one generation to the next is interrupted or destroyed. Children are left without one or more parents to love, raise and educate them. The MDG objective of reducing infant mortality by two-thirds by 2015 is virtually impossible in countries with high rates of infection.
• National security: Many military forces in Africa have infection rates five times that of the civilian population, in some cases rates as high as 50 or 60 percent. In reducing the operational capacity of many of Africa’s armed forces, HIV/AIDS contributes to vulnerability to both internal and inter-state conflict. The South African Institute of Strategic Studies warns that unless the epidemic is reversed among African armed forces, it’s likely that South Africa and other countries will no longer be able to participate in peacekeeping operations.[10]
• Governance: HIV/AIDS prevalence puts governments in affected countries under incredible strain. Having been weakened by decades of structural adjustment, and under ever increasing strictures administered by the World Bank, IMF and WTO governments now need to be radically strengthened in their capacity to serve their citizens’ needs. But they are stalked by the threat of “state failure”. For example, a recent study of the Ministries of Finance, Economic Planning and Development and Public Services and Information in Swaziland, documents that “solely as a result of HIV/AIDS the three ministries will lose 32 percent of their staff complement” over a twenty-year period. To replace teachers lost to the pandemic, Swaziland will have to train 13,000 people between 1999-2016 instead of the 5,093 that would normally be needed. [11]

Saving lives: prevention, treatment and care

The work of prevention, treatment and care requires education, community engagement and functioning health-care systems. As UNAIDS notes “in Africa, where two-thirds of the world’s HIV-positive people live, health-care systems were already weak and under-financed before the advent of AIDS. They are now buckling under the added strain of millions of new patients. In many places, facilities for diagnosis are inadequate an drug supplies are erratic, even for HIV-related conditions that are easy to diagnose and inexpensive to treat.”[12] A comprehensive approach to health, for healthy populations, demands the rehabilitation and in some cases recreation of public health systems. To sustain healthy populations, of course, will require other basics as well – decent nutrition, clean water and decent housing. A successful response to the pandemic will be sustainable only if part of a more general development strategy.

It is only in the last few years that the prospect of access to treatment has become a reality, about a decade ago in affluent countries, and frustratingly in the distant future elsewhere. Probably the first and persistent barrier to access was ignorance, or prejudice, in affluent countries. It was frequently argued that it was impossible to successfully and sustainably administer new anti-retroviral treatments in poorer countries, because they required a level of sophistication and economic development that was simply not there. The prohibitive cost of the so-called triple-therapy was clearly another block. The price of therapy for one patient in early 2000 was U.S. $10,000-$12,000 per year.

Yet by the end of 2000 the price had dropped to US $500-$800 per person for first-time anti-retroviral treatment in low-income countries, and by 2003, the prices of the least expensive generic combination recommended by the WHO was under $300 per person per year.[13]

Perhaps the single most important step forward was taken by the government of Brazil, with strong pressure from civil society organizations. From 1996 Brazil has provided universal free access to triple anti-retroviral treatment. Even in the first year it extended survival to an average of 58 months from an average of 5 months in the 1980s. “It is the first time a study has demonstrated that universal free access to triple anti-retroviral treatment in a developing country can produce benefits on the same scale as in richer countries.”[14] But the study also indicated that perhaps only 40 percent of the 600,000 HIV-positive patients in Brazil are aware of their infection. “The rest just fear the social and physical consequences of this disease and prefer not to undergo the test.”

Other countries have not been even this lucky. In South Africa the resistance of the government to antiretroviral treatment and the obduracy of drug companies in protecting their patents delayed response to a rapidly escalating number of infections for years. The persistence of such civil society activists as the Treatment Action Campaign, with the support of international NGO networks have made significant progress, but the delays have had tragic consequences on a mass scale.

CSOs have demonstrated that treatment can be actualized. In the township of Khyelitsha, near Capetown, MSF clinics helped people stabilize their condition, developing simple ways to assure regular use of complex dosages and training community nurses to supervise and support patients. In Soweto, mother-to-child transmission has been reduced with help from OXFAM, involving the drug Nevirapine, the provision of powdered milk and a supervised community care system. These initiatives need to be scaled up on a massive basis. They also must be supported by basic needs provision, clean water, adequate nourishment and stable housing.

“Today, at least 400 die every day in Kenya from AIDS. …This is the genocidal action of the cartel of pharmaceutical companies which refuse to provide affordable medicines in Africa at the same time as they declared U.S. $ 517 billion in profits in 2002.” [15]

The fight to open up access to life-saving drugs has been going on virtually since their availability was announced. The creation of the World Trade Organization in the mid-1990s was accompanied by a phenomenal extension in protection of privately – largely corporately – held patent, via an international agreement on Trade Related Intellection Property, or TRIPS. That agreement commits participating countries to extend 20-year patent protection to the owners of patents on medicines, a tremendous victory for the large pharmaceutical firms holding many of the world’s drug patents, and funding or controlling much of continuing research.

The TRIPS agreement contained provisions which should, in theory, provide the flexibility for countries to balance these protections with action for public health, for example through issuing a compulsory license to permit the manufacture of lower-cost generic copies of the patented products. In practice, however, some countries, under pressure from corporations or more powerful producer countries, either forbad compulsory licensing or simply didn’t take advantage of the possibility. Development and human rights NGOs, organizations of People Living with AIDS and their allies undertook a persistent and globe-girdling campaign to expand the legal windows for access and offset corporate and big power pressure.

A saw-off of interests occurred at the WTO’s Ministerial Conference in Doha, Qatar. A Declaration, on November 14, 2001, on the TRIPS Agreement and Public Health affirmed that TRIPS “does not and should not prevent members from taking measures to protect public health” and “in particular, to promote access to medicines for all”.

The Declaration left unresolved the situation of countries that lacked the capacity to produce generic medicines themselves. It committed countries to find an “expeditious” solution for this problem. Negotiations ground on for almost two years, and only when the lack of a deal threatened to upset the next WTO Ministerial planned for Cancun, Mexico in September, 2003, did negotiators resolve deadlock. It permits countries with productive capacity to export via a compulsory license to an eligible importing country. Of course, the TRIPS Council of the WTO retains the right to be notified of countries intension and monitor and supervise a number of conditions. The right to drugs, and one might say, the right to health, can be accessed only under the TRIPS Council’s authority. Property’s rights are honoured over those of people.

The agreement is only an “interim waiver” regarding TRIPS provisions, pending agreement to amend the TRIPS agreement itself. Meanwhile, in negotiations like those for the proposed Free Trade Area of the Americas, the large pharmaceutical corporations are seeking TRIPS +, something more than twenty years protection.

Treatment advocates found the agreement “seriously flawed” , giving WTO bodies an intimate and potentially intrusive and complicating role which could delay or prevent progress. Importing countries remain beholden to the decision-making of the wealth. As the spokesperson of Medecins Sans Frontieres stated, the agreements only offered “comfort to the US and the Western pharmaceutical industry.”[16]

Nevertheless treatment advocates are seeking by a variety of means to make sure that every opening created by the agreement is utilized in pursuit of access for those needing treatment.

AIDS does not travel alone. Malaria kills more than a million people a year, 700,000 of them African children. . New treatments – the three-day two-drug combination therapy – cost 40 cents for a child’s treatment, $1.50 for an adult. But many families cannot afford event this, and the Global Fund to Fight AIDS, Tuberculosis and Malaria remains strapped for cash. The World Health Organization estimates it would cost US$1 billion to cut in half the 1.1 million annual deaths due to malaria. This is roughly what Pfizer pharmaceuticals made from the sales of one drug, Viagra, in 1999.

The imbalance in research priorities and expenditures continues to bedevil progress against diseases that attack poor people. The World Watch Institute notes that between 1975 and 1997, 1, 223 new medical drugs were developed, largely to target diseases of affluence and over consumption. In the same period only 13 of the new drugs aimed to treat malaria, schistosomiasis and other ‘tropical diseases’ affecting developing countries. German Velasquez, Coordinator of the Drug Action Program at WHO states “After Doha, it is clear that if drugs are considered as goods, health will remain an extension of the market, with remedies and treatments available only to those with enough purchasing power.”[17] The U.K.’s recent Commission on Intellectual Property Rights went on to ask whether a drug which makes it possible for people to exercise a fundamental human right – the right to health – be bound by rules which thwart access for 20 years? Essential drugs, it could be said, were a global public good, something with benefits that extend to all countries, people and generations. [18]

“This AIDS drug thing is simple. It’s a chance to dip our well-fed toes in the water, by actually using our collective discoveries and inventions to benefit humanity. Maybe we shall find that it isn’t so dangerous and that our economic system doesn’t collapse. And the health benefits will be immediate and spectacular.”
John Sulston, Noble Prize for Medicine (shared), 2002.[19]

“Whatever else, the war in Iraq and the aftermath is going to cost this world in excess of US $100 billion and I want someone to explain to me why there is always so much money for conflict and pennies for the human condition.”
Stephen Lewis

The huge numbers of infected and dying people may deaden our sensitivities and threaten a sense of futility. The Commission on Macroeconomics and Health in 2001 estimated that costs of responding to HIV/AIDS could reach US $14 billion by 2007 and $22 billion by 2015. It would have distributed funds one-third to each of prevention, treatment of opportunistic infections and anti-retroviral therapy. These are based on very conservative estimates.[20] UNAIDS estimates that US $10.5 will be needed by 2005 just to support a “bare bones” effort against the disease.[21]

These may seem large numbers, but they are thrown into dramatic relief by what one country alone can manage when it comes to war.

By the end of 2003, the cost of the war on Iraq to U.S. taxpayers was estimated at more than $200 billion, most of it allocated in one year. This amount is over and above the regular U.S. Department of Defence expenditures of roughly $400 billion.

These amounts dwarf what is needed for HIV/AIDS and indicate that effective funding is not a matter of capacity but of political choice.[22]

An estimated 40 million people live with HIV/AIDS today. The WHO has attempted to build world support and resources for the provision of treatment to 3 million of those by 2005: a modest beginning, but one that thus far seems out of possible grasp.

In sub-Saharan Africa only 50,000 people were estimated to have treatment in 2002. In Asia and the Pacific, only 43,000. In Latin America and the Caribbean the picture is slightly better, in good part due to Brazil’s example, with close to 200,000 getting treatment by the end of 2002.

The Global Fund to Fight AIDS, Tuberculosis and Malaria was created with high expectations in 2001, designed not to replace existing monies but to raise additional funds. In its first two rounds of funding it spent U.S. $1 5 billion of which 65 percent went to HIV/AIDS. For the years 2003-2005 the Fund called for a budget of U.S. $9.7 billion, but had only pledges of $1.5 billion by mid-2003.

Official development assistance (ODA) should be playing a significant role, and the Monterrey Financing for Development Conference (2002) was taken as a sign that the long decline in commitments from wealthy countries was being reversed. Ireland, Belgium, the Netherlands and Sweden all committed to significant increases in the next two to six years. Canada confirmed an 8 per cent per annum increase in each year, but it will take five years to reach levels of expenditure made in 1991.

Debt cancellation could also be a significant source of relief. Conditionalities on loans whether obvious or subtle continue to encourage limitations on public spending, pressure to privatize public services – including health services – and pressure to conform to WTO agreements such as TRIPs. The U.N. Population Fund examined the extent to which the World Bank’s Poverty Reduction Strategy Papers (PRSP) process had been used to optimize opportunities to respond to HIV/AIDS as part of an integrated response to poverty. The report concludes “most PRSPs completed have generally missed the opportunity for effectively assessing the links between poverty, population and “HIV/AIDS.”[23] The report provides a checklist on mainstreaming HIV/AIDS in poverty reduction strategies.

The gap between the need to save lives through treatment and adequate support now and the leadership and commitment necessary on the part of those who control resources and the pricing of treatment remains immense. The expenditure commitments made by some wealthy countries on ‘reconstructing’ Iraq have come within months after the defeat of Saddam Hussein. The effort to cajole or embarrass governments into committing increased resources to combat the global pandemic grinds on slowly. Some dream of something like the “Marshall plan” which aided Europe after World War II.

Speaking at the United Nations, early in 2003, U.N. Special Envoy Stephen Lewis referred to signs of “determination and hope” he had discovered in Africa. “What has changed,” he stated, “is the maturity, vehemence and confidence of the organizations of People Living with HIV/AIDS…they know the cost of generic drugs; they know about the treatment regimes; they know that WHO has undertaken to have three million people in treatment by 2005; they know that the rich members of society vault down to South Africa for treatment, while the poor remain helplessly behind; they know about Doha and intellectual property rights and the World Trade Organization (WTO); they know, from bitter experience, about all the false political promises. Increasingly, we’re dealing with sophistication and determination in equal measure.”[24]

Are we, in fact, at a turning point in the fight against the pandemic? A very few years ago only one or two African governments had developed strategies to deal with the disease, today many have at last begun to implement such strategies and the African Union’s Maputo Declaration (July, 2003) commits African governments to a comprehensive approach and seeks international support.[25] Some countries, like Uganda, and some districts within countries are showing remarkable progress in prevention and reduction in infections. Generic drug manufacturers in low- and middle-income countries, like Brazil, India and Thailand, are producing some anti-retroviral drugs at a reasonable cost. The pre-Cancun agreement on export of generic drugs to countries lacking productive capacity belatedly offers the potential of fulfilling commitments made at the Doha WTO two years earlier. Canada, among wealthy countries, has begun an initiative that would permit firms to produce and export such drugs as well. Demonstration projects, often led by NGOs and community-based organizations are proving that saving lives is practical. United Nations bodies have developed sophisticated guidance on human rights in approaches to disease and to treatment.

Nevertheless the fundamentals necessary to reach millions – strengthened health systems in developing countries with trained and adequately supported staff, adequate supplies of medicines for universal access, sustained security in basic needs – remain tragically out of reach. Just as important is the lack of leadership among the wealthy – whether in the North, among the petroleum rich or in emerging wealthy classes in middle-income countries – in ramping up the level of resources and organization equal to the task. What is required is a multiplication of dollar, francs, pounds, marks or yen. What is offered is usually a small percentage increase, if that.

Special envoy Stephen Lewis has raised the prospect that someday those who prevent the delivery of life saving drugs and the health systems and basic needs which would enable them to be effective and sustainable may face a tribunal, like the authors of the holocaust at Nuremburg after World War II and or the sponsors of genocides today at Arusha and the Hague. Who would be in the dock facing justice? Those who foisted an unnecessary and costly war on Iraq? Those who strive through ever means possible to protect the privilege of patents? Or those who permit through complacency or worse the continuation of this human waste and the misallocation of the globe’s resources. One sick cow in North America can command sustained headlines in the lands of the rich and powerful, while millions die silently abroad.

The provision of universal access in Brazil, the move toward provision of treatment in South Africa, the Doha Declaration and the pre-Cancun compromise on generic drug provision have all be due, in good part, to mobilized networks of activists, of People Living with AIDS, of spirited physicians and health care workers and of a few – too few – politicians who caught the fire of urgency.

It is time for a wildfire of action to free the resources and the ingenuity to save millions of lives and right the grotesque wrong that condemns them and future millions more to suffering and death.

Notes:

[1] From a press briefing given at the United Nations, New York, 8 January, 2003, in ICSW, “AIDS, ender & Poverty: A United Front Against the Pandemic”, Social Development Review, 7:1, ICSW, London, 2003
[2] UNAIDS, AIDS epidemic update. Geneva, UNAIDS, December 2003 www.unaids.org These figures are estimates. The number of deaths is between 2.5 million and 3.5 million, for example. For running figures check the web-site of the United Nations Population Fund www.unfpa.org/aids-clock/clock.htm
[3] UNAIDS, “HIV Prevention and Protection Efforts are Failing Women and Girls” Media Advisory, January 30, 2004.
[4] UNDP, Human Development Report 2003: Millennium Development Goals: A compact among nations to end human poverty. (HDR 2003) (New York and Oxford, UNDP/Oxford University Press, 2003) p. 4.
[5] “The Middle East and North Africa” UNAIDS, AIDS epidemic update: December 2003.
[6] UNDP, HDR 2003. p. 41
[7] Clive Bell, Shantayanan Devarajan and Hans Gersbach. The Long-Run Economic Costs of AIDS: Theory and an Application to South Africa. June 2003. World Bank Research Report.
[8] As noted in Canada. House of Commons, Standing Committee on Foreign Affairs and International Trade (SCFAIT), Report: HIV/AIDS and the Humanitarian Catastrophe in Sub-Saharan Africa. June, 2003. p. 16 www.parl.gc.ca
[9] As found in International Crisis Group, HIV/AIDS as a Security Issue (Washington/Brussels, International Crisis Group, 29 June, 2001) p. 11
[10] Robyn Pharoah and Martin Schonteich. Institute for Policy Studies. AIDS, Security and Governance in Southern Africa: Exploring the Impact. ISS Paper 65. January 2003. (Capetown, Institute for Security Studies, 2003) P. 5
[11] Alan Whitside, et al. What is driving the HIV/AIDS epidemic in Swaziland, and what more can we do about it? National Emergency Response Committee on HIV/AIDS (NERCHA) and UNAIDS. April 2003.
[12] UNAIDS, “Access to HIV Treatment and Care”, Fact Sheet, Geneva, UNAIDS, July, 2003.
[13] Ibid..
[14] Dr. Jose Ricardo Pio Marins, University of Campinas. Quted in “Free HIV Drugs in Brazil Have Boosted AIDS Survival” Reuters (07:25:03), in CDC HIV/STD/TB Prevention News Update, Wednesday, July 30, 2003.
[15] Statement by American Jesuit Angelo D’Agostino, at a press conference held by Archbishop Paul Josep Cordes, President of the Vatican humanitarian agency Cor Unam. From “Le Vatican part en guerre contre les companies pharmaceutiques”, Le Soleil, Quebec, 30 janvier, 2004.
[16] Medecins Sans Frontieres. “Flawed WTO drugs deal will do little to secure future access to medicines in developing countries.” 30 August, 2003. www.msf.org/content/page.cfm?
[17] German Velasquez, “Drugs Should be a Common Good: Unhealthy Profits”  Le Monde Diplomatique. English Edition, July, 2003.
[18] Commission on Intellectual Property Rights. Integrating Intellectual Property Rights and Development Policy. Report of the Commission on Intellectual Property Rights. (London, Commission on Intellectual Property Rights, September, 2002) p. 48
[19] From John Sulston, “The Rich World’s patents abandon the poor to die”, Social Development Review, 7:1, ICSW, London, 2003 Originally published the The Guardian, 18 February, 2003.
[20] The Commission assumed, for example, that only 5 percent of Africans affected are currentlyh aware of their status and therefore in a position to know whether or not treatment is appropriate. WHO. Macroeconomics and Health. (Geneva. WHO. 20 December, 2001) [/ 53
[21] UNAIDS. “Despite Substantial Increases, AIDS Funding is still only half of what will be needed by 2005.” Press release. 26 June 2003.
[22] From a pamphlet by National Priorities, a project based in New England. The figures is made up of $44 billion spent between 2001 and 2003 in war preparations, $70 billion allocated in the spring of 2004, $87 billion requested by the President in fall, 2003. www.nationalpriorities.org/issues/military/iraq/factsheet03/us.pdf
[23] UNFPA. The impact  2003. pp. 85-92
[24] From a press briefing given at the United Nations, New York, 8 January, 2003, in ICSW, “AIDS, Gender & Poverty: A United Front Against the Pandemic”, Social Development Review, 7:1, ICSW, London, 2003
[25] African Union. Maputo Declaration on HIV/AIDS, Tuberculosis, Malaria and other related infections diseases. AU Declarations. Assembly/AU/Decl. 1-5. (Addis Ababa, African Union, July, 2002)

John W Foster is Principal Researcher, The North-South Institute, Ottawa, Canada and chair of the Coordinating Committee of Social Watch.