Sunday afternoon as the Durban conference was just gearing up, some five thousand demonstrators singing, chanting and dancing marched from Durban City Hall to the stadium, calling on world pharmaceutical makers to cede the Third World market to generic drugmakers capable of producing AIDS drugs for a fraction of the cost. Richard Pithouse, of the Treatment Action Campaign (TAC), prepared this report.
In May 1998, Ms. Gugu Dlamini was stoned to death in Durban for revealing that she was HIV-positive. A few days ago, 5,000 people, many wearing "HIV Positive" T-shirts, gathered at the Durban City Hall to demand equitable access to HIV/AIDS treatment. The excited group of nuns, drag queens, sangomas, doctors, communists, teenage punks on skate boards, Pan-Africanists, gay activists, unionists, students and nurses had come from all over Durban, South Africa, and the world to join the Global March for Access to HIV/AIDS Treatment. The official posters castigated the drug companies for making huge profits from the AIDS crisis while the homemade posters said things like, "AIDS is as real as cancer" and, "Mbeki, forget your R3 million jet and buy us medicine."
The march was organized by the Treatment Action Campaign (TAC), a rapidly growing organization with strong support in the trade union movement. It was led by people of the stature of leading Muslim theologian Dr. Farid Essack, Anglican Archbishop Njongonkulu Ndungane and Catholic Archbishop Denis Hurley. The streets of Durban were full of singing, dancing, laughter, warm solidarity and hope. Gugu Dlamini had been vindicated and the demand for equitable access to HIV/AIDS treatment had been turned into the single biggest issue confronting the 13th International Conference on AIDS. Previous conferences had focused on prevention but now treatment -- and equitable access to treatment -- were topping the agenda.
But there was another major issue: Mbeki's reluctance to make AIDS drugs available and his perceived support for the right-wing American AIDS "dissidents." Before the conference he had been "trashed" on the influential U.S. news program 60 Minutes, and the leading intellectual Dr. Mamphele Ramphele had accused him of "irresponsibility bordering on criminality." Mbeki's credibility was further compromised by his government's casual dismissal of the Durban Declaration, the international outrage at his conference speech and the viciousness of his government's response to criticism. Professor Thomas Coates of the University of California went so far as to call the government's stance "genocidal."
There was a danger that Mbeki, rather than the AIDS pandemic, would be the big news story coming out of the conference. But the extent of the crisis was certainly made apparent. (No one had to tell South Africans that they were spending their weekends at funerals.) The world learned that there will be 44 million African orphans by 2010, that South Africa has the highest number of HIV infections on the planet, that 5,000 HIV-positive babies are born in South Africa each month, that 4.2 million South Africans are living with HIV/AIDS and that by 2010 life expectancy in South Africa will drop to 36 years.
Moreover, the government's claim that AIDS drugs are ineffective and toxic was conclusively refuted. South Africans learned that the drugs do work and that those who can afford them can live a long and healthy life with HIV. Scientists presented rigorous research showing that women who were given AZT and 3TC after being raped by HIV-positive men did not become infected with HIV. And although the South African government had repeatedly claimed that nevirapine is ineffective and toxic, research showed that the worst side-effect of nevirapine is that a few patients develop a mild rash on the day after treatment and that nevirapine does prevent mother-to-child transmission. "The position," Jerry Coovadia insisted, "is now absolutely clear."
The Executive Director of UNAIDS, Peter Piot, concluded that, "This conference has made it irreversible -- prevention and care are combined." But, according to Time magazine, only 20,000 of the millions of Africans living with AIDS are receiving treatment. The rest will probably be dead within 2-3 years. High Court Judge Edwin Cameron made the point with headline-grabbing eloquence: "My presence here embodies the injustices of AIDS in Africa. Amidst the poverty of Africa, I stand before you because I am able to purchase health and vigour. I am here because I can afford to pay for life itself."
Influential American economist professor Jeffrey Sachs agreed that, "Talking about prevention without treatment has been ended decisively at this meeting" and added that, "It [treatment] can be afforded." Jerry Coovadia insisted that, "It is too expensive not to intervene," and experts estimate that the cost of non-intervention will be a 17% decline in South Africa's GDP by 2010. The South African Department of Health estimates that it would cost $6 billion a year, at current prices, to provide antiretroviral therapy to all people living with HIV. That would be less than 3% of the national budget -- less than a fifth of the $32 billion which the government recently spent on arms, and less than a sixth of the $40 billion which is spent on paying off the apartheid debt each year.
But South Africans are still drinking bleach in a desperate attempt to self medicate and wandering from hospital to hospital in a fruitless search for help from the state. Nevirapine, which costs R24 a dose, could prevent 5,000 babies a month from being infected with HIV, but there is no treatment for the one in four 15-24 year-old South African women who are HIV-positive. Nevirapine has been approved for use in Uganda and Senegal, but the Medicines Control Council has still not approved the use of nevirapine in South Africa.
The assault on the drug companies began at the march and was carried forward by Edwin Cameron's widely reported comment that, "The drug companies and the African governments seem to have become involved in a kind of collusive paralysis." And with the World Health Organization (WHO) and the highly respected Nobel prize-winning organization Médecins Sans Frontières/Doctors Without Borders (MSF) joining the attack, the drug companies were forced into a defensive position. It was clear that there is a critical mass of people who simply refuse to accept that the Brazilian government can treat a thousand people with dual therapy for the same price that the Ugandan government can treat 228 people, or that 100mg of AZT costs $2.00 in South Africa and $0.30 in Thailand.
In response to the pressure, a group of five drug companies offered to cut prices by 85%, but Médecins Sans Frontières likened the gesture to "an elephant giving birth to a mouse." MSF believes that the answer does not lie with donations or price cuts from drug companies but rather with the Brazilian approach of mass-producing quality generics. Countries that can't afford high prices can either manufacture their own generics or import them from producing countries. This could result in the cost of a year's antiretroviral treatment being cut from the $2,250 (which it would cost with the 85% discount) to a mere $200 a year. This is not a pipe dream. The polio vaccine is sold for several dollars in the U.S. and just a few cents in the developing world.
Pfizer manufactures fluconazole, which is used to treat the opportunistic fungal infections suffered by people with HIV. Pfizer, which made a profit of $800 million last year from fluconazole alone (its total income was $3.35 billion), offered to provide free fluconazole to HIV patients with cryptococcal meningitis. But only about 14% of South Africans with HIV develop cryptococcal meningitis. Pfizer is not, however, making fluconazole available to people with candida -- the most common opportunistic infection plaguing people with HIV. Candida leads to severe discomfort, but one or two fluconazole pills a day can restore quality of life, dignity and hope. So unless they are prepared to smuggle a fluconazole generic in from Thailand (where it costs R3.72 a pill) or India (where it costs R7.81 a pill), South Africans with candida will only be able to get fluconazole if they can pay R86 per pill -- that's over R6,000 a year. Pfizer's offer expires at the end of 2002 -- six months after its fluconazole patent expires -- and many people, including an expert from the World Health Organization, suspect that the offer has been designed precisely to prevent the South African government from buying generics for those six months.
It was no surprise to see left-leaning newspapers like England's Guardian and Australia's Green Left Weekly come out against the drug companies and the governments which support them. But it was highly unusual and noteworthy to see conservative newspapers like The Washington Post and The New York Times making similar arguments. The Washington Post said that the fact that effective treatment is available but priced beyond the means of the poor "constitutes an outrage against the most basic conceptions of international justice, of human dignity, against the very idea of human solidarity."
This would have slotted in perfectly to Winnie Madikizela-Mandela's rousing speech at the TAC march, and it seems that the enormity of the AIDS epidemic has mounted a serious challenge to the orthodox view that the market's thirst for profit must be put before the needs of people. It has been widely recognized, even in conservative circles, that there is simply no way that the AIDS pandemic can be countered until governments insist that people's needs be considered before the profit needs of the multinationals.
The demand to make the market serve the needs of people has passionate and growing global support. What's more, TAC is prepared to take the South African government and the drug companies to court if there is no immediate progress. And they'll have the support of people around the world -- including many of those for whom the autonomy of the market was previously non-negotiable.
But what about Mbeki? Will he continue to equivocate in the face of the avalanche of international condemnation which has even united Winnie and Nelson Mandela and the DP and the PAC in their criticism of the President? Coovadia has acknowledged that, "There is strong disapproval of the government" and expressed his concern that "the gap between the government and its critics is widening." This raises important questions of strategy for AIDS activists. Should they challenge the government directly, or should they, rather, give Mbeki the space to back down gracefully?
The charismatic chairperson of the TAC, Zachie Achmat, has taken a principled decision not to take any antiretroviral drugs himself until the government makes the medication available to all people living with HIV. He describes himself as "an ANC member in good standing -- I attend all my branch meetings!" Moreover, the bulk of the rapidly growing TAC membership comes from ANC-aligned unions and are probably ANC supporters. Achmat explains that, "Our approach is to take a firm, principled stand on the issues. But if it becomes clear that they won't compromise, then we will issue a challenge." He confirmed that if the Minister of Health fails to provide nevirapine to pregnant women, the TAC will launch an urgent High Court application demanding the constitutional right to treatment. TAC has also served notice that it will take legal action against Pfizer to seek a compulsory license to allow South African companies to produce cheaper copies of fluconazole. TAC members have also committed themselves to a defiance campaign: they will import fluconazole and distribute the drug through a number of doctors and nurses who have already indicated their support for the project. Achmat explained that, "We are taking this action because we have been in negotiations with the government for two years. They promised to act as soon as they got the S.A.I.N.T. report on the nevirapine trial. They got it two weeks before the conference, but there has been no announcement."
Mbeki's likely response to this action is still a matter of conjecture, but it is clear that the Treatment Action Campaign and other AIDS activists have major support in South Africa and around the world. If Mbeki treats AIDS activists, rather than AIDS, as the enemy, he runs a serious risk of losing all credibility. Indeed, it seems clear that if Mbeki fails this test, a significant sector of his own electorate will judge him unfit to govern.
Please feel free to visit or support the Treatment Action Campaign via their website at www.tac.org.za. You may also subscribe to their electronic newsletter by sending an e-mail request to email@example.com.
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