Fighting AIDS in Africa: World AIDS Day Report
Kevin Ivers and James P. Driscoll, Ph.D., Liberty Education Fund AIDS Policy Institute
Over the last three years, scientific breakthroughs in treating HIV/AIDS have dramatically changed the course of the epidemic in the United States. Since the introduction of a new generation of anti-HIV therapies, HIV/AIDS has largely shifted from a quickly fatal disease to a chronic long-term condition for a majority of HIV-positive Americans. A successful partnership between community advocates, the pharmaceutical industry and government has worked quickly to maximize access to these treatments, and four straight years of record AIDS funding increases by the Republican Congress above President Clinton's budget requests have played a crucial supportive role in this partnership. As a result, the death rate for AIDS in the United States has plummeted by 65% since 1996.
But breakthroughs in the area of science cannot guarantee immediate results without the necessary health care infrastructure to deliver breakthrough treatments to those who need them to live. Without the existing health care infrastructure in place in the United States, issues of access would be virtually impossible to address. And such is the root cause of the spiraling disaster in Africa, where AIDS is quickly growing beyond a health care issue to become a full-scale geopolitical crisis across the continent.
The 1999 Annual Report by the United Nations Childrens' Fund (UNICEF) found that the global death toll for HIV/AIDS stands at 14 million today, with 11 million occurring in Africa alone. The World Health Organization has labeled HIV/AIDS the world's "most deadly infectious disease," making it the fourth leading cause of death in the world today.
In South Africa, 3.6 million citizens are HIV-positive, with 1,500 new infections daily. The virus will have infected 20 percent of the South African workforce by the end of this year. In Zimbabwe, 1 out of 5 adults is HIV-positive, with a weekly death toll of 1,400 people from AIDS. Life expectancy rates in Botswana, Malawi, Zimbabwe, Zambia and Swaziland have dropped from 65 to 40 – the lowest life expectancy rates in the world – due to high HIV/AIDS mortality rates. And for the next generation, 1,800 babies are born HIV-positive every day in Africa, and HIV/AIDS alone will double infant mortality rates in sub-Saharan Africa and triple child mortality rates across the African continent. AIDS orphans in Africa will number in the tens of millions by 2010.
Unless something is done to change the status quo, HIV/AIDS will reduce by one-fourth the values of the economies of sub-Saharan African nations. The staggering numbers already accumulating make the HIV/AIDS epidemic – in terms of human cost and economic impact – a geopolitical crisis more grave over the long term than the famine of the 1980's and the civil strife and genocide seen in the 1990's.
As seen in the early problems of access and funding for breakthrough treatments in the United States in 1996 and 1997, solutions depended on a health care delivery infrastructure in place. The U.S. has one of the best such systems in the world, and the initial crisis of access to these treatments largely became a matter of funding priorities and forging partnerships with federal and state governments to address the gaps. In Africa, the problem is much more complex, more deeply entrenched, and cannot be solved by funding alone, nor by government-to-government plans alone. A comprehensive solution must quickly address the lack of any health care delivery infrastructure that can handle the epidemic as it exists today in Africa, and must bring non-government partners together in systems that will be minimally impacted by factors such as politics, government inefficiency and corruption, which have undermined anti-famine and other previous relief efforts in Africa.
Some have advocated a "Marshall Plan" solution, relying largely on an infusion of government-to-government funding, flowing from the U.S. to African nations. While the boldness of such a plan is fitting, the comparison to the Marshall Plan which aided Europe after World War II does not in any way fit the problem in Africa. In the 1940's, the west was investing in the rebuilding of a pre-existing economic infrastructure that the war had torn apart. In Africa, no such infrastructure has ever existed which resembles the health care delivery system needed to stem the growing AIDS disaster. Furthermore, the U.S. government's funding would be cycled annually along with every other federal appropriation, and the recipients – the national governments of affected African nations – still have a collective record of corruption, waste, skimming, mismanagement and bureaucratic inefficiency that make it unwise to leave the implementation completely to them. The example of the African famines, and the way in which food has been used as a political and economic weapon within tribal and national conflicts against millions of innocent people, indicates the serious obstacles to such a plan for HIV/AIDS. War and civil strife refugee relief efforts have historically faced similar obstacles in all regions of the continent, including sub-Sahara.
In part, the same reasons can be applied to the concept of price controls and compulsory licensing. By forcing price controls and compulsory licensing under current delivery conditions in Africa, AIDS drug treatments are guaranteed to become another measure of the privileged classes of African societies, where those favored by the current delivery system will have marginally better access to treatments while others less favored will continue to be denied. In short, advocates of compulsory licensing and price controls as a remedy for the AIDS crisis in Africa show a dangerous lack of understanding of the depth of the real problem – one of a missing health care infrastructure that must be in place before any infusion of treatments can actually reach the people who need them. Not only would price controls fail to address the real problem, but they are destructive to global progress by slowing and holding back continued drug research and development. We cannot forget that every breakthrough therapy being used today was funded and manufactured by the private sector, and would not have made it to market as quickly or with such efficacy in an environment of price controls.
Clearly, the best solution would be one which addresses the real problems in delivering vital treatments to the people who need them, and involves partnerships that can ensure a long term structural solution that can grow largely independent of the government bureaucracies in the United States, in Africa and in international agencies like the United Nations. For example, Bristol Myers-Squibb's pioneering "Secure the Future" program provides an early model for the kind of approaches we believe will be most effective. This $100 million private effort is a partnership between one large AIDS drug maker, two major American medical schools, and several South African non-government organizations. It aims to provide, along with drugs, the essential training and basic facilities health care workers need to teach their patients how to use the complex AIDS drugs regimens effectively. We need to encourage more programs like "Secure the Future," and to create bold incentives to spur larger, more expansive private partnerships like it.
Pharmaceuticals are only part of the larger need. Beyond the drugs themselves, there is a tremendous lack of basic technology to track casework and ensure proper treatment compliance patient-by-patient. Computer and internet technology companies should join with academic research and medical institutions to fill this glaring technological gap, which is essential to effective HIV/AIDS treatment and is largely non-existent in Africa. Also, much greater incentives should be available for corporations of all kinds to directly fund independent U.S./African academic partnerships to train more clinical personnel in Africa on the basics of wide-scale HIV/AIDS casework.
Partnerships that involve private corporations (which have the technology, resources and materials necessary), African academic and medical institutions (which have the in-country scientific base of knowledge in Africa), health care organizations and non-government relief agencies (which have the field experience in Africa to understand the needs and the obstacles) are needed to turn this tragedy around. And the role of the U.S. government should not be to create, run and fund the system – which is a proven recipe for failure and inadequacy – but to create bold incentives in the form of tax relief and other inducements for major U.S. corporations to take on larger scale projects like "Secure the Future" in Africa, in close consultation with health care professionals in Africa and AIDS policy and health care delivery experts in the United States.
The exploding AIDS crisis in Africa, one that is certain to further destabilize the African continent socially, politically and economically in the next decade, has not arrived overnight. The Clinton-Gore administration shares part of the blame in allowing the problem to continue festering without any serious proposals which address the core problems, or any efforts to gather international consensus on the gravity of the problem. But this points to a far larger problem with the Administration in the area of foreign policy. The Clinton-Gore White House, since taking office in 1993, has failed to articulate a clear position of strength for the United States in the world, and has presided over a foreign policy that has been late and reactive rather than visionary, political rather than principled. Tragically, under continued leadership by the current administration, America would probably wake up to the AIDS crisis in Africa when it has become so serious that it directly threatens our national security interests and is no longer solvable without tremendous cost.
However, we are in the midst of an election campaign in the United States. We call on Senator Bill Bradley and the Republican candidates for President to step up with bold proposals of their own. This is not only an issue for World AIDS Day – the crisis in Africa is a serious foreign policy issue that the next President cannot ignore.