Daryl Lindsey

A pandemic fueled by poverty

A doctor says the fight to get cheap AIDS drugs to Africa is misguided: These people need water, food and basic healthcare.

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From the first day of the United Nations Special Session on HIV/AIDS in New York this week, activists, nongovernmental organizations and delegates have clashed over how to face the global epidemic. Not surprisingly, one of the most contentious issues facing delegates is money: whether U.N. Secretary-General Kofi Annan’s proposed superfund should be used primarily for prevention of the disease or whether a significant chunk of it should be used to treat those who are already sick with expensive anti-retroviral drugs.

An alliance of groups argues for loosening intellectual-property laws in Africa and easing pharmaceutical patents in order to make available inexpensive, generic versions of the AIDS drugs that have prolonged countless lives in the West. Groups like ACT-UP, Oxfam and HealthGAP have asked the United Nations to use a good portion of its superfund monies to buy those drugs in bulk and give them to developing countries.

But critics of those proposals say that the generic-drugs plan would discourage pharmaceutical companies from continuing to fund AIDS research. More significantly, they say, the sub-Saharan African countries most affected by the disease lack the healthcare infrastructure necessary to distribute the complicated drug regimens. Without that infrastructure, the cocktail treatments would not be effective.

For 16 years, Carole Collins has worked with AIDS patients throughout the world, watching them struggle with the basics of getting clean water and food for the children they will soon leave orphaned. Collins, a public health physician, is the HIV/AIDS policy director for Christian Aid, a London Protestant organization that works with local communities in Africa to provide $85 million worth of AIDS relief each year. In an interview with Salon, she argues that eradicating poverty is the real key to eliminating the AIDS pandemic.

Will the U.N. AIDS superfund provide sufficient monies to combat AIDS in sub-Saharan Africa?

Sadly, I think it will not. The intention may be good, but instead of getting $10 billion, we’re going to get $1 billion to $2 billion. For a global fund dealing with three diseases — HIV/AIDS, tuberculosis and malaria — that’s not sufficient. There’s going to be another level of bureaucracy to administer it, and it’s going to distract from the central problems of Africa.

If you really want to tackle HIV/AIDS, you’ve really got to tackle poverty. There is increasing evidence that the whole pandemic is being fueled by poverty. It’s the poverty that drives young women into prostitution to feed themselves and their children. You’ve got no access to healthcare and little or no access to education. Unless we can address those very simple issues, everything else is window dressing.

These debates over anti-retroviral cocktail drugs are obscuring the greater poverty. People are not eating; the levels of malnutrition I’m seeing are astounding. I see people who have almost scratched themselves to death because of the lack of a simple skin preparation. We see people dying of diarrhea for want of simple diarrhea preparations. Drugs are not filtering down to everyone, never mind the more sophisticated ones. Those very basic drugs are not there.

Whenever I go to visit some of our community-based programs and you’re led into somebody’s home, the first thing that will hit you is that the patient will be on the floor. If that household was not poor before HIV and AIDS infected somebody, then by the end of the first few years, poverty will come to that household as all of their assets are sold off to pay for healthcare. Children have been taken out of school — daughters, particularly — to become caregivers. Invariably, the person you come to see will be on the floor without a blanket or a pillow. If you look around that mud hut for food, you won’t see it, and you won’t smell people cooking. There is no food.

Discussion of issues like prostitution has been difficult at this U.N. meeting. The mention of homosexuality and sex workers even created a battle between Northern European and Islamic nations, over the wording in the U.N. platform of which groups are “vulnerable” to HIV/AIDS.

The term “vulnerability” is causing so much heartache in that building right now. It’s quite astonishing. I flash back to my life in the field and I think about the people I see dying and I think: If they only knew the time and the heartache caused by one word in a very beautiful document, they would be distraught.

The people I deal with on a daily basis are asking for clean water, for food, for pain relief, for simple skin preparations for itchy skins. They seem very far removed from these large declarations and large meetings in U.N. buildings.

But the meeting itself is good in that it’s bringing together lots of different people to talk about this very serious pandemic. In the last 20 years, 58 million people have been infected, many of whom have already died. We are at a crucial time where something must be done — there’s a small window of opportunity for us all to do something substantial. As such, it’s disappointing to see that all we can come up with is a $1 billion to $2 billion fund.

Why is it so difficult for the United Nations to raise funds for such a high-profile cause? Do corporations and governments fear that their contributions won’t be well spent?

Many of us here have had previous experience with these large funds. What happens? Yet again another bureaucracy must be formed to administer the funds. A quantity of the money will be taken for administrative purposes. There are already people talking about this money being spent on drugs and commodities and other people arguing that we need it for prevention.

People are very wary of these large U.N. hierarchies and the so-called panel of experts who will determine how the money is going to be spent and whether the programs are technically good.

Would the money be better spent if it were given directly to local programs and nongovernmental organizations rather than a new bureaucracy?

Our experience is that if you get this money down to the community level, the communities themselves should be directing where the money is spent. It should be community led and community focused.

The NGOs are one means by which the money can get down. Over the last few years, following the Jubilee 2000 debt relief movement, there’s been a lot of interaction between local governments and civil societies for debt relief and poverty reduction strategies. I’m not saying the systems are perfect. We’re saying use the channels that have already been set up — donate the money bilaterally, some to international governments, some to NGOs, some to civil society. Don’t set up another hierarchy, another bureaucracy. These are the problems we see with the fund.

What sorts of community-focused groups would you like to see funded with this money?

In the Congo, we work with women who are HIV-positive through Fondation Femme-Plus. They’re a very practical organization — they’re all HIV positive and concerned about who will look after their children when they die, who will look after them when they are sick.

A lot of them have faced stigma and have been ostracized from the community. They’re a self-help group, and they are incredible, they’re so strong and courageous. Though they don’t set themselves up as a medical agency, they will take people who are sick to the medical services that are available locally. They will make sure that they are paid, they ensure that the women’s children get to school. They also pay the consultation and fees for drugs and for the education of their children. For families without food, they will make sure they have food packets. Life is very difficult for them. Those are the groups we should be supporting.

My personal experience in Africa is that the best work is being done in communities. But the hospitals are now so oversubscribed, and 80 to 90 percent of their occupancy is due to HIV/AIDS, so there’s no room in the hospitals, even if you wanted to provide the anti-retrovirals. The state health systems are crumbling under the strain, and other systems need to be formed.

Throughout Africa, Christians have done a huge amount of health work. In the Congo, 80 percent of the work is being done by the Catholic Church. In Malawi, 50 percent is done by the Anglican Church. Because their state health systems are failing, the churches are having to take up a huge amount of the load. They’re struggling — they need more resources and people. That’s a serious issue for us. A large number of our partner staff have died of the disease, lots of health workers are dying of the disease or getting burnout because it’s exhausting work dealing with people who are so ill and dying all the time. These are very serious issues that have got to be considered in the next few years.

Do you think it’s premature to discuss issues like compulsory licensing for generic anti-retrovirals?

The anti-retrovirals have made a huge impact in the West. We’re not against them. But one of the problems we have is that they’re still hugely expensive. I know they’ve come down dramatically in price.

But what about CIPLA and other companies proposing to offer these drugs for as little as $1 a day?

It still takes them out of the reach of 99 percent of the kind of people I work with in Africa. They need to come down even further in price for them to be effective.

We know that people infected with HIV/AIDS can lead lives of good quality if they have access to food, to clean water, to the simple drugs for opportunistic infections. They can live long enough to see their children grow up, to educate their fellow workers so that their skills can be passed on to the next generation.

We would estimate that if we could have access to the things we’re talking about you could increase life expectancy of those with HIV/AIDS by eight years — which is enough time for their kids to grow up enough to be self-sufficient. We’re having to teach life skills to some of the orphans we’re looking after now. We’re having to teach them how to do simple agriculture and simple household tasks. Simple parenting skills because they’ve never been parented; their parents died when they were so young.

There are many aspects about using anti-retrovirals that worry me. Many countries in Africa do not have the infrastructure — and it’s true. The critics have a strong case here. One has to look at why the healthcare systems are so weak, and you have to look at the impact of structural adjustment [debt repayments] on Africa. For the last two decades, health and education has suffered. I’ve personally witnessed this as health budgets have been slashed and user fees have been introduced. You have to wonder whether it’s the policies of the International Monetary Fund and the World Bank that have actually exacerbated the situation we’re in now.

Many countries don’t have the infrastructure, but it also has to be said that there are some places that do. It exists in the larger cities and some of the missionary hospitals, which are very sophisticated. They could handle anti-retroviral drugs. In those cases, perhaps they should have access to them. But you have to be very careful with these systems.

What could go wrong if the system is not in place?

We’ve seen with the tuberculosis system that even when we had what we think are good structures, we’ve had huge problems with patient compliance. People think after two months they’re better and stop coming to pick up the drugs, particularly if they have to pay for them. The idea of lifetime drugs is a very big issue for Africans. Or perhaps when you feel better, you’ll give the drugs to your neighbor who can’t afford them. That could create new strains. We’ve had huge problems in Africa with multiresistant TB.

There are arguments for and against on this one, but we need to find a line in between. But probably in the majority of situations, it will not be feasible. But you should not be writing off Africa just because you can’t use anti-retroviral drugs. There’s evidence that if you can get basic necessities to them — water, food and simple treatments — we can expand quality and duration of life.

We should also be using AZT and nevirapine to stop transmission from mother to child. But that doesn’t take care of the mother. We need to create a package for mother and child that will allow the mother to live long enough to take care of the child during the first years of its life.

UNAIDS estimates that there are 13 million AIDS orphans — roughly as many as there are children in the United Kingdom. Some of these children are very vulnerable. They become heads of households at the age of 10; many of them have been orphaned two or three times. They’ve lost their parents, their aunts and uncles, their grandparents. There’s a small group of very traumatized children out there — we’re concerned about their winding up on the streets and getting infected.

Your prescription for fixing the problem sounds more like poverty relief than AIDS relief.

We need to rebuild the infrastructure and support these communities. There’s already tremendous strength there. We’re calling for debt relief, fairer trading laws. But we’re also calling for member nations of the Organization for Economic Cooperation and Development to honor the pledge they made 30 years ago to give 0.7 percent of their gross domestic product for overseas aid. As we know, most of them got nowhere near this. The U.S. is at 0.1.

Now, in this time of AIDS, which is on a scale we haven’t seen before, there’s a new dynamism to arguments about giving this money. We’ve calculated the total figure at $100 billion, which would allow us to rebuild the health infrastructure and the education infrastructure. We could target a lot of money into communities for orphans and the vulnerable. That scale of money is what you really need if you’re going to be serious about tackling AIDS.

AIDS conclave off to rocky start

A gay rights groups struggle with Islamic dogma at U.N. meeting.

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AIDS conclave off to rocky start

A special meeting on the international AIDS crisis got off to a rocky start Monday, when some member states tried to block the inclusion of an international gay rights speaker on the agenda.

That dispute was resolved by late afternoon, but members continued to debate whether a draft declaration pledging to halt the spread of HIV and AIDS — and offering support for the $7 billion to $10 billion superfund proposed by Secretary-General Kofi Annan — should specifically cite homosexuals, sex workers or intravenous drug users as people vulnerable to the disease. Conservative Islamic countries, led by Egypt, sought more generic terms that they said would let them support the effort without betraying their religious principles.

The spat over the gay-rights group’s inclusion, as well as over semantics, underscores the difficulty the United Nations faces in mounting a unified international response to the worldwide AIDS crises. In North America and Europe, a high percentage of HIV/AIDS cases have been concentrated among those in the gay community, intravenous drug-using populations and sex workers; in Africa, the population most devastated by the illness has been heterosexual. Meanwhile, frank discussion of homosexuality, which is forbidden under Islam, is difficult if not impossible for the governments of more than a few member nations, as is talk of drug use or prostitution.

Early Monday, the United Nations suddenly withdrew its invitation to Karyn Kaplan of the International Gay and Lesbian Human Rights Commission (IGLHRC). Kaplan had been scheduled to participate in a human rights roundtable on Tuesday morning — one of four high-profile discussions that had been scheduled with participation by nongovernmental organizations. The list of attendees drafted had to be approved by country delegations, and several Islamic countries, reportedly led by Egypt, refused to allow Kaplan’s group to participate.

Late in the day, Kaplan was reinvited after a sharp debate, but members continued to wrangle over the wording of the joint declaration. No agreement was reached by the end of the day.

The United States is reportedly involved in trying to broker a compromise between Islamic nations and more liberal European states on gay issues. On Monday U.S. Secretary of State Colin Powell addressed the delegates, and suggested the U.S. may offer more to the U.N.’s AIDS superfund than the initial $200 million it has pledged, hinting that the funds are “only the beginning.” Powell also said that the U.S. has already provided more than $1.6 billion in AIDS relief funds to developing nations. He pointed out that President Bush has pledged to double AIDS relief funds in his next budget, bringing the annual expenditure to $480 million.

The Canadian and Norwegian delegates have taken the lead in negotiating to include specific references to gays, sex workers and drug users in the declaration, as well as in the successful attempt to restore IGLHRC to the roster of speakers, according to a source familiar with the negotiations.

In a speech before the General Assembly, Norwegian Minister of International Development Anne Kristin Sydnes criticized the silence of many nations about the spread of the disease, noting that effective prevention requires the breaking of societal taboos. “It will take putting an end to abuse, discrimination and stigma,” she told the assembly. “We must offer partnership, not exclusion … Partnership with people infected and affected by HIV/AIDS. Innovative ways of working with such vulnerable groups as men who have sex with men, injecting drug users, sex workers. Openness and cooperation promotes responsible behavior. Stigmatization increases vulnerability.”

Reached by phone, IGLHRC project director Scott Long said he was told Islamic member nations were uncomfortable having a gay and lesbian organization participating in Tuesday’s roundtable meeting in any official capacity. Long said delegates for Canada, Norway and European Union member states had also been battling Egypt and Islamic nations over language.

“Everyone knows that HIV/AIDS is not just a gay disease,” Long said. “But gays faced the brunt of it first and have a wealth of experience on how to respond to it effectively. What the U.N. is now saying, beyond the moral implications, is that our opinions are not worthwhile. They’re ignoring a reservoir of wisdom and truth about AIDS,” he said.

On the other hand, this is one of the first occasions in history where virtually every nation in the world has been asked to discuss in an open forum tough subjects that are still more taboo in some countries than others. It’s easy for the Europeans, especially Scandinavians (where civil unions between gays are legally observed) to promote language that is tolerant toward or inclusive of homosexuality; but it’s a different story for countries where both are considered moral corruption, perversity and sometimes are even punishable by the death penalty. And even in this country, some minority groups have argued that their communities’ concerns haven’t adequately shaped efforts to combat AIDS.

Still, the gap in international values on gay rights issues is one reason organizations like IGLHRC want a place at the table. Plus, gay organizations bring with them 20 years of dealing with the AIDS crisis, prevention and treatment in Western countries that could be useful to leaders of developing nations as they grapple with the staggering problem.

In a separate development Monday, the United States announced it would drop its patent dispute with the Brazilian government at the World Trade Organization. The U.S. was disputing a local-producer provision of Brazilian patent law the country had used to issue licenses for the local generic manufacture of anti-retroviral drugs. The inexpensive generic versions of those drugs, which sell for as much as $15,000 a year in Western markets, are being used there to treat 100,000 HIV-positive Brazilians. Powell, speaking at a press conference following his remarks at the U.N. in New York Monday, said the timing of the agreement was a “coincidence.”

Under the agreement, Brazil must inform the United States of its intention to issue any compulsory licenses at least 10 days in advance. Those terms drew criticism from Jamie Love of Washington’s Consumer Project on Technology, a major proponent of compulsory licensing in developing nations as a means of dealing with the health crisis. “The U.S. Trade Representative should clarify the grounds under which it will ask the Brazil government to consult prior to issuing a compulsory license,” he wrote in an e-mail. “More generally, the U.S. government should not insist on supervising a nation’s day-to-day administration of its patent laws.”

Throughout the conflict, which escalated earlier this year, Brazilians have been unflinching in what ultimately amounted to a game of intellectual-property chicken. Brazilian President Fernando Henrique Cardoso recently stated: “We do not agree that the defense of intellectual property be carried out at the expense of the health and welfare of the people. We are not here to challenge and break patents thoughtlessly. But we are here to say that when it is necessary for the health of our people that we will not hesitate (to do so).”

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Caught in the act

Activist groups are kicked out of U.N. headquarters in a protest at the global AIDS conference.

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Close to two dozen members of activist groups ACT-UP, Oxfam America and the Health GAP Coalition were forcibly removed from the United Nations headquarters Tuesday afternoon after they marched through the basement of the building, calling for debt relief and greater access to AIDS drugs in developing nations. The protest was a tame affair by ACT-UP standards, but no less brave than usual given the U.N.’s ban on demonstrations in its building. It was a continuation of the controversy that began on Monday when U.N. member states and other concerned groups kicked off their meeting about the international AIDS crisis.

Shaking pill bottles filled with pennies, the protesters chanted: “Pills cost pennies, greed costs lives, billions for the fund or millions die.” Though the action lasted only a few minutes before a swarm of U.N. security officers sealed off the corridor in the basement and contained the group, the activists managed to bewilder bystanders and delegates alike, some of whom loudly clapped or otherwise cheered the group. The protesters had intended to march around a crowded cafeteria in the bowels of the U.N. headquarters, but made a tactical mistake when they marched down a hallway that led to an exit instead.

A security officer cornered one demonstrator and warned him sternly: “You were told that the U.N. does not allow protests.” Before I could ask him for his name, he had been removed from the building. Security officers quickly separated demonstrators from the press and delegates and ushered them out of the building. There were no immediate reports of arrests, but organizer Paul Davis of ACT-UP Philadelphia told Salon that U.N. officials are threatening to permanently ban the organizations from its headquarters.

Minutes earlier, the coalition of activist groups held a U.N.-sanctioned press conference for reporters that included speakers from Africa, Latin America and India, and pledged support for the global AIDS fund. But they also criticized U.N. member states for not doing more to lower drug prices through compulsory licensing and generic manufacture of drugs. The group also called for debt relief and poverty eradication measures to help developing countries deal with the costs of healthcare.

“Fundamentally, we support the fund and the secretary general’s call for a $7 billion to $10 billion fund,” said Raymond Offenheiser, president of Oxfam America. “However, we have a variety of concerns about the fund, the amount of money that’s been contributed so far and the level of commitment we see among the delegations who are present here today and through the course of the week.”

Offenheiser criticized the U.N. for its apparent focus on prevention rather than treatment this week. “For us, those are not separable concepts. It’s not a morally acceptable position from our point of view. A $1.1-2 billion [plan] in effect is a public statement that all we care about is prevention, we don’t care about treatment. That’s not an acceptable amount of money from the international community to deal with this crisis.”

Offenheiser also leveled criticism at the pharmaceutical industry. “While we support treatment, we don’t support corporate welfare,” he said. “The fund cannot underwrite the patent monopolies enjoyed by pharmaceuticals. You need to cut the costs of medication. And we need global laws to protect patients’ lives, not profits.”

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AIDS activists change their act

On the eve of a United Nations conference, the once-militant ACT-UP revises its tactics and focus.

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Talk to the founding members of ACT-UP, the ones who survived the first wave of AIDS deaths in the 1980s and lived long enough to be able to undergo cocktail therapy treatments, and they like to tell you about guilt.

“I feel a great degree of survivor guilt that I am able to live for 20 years with HIV when my brothers and sisters around the world are dying because they don’t have my privilege of wealth and access to these drugs,” said Eric Sawyer, the 47-year-old co-founder of ACT-UP New York. It compels me to spend every hour I can fighting for their right to access essential medicines.”

The fight for access to life-prolonging drugs has led to a remarkable transformation in the public tactics of ACT-UP. Twelve years ago, ACT-UP made global headlines with over-the-top and occasionally violent protests against the government and religious leaders for their slow and sometimes homophobic response to the AIDS epidemic. In the 1990s, many of the organization’s early leaders died — literally. Then came promising new treatments and a focus on lowering drug prices — a less dramatic story. The group slipped into a state of semi-obscurity until the battle in South Africa began, in 1998, over the manufacture of generic drugs and importation of less expensive brand-name drugs from other countries.

Today, ACT-UP — primarily led by its Philadelphia and New York chapters — is aligning itself with other organizations, like churches, Third World debt relief groups, labor and other groups combating AIDS in developing nations.

The group debuted its new face to an international audience Saturday at a protest on the eve of the United Nations’ General Assembly Special Session on HIV/AIDS, the first-ever meeting of the global organization dedicated to any disease. The session convenes officially Monday at the U.N. headquarters in Manhattan.

Though the U.N.’s decision to hold the unprecedented session is a symbol of how far governments have come in acknowledging the spread of the disease, ACT-UP and other AIDS activists are concerned that the proposals and pledges coming out of the countries and organizations involved in the closed-door negotiations will focus almost entirely on prevention, with no plans for treatment of the 36 million people around the world who are currently HIV positive. U.N. member nations have been negotiating over the language of a resolution on AIDS for several weeks now. It’s a debate that has pitted industrialized nations against developing nations — some of which want to produce inexpensive generic versions of HIV cocktail drugs to treat those who are ill. It has also created a divide between socially liberal countries in places like Northern Europe and socially conservative nations, such as some Islamic ones, in which discussions of homosexuality, sexual activity or drug use are still verboten.

By the end of the session Wednesday, a formal plan will be unveiled for a $7 billion to $10 billion fund devised by U.N. Secretary-General Kofi Annan and professors at Harvard University. U.S. officials have stated that they will invest little, if any, money in treatment and will instead focus on prevention programs to help stop the spread of the disease. AIDS activists, however, say that treatment is just as crucial in halting the disease as prevention. They describe letting people die of the disease untreated as the result of a sort of genocidal apathy of world leaders and government.

The protest was endorsed by Sen. Jesse Helms’ new best friend, Bono Vox of U2, and rock band Radiohead — both of whom advertised the event on their Web pages. Bono, a leader in the debt relief movement, visited Washington in early June to meet with U.S. officials and the president of the World Bank. He asked them to forgive the debt of certain developing nations to free up money for HIV/AIDS treatment. And that was the message they brought to New York in the “Stop Global AIDS Rally” Saturday.

Hundreds of people, including 500 HIV-positive men and women bused in from Philadelphia, gathered on a torrentially rainy and humid day in Washington Square before departing on an hourlong march down the Avenue of the Americas to Bryant Park. They filled one lane of the broad avenue for blocks, flanked on each side by NYPD officers. Showing that there’s still at least an ounce of camp and irony in ACT-UP, some marchers chanted: “We’re here, we’re wet, it’s time to drop the debt.” To which one marcher joked, “I feel a little dirty when I say that.”

They carried signs driving home the day’s message of taking President Bush and other politicians to task for their recent AIDS policies: “Trillions for tax cuts, death for people with AIDS.” “Bush: Killing time is killing people.” “Death by patents, drugs for Africa.” “Bush AIDS policy: Coffins for kids, not condoms.”

It is a radical transformation for an organization founded in 1987 that garnered international attention for its theatrical and sometimes violent protests, among them the disruption of a service by John Cardinal O’Connor at St. Patrick’s Cathedral in 1989 and a confrontation with the government at the National Institutes of Health in Washington in 1990. In its dramatic “Day of Desperation” protest in 1991, 2,000 ACT-UP members delivered coffins to local, state and federal offices in New York. In the late ’80s and early ’90s, it seemed that everywhere ACT-UP went, violent clashes with police and arrests followed. Though Saturday’s march was peaceful, some of the heated rhetoric evoked the organization’s earlier days.

“I am mad as hell that drug company greed kills 10,000 people every day because AIDS drugs cost too much,” Sawyer said at a rally preceding the march. “I am mad as hell that 16,000 people get HIV every day because our world leaders are heartless cowards who can’t admit that people have sex” — to which the audience chanted, “Shame! Shame! Shame!” “I am mad as hell that white people in the First World value money more than the lives of people of color around the world. I am mad as hell that 20 years into this epidemic some people still think treatment and prevention are separate and that prevention is more important than treatment. We are here to say that treatment and prevention are inseparable — one can’t work without the other.”

The message of the coalition of ACT-UP, HealthGAP and Jubilee USA Network and others was simple: Donate the dollars, drop the debt, treat the people, save the lives.

The coalition criticized the $200 million U.S. contribution to the global AIDS fund, arguing that it’s too little to make a significant dent in the problem and noting that it is a mere fraction of the $2 billion-plus Annan has requested from the U.S. government and industry. (So far, the only American organizations besides the government that have stepped forward to pledge funds are the Gates Foundation, which is providing $100 million, and Coca-Cola, which says it will use its massive distribution network in Africa to assist the U.N. with its prevention programs.) Activists also demanded that anti-retroviral cocktail treatments be provided to the tens of millions who are already sick with AIDS, and that industrialized nations, the World Bank and the International Monetary Fund immediately forgive debt to the hardest-hit countries so they can instead use their annual debt repayments to purchase the lifesaving drugs.

“We’re here to tell the do-nothing governments and the do-nothing governmental leaders at the U.N. that if they don’t know how to fight AIDS, they should get out of the way and let people with AIDS tell them how to fight AIDS,” Sawyer continued, eliciting catcalls and whistles. “People with AIDS know how to fight AIDS, and it all boils down to simple things: dollars, debt cancellation, treatment and saving lives.” He went on to describe the America’s $200 million contribution to the fund as an insult, as “chump change.”

No paper dummies were burned in effigy Saturday, but there were two boogeymen who were the focus of most of the scorn and derision: Andrew Natsios, administrator of the U.S. Agency for International Development, which oversees U.S. contributions to the AIDS fund, and President Bush, who activists say is not doing enough to battle the AIDS epidemic.

Natsios enraged AIDS activists earlier this month when he told the Boston Globe that U.S. contributions to the global AIDS fund should not be used to treat those who are HIV positive because of a lack of healthcare infrastructure and because Africans “don’t know what Western time is,” implying they would not be able to follow the precision today’s regimens of cocktail drugs dosages require. Of the proposed widespread anti-retroviral treatments, he said: “We cannot get it done because of conflicts, because of lack of infrastructure, lack of doctors, lack of hospitals, lack of clinics, lack of electricity.”

At Saturday’s rally, I cornered Sheila Kibuka, executive director of Hope Africa in Nairobi, Kenya. “These infrastructure arguments are absurd,” she told me. “We don’t have time for these myths anymore. The people are dying. We’ve had healthcare infrastructure in Africa for 100 years. We have clinics, hospitals, schools and churches. Many people have access to this infrastructure, and you have to make the drugs available to them. You have to start somewhere.”

Former Manhattan borough president Ruth Messinger, who now heads the American Jewish World Service, also took Natsios to task. “We are citizens of a country whose top officials have explained their refusal to make drugs available with the unbelievably insulting remark that Africans lack the requisite sense of time,” Messinger said. “Let’s be as clear as we can. The people who lack the requisite sense of time are the leaders of our government who are turning their backs on people who are dying, who are refusing to step forward and save lives. We demand that our government, that the United Nations and the G7 nations, that the World Bank and the IMF cancel the debt, that they create the global AIDS fund that Kofi Annan has asked for, that the dollars be used to make drugs available to provide treatment, to build a health infrastructure, to support grass-roots groups that are making a difference every day in people’s lives.”

Mara Vanderslice of Jubilee USA hammered home the debt cancellation message, pointing out that African nations pay $13.5 billion in debt service each year — $3.5 billion more than what Annan is calling for in contributions to the AIDS fund. “You want to ask where we’re going to get the money to fight AIDS? We’re going to get it from canceling the debt. The United States government has given a paltry $200 million to the AIDS fund, yet Africa pays back $200 million in one week of debt service. This is money we need to stop taking. It is unconscionable to take money that could be used for prevention on the ground, treatment and lifesaving drugs, clean water and clean healthcare,” she said.

ACT-UP first began to focus on the epidemic in sub-Saharan Africa and other regions in the late ’90s, when intellectual property disputes over AIDS-related drugs first came into serious public play. Jamie Love of the Ralph Nader-funded Consumer Project on Technology, who has been a behind-the-scenes player throughout the international AIDS crisis, went to the group in 1998 and alerted it about then-presumed presidential candidate Al Gore’s role in tightening the screws on the South African government. In a Feb. 17, 1999, meeting with South African President Thabo Mbeki, Gore told him, “I’m concerned that, without significant progress toward a resolution, a single trade issue could overshadow our bilateral relationship.” He was referring to South African legislation that would make it easier to distribute inexpensive drugs in the AIDS-ravaged country. The legislation was unpopular with the American pharmaceutical industry, a deep-pocketed friend of Washington politicians and lobbyists. And there was growing pressure in Congress and the White House for trade sanctions against South Africa.

ACT-UP took on the veep, initiating “Gore zaps” at his campaign appearances from the day he announced his candidacy for president in Carthage, Tenn. In one of the best examples of the newly reinvigorated ACT-UP, an activist unfurled a banner just feet behind Gore onstage during a nationally televised prime-time town hall meeting in New Hampshire, chanting “Gore’s greed kills.” In the end, then President Clinton issued an executive order pledging not to impose trade sanctions against South Africa or other African nations related to pharmaceutical disputes as long as they adhered to the requirements set forth for intellectual property protection by the World Trade Organization. Under the TRIPS provision of the WTO, countries can issue compulsory licenses for the generic production of drugs if they declare a national health emergency.

But Gore wasn’t the only subject of ACT-UP’s zaps. Mark Milano, a 45-year-old HIV-positive ACT-UP member since 1989, said he crashed a $500-a-plate George W. Bush fundraiser outside Philadelphia, where he unfurled a poster he had hidden in his T-shirt and screamed: “Bush is a drug company puppet.” The Secret Service escorted Milano out of the dining room to question him, but ultimately let him go. ACT-UP also stormed the offices of President Clinton’s U.S. trade representative, Charlene Barshefsky, when she pressured developing nations to strengthen patent protections for pharmaceutical companies.

According to Love, the Gore zaps staged by ACT-UP were crucial in drawing media, and thus public, attention to the AIDS crisis in Africa and how intellectual property protections and drug patents are keeping essential medicines out of the hands of millions who are infected with HIV or dying of AIDS.

Though the primary focus of ACT-UP became international only during the last presidential campaign, it has always been a part of the global movement. “ACT-UP started the Global Aids Action Committee in 1990, 11 years ago,” said co-founder Sawyer. “We started doing demonstrations at the U.N. on World AIDS Day to call for access to AZT and Bactrum for pneumonia. We’ve done major demonstrations at every international AIDS conference and many regional conferences and a lot of press and advocacy work on global AIDS issues ever since. It became the primary focus when people here started living longer and [having] a better quality of life because of protease inhibitors and when we finally got the world’s attention to the extent of the global AIDS crisis during the Gore campaign.”

Nonetheless, the Philadelphia chapter has continued its involvement with local AIDS initiatives. It works with intravenous-drug users, prisoners and other groups at high risk for infection. “Our idea has always been to follow the epidemic wherever it goes,” said Katie Krause, a longtime ACT-UP activist in Philadelphia and San Francisco. ” If AIDS were decimating Alaskans, that’s where we would be. But if we need to talk to the U.S. trade representative or the Brazilian health minister, we’re there too,” Krause said.

Different places, Krause said, require different approaches. “AIDS is demolishing a number of African and Asian countries. And if our aim is to support people with AIDS in those countries, and they tell us they need treatment, then we try to get access to top U.S. officials. But when we’re trying to get more AIDS drugs for low-income people in Philadelphia, we need to talk to the health commissioner and local drug companies. The goals are always the same; we just use different tools to get there.” The Philadelphia chapter is also well-known for its laborlike ability to bus in hundreds of activists to protests on the East Coast.

Krause doesn’t make much of ACT-UP’s transformation to an international organization. She says much of the inspiration comes from AIDS activists who attended conferences in Paris, Geneva or Durbin, South Africa, where one might sit next to someone who is dying because they don’t have access to AIDS drugs. “Could you please give me a Bactrum or something I can bring back to my clinic?” he might ask. “That’s a searing experience for any person with feeling. It’s not much of a jump from caring about your local community which is being ravaged by AIDS to caring about a neighboring community.”

In Philadelphia, where the ACT-UP membership is extraordinarily diverse, Krause says there is tremendous sympathy for the suffering of sub-Saharan Africans. “We have hundreds of African-Americans participating from Philly who have very strong empathy for people with AIDS in Africa, who are also personally connected.”

I talked to one of those women during the march. Donna, who would not reveal her last name or age, rode a Trailways bus from Baltimore to participate in the protest. Donna has been trying to kick her drug habit through Philadelphia’s Stop and Surrender program, which encouraged its members to join in the march. “AIDS doesn’t just affect gays,” said Donna. “It affects everyone — in Africa and in the United States.”

ACT-UP thinks it can make a bigger difference through coalition building with like-minded constituencies. Says Milano of ACT-UP New York: “We haven’t given up our direct actions. We will still have demonstrations and are arrested.” Of Saturday’s fairly subdued march, he said: “Normally, we’d do this without a police permit; we’d be taking arrests. That was 10 years ago, when we had a thousand white gay men doing it. But nowadays it’s a coalition building. It’s people of color, it’s labor leaders, it’s religious groups, it’s drop-the debt-people. It’s a different type of activism.”

But in these days of political apathy, when the major industrialized nations have teamed up against proposals to provide treatment for the HIV and AIDS infected in Africa with very little dissent, some must yearn for the outrageous ACT-UP of yore. And there is a hint of frustration and exasperation in some ACT-UP members.

“After the Gore zaps and the South African lawsuit, there was a real momentum toward treatment,” says Milano. “We were on the verge of getting treatment to people in Africa. I thought, ‘My God, the efforts of a few core activists really may have made a difference.’ But, suddenly, everything has switched. Bush is talking about prevention only, no treatment; the dollars are incredibly small. Did you know Pfizer is on the official U.S. committee? It became very clear that the drug companies were calling Bush’s shots. We’re on the verge of losing all of our momentum now. But we’re not going to give up.”

The question is how ACT-UP can make the biggest dent. Should it rekindle the outrage and angst that fueled its effective protests of the ’80s and ’90s, or should it try to achieve strength in numbers by building powerful coalitions? The divided thinking about which way to go is clear from conversations with ACT-UP members, and is an inevitable outcome for a maturing political organization — which has to create a more mainstream message to access political leaders and not alienate coalition partners.

In a telephone conversation last week, ACT-UP Philadelphia’s Krause compared the current international AIDS crisis to the Holocaust. Then she backed away from her comments, saying she felt uncomfortable using the comparison to quantify political goals. But two days later, in New York, the organization distributed a press packet with the following quote from New York ACT-UP member Peter Roberts: “It’s like living through World War II and hearing [that] U.S. groups [spoke] out against bombing the trains to Auschwitz but did not attempt to bomb the crematoriums.”

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The AIDS-drug warrior

Activist Jamie Love says pharmaceutical companies must be forced to yield their patents to save hundreds of thousands of lives. Is he a visionary -- or a dangerous radical?

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The AIDS-drug warrior

Every day a new headline emerges touting a victory in the global fight against the AIDS epidemic. One day, a pharmaceutical company announces it will deeply discount its drugs for the African market. The next, Yale University and Bristol-Myers Squibb announce they will no longer enforce their patent on an AIDS drug used in HIV-ravaged South Africa. Then 39 companies abruptly withdraw their lawsuit against the South African government over a 1997 law that would make it easier for the country to produce generic versions of patented drugs or import brand-name drugs from other countries to sell at cheaper prices.

All good news, right?

Wrong, says Jamie Love. It’s just slick humanitarian-flavored spin.

For Love, one of the leading — and most outspoken — activists on the front lines of the AIDS-drug pricing wars, the real issue is that the major pharmaceutical companies still maintain control over who can manufacture their patented drugs and how much they cost. As the head of the Ralph Nader-founded Consumer Project on Technology, Love has been trying for years to persuade governments in developing nations to wrest control of AIDS-drug policy and pricing from the pharmaceuticals. Love argues that by issuing so-called compulsory licenses that would allow generic drug manufacturers to create cheap and ubiquitous versions of AIDS drugs, developing nations would drive down the cost of raw materials, increase competition and make the drugs more widely available.

Love is unimpressed by the fact that pharmaceutical companies, pressured by public opinion and media coverage, have taken positive steps to make AIDS drugs cheaper and easier to get. In almost every case, as he points out, they are simply dropping prices or just giving the pills away rather than granting licenses for local manufacture. And he doesn’t believe that corporate largess alone will be enough to stave off one of the worst epidemics in human history.

Love has been engaged in the drug intellectual property debate since the early ’90s. His absolute and uncompromising pursuit hasn’t won him any friends in the pharmaceutical industry or in bureaucrat-magnet Geneva: He accuses officials in the nongovernmental organizations (NGOs) that control the global AIDS agenda of being lazy, timorous salary collectors who go out of their way to protect the interests of pharmaceutical companies.

More fundamentally, Love denies that the pharmaceuticals even own the rights to the drugs in the first place. He points out that many of the anti-retroviral drugs used to treat HIV and AIDS today stem from the government-funded cancer drug research of the 1980s. The rights to government-created innovations were sold to pharmaceutical companies at low prices (not at the astronomical rates demanded in recent airwave spectrum auctions, for example), guaranteeing companies like Bristol-Myers Squibb huge returns on investment. Given the public investment in these drugs, Love doesn’t believe drug companies have the moral authority to determine who can or can’t access them. And the fact that thousands of people in Africa continue to die because they can’t afford the drugs adds urgency to his argument.

Love’s position that Big Pharma doesn’t own its medicines is an extension of his earlier work on cancer medicine patents. In 1991, he testified before Congress about a patent agreement between the federal government and Bristol-Myers Squibb that allowed the company to extend its patent protection for the cancer drug Taxol. The drug was invented by the National Institutes of Health’s National Cancer Institute — and it brought the drug company $1.6 billion a year in profits. Scrutiny led Congress to demand better accounting of the relationship between government-funded operations and pharmaceutical companies to determine whether the government was getting an adequate return on its investment. The Taxol case turned out to be a major precedent, since government funds have also been used to create other drugs for cancer, AIDS and other chronic or life-threatening conditions.

“Jamie, it seems to me, starts from a simple but hard-to-refute premise,” says New York University journalism professor Merrill Goozner, who covered the drug industry as a reporter for the Chicago Tribune for years. “If the taxpayers paid for the development of the intellectual property, then they ought to get some kind of return on their investment when that I.P. turns out to be a significant scientific advance that leads to new products.”

The biggest hurdle in the way of compulsory licenses are strict international intellectual property laws, which protect the patents and the bottom lines of pharmaceutical companies and thus encourage them to continue investing the millions in research required to develop new medicines. Western countries, led by the United States, have fought strenuously on the international front to protect those patents — in effect, placing a greater value on intellectual property, in the name of spurring innovation and saving more lives in the future, than on saving lives currently at risk.

Increasingly, those battles are pitting industrialized nations against developing countries. Ninety-five percent of the world’s HIV and AIDS cases are concentrated in developing nations, with the vast majority dying in Africa, but Africa comprises a minuscule 1.3 percent of the global pharmaceutical drug market. The World Health Organization estimates that only 10,000 to 25,000 of the 25 million HIV-positive or AIDS-infected people in Africa have access to the drugs they need.

Such dreadful statistics raise profound questions about how strict drug patent laws should be — and explain Jamie Love’s fixation on compulsory licensing. Compulsory licensing allows governments to suspend intellectual property laws — either because they’re impractical or because they interfere with a country’s ability to deal with a health crisis. “I believe developing countries should be permitted to embrace weak levels of intellectual property protection on medicines, and specifically either exempt essential medicines from patent protection or use compulsory licensing liberally,” Love recently told participants of a joint WHO/WTO meeting on intellectual property in Norway.

In fact, Love goes further: He believes pricing controls should be applied to essential drugs not just in the developing world but in the United States and other industrialized nations as well. He also calls for limiting patent protections for biomedical innovations.

It’s this kind of quasi-socialist thinking that scares and angers conservatives, pharmaceutical companies and the politicians on Capitol Hill they funded to the tune of $26 million during the last election. In a recent article on the Wall Street Journal’s editorial page, public health policy expert Robert Goldberg accused Love of being “more interested in eliminating profits from the pharmaceutical industry” than in eliminating AIDS. Calling Love’s organization “selfish,” Goldberg charged that pursuing Love’s policies would “suck profits out of companies and eliminate research funding.”

Not surprisingly, AIDS activists take a more positive view of the work of the fiery Love. “Jamie has played a pivotal role in establishing the framework of much of the treatment access campaign,” says Kate Krause of the HealthGap Coalition and ACT-UP Philadelphia. Krause attributes the recent round of brand-name drug discounts in Africa to Love’s work with Indian generic-drug manufacturer CIPLA. “He has been among the first to investigate issues that no one touches, such as drug company costs; and realizing that the stakes are so high, he makes audacious demands of the drug industry.”

Journalism professor Goozner says that while Love is only one of hundreds of activists dedicated to the AIDS fight, “he’s an awful important player.” He notes that Love’s Internet list-serv, where he posts virtually every significant news story and government report on intellectual property issues in the healthcare field, “knits that entire community together and serves as a forum for instantaneously keeping it informed of the latest and most significant developments.”

“He’s a tireless lobbyist in the cause,” Goozner says, “traveling to all the major meetings around the globe and firing off instant e-mails to those not in attendance … That he does it for a fraction of the pay of the hundreds of industry flacks and bureaucrats arrayed against him, yet exposes them at their own game time after time, never ceases to amaze me. I won’t say that forcing the drug companies to back off in South Africa is his greatest victory, because it wasn’t his alone. But it’s hard to imagine it would have happened as soon as it did without him.”

Love is a blue-eyed firebrand whose silver-streaked locks of brown hair are the only thing that hint at his 51 years of age. The day I visited Love’s modest digs at the Carnegie Foundation offices in Washington — Love’s operation runs on a fraction of the budget of most NGOs involved in AIDS policy — he had just returned from yet another trip to Europe, where he attended an international meeting on AIDS and intellectual property. He took me on a quick tour, through a fortress of bookshelves and metal filing cabinets, where he gave terse orders to colleagues and tried to make the world of intellectual property policy more thrilling for a reporter.

Love explained that he is pursuing a three-part strategy in his push for compulsory licensing, with South Africa as the centerpiece. First, he’s working with CIPLA, the generic drug manufacturer, to demonstrate what it actually costs to manufacture AIDS drugs: Love and CIPLA claim that it costs less than $1 a day to manufacture a three-drug cocktail for one patient. Second, he’s turning to the private sector, lining up the international mining company Anglo American and healthcare providers to demand compulsory licenses from the South African and other governments. Finally, if those licenses are issued, he will work with CIPLA to get drugs to the corporations and healthcare providers that want to provide them to their employees and patients.

The foundations of Love’s compulsory licensing push were laid in 1997, when the South African government passed a law that would make compulsory licensing and parallel importing easier. (Parallel importing is the practice of purchasing drugs from a third party in another country instead of directly from the manufacturer. It’s cheaper because pharmaceutical companies usually charge lower prices in poorer countries.) The United States, under the stewardship of then-Vice President Al Gore, pressured South Africa to abandon or revise the legislation, and the pharmaceutical companies sued. In 1998, the South African government backed off, saying it would not issue compulsory licenses. Then, in March, a month before the trial was slated to begin, it also said it would not seek to do parallel imports. A month later, the pharmaceutical companies dropped their case against South Africa.

It’s been over a month since the case was dismissed. Unwilling to take on a difficult legal battle against the South African government, few companies have stepped forward to demand licenses to produce generic versions of AIDS cocktail drugs: Only CIPLA and Aspen Pharmacare, South Africa’s largest generic drug manufacturer, have attempted to do so. Meanwhile, drug companies have been slashing their prices — in order to discourage South Africa from succumbing to the temptation of compulsory licensing. But he says they haven’t dropped them to rock-bottom production cost, and working with CIPLA, he has numbers to prove it.

The pharmaceutical GlaxoSmithKline, for example, announced on June 11 that it would discount Combivir — a two-drug combination — to $2 a day for governments, charity organizations and NGOs in Africa. CIPLA, however, has offered the same drug combination of Lamivudine and zidovine plus a third drug, nevirapine, for between 96 cents a day for nonprofits or $1.64 for governments — at a low-end cost of $350 a year, as much as 50 percent less than Glaxo’s lowest bid, according to the World Health Organization.

Given these numbers, in a situation where even pennies more in cost mean lives lost, Love keeps hammering away on the generic-licensing theme. And he’s lined up some heavy hitters in the private sector to back him: The international mining company Anglo American, the largest mining company in South Africa, has proposed supplying as many as 50,000 of its HIV-positive employees with generic drugs made by CIPLA. In March, CIPLA registered a request with the South African government for a compulsory license for the key drugs it needs to produce the cocktail. The company expects a prolonged legal battle with the government.

Love turned to the private sector in part because of his frustration with the South African government’s slow response to the AIDS crisis — a frustration born of his experiences during the South African trial, when he served as an advisor to the Health Ministry, a party to the suit. South Africa’s hesitations and missteps on the issue are well-chronicled. President Thabo Mbeki has expressed concerns about the safety of cocktail treatments and even questioned publicly, to international dismay, whether HIV is the true cause of AIDS. The South African government has so far refused to declare the AIDS crisis a national emergency — although a staggering 4.7 million South Africans are infected. And it has been reluctant to issue compulsory licenses or support proposals like Love’s. In a recent interview with the U.K. Guardian, South African Health Minister Manto Tshabalala-Msimang said: “To be frank … we haven’t thought it through.” In her Guardian interview, Tshabalala-Msimang asked the reporter whether Anglo American, the company that Love is working with to distribute anti-retrovirals to its workers, would provide the families of its miners with access to the drugs and also what effect the heat in the mines would have on workers taking the drugs. These were not questions that inspired confidence that the minister was fully informed.

To be fair, the South African government also has a more legitimate reason for its ambivalent attitude toward drug treatment: Proper use of retrovirals requires a healthcare infrastructure that the country lacks. Anglo American has a better chance of efficiently delivering and administering the drugs — which is another reason Love is optimistic about private initiatives. Lending credence to his position is the decision made by auto giant DaimlerChrysler earlier this week to provide anti-HIV cocktail treatments to employees and their families, totaling as many as 23,000 patients.

Mention the global AIDS bureaucracy, centered in the U.N. organization UNAIDS and spread through innumerable NGOs, and Love scoffs derisively. “I pitched this private-sector stuff because if you sit around and wait for these assholes at the U.N. agencies to get their acts together, a lot of caskets are going to go into the ground,” he says. “They’re not men of action. They’re followers, not leaders. There’s no leadership taking place at the U.N. agencies. There’s a lot of great pensions that are coming down. There are some high salaries being paid and sumptuous meals being consumed and business-class tickets being given out. But I have to say: Leadership? No, I’m sorry. I mean, this is Basic 101 stuff. What are we doing? We’re figuring out how much it costs to manufacture drugs, we’re figuring out how you can solve the intellectual property problems, how you can solve the drug registration problems. We’re trying to get people to act,” he says.

Love isn’t impressed when I point out that UNAIDS has met with CIPLA, and that international organizations monitoring essential drug pricing routinely cite CIPLA’s quotes in their comparison charts. “When things are on the front page of the New York Times, they have to acknowledge them,” he says, raising his voice. “They haven’t been the people pushing compulsory licensing. Instead, they’re the ones making the big bucks. And that’s wrong because they’re the ones with the big megaphone and the big voice.”

The United Nations recently announced that it would create a $7 billion superfund to fight AIDS, malaria and tuberculosis. Details of that plan are expected to be announced at a U.N. General Assembly meeting on the AIDS crisis in New York next week. But Love has little confidence that the money will be used in the most effective way.

Officials from the United Nations and global AIDS organizations, for their part, say that activists like Love, fixated on treatment, ignore the crucial element of prevention. Instead of emphasizing widespread administration of AIDS cocktail treatments, organizations like WHO and UNAIDS have stressed education and prevention programs, which are easier to administer and potentially have the most long-term impact. Pieter Piot, the famous Belgian epidemiologist who helped identify the Ebola virus and is executive director of UNAIDS, recently described his view for how the U.N. plan should work in the New York Times: “We feel strongly that the response to AIDS has to be a balanced one: prevention and treatment. In the current climate, people forget that. I’m really getting tired of the fact that a terribly complex problem of treatment and care for people having H.I.V. is reduced to the price of anti-retroviral drugs.”

Those are exactly the kinds of statements that raise Love’s ire. “Are we supposed to say that since we can’t save all of them, we’re going to let them all die? That’s an appalling, racist attitude. We’re going to do all we can to save them,” he says. “We make our little contribution on the intellectual property side and you’d think we’d raped Queen Mary.”

Love says that when famous AIDS bureaucrats like Piot criticize his work, they fail to see the forest for the trees. He says that what he and his organization are doing is just one part of the puzzle, though admittedly one that’s currently getting a lot of attention. “We’re not saying prevention’s not important. We don’t campaign against those things — everyone knows those are important.”

What of the argument, proferred by pharmaceuticals and the South African government, that sloppy distribution and administration of cocktail drugs not only undermine their effectiveness but could lead to more resistant strains of HIV — that it would be more effective to focus on HIV education and prevention, and on use of the drug AZT, which can reduce transmission of the virus from mothers to babies? Such arguments were recently echoed by the Bush administration’s highest-ranking foreign aid official, Andrew Natsios, who told the Boston Globe that monies given to the United Nation’s new AIDS superfund should be used almost exclusively for prevention.

In his comments to the paper, Natsios cited poor medical infrastructure and a lack of familiarity with Western ways, including the ability to tell time effectively enough to administer cocktail treatments. “You have to take these [AIDS] drugs a certain number of hours each day, or they don’t work,” Natsios told the Globe. “Many people in Africa have never seen a clock or a watch their entire lives. And if you say, one o’clock in the afternoon, they do not know what you are talking about. They know morning, they know noon, they know evening, they know the darkness at night.”

Love joins other AIDS activists (and New York Times columnist Bob Herbert, who accused Natsios of perpetuating stereotypes about African culture) in rejecting the argument that anti-retrovirals are too complex to be effective in Africa. He points out that combinations of different medicines now enable HIV patients who have access to such pills to take as few as four pills each day. This treatment regimen is currently being used on HIV-positive homeless both in San Francisco and in South Africa, where Doctors Without Borders is providing cocktail treatments to one village.

The real issue, Love says, is price. And by teaming with CIPLA, he is attempting to prove that AIDS drugs can be made affordable, even in impoverished nations like South Africa. In CIPLA, Love found a company willing to stick its neck out — and take the heat for doing so. When CIPLA made headlines around the world by quoting $350, the lowest cost ever for a three-drug anti-HIV cocktail, the pricing came as the result of Love’s negotiations with CIPLA CEO Yusuf Hamied — the generic drug mogul who has become a huge thorn in the side of the pharmaceutical giants with his rock-bottom pricing. It was a watershed moment for international activists fighting for inexpensive access to AIDS drugs. Even the international organizations Love scoffs at cite the figure as a standard in international drug pricing.

“It shocked everyone and blew up in smoke the idea that the pharmaceutical companies were making donations,” says Love. “It was a third of the best prices you could get out of the branded guys in what they thought were donations.”

Not surprisingly, the action didn’t exactly elicit praise from the pharmaceutical industry. At a recent industry conference GlaxoSmithKlein CEO Jean-Pierre Garnier described CIPLA as price-undercutting “pirates,” and said the company “is not doing this to get a Nobel prize.” CIPLA’s Hamied responds to such criticism by saying, “Indeed, we are a commercial company. But I market 400 products in India. If I don’t make money on a half-dozen of them, it’s no big deal. I don’t make any money on the cancer drugs we sell or drugs for thalassemia, a blood disorder that’s common in India. We sell these drugs virtually at cost because I don’t want to make money off these diseases which cause the whole fabric of society to crumble. India alone will have 35 million HIV cases by 2005, and it’s something we can’t afford.”

In fact, CIPLA needs to make a profit, however tiny, to demonstrate that the pharmaceutical companies can lower their prices dramatically and still turn a profit on AIDS drugs in developing nations like South Africa. Although the margins are razor-thin, Love says CIPLA will be able to turn a profit on its generic AIDS drugs in South Africa and wherever else it is able to sell them. But to make that profit it will need to get a compulsory license from the government — otherwise, it won’t have a market. Love believes that if the license is granted, a private medical infrastructure can be gradually built, making treatment possible for thousands. And successes in the private sector will increase pressure on South African and other governments to act, Love says.

“At a certain cost, the private sector and people can pay out of their own pockets for drugs. We’re interested in those cases,” he says. He also claims that competition among generic-drug manufacturers could push the price even lower than what CIPLA is offering. “We could get to $250 within a year,” he says.

To bolster that argument, he cites Brazil, where looser intellectual property laws have allowed local manufacturers to produce generic cocktail drugs. The country has a highly developed healthcare infrastructure for a developing nation, and provides treatment to more than 100,000 HIV-positive and AIDS patients. Love, who is a Princeton-trained economist, estimates that the demand for the raw materials in the cocktail drugs in Brazil has reduced their cost from $10,000 per kilo three years ago to $700 today.

In other words, the competition among generics is driving prices down. That’s the sort of economy of scale that Love hopes will be reproduced in South Africa and, later, in industrial nations in Europe and the United States. But with big pharmaceutical companies attempting to undercut compulsory licensing by negotiating with employers and healthcare plans in South Africa to sell them their drugs directly, the question is whether Love and Hamied can outfox the global corporations. So far they have — at least in terms of pricing.

“People have been trying to deal directly with the pharmaceutical companies for years,” says Love, addressing the differences between what CIPLA and the Consumer Project on Technology are trying to do and the ambitions of Aspen Pharmacare, the South African generics company that is seeking licenses directly from the patent holders. “The drug companies want to avoid compulsory licensing because it’s the big stick. If you give a voluntary license, that pulls the rug out from beneath generic-drug manufacturers like CIPLA.”

Even if Love fails in South Africa, there are more fronts in the compulsory licensing battle. As part of its anti-AIDS initiatives, CPT has been developing model legislation countries can use to pass their own laws making compulsory licensing easier and more efficient. The first is likely to be Brazil, which flouted American pressure and issued its own compulsory license for AIDS drugs.

CPT is pressuring the Bush administration to drop the intellectual property rights action it recently lodged against the Brazilian government with the World Trade Organization. The dispute stems from a Brazilian law that permits local companies to manufacture generic versions of a drug if the company holding the patent does not produce it in that country. Though the U.S. government believes the law is protectionist, it has allowed Brazil’s local manufacturers to produce widely distributed generic AIDS drugs. It’s the kind of success that Love likes to cite when pressing his case for compulsory licensing. But the legal dispute could go on for years.

The U.S. was able to file the complaint under the TRIPS (Trade-Related Aspects of Intellectual Property Rights) provision of the WTO agreement, which requires strict drug patents in all member nations. In fact, however, the U.S. is complaining about the local-producer provision of Brazil’s patent law. If Brazil had declared a public health emergency, it could have legitimately issued the compulsory license for the drugs and the U.S. would have no case. CPT researchers identified three European countries with similar local production provisions. “If the U.S. wants to establish a precedent, why is it suing Brazil? Why don’t they just sue Greece, Ireland or the Netherlands?” Love asks.

According to Love, the Clinton administration wasn’t any better than the Bush White House. Al Gore was often criticized for his heavy-handedness in dealing with South Africa as its legislature moved toward passage of its patent law in 1997. And Love says Clinton’s trade representative often sought unilateral intellectual property agreements with countries that provided even less wiggle room for compulsory licensing than TRIPS.

In the end, the underlying issue raised by Love’s crusade is the ethics of compulsory licensing. The most common argument against compulsory licensing is that taking away the right of pharmaceutical manufacturers to set prices in a given market serves as a disincentive for them to invest the $500 million in research and development costs necessary to create a new drug (a figure widely quoted by the Pharmaceutical Research and Manufacturers Association). It’s an argument that can’t be easily dismissed when talking about the developed world. No doubt, if American and European patients demanded the same generic drugs and low prices — a stance Love has endorsed — profits would be severely threatened. But with the minuscule size of pharmaceutical markets in developing countries, the argument doesn’t hold much weight.

In an attempt to address these profit-incentive concerns, Yale economist Jean Lanjouw laid out a possible third way of addressing the intellectual property problem in a report for the Brookings Institution released last week. In effect, Lanjouw’s proposal would require pharmaceutical companies when applying for intellectual property protections to choose between getting patent protection in industrialized nations or developing nations. Under that solution, patents for all new AIDS drugs would likely be protected in places like the United States or Europe, but generics could be produced in poorer nations where the demand is high but the market small. In contrast, a research-based pharmaceutical company could choose to protect a patent for a malaria drug in developing nations, where cases are clustered, rather than the U.S. or Europe, where there are very few cases.

“Neither price controls nor compulsory licensing offers what the proposal here was designed to provide  a feasible way to allow competitive pricing in some areas while keeping in place incentives for private firms to invest in research on diseases specific to poor countries,” Lanjouw wrote in her policy paper. She argues that the current proposals for compulsory licensing are “indiscriminate” and could serve as disincentives for pharmaceutical companies to produce new drugs.

With typical frankness, Love dismisses Lanjouw’s proposal as “stupid,” not to mention possibly unconstitutional. “It’s based on the idea that somehow, it’s legally possible for countries in the north to take away the rights of their own companies to enforce patents in the south.” Nonetheless, Lanjouw’s proposal has attracted the interest of the World Bank, the United Nations and the Treasury Department, which are all said to be studying it.

Meanwhile, the death toll mounts. And those who believe in compulsory licensing, or weaker intellectual property laws for drugs in developing countries, like to cite the case of Jonas Salk, the inventor of the polio vaccine. As the ancient scourge of polio was rolled back by his vaccine 50 years ago, Salk was asked why he never took a patent out on the medicine — a patent that would have made him wildly rich. “There is no patent,” he replied. “Could you patent the sun?”

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Olson by a whisker

In a surprising reversal of fortune, before relinquishing control of the Senate, Republicans force a vote on the controversial solicitor general -- and win.

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Olson by a whisker

As the clock on solicitor general nominee Ted Olson wound down, Republicans took a bold final shot, and Democrats, perhaps already satisfied knowing that they would soon be the new majority party in the Senate, made only a token effort to block it, and Olson won by a 51-47 vote.

While it might have looked like the Democrats were firmly opposed to Olson’s nomination, the party, according a senior Democratic staffer close to the proceedings, could not recruit the requisite number of 41 to support a filibuster to hold up the Olson nomination. So when the roll call finally came, only two Democrats (Sen. Zell Miller, D-Ga., and Sen. Ben Nelson, D- Neb.) voted for Olson, but the other 47 who voted against him already knew he was a sure thing.

Olson’s success was a remarkable reversal of fortune. When word spread earlier in the week that Sen. Jim Jeffords, R-Vt., would be abandoning the GOP to become an independent, it slowly became clear that the Democrats would win control of the Senate, and Olson’s chances began to look grim. Sen. Joe Biden, D-Del., predicted Wednesday that, under Democratic Senate rule, “Ted Olson will be practicing law, making a lot of money” in the private sector.

By Thursday morning, Margaret Aitken, Biden’s press secretary, tried to soften her boss’s earlier statement. “I don’t think it’s really clear yet how it’s going to shake out,” she said. “I think it is too early to speculate about that.”

Actually, it was already too late.

In less extraordinary times, Olson’s nomination would already have been long dead. On May 18, the Senate Judiciary Committee split 9-9 over Olson, with Democrats still loudly questioning his answers under questioning about his ties to the Arkansas Project, the anti-Clinton scandal-hunt run through the American Spectator and funded by Richard Mellon Scaife during the mid-1990s. In ordinary times, a tie vote is a losing vote in the Senate. But the Republicans and Democrats in the evenly split Senate had agreed in December to allow Senate Majority Leader Trent Lott, R-Miss., to break such deadlocks by filing a “discharge motion.”

Lott did that last week, so Olson’s nomination could’ve been moved to the floor any time after that. But committee Republicans, in deference to continued Democratic complaints and possibly in fear of a filibuster, allowed the minority members to continue probing Olson.

But when it became clear that the Democrats would assume control of the Senate, Lott set the Olson vote, frustrating opponents, including a prime target of the Arkansas Project. “It strikes me as a desperate measure,” New York Democratic Sen. Hillary Rodham Clinton told reporters, accusing the GOP of “try[ing] to jam this through while they still control the floor.”

For Clinton, this nomination was personal. While Republicans publicly accused Democrats of opposing Olson purely for his role in successfully representing George W. Bush before the Supreme Court in the decision that effectively awarded Bush the presidency, they shied away from the virulent role the Spectator — and Olson — played during the 1990s as a critic of the Clintons. Olson himself, writing under a pseudonym, coauthored an outlandish article outlining the possible crimes that had been committed by President Clinton and Hillary Clinton and how stiff the penalties might be for those crimes. His wife, former federal prosecutor and conservative cable-TV pundit Barbara Olson wrote “Hell to Pay,” the bible of anti-Hillary books among the far right, in which she described the former first lady as a woman “who has gone to the brink of criminality to amass wealth and power.”

Clinton made an appearance before reporters to attack Olson, a man she said didn’t “meet the standards that we should expect from somebody nominated for solicitor general.”

But as the day wore on, even Leahy’s office began to downplay the need to continue with a probe. “The bipartisan inquiry has gone on all week,” said Leahy’s press secretary, David Carle, when asked if the vote would cut off the probe prematurely. As for whether all Leahy’s questions about Olson had been answered, a flustered Carle replied, “Yes.”

But the committee planned on asking more questions for David Brock, an American Spectator reporter who has been the chief source contradicting Olson’s account of his involvement with the Arkansas Project. The Spectator was the home of Scaife’s effort. In recent weeks, Brock has offered a far different account of the project and Olson’s part in it than the nominee had testified to, and Brock’s words provided a foundation for the suspicions of Democrats. As a result, Hatch had issued an invitation to Brock on Tuesday to speak to Senate investigators as soon as possible, but a date was never scheduled.

Investigators also didn’t get a chance to hear from Ronald Burr, former publisher of the American Spectator who left the publication in a cloud reportedly after criticizing the Arkansas Project. Salon has previously reported that Burr, after receiving a $350,000 severance package from the Spectator, signed a non-disclosure agreement that prohibits him from making public statements about the company.

Though Burr hasn’t spoken for himself, Ralph Lemley, his advisor and friend at the time of departure from the Spectator, declared earlier Thursday in a letter that Olson had been a part of the Arkansas Project from the beginning, and that Burr was pushed out of his post because he objected to the Arkansas Project, and had asked for an internal “fraud audit” of the enterprise. Salon obtained and published that letter on Thursday afternoon, about an hour before the Senate voted to confirm Olson. Lemley had earlier sent a copy of the letter to the Judiciary Committee, but after discussion had already begun on the floor of the Senate.

Had that letter come out earlier, according to Clinton spokesman Jim Kennedy, it may well have affected the outcome. “The Republicans seemed eager to cut off any further inquiry,” he said. Kennedy added that the quick vote virtually ended Democratic hopes to engineer a filibuster. “There just wasn’t enough time,” Kennedy said.

That could account for the tone of grumpy resignation that characterized Leahy’s remarks after the Olson vote. “We could have held him up forever,” Leahy hypothesized before reporters outside the Senate chambers. But Leahy, putting a brave face on defeat, said that he didn’t want the first Democratic Senate majority since 1994 to take over in an atmosphere of gridlock. “I don’t believe in doing the kinds of things they did for six years,” he said.

Biden — predicting Olson’s doom just a day earlier — seemed anxious to put the fight in the past. “What’s done is done,” he said, leaving the Capitol. Sen. Ted Kennedy, D-Mass., struck a more defiant stance, claiming that the 47 votes against Olson would “send a message” to Bush. “It proves that we will not be a rubber stamp for his nominees,” he said.

Meanwhile, Olson’s conservative allies were celebrating his good fortune. R. Emmett Tyrrell, editor in chief of the Spectator, responded angrily to inquiries for a reaction. “You have never run anything accurate in Salon magazine about me, Ted Olson or the so-called Arkansas Project,” he said. Wladyslaw Pleszczynski called inquiries about the Arkansas Project “a ghoulish, nightmarish attempt” to rewrite the history of legitimate Spectator criticism of the Clintons. He described the experience as “Kafkaesque.”

Salon published investigations in 1998 that first raised questions about the Arkansas Project and its dealings with David Hale, the controversial main witness in the Whitewater investigation against the Clintons. The relationship between Hale and the Spectator was ultimately the subject of a federal investigation. Olson’s relationship with Hale, whom he represented when Hale fought a federal subpoena, was also a subject of the federal probe. The articles in Salon, as well as “The Hunting of the President,” a book by Salon columnist Joe Conason and Gene Lyons, were frequently used in documents that Leahy presented to bolster his case against the Olson bid.

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