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There are few places in South Africa where the looming AIDS catastrophe is more apparent, or more frightening, than in this hamlet built around an old Catholic medical mission. The HIV infection rate among women who come to prenatal clinics here is 30 percent. Tuberculosis is soaring -- there were 2,000 cases last year -- and 70 percent of TB patients are also HIV positive.

"The people in the upper echelons don't appreciate the size of the tidal wave that is coming," said Dr. Sean Drysdale, who recently stepped down as the hospital's superintendent, and seems burned out by the experience. Asked what was broken that he could not afford to fix, he muttered: "Everything."

Last week, in response to the growing AIDS crisis throughout southern Africa, five leading pharmaceutical firms offered to slash the price of HIV drugs in developing countries, in some cases by as much as 85 percent to 90 percent off U.S. prices. AIDS activists around the globe were jubilant. But in South Africa the reaction is far more complicated. The government has had a sluggish, strange and downright scary response to the AIDS disaster about to wash over the country. And that's not likely to change because of long-overdue price concessions from the West.

Ten years ago, AIDS barely existed here. Now, more than 4 million people, roughly 10 percent of the population, are infected. Treating those people -- in particular, making available the lifesaving anti-retroviral drugs that have dramatically changed AIDS care in the West -- is simply not a government priority. For one, leaders will not readily accept a program that brings drugs to South Africans with AIDS, but not to those with malaria or TB or other rampant, devastating illnesses. On a deeper level, leaders fear that high-priced AIDS treatment will derail precious economic development in a country finally emerging from oppression. Faced with a choice of AIDS drugs or new water systems, AIDS drugs or housing, AIDS drugs or health clinics, schools and highways, the drugs fall short.

"People with AIDS expect you to drop everything for AIDS," Dr. Manto Tshabalala-Msimang, South Africa's health minister, recently told reporters. "As my daughter said to me, 'You are the minister of health, not the minister of AIDS.'''

It is a rational, yet cold-blooded calculation. And it helps explain some of the baffling actions taken by leaders in recent months.

Next page | Will drug companies call the shots?