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.

Published June 27, 2001 8:00AM (EDT)

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.

By Daryl Lindsey

Daryl Lindsey is associate editor of Salon News and an Arthur Burns fellow. He currently lives in Berlin and writes for Salon and Die Welt.

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Related Topics ------------------------------------------

Africa Aids Drugs Health Healthcare Reform United Nations