The Global AIDS Pandemic and the Response of the Relevant Actors
Over 25 million people have died of AIDS since the first identified cases in 1981. Approximately 3 million people continue to die of AIDS every year (that is more than 8000 people every day – 2) although the medicines largely capable of preventing these personal and community tragedies already exist. The Global AIDS Pandemic and the Response of the Relevant ActorsDan Jakopovich*
“The same conditions have governed the emergence of epidemics for thousands of years. Epidemics are preceeded by rapid population growth that tails into famine and malnutrition, urban crowding, poverty, and lack of sanitation and fresh water.” (1)
Over 25 million people have died of AIDS since the first identified cases in 1981. Approximately 3 million people continue to die of AIDS every year (that is more than 8000 people every day – 2) although the medicines largely capable of preventing these personal and community tragedies already exist.
With the advent of antiretroviral therapy HIV/AIDS has become a manageable, chronic disease for people who can afford these drugs. Stark differences in access to treatment are evident in mortality rates. In the US, the decline in infection levels among better-off whites in the US has recently been paralleled by a simultaneous increase in infection rates among poor black and Latino populations.
Cumulative factors include poverty and social upheaval, widespread incidence of wars, social dislocation and persecution (directly connected with the “divide and rule” legacy of traditional colonialism, the creation of artificial borders, neocolonialism etc.) contributing to high mobility of people and therefore the spread of the virus, government corruption, ineffectiveness and subservience to the transnational companies and wealthy and powerful states and institutions, debt bondage (with most African governments spending up to three times more on debt repayments than on health care- 3), social cuts and the privatization of health services, high illiteracy and limited access to information, “brain drain” of health professionals (The current ratio is one doctor per 500 patients in wealthy countries and only one per 25 000 in the 25 poorest countries - 4), lack of hygiene, erosion of the immune system due to hunger, malnutrition, untreated opportunistic infections etc. 66% of the infected live in sub-Saharan Africa.(5)
The epidemic is having a crippling effect on the economies of the poor countries. It is wiping out the most economically productive age groups. FAO reported that in Namibia in 2002 half of the informants had left their land uncultivated due to labour shortages because of AIDS. (6) The damaging effects on the economies of poor countries afflicted with the epidemic are great and multi-layered. The UNAIDS 2002 AIDS Report estimates that per capita GDP in some countries may drop by 8 per cent by 2010, with heavily affected countries losing more than 20 per cent by 2020. The region is said to have experienced a 2-4 per cent decrease in economic growth due to AIDS. (7)
Only when the spread of the virus to heterosexual middle classes did the richer countries start showing concern (why care about gay men, sex workers, their customers, or injecting drug users - they are “getting their just desserts” after all ).(8) Similarly, only when it became obvious it is threatening global security did it become an international issue. Only the goal of preserving the stability of a system which produces so much human tragedy could mobilise the elites.
Under capitalism, the right to stay alive doesn’t come cheap, and few of the HIV-positive poor can afford to buy their lives. Health care has been turned into a commodity, so health follows wealth.
“The AIDS pandemic has has taken more lives than the Black Death in Europe of the Middle Ages. (…) HIV/AIDS (…) has infected over 60 million people, claiming almost 22 million lives. This is the equivalent of 7000 World Trade Center 9/11 disasters, 4 Holocausts and more than 22 genocides in Rwanda. By the time you read this, it will have risen even higher. (…) At the close of the second year of the new millennium, the United Nations global estimates of people living with HIV/AIDS (…) stood at 42 million adults and children, most of them in sub-Saharan Africa. Five million people were infected in the year 2002 alone. In the same year, 3 million people died of AIDS; by 2002 14 million children were orphaned“ (9)
Children, most often girls, have been forced to quit school in order to look after their sick parents or relatives, and there is a growing phenomenon of “child-headed households” where the parents have died. UNAIDS estimates that 40 million more children will lose their parents to AIDS in the next 20 years. (10) Girls and women are usually the main caregivers in AIDS-afflicted families and communities (UNAIDS notes that school enrolment in Swaziland for instance – mostly of girls – has fallen by 36 per cent as a result of the epidemic – 11), and are often more likely to bear the brunt of the disease - not only due to greater biological vulnerability when it comes to contracting the infection, but also as a result of patriarchal relations and a subsequent lack of protection, sexual puritanism (especially when it comes to young women’s and youth sexuality in general) aided by the catastrophic and callous stance of the religious institutions and leaders (most notably the last pope) against the use of contraceptives. In its perversity, the US administration is also exploiting the AIDS crisis to promote abstinence and sexual conservativism internationally.
Average life expectancy according to the CIA World Factbook in Swaziland is now below 33 years (12). In Botswana, for instance, where 39 per cent of adults are HIV-positive (! –13) there has been a drop in life expectancy to pre-1950 levels – only 39 years – while the predictions without AIDS are 72 years. (14) According to UNAIDS, the average life expectancy in sub-Saharan Africa has decreased from 62 years to around 47 years (15). The gains made during the African development era have largely been nullified.
Patents & death
“We wonder what is deadlier in sub-Saharan Africa – AIDS or businessmen with briefcases full of patent applications.”
Christopher Ouma, Kenyan doctor, Action Aid
As a result of the neoliberal cuts in social services (including the health service), the profit motive of the pharmaceutical companies, and the protection they get from the wealthy nations, international economic institutions and corrupt domestic elites, life-saving antiretroviral medications (ARVs) which have transformed HIV/AIDS into a chronic disease in richer countries (16) - still remain almost completely beyond reach for poor people in the Third World. “In 2001 only 30,000 of over 28 million infected people in sub-Saharan Africa were on treatment and over 2 million died of AIDS.” (17) In Kenya, for instance, a quarter of the population is HIV-positive, yet only 2 per cent can afford treatment. (“In many countries, the cost of providing overpriced antiretroviral treatment would exceed the entire national health budget … Even if Zambia were to spend its entire national income on HIV/AIDS drugs, it still could not afford to treat every person infected with HIV in the country” - 18). Meanwhile, the respected state and corporate criminals most responsible for the tragedies of so many people and their loved ones are reaping huge social and economic rewards.
An early pioneer in AIDS prevention among the Ugandan soldiers, Major Rubamira Ruranga, rightly attacked the modesty of projects aimed at helping the infected “die with dignity” while the companies are profiteering through extortionate drug prices, a glaring injustice to anyone who wants to see: “What is dying with dignity? Why do you train me to die with dignity when actually I should not die?” (19)
Additionally, combined use of ARVs with breastmilk substitutes has “virtually eliminated the pediatric AIDS epidemic in countries in the North”.(20)
“At the 1996 international AIDS Conference, Noerine Kalleba of UNAIDS in Uganda said: ‘We have heard…about the exciting advances that have been made with regard to the use of AZT in interrupting mother-to-child transmission of HIV. The young infected woman in Africa is asking where, how, when does she access this?’ seven years later Kalleba will still be asking this question. (…) In Northern countries, the use of drug therapy and breastmilk substitutes has virtually eliminated the pediatric AIDS epidemic. In many Southern countries by contrast, HIV-positive mothes are advised to continue breastfeeding since the lack of access to clean water (to wash bottles and mix powdered milk with) means the risk of their children dying from diarrhea and dehydration through bottle-feeding is still higher than the risk of transmission of HIV through breastmilk. The cost of formula milk and the drugs are also obstacles in poor countries” –21).
The pharmaceutical industry, perhaps only rivaled by the arms industry in its hideousness centered around profiteering off people’s misery, is sentencing millions – even children and babies - to premature death. In the real world, beyond UN declarations and international human rights conventions, the rights to life and dignity are dwarfed by intellectual property rights and the right of transnational pharmaceutical companies to make exorbitant profits.
Pharmaceutical giants maintain its monopoly on the market through patents which prevent the production of cheaper generic medicines for at least 20 years. In many cases, “generic production would reduce the price by anything between 70-95 per cent, depending on the manufacturing costs”(22)
Drug patents and intellectual property laws are enforced globally by the World Trade Organization (WTO) agreement known as TRIPS (Trade Related Aspects of Intellectual Property Rights), and all WTO members are obliged to conform to them.
The patent rights dogma is all the more despicable considering the fact it is often the governments rather than the drug companies that pay for clinical and preclinical research which later goes into the hands of the private sector to patent and monopolise for itself (23). In any case, it isn’t the scientists who are the real beneficiaries of intellectual property rights, but the capitalists of course. Being wage labourers, the scientists are also exploited.
Moreover, only 10% of Big Pharma’s research and development expenditure goes into drugs that account for 90 per cent of global diseases. (24) The former head of the pharmaceutical giant Merck, which controls one-tenth of the world’s pharmaceutical market, explained the structural causality behing company behaviour: “A corporation with stockholders can’t stick up a laboratory that will focus on Third World diseases because it would go broke.”(25)
However, it is a piece of fiction that the companies have no leeway in setting prices. In only one year, Bristol-Myers Squibb paid its CEO $146 million, while more than a billion people in this criminal system under which we live is forced to survive with less than $1 a day, and still hasn’t got access to the bare necessities of life – food, water, sanitation, housing, health care and education.
Importing generic (non-patented) drugs from countries like India could reduce the price of therapy to less than $300 per year (and Thailand believes it can drive the price down to $200) from $10-15,000 in the US, but this is fiercely opposed.
The pharmaceutical giants are defending “(p)rofits that are undreamed of in any other industry: the combined worth of the top five pharmaceutical companies is twice the combined GDP of all the sub-Saharan African countries”. (26)
UNAIDS estimates that 68 million people are expected to die prematurely due to AIDS between 2000 and 2020. (27) The amount of suffering is unquantifiable.
New scientific discoveries should be a part of a free historical process of accumulation of collective knowledge which could benefit the entire human kind.
The institutional response
The astonishing lack of urgency in the reaction to the growth of the epidemic (5 million newly effected in 2002 for instance – 28) is possible only in a system in which profit and power are put before living, breathing human beings.
WTO’s epidemic control strategies have concentrated on cost effectiveness rather than humanitarianism. “The tortured deaths of “less valuable” humans can be justified because saving them is not “affordable” or “economically viable.(…)World Bank policymakers have argued, for example, that poor countries should not consider providing treatment to the afflicted and that prevention programs should come first even if people were dying in absolute agony.” (29)
In 2002, the Global Fund to Fight AIDS, Tuberculosis & Malaria was established, since its inception it has given $3.1 billion to 310 grants in 127 countries (as of July 2005 - 30). Bush also announced the US would give $15 billion over a five year period (31), a negligible sum compared to about half a trillion dollars annually spent on the US war machine for instance. Nevertheless, there has been a marked (if grossly inadequate) increase in financial support. The Fund itself has set rather modest goals – it is projected that 1.8 million will receive antriretroviral treatment, 62 million people will be reached through voluntary counseling and testing for prevention & “more than one million orphans will be supported through medical services, education and community care” (32)
The Doha declaration, unsuccessfully opposed by Switzerland and the US (both homes to the biggest pharmaceutical companies), adopted a position allowing for some flexibility in matters of public health emergencies, stating that “the TRIPS agreement does not and should not prevent members from taking measures to protect public health” (33). However, the pool of generic alternatives has been diminished by pressure from the North against selling these cheaper drugs abroad.
Supported by numerous informal connections and substantial corporate financial contributions to the Democrats and the Republicans, US administration continues to use its might to close TRIPS’ “flexibility clauses” and tighten intellectual property rights rules. It also continues to intimidate and blackmail those countries that want to produce generics. It has bullied the government of Thailand into submission when it attempted to manufacture its own retroviral drugs (there are about a million HIV-positive people in Thailand, and the cost of AIDS treatment is seven times more than an average office worker’s salary, but a quarter of Thai exports go to the US), and it has also threatened South Africa with trade sanctions in response to their domestic legislative changes allowing generic ARV importation. The pressure on South Africa was additionally backed by French, German and Swiss administrations for instance, and a coalition of 39 drug companies under the banner of the Pharmaceutical Manufacturers Association sued the government, but the drug companies were shamed by world opinion into dropping the case, after a successful publicity campaign by civil society organisations. US Vice-President Al Gore was also strongly implicated in this repressive ordeal, which didn’t stop him from making hypocritical statements of concern with regards to the AIDS crisis.
The struggle for life and dignity
Of course, these changes in the South African legislation (the Medicines Act of 1997) were achieved through an aggressive alliance of trade unions and civil society groups, and civil society groups had been illegally importing the medicines for some time anyway, embarrassing the government.
However, having passed the law, the government did nothing with it. It allowed private patients to import generic drugs, but the government made no effort to distribute the drugs at hospitals. These are also not just anti-retrovirals - the most notorious case was a drug called Nevirapine. If a single dose costing £2 were given to a pregnant woman, it would halve the chance of her baby being born HIV positive. Yet the government refused to make it available, famously saying 'but what would we do with all the orphans'. (In other words saying they prefer the babies to get Aids and die so that they wouldn't drain state resources in orphanages).
The Treatment Action Campaign (TAC) - with financial and public support from the unions - took the government to court on a number of occasions, and forced it to provide anti-retrovirals to patients at state hospitals, and to tender for the drugs to be made locally. The government now likes to boast it has the world's biggest treatment plan, but it still reaches only 25% of those who need the drugs, and at very stage the TAC has had to drag the Department of Health through the courts to get them to deliver.
The health minister and the widely reviled Mbeki loyalist Manto Tshabalala-Msimang is still publicly claiming that a diet of garlic, beetroot, olive oil and lemon juice is the best response to the virus.
The TAC's success is that it built a mass movement by linking with other groups, such as church groups and trade unions, which ensured that the message spread. Many trade unionists are HIV positive and are also TAC activists, so there is a massive cross over and the SA unions are quite good on the issue. Perhaps the best union Aids policy in the world is provided by the textile union SACTWU - apart from all the campaigning they do to win workplace HIV- Aids policies and treatment from government, the union also employs Aids specialist doctors and provides free voluntary testing and counselling to members. If they are HIV positive, it provides them with multivitamin and mineral supplements (they can't afford anti-retrovirals), and links them to a support group of other union members living with the virus.
Brazil managed to largely turn back its epidemic by defying the transnational drug industry and producing accessible antiretrovirals. The US threatened to use retaliatory measures, and filed a complaint with the WTO, but Brazil won international support and the US complaint has subsequently been dropped.
The struggle for access to medicines as a basic human right is still being fought all over the globe, and critically in the context of the AIDS pandemic, where huge but insufficient price reductions have already been won.
The industry itself could make substantial profits on higher volume of sales, but it seems the pharmaceutical giants are worried about the emerging global “black market” of accessible medicines, and that consumers in the North will also begin to demand fairer prices. A North-South consumer alliance along these lines might be a way forward for the HIV-positive and their loved ones.
Generic competition and enhancing generic community capacities are the most effective mechanism to ensure universal access. People have to rely on grassroots mobilization, social movements that are leading aggressive campaigns directed from below and challenging the status quo. The important steps forward achieved so far - including the concept of freedom of access to medicines itself - would be unthinkable without civic participation and self-organisation. Wider demands for debt relief, protection of public services etc. have to be coupled with restorative elements of community empowerment, promotion of education and gender equality, mutually respectful relationships, and early, realistic, non-moralistic sexual education. The stigma, ostracism, hysteria and fatalism have to be overcome through openness and greater determination to fight back – both against the disease itself and the corporate Machiavellians who profit from it.
The indifference of the rulers and the “international community” to the suffering of millions upon millions of women, men and children is a bleeding wound on the body of humanity. But the courage and compassion of those fighting for justice leave hope on the otherwise bleak and brutal horizon.
* with generous advice by Walton Pantland
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(1) Susan Hunter, Who cares? AIDS in Africa, Palgrave Macmillan, New York, 2003.
, pp.85-86.
(2) Shereen Usdin, The No-Nonsense guide to HIV/AIDS, Verso in association with New Internationalist, London, 2002, p.112. It is estimated that in 2005 somewhere between 2.8 and 3.6 million people died, of which more than 570,000 were children. (UNAIDS, AIDS epidemic update, 2005 in Wikipedia, http://en.wikipedia.org/wiki/AIDS#_note-UNAIDS – retrieved May 7)
(3) Ibid, p.41. The conduct of the major international institutions with regards to the debt crisis (which is one of the core reasons for the inadequate response to AIDS) is quite illustrative. There has been a five-fold increase of debt in 1970s for non-OPEC underdeveloped countries, and a steep rise in interest rates through the US anti-inflation policy. Following the re-negotiation of loans in the 1980s, the interest rate came out much higher. In six of the eight years from 1990 to 1997 underdeveloped countries paid out more in debt service than they received in loans (due to usurious interest rates) – total transfer of money from the poor South to the rich North was $77 billion; the poor are giving to the rich. (Ellwood, W., The No-Nonsense Guide to Globalization, New Internationalist Publications & Verso, Oxford & London, 2001, p.47) Under the IMF “structural adjustment programmes” the underdeveloped countries are servicing the debt rather than being able to concentrate on development and social services vital to combating AIDS, such as education and health care.
(4) D. Frommel, Global market in medical workers, Le Monde Diplomatique, May 2002 in R. Labonte, & T. Schrecker & D. Sanders & W. Meeus, Fatal Indifference, The G8, Africa and Global Health, UCT Press, 2004, p. 58.
(5) Yvette Collymore, HIV/AIDS Epidemics Expand Rapidly in Asia, http://www.prb.org/Template.cfm?Section=PRB&template=/ContentManagement/ContentDisplay.cfm&ContentID=11014, accessed May 8th.
(6) Shereen Usdin, op.cit., p.44.
(7) Ibid, p.44.
(8) The compassion, mutual aid, openness and anti-puritanical dissidence of the ACT-UP (AIDS Coalition to Unleash Power) movement in North America, for instance, offered a radically different narrative.
(9) Shereen Usdin, op.cit., pp. 11-12.
(10) Ibid, p.30.
(11) Ibid, p.45.
(12) www.cia.gov/cia/publications/factbook/rankorder/2102rank.html
(13)Ibid, p.134.
(14) Ibid, p. 12-13.
(15) Ibid, p.43.
(16) Ibid, p.8.
(17) Ibid, p.28.
(18) Ibid. p.42. & p.88
(19) Ibid, p.26.
(20) Ibid, p.24.
(21) Ibid, p. 26 & p.43.
(22) Ibid, p.90.
(23) “The private sector funds just over half of the total health care research, but reaps most of the profits” (D. Watson, US pharmaceutical companies reap huge profits from AIDS drugs, World Socialist Website in Shereen Usdin, op.cit., p.91.)
(24) Ibid, p.92.
(25) Ibid, p.92.
(26) Ibid, p.93
(27) Ibid, p. 30
(28) Ibid, p.26
(29) Susan Hunter, op.cit., p.209.
(30)The Global Fund to Fight AIDS, Tuberculosis & Malaria website -theglobalfund.org/en/files/about/replenishment/progress_report_en.pdf
(31) http://www.data.org/archives/000226.php
(32) - http://www.theglobalfund.org/en/about/aids - retrieved May 9
(33) World Trade Organization, Declaration on the TRIPS agreement and public health, Geneva, 2001 in R. Labonte, & T. Schrecker & D. Sanders & W. Meeus, op.cit., p.62.
Bibliography:
Collymore, Y, HIV/AIDS Epidemics Expand Rapidly in Asia, Population Reference Bureau
Ellwood, W., The No-Nonsense Guide to Globalization, New Internationalist Publications & Verso, Oxford & London, 2001.
Hunter, S, Who cares? AIDS in Africa, Palgrave Macmillan, New York, 2003.
Labonte, R. & Schrecker, T. & Sanders, D. & Meeus, W., Fatal Indifference, The G8, Africa and Global Health, UCT Press, 2004.
Usdin, S, The No-Nonsense guide to HIV/AIDS, Verso in association with New Internationalist, London, 2002.
The Global Fund to Fight AIDS, Tuberculosis & Malaria website -
CIA World factbook