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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?

  1. 1

    See George Soros on Globalization (Public Affairs, 2002).

  2. 2

    See AIDS in the World, edited by Jonathan Mann, Daniel Tarantola, and Thomas Netter (Harvard University Press, 1992) and references therein.

  3. 3

    See “Viagra Is a $50 Million Pentagon Budget Item,” The New York Times, October 4, 1998. The actual amount spent on Viagra turned out to be far less than this, however.

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