November 26, 2002
In the wake of the CIA report, the pandemic has been discussed as a potential "security threat" and "economic disaster" in media ranging from Foreign Affairs, to Newsweek, to the editorial pages of national and regional newspapers. The administration of U.S. President George Bush, in the person of Secretary of State Colin Powell, has called the pandemic "the biggest problem that we have on the face of the earth today."
Apart from pushing for such expressions of concern to be followed with commensurate actions by all world governments, IAPAC President/CEO José M. Zuniga asserted that the argument for a battle against AIDS merely on the grounds of national security and fiscal well being is problematic.
"It is a positive development that the global spread of HIV is drawing broader and more frequent attention from media and government," Zuniga said. "However, IAPAC is greatly concerned about the way much of this recent coverage seems to assign different values to human lives in different parts of the world. While economic development and national security are real and far-reaching concerns, we must remain vigilant in our definition and description of HIV/AIDS as a threat, foremost, to health and human dignity."
Zuniga decried the fact that, after largely ignoring the spread of HIV/AIDS in southern Africa, where it has raged for over a decade, the governments and media of the United States and its wealthy allies have very quickly expressed concern over the prospect of the epicenter of infection moving to Asia, largely due to potential political and economic problems that might affect them at home. IAPAC also took issue with the position, sometimes implied and sometimes explicitly stated in much recent writing on the pandemic, that it should not be a priority to provide antiretroviral therapy (ART) in developing countries.
"The implication is that the expense of such treatment is not warranted except for the citizens of the wealthiest nations," Zuniga stated. "While there are a number of issues that must be addressed around the capacity of countries to absorb the cost of antiretroviral drugs and to ensure patient access and adherence to drug regimens, this is no excuse to delay action. What it points to is the need for governments, pharmaceutical companies, and lending institutions to step up cooperative arrangements, and for all involved to ensure that greater attention is given to capacity-building measures such as training of HIV-treating physicians and allied healthcare professionals."
Zuniga added further that the varying valuations of human life that are becoming increasingly evident are not only morally unsound, but, because they often lead to an almost exclusive focus on prevention rather than treatment, also prove a poor overall strategy for redressing the pandemic, and thereby ensuring the desired socioeconomic stability. "Most agree that there are very real difficulties of cost and medical infrastructure associated with providing antiretroviral therapy in the developing world. Especially since the CIA report engendered the idea of employing a strict cost/benefit analysis in HIV/AIDS spending, however, there is an unfortunate tendency to inflate these difficulties and to write off lives."
Nicolas Eberstadt, in an article featured in the November/December issue of Foreign Affairs, dismisses the prospect of providing antiretroviral therapy in Russia, China, and India. "[E]ven if they [governments] had the money," he writes, "the unfortunate fact is that they would probably not spend it on this cause, because the cost of distributing the treatment (even assuming that the drugs were given away free) would often be more than the economic value to governments of lives thus saved."
This statement ignores the example of Thailand and Brazil, however, where governments have been able to manufacture or otherwise procure generic versions of antiretroviral medications and distribute them quite effectively. Much evidence suggests that the associated savings incurred to the public healthcare system through reduced hospital visits alone more than compensates for the cost of drug distribution. Other countries' efforts in this area are less advanced, but a Chinese pharmaceutical company, Desano, recently developed a complete generic regimen that is 1/10th the cost of the imported drugs previously available in China. Desano also plans to export the drugs to other developing nations. In South Africa, a native pharmaceutical company recently entered an agreement to produce generic antiretroviral medications in that country, while the government is taking at least modest steps to gear up the medical infrastructure for their disbursal.
Evaluations such as Eberstadt's also miss evidence from southern Africa, where we have seen that the economic cost of a young life cut short is not merely that of having one less worker. It is multiplied by the cost of caring for orphaned children, for example. It compounds problems such as famine and poverty, as Alex de Waal pointed out in a recent New York Times op-ed, because a community in which so many younger people are sick or already dead is less able to cope with disaster and hardship, and unable to pass on skills and inheritance to subsequent generations. In short, there is ample evidence from both a clinical and public health perspective, even when calculated in the coldest economic terms, that it pays for governments to work for both prevention and treatment of HIV/AIDS.
This evidence also includes the fact that having effective treatment programs in place does a lot to improve prevention because people are more likely to be tested for HIV if they know that a positive result is not an immediate death sentence. Paul Farmer, a Harvard physician who runs an AIDS clinic in Haiti and may have as much experience administering antiretroviral medication in resource-limited settings as anyone, recently said, "It is unwise to attempt prevention without treatment."
This outlook underscores IAPAC's position on redress of the global pandemic, and gives further testimony to the need to move forward measures such as the association's Global AIDS Learning & Evaluation Network (GALEN) in order to ensure effective and ethical provision of HIV treatment.