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Withdrawal/Redaction Sheet
Clinton Library
DOCUMENT NO.
SUBJECT/TITLE
DATE
RESTRICTION
AND TYPE
001. memo
Sandra Thurman to the President re: Report on Presidential Mission
04/21/1999
P1/b(1)
Looking at Children Orphaned by AIDS in sub-Sahara Africa (6
pages)
COLLECTION:
Clinton Presidential Records
First Lady's Office
Melanne Verveer
OA/Box Number: 20018
FOLDER TITLE:
AIDS [Acquired Immune Deficiency Syndrome] [Folder 2] [2]
2013-0534-S
ry1535
RESTRICTION CODES
Presidential Records Act - [44 U.S.C. 2204(a)]
Freedom of Information Act - [5 U.S.C. 552(b)]
P1 National Security Classified Information [(a)(1) of the PRA]
b(1) National security classified information [(b)(1) of the FOIA]
P2 Relating to the appointment to Federal office [(a)(2) of the PRA]
b(2) Release would disclose internal personnel rules and practices of
P3 Release would violate a Federal statute [(a)(3) of the PRA]
an agency [(b)(2) of the FOIA]
P4 Release would disclose trade secrets or confidential commercial or
b(3) Release would violate a Federal statute [(b)(3) of the FOIA]
financial information [(a)(4) of the PRA]
b(4) Release would disclose trade secrets or confidential or financial
P5 Release would disclose confidential advice between the President
information [(b)(4) of the FOIA]
and his advisors, or between such advisors [a)(5) of the PRA]
b(6) Release would constitute a clearly unwarranted invasion of
P6 Release would constitute a clearly unwarranted invasion of
personal privacy [(b)(6) of the FOIA]
personal privacy [(a)(6) of the PRA]
b(7) Release would disclose information compiled for law enforcement
purposes [(b)(7) of the FOIA]
C. Closed in accordance with restrictions contained in donor's deed
b(8) Release would disclose information concerning the regulation of
of gift.
financial institutions [(b)(8) of the FOIA]
PRM. Personal record misfile defined in accordance with 44 U.S.C.
b(9) Release would disclose geological or geophysical information
2201(3).
concerning wells [(b)(9) of the FOIA]
RR. Document will be reviewed upon request.
AIDS Convening
September 7, 1999
Briefing Book
I-
Briefing Memo
II -
Participants
1 -
List
2- -
Bio of Dr. Peter Piot and fact sheet on UNAIDS
3 - -
"Bristol Myers Heeds Calls to Bolster War Against HIV in Africa" - - Wall Street
Journal
4 - -
"Gates to Give Away Fortune" - UPI
5 - -
"The Global HIV/AIDS Epidemic" - The Surgeon General
III - Agenda
IV -
Invite Letter
V - -
Background Information
1 - -
AIDS in Africa is a Serious Crisis
2- -
Press Release on Administration Initiative
3 - -
Backgrounder on Administration Initiative and Q&A
4 - -
Wolfensohn Letter to the President
5 - -
USTR Paper in Intellectual Property Rights
6 - -
"Helping the Poorest" - The Economist Editorial
7- -
Statement and Fact Sheet on Cologne Debt Relief Agreement
8 - -
"Helping the Poorest" - The Economist, Jeffrey Sachs article
9 - -
"Balms for the Poor" - The Economist
10 - "Orphans of the Virus" - The Economist
11 -
"Drugs for AIDS in Africa"- New York Times Editorial
12 -
"Facing a Global AIDS Crisis"- - The Washington Post
13 - "A Global Disaster" - The Economist
14 -
"In Africa, a Deadly Silence About AIDS is Lifting" New York Times
15 - -
HIV/AIDS Prevalence Rates for Sub Saharan Africa
VI-
Talking Points
THE WHITE HOUSE
WASHINGTON
September 3, 1999
MEMORANDUM TO THE FIRST LADY
FROM:
Sandra Thurman, Director, Office of National AIDS Policy
SUBJECT: Need for an Enhanced Response to the AIDS Crisis in Africa and Around the
World
Summary
In the next decade, 40 million children will be orphaned as a result of losing one or both
parents to AIDS.
AIDS is not just taking lives, it is threatening economics, stability, and civil society.
AIDS is wiping out decades of progress on a variety of development fronts, including per
capita GNP, infant mortality, and life expectancy.
Leadership and investment can help, and has helped, to turn the tide.
Political support for a more aggressive United States response is building.
As goes Africa, so will go India, Asia, and the new Soviet states, and by 2005, more than 100
million people worldwide will have been infected with HIV.
Background
On World AIDS Day last year, the President highlighted the growing global tragedy of children
orphaned by AIDS in sub-Saharan Africa. At that time, he directed me to lead a fact-finding
mission to the region and to report back to you with recommendations for productive action.
From March 27 through April 5, I led a Presidential Delegation to Zambia, Uganda, and South
Africa. I was accompanied by Representatives Jackson-Lee, Kilpatrick, and Lee, and assorted
senior staff. We were also joined by a select group of individuals from outside of government
including Mayor Dinkins, Bishop Felton May, and William Harris. [Attachment A: Manifest]
The goals of the trip were: to heighten awareness, promote leadership, and identify promising
interventions. In Zambia and Uganda, we met with the Presidents and a variety of government
ministers (health, welfare, community development, finance, etc.). In each country we visited a
host of community-based programs serving children and families affected by AIDS, and talked
with donors, experts, providers, and consumers about actions taken, lessons learned, and barriers
to further progress.
On July 19, 1999 the White House released the subsequent report to the President on the mission
and our proposed plan of action (press release attached). The new initiative includes a request to
the Congress for an additional $100 million to combat AIDS primarily in Africa. This is the
largest-ever budget increase in the global battle against AIDS and more than doubles the United
States efforts.
In addition to the $100 million, the initiative includes a variety of strategic opportunities for
challenging other partners to join in an enhanced effort starting with your meeting with key
stakeholders on Tuesday. Others include:
-
Business Leaders Meeting - The Department of Commerce will facilitate a meeting of
business leaders active in Africa to encourage them to increase their efforts in the
battle against AIDS. This is tentatively scheduled for early November and the Vice
President has expressed interest in participating.
-
Labor Leaders Meeting - The Department of Labor, led by Secretary Herman, and
the AFL-CIO will co-host a meeting of US and African labor leaders to determine
ways to expand existing programs which use trade unions to provide outreach and
HIV/AIDS education (Note: In many parts of South Africa one in four mine workers
in HIV-positive).
-
Religious Leaders Summit - The Office of National AIDS Policy will facilitate a
meeting of African, American and other religious leaders to discuss ways to more
effectively engage communities of faith in the fight against AIDS. Several prominent
religious leaders have tentatively committed to participate including Reverends Jesse
Jackson, Leon Sullivan, Andrew Young and Archbishop Desmond Tutu.
-
UN Conference on Children Orphaned by AIDS - On December 1,1999 (World
AIDS Day), the United Nations in conjunction with the National Black Leadership
Commission on AIDS (chaired by David Dinkins), The White House Office of
National AIDS Policy, The Magic Johnson Foundation and a variety of NGO's will
hold a conference to focus attention on the growing number of children orphaned by
AIDS. You have been asked to deliver a keynote address.
Attached please find the Memoranda to the President on this issue for your review.
I welcome the opportunity to discuss this with you further, and greatly appreciate your continued
support and leadership on behalf of people living with HIV/AIDS both at home and abroad.
2
Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
SUBJECT/TITLE
DATE
RESTRICTION
AND TYPE
001. memo
Sandra Thurman to the President re: Report on Presidential Mission
04/21/1999
P1/b(1)
Looking at Children Orphaned by AIDS in sub-Sahara Africa (6
pages)
COLLECTION:
Clinton Presidential Records
First Lady's Office
Melanne Verveer
OA/Box Number: 20018
FOLDER TITLE:
AIDS [Acquired Immune Deficiency Syndrome] [Folder 2] [2]
2013-0534-S
ry1535
RESTRICTION CODES
Presidential Records Act - [44 U.S.C. 2204(a)]
Freedom of Information Act - [5 U.S.C. 552(b)]
P1 National Security Classified Information [(a)(1) of the PRA]
b(1) National security classified information [(b)(1) of the FOIA]
P2 Relating to the appointment to Federal office [(a)(2) of the PRA]
b(2) Release would disclose internal personnel rules and practices of
P3 Release would violate a Federal statute [(a)(3) of the PRA]
an agency [(b)(2) of the FOIA]
P4 Release would disclose trade secrets or confidential commercial or
b(3) Release would violate a Federal statute [(b)(3) of the FOIA]
financial information [(a)(4) of the PRA]
b(4) Release would disclose trade secrets or confidential or financial
P5 Release would disclose confidential advice between the President
information [(b)(4) of the FOIA]
and his advisors, or between such advisors [a)(5) of the PRA]
b(6) Release would constitute a clearly unwarranted invasion of
P6 Release would constitute a clearly unwarranted invasion of
personal privacy [(b)(6) of the FOIA]
personal privacy [(a)(6) of the PRA]
b(7) Release would disclose information compiled for law enforcement
purposes [(b)(7) of the FOIA]
C. Closed in accordance with restrictions contained in donor's deed
b(8) Release would disclose information concerning the regulation of
of gift.
financial institutions [(b)(8) of the FOIA]
PRM. Personal record misfile defined in accordance with 44 U.S.C.
b(9) Release would disclose geological or geophysical information
2201(3).
concerning wells [(b)(9) of the FOIA]
RR. Document will be reviewed upon request.
ATTACHMENT A
PRESIDENTIAL MISSION TO AFRICA
MARCH 27, 1999 - APRIL 5, 1999
MEMBERS OF CONGRESS
Rep. Carolyn Kilpatrick, Foreign Operations Subcommittee, Appropriations,
Congressional Black Caucus
Rep. Barbara Lee, Africa Subcommittee, International Relations,
Congressional Black Caucus
Rep. Sheila Jackson Lee, Founder and Chair, Congressional Children's Caucus,
Congressional Black Caucus
CONGRESSIONAL STAFF
Bruce Artim, Health Staff, Senator Hatch
Mary Lynn Qurnell, Legislative Assistant, Senator Helms
Stephanie Robinson, General Counsel, Senator Kennedy
Carolyn Bartholomew, Legislative Director, Rep. Pelosi,
Minority Staff, Foreign Operations Subcommittee, Appropriations
NON-GOVERNMENTAL PARTICIPANTS
William Harris, President, Children's Education and Research Institute
Bishop Felton May, General Board of Global Ministries, United Methodist Church
David Dinkins, Chair, Black Leadership Coalition on AIDS
Dr. Jacob Gayle, World Bank
Rory Kennedy, Documentary filmmaker
Nick Doob, Documentary filmmaker
ADMINISTRATION OFFICIALS
Sandy Thurman, Director, Office of National AIDS Policy
Michael Iskowitz, Consultant, USAID
Dr. Paul DeLay, Director, HIV/AIDS Programs, USAID
Maria Sotiropoulos, Protocol Officer, State Department
Phil Drouin, Africa Bureau, State Department
MILITARY PERSONNEL
Lt. Commander James Erskine
Dr. Anthony Barile
Brenda Geist, Director Congressional Travel
ATTACHMENT B
Peter D. Hart Research Associates, Inc.
1724 Connecticut Avenue, N.W
Washington, D.C. 20009
202-234-5570
202-232-8134 FAX
Increase U.S. Assistance to Fight
AIDS in Africa
54%
29%
17%
Favorable
Neutral/not sure
Unfavorable
Peter D. Hart Research Associates surveyed 1,411 registered voters, including 310 African Americans, by
telephone between February 20 and 26, 1999, for the Children's Research and Education Institute.
American voters view the spread of AIDS in Africa as a serious problem. Although many voters have not
heard much about the issue, they nonetheless believe that it is likely to have an impact here at home. A
majority of Americans have a favorable view of a proposal to increase U.S. government assistance for
international AIDS programs in Africa.
The spread of AIDS in Africa is viewed as a serious problem by two-thirds (67%) of American
voters, with 45% saying that it is an extremely serious problem and an additional 22% describing
it as a quite serious problem.
The same proportion (67%) believe that it is false to say that the global AIDS crisis is coming
under control.
In addition, three-quarters (75%) of voters believe that the AIDS epidemic in Africa will affect
people in the United States.
Although the issue is important, only 19% of voters say that they have read or heard a lot about it.
Nearly half (48%) say that they have heard little or nothing about it.
A 54% majority are favorable to a proposal to increase government assistance for international
efforts to fight the spread of AIDS in Africa. Only 29% are unfavorable.
-
An overwhelming 83% majority of African Americans are favorable (55%
strongly favorable), and only 10% are unfavorable.
Support for greater assistance increases when it is placed in the context of an international effort.
Three-quarters (76%) of voters say that they would be more likely to support assistance to help
Africa deal with the AIDS epidemic if they knew that it would be a part of a larger international
effort with Europe, Japan, and other countries doing their share.
Study #5408
CREI/Social Issues
Interviews: 1411 voters, including 310 African Americans
Dates: February 20-26, 1999
AIDS in Africa
I'm going to mention some different issues, and I'd like to find out how serious a problem you consider each
one to be in our country today. For each one, please tell me whether you consider it to be an extremely
serious problem, a quite serious problem, a somewhat serious problem, or not that serious a problem.
Extremely
Quite
Somewhat
Not That
Serious
Serious
Serious
Serious A
Not
Problem
Problem
Problem
Problem
Sure
The spread of AIDS in Africa
45
22
13
8
12
Now I'm going to read you another list of statements. For each statement, please tell me whether you're
sure it's true, think it's probably true, think it's probably false, or are sure it's false.
Think
Think
It's
It's
Sure
Sure
Probably
Probably
It's
Not
It's True
True
False
False
Sure
The global AIDS crisis is coming
under control
2
20
37
30
11
Now, I'm going to mention several proposals and I'd like to get your reaction. For each proposal I read,
please tell me whether your reaction is very favorable, somewhat favorable, neutral, somewhat unfavorable,
or very unfavorable.
Very
Somewhat
Somewhat
Very
Not
Favorable
Favorable
Neutral
Unfavorable
Unfavorable
Sure
Increasing U.S. government
assistance for international
efforts to fight the spread of
AIDS in Africa
ALL VOTERS
23
31
15
14
15
2
African Americans
55
28
6
5
5
1
How much have you heard or read about the issue of AIDS in Africa - a lot, some, just a little, or not very
much?
**
ALL
African
VOTERS
Americans
Heard/Read
A lot
19
31
Some
32
28
Just a little
22
22
Have not heard/read very much
23
16 -
Heard/read nothing (VOL)
3
1
Not sure
1
2
** Asked of one-half the respondents (FORM B).
CREI/Social Issues
Interviews: 1411 voters, including 310 African Americans
Dates: February 20-26, 1999
AIDS in Africa
Do you think that the AIDS epidemic in Africa will affect people in the United States, or not? **
ALL
African
VOTERS
Americans
Yes, will affect people in the U.S
75
83
No, will not affect people in the U.S
16
10
Not sure
9
7
** Asked of one-half the respondents (FORM B).
If you knew that the U.S. assistance to help Africa deal with the AIDS epidemic would be part of a larger
international effort with Europe, Japan, and other countries doing their share, would you be much more
likely to support it, somewhat more likely to support it, or no more likely to support it? **
ALL
African
VOTERS
Americans
Much more likely to support
37
49
Somewhat more likely to support
39
35
No more likely to support
20
12
Less likely to support (VOL)
1
-
Not sure
3
4
** Asked of one-half the respondents (FORM B).
Study #5408
CREI/Social Issues
Interviews: 1411 voters, including 310 African Americans
Dates: February 20-26, 1999
AIDS in Africa
Now I am going to read you some reasons that people might give for supporting increased U.S. government
assistance to fight the spread of AIDS in Africa For each one, please tell me how convincing a reason it
is to support increased assistance - very convincing, fairly convincing, only somewhat convincing, or not
that convincing. **
Only
Very
Fairly
Somewhat
Not That
Not
Convincing
Convincing
Convincing
Convincing
Sure
We all live on one planet,
and the whole world benefits
from fighting the spread of
AIDS-if the epidemic has
spread that much in Africa,
we are fooling ourselves if
we think that it won't affect
the U.S.-it will, unless we do
something
now
ALL VOTERS
44
14
21
16
5
African Americans
67
12
11
7
3
The AIDS epidemic is
creating millions of orphans
that are overwhelming the
capacities of orphanages
and churches, and filling the
streets of many African
cities. An estimated forty
million children will lose a
parent to AIDS by 2010
ALL VOTERS
40
15
23
15
7
African Americans
56
18
17
6
3
5 24-99
THE WHITE HOUSE
WASHINGTON
l'dlinto
May 21, 1999
(c
Bruhtown-
MEMORANDUM TO THE PRESIDENT
CC: NSC/sandy
FROM:
CC Gene S
Sandra L. Thurman, Director, Office of National AIDS Policy
)
a Back to me
SUBJECT:
AIDS in Africa - Response to Your Request for Additional Information
Idlike to
helpre this
Thank you for calling me in Ghana and for reiterating your concern about the AIDS emergency
in Africa and the need for an invigorated US effort. As a follow-up to our conversation, this
memorandum provides additional information that seeks to put the issue of AZT for pregnant
women in the broader context of the AIDS pandemic in Africa.
AIDS is a plague of biblical proportion
Thanks to the commitment of Rev. Leon Sullivan, for the first time, the African African-
American Summit focused much needed attention on the issue of AIDS in Africa and
acknowledged the following bleak realities:
AIDS buries more than 5,500 people a day in Africa and that number will more than double in
the next few years. The WHO just declared AIDS the leading cause of death among all people of
all ages in Africa, and each day, an additional 11,000 people become HIV infected. Most of these
new infections are among young people, under the age of 25. By 2005, more than 100 million
people worldwide will be HIV-positive.
AIDS is leaving a generation of children in jeopardy. In many countries, between one-fifth and
one-third of all children have already been orphaned by AIDS, and the worst is yet come.
Within the next decade more than 36 million children will be orphaned by AIDS in sub-Saharan
Africa, and this tragedy will continue to grow for at least another 30 years.
AIDS is wiping out decades of steady progress in development, doubling infant mortality,
tripling child mortality, and slashing life expectancy by 20 years or more. AIDS is devastating
economic growth, threatening political and regional stability, and stands a serious obstacle to the
realization of your new partnership with Africa, again celebrated in Ghana.
copied
The combination of leadership and resources can turn the tide.
POTUS
In our battle against AIDS, Uganda is the model for success in the developing world. President
NSC we
Museveni has been a strong and effective AIDS leader, and has created an environment ripe for
Berger
change. In response, the US has invested more than $50 million on AIDS in Uganda over a ten-
Sperling
Podista
Thurmar
year period. Through this combination of leadership and sustained resources, Uganda has cut the
rate of HIV by more than half, and organized model AIDS care programs.
As an essential component of your new partnership with Africa, we need to help cultivate AIDS
leadership among more African leaders, and we need to help enhance the overall investment in
the war on AIDS to a level that meets the magnitude of this crisis. On the leadership front, we
are beginning to see positive movement. As the realities of the AIDS become increasingly
unavoidable, a growing number of African leaders are stepping up to the plate. However, the
resources currently dedicated to winning this war, from both host governments and donors, are
All
grossly inadequate. As I said in my previous memorandum, in the face of a 300% rise in annual
HIV incidence and an AIDS explosion in sub-Saharan Africa, the USAID global AIDS budget
has remained essentially stagnant since 1993 Other donors have followed suit. Without a
dramatically enhanced response, we will lose this war.
Our Global AIDS Emergency Working Group is exploring three strategies for increasing the
availability of resources to begin to meet the ever growing global AIDS crisis. First, we are
looking at an increase in the USAID global AIDS budget. In this context, it is important that this
increase be new money and not taken from other essential development accounts. Health,
education, child-survival, and micro-finance are all interconnected components of a
comprehensive human investment and AIDS strategy. Shifting money from one account to
another will not improve our collective effort. Second, we are looking at an approach to debt
relief that not only considers a debtor nation's economic policy but its strong commitment to
investing in human capacity, particularly HIV and AIDS. Countries such as Côte d'Ivoire,
:
Kenya, Nigeria, South Africa, and Zambia all hold considerable US debt and have a serious and
growing AIDS emergency. Third, we are looking at public-private partnerships.
Finding ways to increase access to AZT for HIV-positive pregnant women is an integral
part of an invigorated response to AIDS in Africa.
With additional resources, the US can partner with host governments and other donors to
promote an aggressive strategy on four fronts including: containing the AIDS pandemic,
providing home and community-based AIDS treatment and support, caring for children orphaned
by AIDS, and gearing up for the long haul through health infrastructure and capacity
development.
In the context of containing the AIDS pandemic, developing ways to prevent mother-to-child
transmission that are workable in Africa is a high priority. In Africa today, for every ten children
born to HIV-positive mothers, two become infected during delivery, one becomes infected
through breast-feeding, and seven remain HIV-negative. A "short course" of AZT at the time of
birth and for a week following has been found to reduce the number of babies who become HIV-
positive during delivery by nearly 40%. This is extremely encouraging news. However, a host
of additional issues need to be explored and addressed before this knowledge can be effectively
implemented.
USAID is now devoting $6 million to answering key questions surrounding the use of AZT to
reduce mother-to-child transmission of HIV in the developing world. For example, to keep
babies HIV-negative, mothers who receive AZT during delivery should not breastfeed.
However, in many areas of sub-Saharan Africa, babies are as likely to die from diarrhea resulting
from misuse of formula as they are from AIDS. The lack of health care infrastructure is also a
serious issue. More than 95% of pregnant women do not know they are HIV-positive and
currently lack access to vital testing and counseling services needed to find out. Further, in many
areas, most women deliver their children with the assistance of midwives in their homes, or in
makeshift clinics unequipped for AZT interventions.
Finally, the AIDS stigma is so great in places like South Africa, that fear and denial keep
pregnant women from discovering their status, even if they have the option. Recently a woman
in South Africa with HIV went public with her status and was stoned to death by her neighbors,
and countless others have been left destitute on the street with their children after their husbands
found out they were HIV-positive. As we begin to address these issues, we will increase our
ability to move forward with the implementation of an AZT intervention.
The cost of AZT remains a serious concern. Even with a price reduction from Glaxo Wellcome,
AZT is expensive, particularly by African standards, and health planners face difficult choices
over the best use of scarce resources. In South Africa, Health Minister Zuma has opposed
providing AZT to pregnant women because it cannot be made available to all who need it and
because she believes that other approaches are more cost effective. For example, she believes
that it is better to focus on keeping women of childbearing age HIV-negative, thereby not only
saving children from becoming infected but from becoming orphaned as well. In addition, this
AZT discussion has been caught up in the debate over US policy on compulsory licensing, and
South Africa's desire to produce AZT at a more affordable price. It is for these reasons that the
delivery of AZT to pregnant women is one prong of a multifaceted approach to respond to AIDS
:
in Africa.
I welcome the opportunity to discuss this with you further, and hope to have a report to you on
AIDS in Africa, including recommendations from the Global AIDS Emergency Working Group,
in early June.
II. Participants
1- List
2-
Bio of Dr. Peter Piot and fact sheet on UNAIDS
3- "Bristol Meyers Heeds Calls to Bolster War Against HIV in
Africa" - Wall Street Journal
4-
"Gates to Give Away Fortune" - UPI
5-
"The Global HIV/AIDS Epidemic" - The Surgeon General
AIDS Convening
September 7, 1999
Participants List
Administration
First Lady Hillary Rodham Clinton
Secretary Donna Shalala
Department of Health and Human Services
The Honorable David Satcher
Surgeon General
Secretary Lawrence Summers
Department of the Treasury
Administrator Brady Anderson
US Agency for International Development
The Honorable Leon Fuerth
Assistant to the Vice President for National Security Affairs
The White House
The Honorable Sandy Thurman
Director
National AIDS Policy Office
The White House
Ms. Gayle Smith
Senior Director for African Affairs
National Security Council
The White House
Under Secretary Frank Loy
Under Secretary for Global Affairs
Department of State
Melanne Verveer
Assistant to the President and Chief of Staff to the First Lady
The White House
Dr. Ken Bernard
International Health Affairs
National Security Council
The White House
Multinational Organizations
Mr. James Wolfensohn
President
World Bank
Ms. Jan Piercy
The Executive Director of the United States
The World Bank
Dr. Peter Piot
Executive Director
Joint United Nations Program on HIV/AIDS
Foundations
Dr. Timothy Evans
Team Director for Health Services
The Rockefeller Foundation
Mr. Aryeh Neier
President Soros Foundations Network
Open Society Institute
Mr. Stewart Burden
Senior Program Officer
The John D. and Catherine T. MacArthur Foundation
Dr. Gordon Perkin
President of PATH
William H. Gates Foundation
Dr. Drew Altman
President and CEO
Kaiser Family Foundation
Corporations/Others
Mr. Charles Heimbold
Chairman and Chief Executive Officer
Bristol Myers Squibb
Mr. Robert Johnson
Chairman and CEO
Black Entertainment Television
Observers
B.A. Rudolph
Chief of Staff to the Administrator
Agency for International Development
Paul Delay
Agency for International Development
Duff Gillespie
Agency for International Development
Dr. Jim Sherry
United Nations Joint Program on HIV/AIDS
Mr. Eduardo Doryan
Vice President and Head of Network
The World Bank
Ms. Debrework Zewdie
Lead Specialist, Population
The World Bank
Timothy Geithner
Under Secretary for International Affairs
Department of the Treasury
William Schuerch
Deputy Assistant Secretary for International Development, Debt and Environmental Policy
Department of the Treasury
Ms. Debrah Lee
President and COO
Black Entertainment Television
Mr. Ken Weg
Vice Chairman
Bristol Myers Squibb
Dr. Seth Berkley
President
International AIDS Vaccine Initiative
The Rockefeller Foundation
Mr. Terry Anderson
Executive Director of Public Policy
National Association of People with AIDS
Mr. Paul Boneberg
Director
Global AIDS Action Network
Ms. Diane Graham
Special Assistant for Global Affairs
State Department
Richard Socaridies
Special Assistant to the President and Senior Adviser for Public Liaison
Office of the Public Liaison
The White House
UNAIDS
UNICEF
UNDP
UNFPA
UNESCO
WHO
WORLD BANK
Joint United Nations Programme on HIV/AIDS
PETER PIOT
Executive Director, UNAIDS
Biographical information
Peter Piot was appointed Executive Director of the Joint United Nations
Programme on HIV/AIDS (UNAIDS) and Assistant-Secretary-Genera of the United
Nations on 12 December 1994.
Dr Piot joined UNAIDS from a position as Director of the Division of
Research and Intervention Development at the Global Programme on AIDS of the
World Health Organization. Dr Piot had previously served hom 1980 10 1992 as
Professor of Microbiology and Head of the Department of Infection and Immunity at
the Institute of Tropical Medicine in Antwerp, Belgium. During this period, hc also
launched and expanded a series of collaborative projects in Burundi, Côte d'Ivoire,
Kenya, Tanzania and Zairc, including "Projet SIDA" in Kinshasa, Zaire, which was the
first international HIV/AIDS project to be established in the developing world.
Dr Piot was Associate Professor of Public Health at the Free University of
Brussels from 1989 to 1992, and Associate Professor of Microbiology at the
University of Nairobi from 1986 to 1987. From 1978 to 1979, he was Senior Hellow
at the University of Washington, where he carried out research on infections diseases.
During an investigation into an outbreak of haemorrhagic fever in northern Zaire in
1976. he became co-discoverer of the Ebola virus. He served as the President of the
International AIDS Society from 1991 to 1994. Prior to joining UNAIDS, he was
editor of AIDS, the leading scientific journal in its field.
Dr Piot qualified as a Doctor of Medicine at the University of Ghent in 1974
and received a Doctorate in Microbiology from the University of Antwerp in 1980. He
has received many awards for scientific achievement and public service, and has
published over 500 articles and 14 books, mostly on issues related to AIDS, scxually
transmitted diseases and women's reproductive health. Hc was awarded a baronetcy
by II.M. King Albert II of Belgium in 1995. Dr Piot was born in Leuven, Belgium in
1949.
14.01.99 Doc #9496
20, avenue Appia
CH-1211 Geneva 27
Switzerland
Tel: (+4122) 791,3666
Fax: (+4122) 791.4187
e-mail: [email protected]
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Peter Fiot. Executive Director, Joint United Nations Programme on HIV/AIDS (UNAIDS).
For information, please contact UNAIDS, Geneva, Switzerland. Phone: (+4122) 791 3556,
Fax: (+4122) 791 4187. e-mail UNAIDSIWHO ch. internet http://158.232 20 3/unaids.htm
UNAIDS
Please give credit to UNAIUS/Yosn: Shimizu.
000 7
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UNAIDS
FACT SHEET
UNICEF
UNDP
UNIPA
UNESCO
WHO
WORLD BANK
Joint United Nations Programme on HIV/AIDS
November 1998
UNAIDS
The HIV/AIDS epidemic continues to progress. Each day. some 16 000 people are newly infected
with HIV. the virus that causes AIDS. UNAIDS estimates that more than 33 million people are
currently living with HIV/AIDS, over 90% of whom live in the developing world.
Meeting the complex long-term challenge of HIV/AIDS calls for an expanded response. Direct
health interventions and action to influence the immediate aspects of AIDS prevention and care
must be pursued and intensified, while innovative action must be undertaken to address the
broader context of the epidemic, including its socio-economic causes and consequences.
A major reform
In recognition of this concern, the Joint United Nations Programme on HIV/AIDS (UNAIDS) was
established in January 1996. UNAIDS is a co-sponsored programme that brings together the
United Nations Children's Fund (UNICEF), the United Nations Development Programme (UNDP),
the United Nations Population Fund (UNFPA), the United Nations Educational, Scientific and
Cultural Organization (UNESCO), the World Health Organization (WHO) and the World Bank in a
common effort against the epidemic. It is the first programme of its kind in the UN system. a small
programme with a large outreach and the potential to lever significant resources and action
through the creation of strategic partnerships.
The UNAIDS cosponsors bring to this joint endeavour complementary mandates and
multisectoral expertise, ranging from education and socio-economic development to women's
reproductive health. They are committed to joint planning and action, giving UNAIDS a
"cooperative advantage" that translates into greater synergy and efficiency. Benefits include more
effective advocacy, more effective use of UN system resources through the sharing of COSTS, and
greater coherence in United Nations support to national AIDS programmes.
Mission of UNAIDS
As the main advocate for global action on HIV/AIDS, UNAIDS leads, strengthens and supports an
expanded response aimed at preventing the transmission of HIV, providing care and support,
reducing the vulnerability of individuals and communities to HIV/AIDS, and alleviating the impact
of the epidemic.
1
20. ovenue Appia
CH-1211 Geneva 27
Switzerland
Tel: (+4122) 791,3666
Fax: (+4122) 791.4187
e-mail: [email protected]
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Guiding principles of UNAIDS
Long-term response: HIV/AIDS requires a long-term sustainable response, including coping
capacity on the part of Individuals and communities. UNAIDS helps to strengthen national
capacity for action ranging from prevention and care to impact alleviation.
Technical soundness: Action In response to the HIV/AIDS epidemic must be not only
expanded but also improved in quality through the identification and use of technically sound
policies, strategies, tools and approaches.
Focus on vulnerability: An effective response requires societal and structural change to
reduce the vulnerability of women, young people, migrants, drug users, sexual and ethnic
minorities and other population groups.
Support, not coercion: A supportive social; political and legal environment helps individuals
exercise their responsibilities to protect themselves and others from HIV infection.
Human rights: People are entitled to enjoy all human rights without discrimination, including
discrimination based on HIV infection status. These include the right to health, travel and
privacy, the right to freedom from sexual violence and coercion, and the right to the
information and means to prevent infection.
Participation and partnership: A multisectoral response to HIV/AIDS can best be achieved
through partnership.
National autonomy: It is a national responsibility to design, implement and coordinate the
response to HIV/AIDS at the country level. The role of external partners, including UNAIDS, is
to support and build on national action.
Complementarity: Rather than undertaking itself what can be or is already being done by
others. UNAIDS attempts to facilitate these efforts and to fill gaps in action and research.
Global and local impact
At the global level, UNAIDS is the AIDS programme of the six cosponsors, carrying out the roles
of policy development and research, technical support, advocacy, and coordination. At the same
time, the six cosponsoring organizations integrate HIV/AIDS-related issues and UNAIDS policies
and strategies into their ongoing work.
At the country level, UNAIDS can best be seen as the sum of AIDS-related activities carried out
by its six cosponsors with the backing of UNAIDS technical guidance and resources. In countries
where some or all of the cosponsors are present, their representatives meet regularly in a special
"Theme Group" to jointly plan, programme and evaluate their AIDS-related activities.
In addition, UNAIDS has staff known as Country Programme Advisors posted in selected
countries to support the Theme Groups on HIV/AIDS, to strengthen cooperation with national
partners, and to provide technical support.
Important partners in national AIDS activities include governments (through both political
leadership and the relevant ministries): community-based organizations; nongovernmental
organizations (NGOs): the private sector; academic and research institutes; religious and other
social and cultural institutions: and people living with HIV/AIDS.
Governance
UNAIDS is the first programme of the United Nations system to have NGO representation on its
governing body. The Programme Coordinating Board (PCB) is comprised of representatives of 22
Member States of the UN system, (including both donor and recipient countries), of the six
cosponsors, of NGOs and people living with HIV/AIDS.
2
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Strategic areas
Country support: The overriding goal of UNAIDS at country level is to enhance national
capabilities to mount an expanded, multisectoral response to HIV/AIDS. Priority is given to
nationally determined needs, in particular those of developing countries and economies in
transition.
International best practice: Gamering practical experience from around the world. UNAIDS
identifies sound policies and strategies that have proven to be effective what is known as
"intemational best practice". These approaches are analysed and promoted with a view to their
adaptation at country level.
The programme also supports research to develop now tools and innovative approaches for
slowing the spread of HIV and advocates for improving the quality of life of people living with
HIV/AIDS. Examples are vaccine development, vaginal microbicides for women, practical
approaches to reducing mother-to-child transmission of HIV, and better ways of preventing and
treating the common opportunistic infections in HIV-infected individuals.
Structure & staffing
UNAIDS has adopted a flat organizational structure, with as few layers of management as
possible. The programme consists of four departments: Policy, Strategy and Research; Country
Planning and Programme Development; External Relations; and Programme Support. A total of
175 posts have been budgeted. The New York and Geneva offices currently comprise 49
professionals and 33 support staff. At country level there are 42 Country Programme Advisers, 10
Technical Advisers, 7 intercountry team members and 8 support staff. The working culture values
partnership, team work and facilitation.
Funding
With its modest resource base of US $ 120 million for the 1998-99 biennium, UNAIDS is not a
funding agency. It is a small programme that aims to increase its impact and outreach through
strategic alliances with its cosponsors and other partners. UNAIDS cosponsors fund their own
HIV/AIDS country-level programmes and activities. A further US $ 20 million was sought for 1998-
1999 cosponsor activities at the global and regional levels through the UNAIDS Coordinated
Appeal for Supplemental Funded Activity. Funds are received from traditional donor countries,
but also from developing countries (e.g. China and Thailand) and the private sector. UNAIDS
aims to increase the resources available to national AIDS programmes by supporting fund-raising
activities at the national level and providing training in resource mobilization to its national
partners.
For more Information, please contact Anne Winter, UNAIDS, Geneva, (+41 22) 791.4577 or Lisa
Jacobs. UNAIDS. Geneva: (+41 22) 79 1.3387. You may also visit the UNAIDS Home Page on
the Internet for more information about the programme (http://www.unaids.org)
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001/003
FRANCE SOCIAL US
0202 944 0251
03/00/99 wall 19:01 St. Journal 6.5.99
World-wide, 34 million people are believed
to be infected with HIV. the virus that
causes AIDS.
Bristol-Myers Chairman Charles Heim-
bold, in an interview yesterday, said
Foreign Aid
his company's action, while perhaps slow
in coming two decades into the epidemic. is
a sincere effort to get other companies to
Bristol-Myers Heeds
join with it or to begin similar undertak-
ings of their own. The 65-year-old execu-
Calls to Bolster War
tive says the company acted quietly and on
its own "because that's the way to get
things done quickly and given the
Against HIV in Africa
numbers we were seeing. speed seemed to
be critical."
While Bristol-Myers says altruism is
Plan Focuses on Training.
driving its efforts, there are other factors
at work. The pro-
Prevention Where Virus
gram will allow it to
develop longer-term
Is Raging Most Fiercely
business interests
in developing na-
tions for its AIDS
It Isn't Only About Altruism
drugs and other
therapies.
And in a move
By MICHAEL WALDHOLZ
certain to rouse eth-
staff Reporter of THE WALL STREET JOURNAL
ical questions in the
Drug companies are facing a dilemma
U.S., Bristol-Myers
when it comes to dispensing powerful new
hopes to support
AIDS medicines where they are needed
South African stud-
most: sub-Saharan Africa. home to 70% of
ies involving 20,000
Charles Heimbold
the world's HIV-infected population. The
AIDS
patients,
therapies are too expensive for most pa-
mostly women and children, taking drug
tients, and much of the region lacks basic
cocktails that in some cases consist solely
medical services.
of Bristol-Myers's three AIDS products: its
So far. most companies have tried to
antiviral drugs Videx. Zerit and hydrox-
deal with the problem through limited
yurea. Some of the trials will involve only
drug giveaways or discounting programs.
two drugs, perhaps even in intermittent
But many international health officials
therapy, an approach considered subopti-
and AIDS activists view those efforts as
mal in the U.S. If proved effective, how-
grossly inadequate. Already, several gov-
ever, this lower-cost therapy could be a
ernments, including South Africa's. are
boon in the developing world.
threatening to hand over drug patents to
Bristol-Myers was prodded into action
local manufacturers, potentially flooding
when Mr. Heimbold happened to sit next to
markets with cheap copycat versions of the
United Nations Secretary General Kofi
industry's hugely profitable anti-AIDS
Annan late last year at a dinner party.
medicines.
and the U.N. official urged him to do
Now, Bristol-Myers Squibb Co., maker
something for AIDS in Africa.
of three AIDS drugs, is trying another
Officials with the U.N.'s AIDS program.
approach. Today it is expected to an-
UNAIDS, have been pounding the doors of
nounce that it will spend $100 million in
U.S. and European drug companies for
five southern African nations over the next
several years. Led by a Lebanese-born.
five years to fund extensive research
Paris-trained physician named Joseph
trials, train more than 200 physicians and
Saba, UNAIDS staffers in early 1997 began
help nongovernmental organizations bol-
urging AIDS drug makers to join a pilot
ster community AIDS-prevention and
effort to get lower-priced medicines into
treatment programs. The program won't
four countries, including two in Africa:
include drug discounts or handouts.
Uganda and the Ivory Coast.
A Drop in the Bucket?
But while sympathetic to the problem.
the companies were uncomfortable with
The effort is designed to help provide
setting a precedent for a two-tier pricing
the sort of in-depth, long-term care and
system one for the West and one for poor
research that is common in the West.
nations. Their main concerns: that activ-
where the death toll from AIDS has
ists in Western nations would demand
plunged by two-thirds in recent years.
similar discounts, and that the low-priced
largely as a result of the widespread use of
medicines would find their way onto the
the new "cocktails" of AIDS medicines.
black market and end up in the U.S. and
No one, not even Bristol-Myers. with
Europe.
$18.3 billion in annual sales, believes
Moreover. Merck & Co. argued that
$100 million will come close to solving the
even if it halved the price of its big-selling
problem. even though the company calls
protease inhibitor Crixivan, which costs
the effort the largest AIDS grant ever by a
about $600 a month in the U.S., few Afri-
corporation. The infection rate in sub-Sa-
cans could afford it or use it properly
haran Africa is growing by 20% a year, and
because of a lack of the necessary medical
in South Africa alone the number of HIV-
infrastructure. Protease inhibitors are an
infected people has almost doubled to close
to four million in the past two years.
Please Turn to Page A8, Column I
Bristol-Myers Heeds Call to Bolster AIDS Warin A rica
F
Continued From First Page
counted its AIDS drugs by 33% to 46% under
essential ingredient in the multidrug cock-
The Spread of HIV in Africa
the pilot program. So when Mr. Annan, the
tail that must be taken several times a day,
U.N. secretary general, turned to Bristol-
without interruption, 10 be effective in re-
1987
1997
Myers's Mr. Heimbold and asked him to
ducing virus levels in the blood. Even in the
take drastic action against African AIDS,
U.S., many patients have difficulty adher-
top management had a fairly clear under-
Ing to the complex daily regimen. Merck's
standing of what was needed.
concern was that if patients in the pilot
That was underscored when Kenneth
countries went on and off the cocktails,
Weg, the company's vice chairman, and
they would develop drug-resistant strains
several other managers visited Botswana,
of the virus that could spread throughout
Africa, and even imperil countries else-
Swaziland and South Africa over the win-
where, including the U.S.
ter, accompanied by former Congressman
But from the perspective of UNAIDS's
Estimated
Ron Dellums, a consultant and frequent
Dr. Saba, a courtly man who gave up a lu-
percentage of adults
go-between for American companies and
crative practice to work on HIV-vaccine de-
Infected with HIV
African governments.
velopment in Rwanda, il appeared that the
"You can't help but become involved
16%-32%
world drug industry was principally can
when you go out and see people," says the
FRANCE SOCIAL US
cerned about protecting huge AIDS drug
8%-16%
normally strait-laced Mr. Weg. 60, who,
profits in the U.S.and Europe.
0.5%-8.0%
during an interview in his plush Manhat-
For months, he and Brian Elliot, a gre-
tan office, becomes emotional when de-
Unavailable
garious Irish consultant to UNAIDS,
scribing his encounters with HIV-infected
Source: UNAIOS
women and children in Africa. At one hos-
pitched their plan to company after com-
pany. Their proposal called on the compa-
Creating a Marketplace
pital, he says quietly, he was introduced to
nies to put up just $25,000 in each pilot
it had to do something. "When we look
a mother and her four-year-old child, both
Beyond price, it was becoming clear to
country to help fund an independent body
back in 20 years or so, 1 wanted us to be
infected, and on the spot decided to pay for
UNAIDS that much more than cheap drugs
that would buy AIDS drugs at steep dis-
seen as on the side of those who tried, who
their future medical care.
was needed. Mr. Elliot, who formerly ran a
counts and closely monitor their adminis-
tried to do something, even in the face of
Provided with data by UNAIDS, includ-
Johnson & Johnson unit's drug-marketing
tration to avoid misuse and theft.
insurmountable odds," Mr. Young says.
ing a map illustrating the disease's rapid
operations in Africa in the early 1990s, had
Critics in Africa were quick to point out
incursion, Mr. Weg and others at Bristol-
Deep Cut
come to realize that a pharmaceuticals
that Glaxo Wellcome's patent on AZT was
Myers say they were stunned by the mag-
The unlikely duo was largely met with
marketplace needed to be created. In this
about to expire, and said that the company
nitude of the problem. "OI the 2.9 million
skepticism, with one exception: Peter
forum, drug makers would compete with
Young, a top executive based at Glaxo
was merely motivated by a desire to sus-
children who have died due to AIDS, 2.5
202 944 6257
each other for patients, help train doctors
Wellcome PLC's North Carolina opera-
tain sales. In Uganda, Peter Mugenyi, an
million of them live in sub-Saharan
and support clinics and hospitals-much as
eminent AIDS physician and researcher,
Africa," he says. In addition, up 10 40% of
tions, whose AZT Is a mainstay in treating
occurs in the U.S. and in Europe.
says, "I'm glad Glaxo cut its price, but if
women in Swaziland and one-third of their
AIDS. Mr. Young was the first drug-indus-
Even Dr. Saba had to be convinced of
try official to agree to slash prices, last
they didn't, we would have gone else-
children are also infected. In South Africa,
this necessity, however. One January
where" for AZT-namely to generic-drug
there are 200,000 children orphaned by the
June cutting AZT's monthly cost to pa-
night at an Italian restaurant in Chicago,
makers.
disease.
tients in Uganda and the Ivory Coast by
where they were attending an AIDS confer-
Pharmaceuticals executives say
The Bristol executives weren't always
more than two-thirds to about $60 a month.
ence and lobbying drug makers, tempers
Glaxo's willingness to slash AZT prices in
warmly embraced in southern Africa-es-
The company also is providing short-term
flared. The normally even-keeled Dr. Saba
Africa forced several other reluctant AIDS-
pecially in South Africa. In one instance,
AZT dosages free to pregnant women to
raised his voice in frustration and said he
the South Africans bristled at the com-
19:51
block the transmission of the virus to their
drug makers, including Bristol-Myers and
was certain the drug companies would re-
Roche Holding Ltd.'s Hoffmann-La Roche
pany's suggestion to train African physi-
newborns.
duce their prices even more, "because it's
Mr. Young understood that this wasn't
unit to join the UNAIDS pilot project.
cians in the U.S., under a fellowship pro-
right." Mr. Elliot countered sharply,
However, since the project's start last
gram run by Baylor College of Medicine in
a solution, but he says Glaxo Wellcome felt
"Joseph, the drug makers are run by busi-
summer, only 650 of the two million in-
Houston, rather than in Africa; it. also did-
nessmen, and they respond to the market
fected Ugandans have been able to afford
n't seem to make sense to teach doctors
05/09/90
and to profits. Our job is to show them it's
the discounted drug cocktail. Even at $200
how to use drug regimens, methods and
in their interest to lower prices and help
to $400 a month for the cocktail, it wasn't
equipment that wouldn't be available in
build a medical infrastructure in Africa."
affordable for most AIDS patients in
South Africa. William Malegapuru
Mr. Elliot had been hammering away at
Uganda. where there is virtually no health
Magkoba, director of the Medical Research
this theme in dozens of meetings with
insurance and the cash-starved govern-
Council in South Africa, says he and other
drug-company executives, including sev-
ment doesn't pay for drugs.
black South Africans, given the recent his-
eral at Bristol-Myers, which had dis-
003/003
05/06/99
19:53
20202 944 6257
FRANCE SOCIAL US
tory of apartheid, are sensitive about being
dictated to by white Westerners. In the
end, the two sides reached a compromise:
50 South African doctors will be trained in
"What Bristol is doing is sure to be seen
Texas, 50 in Africa.
as a mix of good citizenship and commer-
cial interest," says UNAIDS's Mr. Elliot.
Naive Approach
"It can't help but be seen that way."
Bristol-Myers staffers also concede
Allen Herman, dean of the National
they were "embarrassingly" naive about
School of Public Health at the Pretoria-
what could be accomplished. "We thought
based Medical University of Southern
there'd be easy answers once we got in-
Africa, readily acknowledges that Bristol-
volved," says Mark Ahn, the company's
Myers's effort is only a tiny plece of what's
project leader, who hadn't been to Africa
needed. But, paraphrasing an African
until a weeks-long fact-finding trip in early
proverb, he says, "How do you eat an ele-
February.
phant? One bite at a time." Then he adds,
"Our assumption was that what people
"What Bristol is doing is only a bite, but
needed most were drugs; maybe we could
it's a big bite."
make a large drug donation," Mr. Ahn
says. That was before he dropped in on a
support group in Soweto for 11 HIV-in-
fected mothers. The women, who survived
by making. peanut butter, told him they
would probably best be helped with funds
to pay for more equipment rather than
drugs. "These women were primarily wor-
ried about how they were going to support
themselves today and tomorrow, not about
whether they would be alive in five or 10
vears." he says.
A large chunk of Bristol-Myers's money
will go to train community workers in pub-
lic health, and to provide existing pro-
grams like the African Red Cross "with the
ability to greatly expand what they are al-
ready trying to do. such as caring for the
orphans," Mr. Ahn says.
He adds that in recent weeks, there was
a "raucous" debate inside the company
over exactly how much to spend, especially
since the funds will come off Bristol-My-
ers's bottom line. (The company says the
tax deductible grant could reduce earnings
by a bit less than one cent a share in each
of the five years.) Only last week, Messrs.
Heimbold and Weg decided on the $100 mil-
lion figure, topping lesser amounts pro-
posed by Mr. Ahn and others.
Patent Threat
Although Bristol-Myers says there isn't
any connection between its effort and re-
cent drug-licensing moves in Africa, some
observers tie the two together. Last year,
South Africa pässed a law saying it. will li-
cense local manufacturers to make the
anti-AIDS medicines unless big drug com-
panies voluntarily reduce prices. This so
upset the U.S. pharmaceuticals industry
that it lobbied Congress to place a rider in
a foreign appropriations bill to temporarily
cut off foreign aid to South Africa: That
threat postponed the South African action.
Nonetheless, later this month in
Geneva, the World Health Assembly of
health ministers will vote at its annual
meeting on a proposal to open access to the
medicines through so-called compulsory li-
censing that would encourage poorer na-
tions to pass laws similar to the one in
South Africa.
FYI
Richard Socarides 08/02/99 09:01:46 AM
Record Type:
Record
To:
See the distribution list at the bottom of this message
CC:
Subject: NC10751: Gates to give away fortune
Forwarded by Richard Socarides/WHO/EOP on 08/02/99 09:01 AM
[email protected]
08/02/99 03:40:00 AM
Record Type:
Record
To:
Richard Socarides@EOP
CC:
Subject: NC10751: Gates to give away fortune
This item is copyrighted. Do not print it without permission from the
originating media operation. Do not post this item in a public online
forum. Items on this mailing list that are not copyrighted will not
contain this message. This free mailing list is open only to people with
whom I am acquainted. It has 242 recipients.
LONDON, Aug. 1 (UPI) -- Bill Gates, the richest man in the world,
plans to give away his $100 billion fortune, his father told the Sunday
Times of London.
In an interview published today, William Gates Sr. said that after
leaving more than $20 million to his son, the founder of Microsoft will
give the rest of his money to the William H. Gates Foundation to wipe
out deadly diseases such as AIDS and malaria.
The 73-year-old father of Gates said that in the next three months,
the foundation will announce a number of newly funded programs that will
go a long way toward its ultimate aim of becoming the world's largest
private charity.
Bill Gates Jr. lives with his wife and child in a mansion on the
shores of Lake Washington near Seattle. Gates and his wife Melinda have
previously funded a family charity that currently has $10 billion in its
coffers and ranks fifth in the league of the world's philanthropic
foundations.
William Gates Sr., who runs the family foundation, said one of his
son's favorite books is Andrew Carnegie's `The Gospel of Wealth," in
which the philanthropist wrote, "The man who dies rich dies in
disgrace."
Gates Sr. said his 43-year-old son and daughter-in-law have been
worried about world health since their visits to South Africa and India
in the mid-1990s.
Gates Sr., 73, said the couple found themselves increasingly
concerned about the effects of disease and poverty in developing
countries. "Bill and Melinda believe that one's success is not some
sort of God-given thing," he said.
In May, the Gates Foundation donated more than $20 million to the
International AIDS Vaccine Initiative, a group based in New York that
invests money in a number of research teams looking to cure Acquired
Immune Deficiency Syndrome.
Some have criticized Gates Jr. for making relatively small donations
to charity and has been especially scorned for making donations of
Microsoft-based computers to libraries.
Gates Sr. said: "My son is going to have critics all his life
because of his wealth. But I'm optimistic now that we have put to rest
any criticism on the basis of his not being sufficiently generous. We've
pretty much drowned that out."
Message Sent To:
Bruce N. Reed/OPD/EOP@EOP
Thomas L. Freedman/OPD/EOP@EOP
Maureen T. Shea/WHO/EOP@EOP
Sandra Thurman/OPD/EOP@EOP
Katharine Button/WHO/EOP@EOP
Global HIV/AIDS Epidemic. JAMA. 1999;281:1479] (c) ht/9w.ama-assn.org/sci-pubs/jo.ost/recent/issues/jama/jsg91001.htm
Journal:
JAMA
The Journal of the American Medical Association
Medical News & Perspectives - April 28, 1999
From the Surgeon General
The Global HIV/AIDS Epidemic
An enormous human tragedy is unfolding in many
less-developed countries because of the spread of
HIV/AIDS. Of the 33.4 million HIV-infected people
around the world, there are an estimated 22.5 million in
sub-Saharan Africa, 6.7 million in South and Southeast
Asia, 1.4 million in Latin America, and 665,000 in the
United States. Globally, more than 14 million people
have died of the disease, including 2.5 million last year.
In many southern African countries, HIV/AIDS has
become an unprecedented emergency, with 20% to 26%
of people between the ages of 15 and 49 infected. In
Botswana, Kenya, Malawi, Mozambique, Namibia,
Rwanda, South Africa, Zambia, and Zimbabwe,
HIV/AIDS will reduce life expectancy from 64 to 47
years by 2015. The progress of decades of work
immunizing children, controlling diseases, and improving
nutrition is being negated by HIV/AIDS.
Conditions in many parts of the world promote rapid
spread of the HIV/AIDS epidemic. For example, India,
with a population approaching 1 billion, has estimated
that 3 million to 5 million of its people are infected, and
the number of new infections will double every 14
months.
Social and political issues surrounding sex, injecting drug
use, and blood transfusion in many countries have created
special circumstances in which the disease has been able
to spread unchecked. Some less-developed countries also
bear a burden of political and economic instability that
makes prevention even more difficult. It was only a few
years ago that epidemiologists offered projections of
disease prevalence for sub-Saharan Africa that were met
with disbelief. If the present warnings go unheeded,
South Asia, Southeast Asia, and, perhaps, China will
follow the disastrous course of sub-Saharan Africa.
More than a decade of experience has taught us how to
control HIV/AIDS-we know what works. Many
developed countries have successfully checked the spread
of the epidemic. While development of therapy and a
vaccine continue, prevention must be emphasized. The
basic elements of prevention include education, behavior
change, voluntary testing and counseling, prevention of
perinatal transmission, and political commitment. Each
country must find the mix of methods appropriate to its
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particular conditions.
Education about HIV/AIDS is necessary but alone does
not change the behavior of populations. Promotion of
voluntary testing and counseling must complement
education. Testing and counseling break the deadly
silence around HIV/AIDS and empower individuals to
make informed decisions and change behaviors. Breaking
the silence also will begin to diffuse the stigma
surrounding the disease. We have seen success with
behavioral change in Uganda and Thailand, the only two
less-developed countries with extensive capacity for
voluntary testing and counseling.
It is known that perinatal transmission of HIV can be
reduced by more than 50% by using antiretroviral
therapy; however, problems with access to these drugs
limit their use in some countries. Transmission of HIV
through breast-feeding and poor survival of orphans make
the avoidance of disease via treatment for perinatal
transmission more complex. We continue to work with
international organizations, other governments, and
pharmaceutical companies to lower costs and expand
access to antiretroviral drugs. Current treatment for
perinatal transmission (as well as use of antiretrovirals in
general) in less-developed countries is also limited by the
fact that very few people have been tested for HIV
infection.
Treatment of other sexually transmitted diseases (STDs)
is important to control the spread of HIV. One of the
reasons HIV has spread so rapidly in Africa is that so
many STDs go untreated. Untreated STDs break down
natural barriers that prevent transmission. Access to even
basic treatment for STDs remains a problem for many
less-developed countries.
Perhaps most important in the global battle against
HIV/AIDS is political commitment. Leaders at the
national, provincial, and local levels of government must
speak out about HIV/AIDS and encourage businesses and
nongovernmental organizations to commit to work
against the disease. I was encouraged by US Vice
President Al Gore and Deputy President Thabo Mbeki of
South Africa, who put the HIV/AIDS threat at the top of
the international agenda at the recent meeting of the
United States-South Africa Joint Commission. They set
an important example for leaders in developed and
less-developed countries.
American medicine and public health have an important
role to play in the global battle against HIV/AIDS by
supporting international organizations such as the Joint
United Nations Program on HIV/AIDS, the World Health
Organization, and the World Bank.
HIV/AIDS can be likened to the plague that decimated
the population of Europe in the 14th century. While the
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modern epidemic affects people of all age groups, those
of working age are at highest risk, posing potentially dire
economic, social, and political consequences for the
global community. Unfortunately, the world continues to
devote greater attention and resources to traditional
national security issues such as wars, postponing notice
of an epidemic that, if left to spread unchecked, will kill
more people than any of the terrible conflagrations that
have so marked this century.
-David Satcher, MD
Surgeon General of the United States and Assistant
Secretary,
Department of Health and Human Services
(JAMA. 1999;281:1479)
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3 of 3
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HIV/AIDS Leadership Meeting
The White House
September 7, 1999 - 10:30 a.m.
Overview and scope of the problem
Brief outline of the Administration's new Global AIDS Initiative
Increasing U.S. Government investment
- Prevention
- Care and treatment
- Infrastructure/capacity development
- Care of orphans
Building partnerships
Open discussion by key stakeholders
Sectors
Topics
- Enhancing and coordinating AIDS efforts
- Incorporating AIDS into existing portfolios (AIDS as a development
issue; AIDS as a business issue; AIDS as an international finance issue)
- Innovative approaches and partnerships
Next steps
August 4, 1999
Mr. John M. Doe
Address Line 1
Address Line 2
City, State 20001-Zip
Dear John:
I am pleased to invite you to the White House on
September 7, 1999, to join me and a small group of senior
representatives from the United States government,
multinational institutions, foundations and the corporate
sector for a meeting to explore strategies to better address
the international AIDS crisis.
This devastating epidemic is an assault on health and
development that has few, if any, modern equals. Only 20 years
ago we did not know that HIV existed. At the beginning of
this decade, who among us would have thought that by 1999 AIDS
would be the leading cause of death in sub-Saharan Africa and
the fourth leading cause of death worldwide?
In the face of this reality, the President has recently
asked for a $100 million increase in funding for international
HIV/AIDS programs as the cornerstone of a broad and
comprehensive new international initiative to combat the
epidemic. This is just a part of the international effort
necessary to control the spread of HIV and to deal with the
associated problems of patient care.
Today 34 million people worldwide are living with HIV or
AIDS. AIDS related diseases have killed 14 million men, women
and children--mostly in Africa where more than 5,000 deaths
are reported each day. By 2010, 40 million children will have
been orphaned by HIV/AIDS. Economic development in many
African countries has come to a stop and the hard won social
and health advances of the last 20 years are being reversed by
the new realities of the epidemic. These statistics do not
begin to describe the personal tragedy for many of those
living with HIV/AIDS and their families.
Still there is cause for hope. Throughout the world,
heads-of-state are increasingly acknowledging AIDS prevention
as a public health and political priority. National HIV/AIDS
control strategies have been written, and Uganda and Thailand
have shown that successful national AIDS prevention programs
can work. Unfortunately, a serious crisis remains and much
more needs to be done. Many developing countries, overwhelmed
by human and financial costs, are losing the battle with the
epidemic.
I am asking you to join me to help build the momentum
necessary to engage all stakeholders in winning the war
against HIV/AIDS. Although financial support for AIDS
prevention efforts remains the most critical unmet need, this
meeting is not intended to be a donors conference. Rather, we
will discuss strategies and identify priorities and new
partnerships for assisting countries in their HIV/AIDS control
efforts.
We will meet at the White House on Tuesday, September
7th. Please plan to arrive at the East Appointments Gate no
later than 10:00am. To confirm your participation, please
call Katy Button in my office at (202) 456-6266. I look
forward to seeing you on September 7th.
Sincerely yours,
Hillary Rodham Clinton
V.
Background Information
1-
AIDS in Africa is a Serious Crisis
2-
Press Release on Administration Initiative
3-
Backgrounder on Administration Initiative
4-
Wolfensohn Letter to the President
5-
USTR Paper in Intellectual Property Rights
6-
"Helping the Poorest" - The Economist Editorial
7-
Statement and Fact Sheet on Cologne Debt Relief Agreement
8-
"Helping the Poorest" - The Economist, Jeffrey Sachs article
9-
"Balms for the Poor" - The Economist
10- "Orphans of the Virus" - The Economist
11- "Drugs for AIDS in Africa" - New York Times Editorial
12- "Facing a Global AIDS Crisis" - The Washington Post
13- "A Global Disaster" - The Economist
14- "In Africa, a Deadly Silence About AIDS is Lifting" - New
York Times
15- HIV/AIDS Prevalence Rates for Sub Saharan Africa
AIDS in Africa is a Serious Crisis
But Opportunities Exist for Helping to Save Millions of Lives
AIDS in sub-Saharan Africa is shattering families and communities.
In many countries in southern Africa, between 16% (South Africa) and 26% (Zimbabwe) of the
adult population (15 to 49) is already HIV+.
UNAIDS has declared HIV/AIDS in Africa "the worst infectious disease catastrophe since the
bubonic plague." In sub-Saharan Africa, each and every day more than 11,000 additional
people become HIV+. In South Africa alone, at least 1,500 people a day become HIV+, 1,000
of whom are under the age of 20.
83% of all AIDS deaths to date, nearly 12 million people, have been in sub-Saharan Africa.
There are over 5,500 AIDS related funerals a day in Africa. That number will rise to 13,000 a
day by 2005.
By 2010, more than 40 million children worldwide will be orphaned by AIDS; 95% in sub-
Saharan Africa.
AIDS is wiping out decades of progress on a host of development objectives in sub-
Saharan Africa.
According to US Census Bureau, AIDS has already reduced life expectancy Zimbabwe from
65 to 39 years, in Uganda from 54 to 43 years, and in Zambia from 56 to 37years. In the next
few years, AIDS will reduce life expectancy in South Africa by a third, from 60 to 40 years.
In the coming decade, AIDS will double infant mortality (infants under the age of 1) in many
sub-Saharan Africa countries and triple child mortality (children ages 1 to 5).
AIDS is not only causing unfathomable human suffering it is jeopardizing the
economies, the stability, and civil society of many sub-Saharan African nations.
AIDS is a trade and investment issue. At the recent meeting with African trade and finance
ministers, Professor Jeffrey Sachs, director of the Harvard Institute for International
Development, stated that, "a frontal attack on AIDS in Africa may now be the single most
important strategy for economic development."
According to The Economist, a recent study in Namibia estimated that AIDS cost the country
almost 8% of GNP in 1996. Another analysis predicts that Kenya's GNP will be 14.5%
smaller in 2005 than it would have been without AIDS, and the per capita income will be 10%
lower.
A report released by the World Bank last week states: "The question is, will this pandemic
destroy the developing nations' hard earned economic gains or will governments get their act
together in time? Clearly time is running out."
AIDS has hit professionals hard in sub-Saharan Africa, particularly civil servants, engineers,
teachers, miners, and military personnel. According to one study in Kigali, Rwanda, 34% of
people with post-secondary education were HIV positive, compared to 18% of those with
primary education, and civil servants were more than three times more likely to be HIV
positive than farmers. Increased benefits and training costs, and disruption due to sick and
bereavement leave are seriously affecting both the private and public sectors. Companies like
British Petroleum and Barclay Bank told us that they are now hiring two employees for every one
skilled job, assuming that one will die of AIDS.
AIDS is a security issue. According to the Economist, "the estimated HIV prevalence in the
seven armies embroiled in the Congo range from 50% for the Angolans to 80% in
Zimbabweans". Recent reports confirm that 40% of the South African military is already HIV
positive. US military officials have raised this as a serious stability concern.
A South African anti-crime institute has linked the growing number of children orphaned by
AIDS to future increases in crime and civil unrest. Without appropriate intervention, many of
the 2 million children projected to be orphaned by AIDS in South Africa will raise themselves
on the streets, often turning to crime, drugs, commercial sex, and gangs for survival. This not
only effects social stability but also dramatically increases their risk of HIV.
Determined leadership and partnerships have made, and are continuing to make, an
extraordinary difference, saving millions of lives.
Uganda has been the world leader in demonstrating that even a country with limited resources
and low levels of literacy could turn the tide on a burgeoning epidemic. President Museveni
demonstrated bold leadership early on, making every government ministry take the problem
seriously, and develop and implement its own plan for reducing stigma and transmission, and
caring for those who become sick.
Uganda has created an enabling environment for donors, such as the US, to be active partners
in the battle against AIDS. The US has invested $46 million in HIV prevention and care in
Uganda (26% of all donor AIDS funding), and as a result, HIV rates have been slashed by
more than half. Through stigma reduction, education, HIV counseling and testing, treatment
of STDs, and community based HIV care and support, Uganda has begun to turn the tide.
Countries such as Zambia, Malawi, Uganda, and Kenya have begun to develop initiatives to
respond to the growing number of children orphaned by AIDS. In the longstanding African
tradition, communities are finding creative ways to support the village in its efforts to raise its
children, but the growing number of orphaned children already overwhelms many of these
villages.
Through micro-finance programs like FINCA (Foundation for International Community
Assistance), women are receiving loans, starting small businesses, and with increased
household incomes, taking in children orphaned by AIDS. With support of non-governmental
organizations, communities are coming together to deal with school fees, nutritional
assistance, immunization and oral hydration, counseling, and the range of other needs that
arise for orphaned children. These efforts are low cost strategies designed to empower
women, protect children, and support extended families and communities in carrying for their
own. For a small fraction of the cost of one orphanage bed an entire community of vulnerable
children can receive care. The problem is that only a very small number of children receive
even this modest level of support.
JUL-13-1035 15.14
HIDS POLICY
P.02
THE WHITE HOUSE
Office of the Vice President
For Immediate Release
Contact:
Monday, July 19, 1999
(202) 456-7035
VICE PRESIDENT GORE ANNOUNCES ADMINISTRATION WILL SEEK $100 MILLION
INITIATIVE- A RECORD INCREASE- IN FUNDS TO FIGHT AIDS AROUND THE WORLD
Washington, DC - Vice President Al Gore today joined Archbishop Tutu, Director of the Office
of National AIDS Policy Sandra Thurman, Members of Congress, and leaders of the African-American,
religious, children's, and AIDS communities to announce that the Administration will seek the largest-
ever budget increase in the global battle against AIDS - a new investment of $100 million, The Vice
President also unveiled a new report from the Office of National AIDS Policy that assesses the AIDS
crisis in Africa and recommends this investment. In addition, the Vice President announced new efforts
to encourage other public and private entities across the world to address AIDS across the world.
"AIDS in Africa is the worst infectious disease catastrophe in the history of modern medicine,"
Vice President Gore said. "More than twenty million people are now infected and nearly 500 more
become infected each hour. We hope this initiative will not only provide much-needed relief but will
inspire decisive action by other countries and institutions - and bring hope to the millions of children and
families trapped in this horror." Today, the Vice President:
RELEASED A NEW REPORT ON THE PRESIDENTIAL MISSION ON CHILDREN
ORPHANED BY AIDS IN SUB-SAHARAN AFRICA. Last December, President Clinton directed the
Director of the Office of National AIDS Policy to go on a fact-finding mission to assess the problem of
HIV/AIDS in Africa. Today, the Vice President is releasing the report that includes new findings and a
plan of action resulting from this mission. The report finds that:
AIDS in sub-Saharan Africa is one of the largest health crises in the history of the world. In the
past decade, twelve million people in sub-Saharan Africa have died of AIDS -- one quarter of them
children -- and each day AIDS buries another 5,500 women and children. Over the next decade,
AIDS will kill more people in sub-Saharan Africa than the total number of casualties in all of the wars
of the 20th century combined. By 2005, the daily death toll will reach 13,000 people per day.
Millions of children will be orphaned by this epidemic. In some areas up to one-quarter of all children
already live with an HIV-positive parent. In the next decade, more than forty million children in sub-
Saharan Africa will lose a parent to HIV/AIDS.
This epidemic has a devastating impact on many aspects of life in sub-Saharan Africa. AIDS is
undermining much of the progress in development that has been made in Africa. AIDS is reducing
life expectancy by more than 20 years in some countries. Many children are dropping out of school to
care for dying parents undermining improvements in education, and AIDS will continue to have a.
major negative impact on the economy, hitting a range of professionals, from teachers to military to
business leaders and therefore undermine its current trade with other nations throughout the world.
UNVEILED NEW $100 MILLION INITIATIVE TO COMBAT HIV/AIDS ACROSS THE
GLOBE. The Vice President also unveiled a new initiative to double the existing efforts to prevent and
treat AIDS. This initiative will be targeted to Africa in addition to other parts of the world where this
epidemic is growing. It will help move forward on four critically important and interconnected fronts
including:
Containing the AIDS Pandemic. A new $48 million initiative will be used to implement a variety of
prevention and stigma reduction strategies including: HIV education; engagement of political,
religious and other leaders; voluntary counseling and testing; blood supply screening, and,
interventions to reduce mother-to-child transmission (MTCT). In addition, the Department of Defense
(DoD) will begin new efforts to work with African militaries to provide educational material and
training on AIDS prevention.
Providing Home and Community-Based Care. This $23 million investment will be used to deliver
counseling, support palliative and basic medical care including treatment for sexually transmitted
diseases, opportunistic infections, and tuberculosis (TB) through community-based clinics and home-
based care workers and enhance training and technical assistance efforts.
Caring for Children Orphaned by AIDS. This new $10 million initiative will be used to assist
families, extended families, and communities in caring for their children through nutrition, education,
health and counseling support, in coordination with micro-finance programs.
Strengthening Prevention and Treatment by Augmenting Planning, Infrastructure, and Capacity
Development. This $19 million initiative will help strengthen host country ability to plan and
implement effective interventions. It will also strengthen the capacity for effective partnerships
between local government and community-based organizations. Strengthen local surveillance
systems to track the spread of HIV infection, AIDS, and the effects of interventions to enable the best
targeting of HIV/AIDS prevention programs.
This United States Government investment would be provided through AID ($55 million), HHS ($35
million) and DOD ($10 million) and will be fully offset.
ENGAGING OTHER PARTNERS TO ADDRESS THIS CRISIS. Addressing the crisis of AIDS
worldwide will require a broad-based commitment from public and private partners across the globe, The
Vice President also unveiled a series of new initiatives to enhance efforts to address this problem
including:
Multi-lateral Partners Meeting to Enhance Coordination Around the World. On September 7,
1999, First Lady Hillary Rodham Clinton will convene a meeting of donors, The World Bank,
UNAIDS, international foundations, CEOs and others to discuss how we can best enhance and
coordinate our AIDS efforts in Africa and around the world.
A United Nations Conference on Children Orphaned by AIDS. The United Nations, in conjunction
with the National Black Leadership Commission on AIDS, The White House Office of National
AIDS Policy, The Magic Johnson Foundation and a variety of NGOs, will organize a conference on
World AIDS Day to focus attention on the growing number of children orphaned by AIDS
worldwide, with a special emphasis on sub-Saharan Africa.
New Partnerships with Private Sector Leaders to Address This Crisis, Such As the Religious,
Business and Labor Communities.
-- Given the impact of AIDS on businesses active in Africa as well as the overall economic-impact
on African countries, the White House will facilitate a meeting of business leaders to encourage
commitment and involvement in AIDS programs, such as workplace education, outreach to
communities, and increased funding support for AIDS efforts.
-- The White House will host a meeting of US and African labor leaders, co-chaired by the AFL-
CIO, to build on successes in working with the Council of South African Trade Unions to address
AIDS.
-- The White House will also facilitate a religious summit of African, American, and other religious
leaders to discuss the important role of communities of faith in the fight against AIDS. In Uganda and
Senegal it is very clear that the involvement of religious communities and leaders had a dramatic
impact on the ability of these two countries to reduce HIV prevalence or to maintain it at low levels
over time.
Joining Forces for LIFE:
Leadership and Investment in Fighting an Epidemic
A Global AIDS Initiative
I.
Increasing the US Government investment in the global battle
against AIDS to begin to reflect the magnitude of this rapidly
escalating pandemic.
Making a difference in Africa and in other highly impacted areas requires
broader political commitment, enhanced community mobilization, and,
most urgently, increased resources. In 1998, spending on AIDS in Africa
totaled only $165 million. Compared to the ever-escalating need and
other health programs, this amount is woefully inadequate. For example,
in 1998, over $500 million was spent for basic childhood immunization
programs in Africa. Based on our experience in those countries that are
starting to demonstrate success, such as Uganda and Senegal, UNAIDS
and donors now agree that a minimum of $600 million is needed in sub-
Saharan Africa per year for HIV prevention alone ($2 per adult per year).
While we acknowledge the leadership role that the US plays globally and
the urgent need to act, clearly an effort to combat AIDS must be driven by
many actors including host countries, multi-lateral organizations, and bi-
lateral donors, to be successful. In FY1999, the US Government spent
$74 million in USAID prevention and care in Africa and $38 million in HHS
research and surveillance/prevention. But more remains to be done in
sub-Saharan Africa and in other seriously affected parts of the world.
The Administration proposes to commit an additional $100 million in
FY2000 to the global battle against AIDS. This initiative will enable us to
move forward on four critically important and interconnected fronts
including:
Containing the AIDS Pandemic ($48 million) Implement a variety of
prevention and stigma reduction strategies, especially for women and youth,
including: HIV education, engagement of political, religious, and other leaders;
voluntary counseling and testing; interventions to reduce mother-to-child
transmission (MTCT); and enhance training and technical assistance efforts,
including Department of Defense efforts with African militaries.
Providing Home and Community-Based Care ($23 million) Deliver
counseling, support, palliative and basic medical care including treatment for
sexually transmitted diseases, opportunistic infections (Ols), and tuberculosis
(TB) through community-based clinics and home-based care workers.
Enhance training and technical assistance efforts.
Caring for Children Orphaned by AIDS ($10 million) Assist families,
extended families, and communities in caring for their children through
nutritional assistance, education, training, health, and counseling support, in
coordination with micro-finance programs.
Strengthening Prevention and Treatment by Augmenting Planning,
Infrastructure, and Capacity Development ($19 million) Strengthen host
country ability to plan and implement effective interventions. Strengthen the
capacity for effective partnerships and the ability of community based
organizations to deliver essential services. Strengthen surveillance systems to
track the epidemic and target HIV/AIDS programs.
This US Government assistance would be provided through AID ($55 million),
HHS ($35 million), and DoD ($10 million). The focus of this funding is HIV
prevention, and AIDS care and treatment. In those areas, this initiative
represents nearly a doubling of funding in Africa from current levels ($81 million
in FY99, which excludes research). The Administration recognizes the fight
against AIDS must be sustained to keep pace with this burgeoning epidemic, and
is committed to a multi-year effort in this critical area.
II.
Building partnerships with other key stakeholders to maximize our
impact on the rapidly expanding pandemic.
Increasing US investment in the global battle against AIDS is critical, but is
not sufficient to achieve the outcomes needed. The commitment of in-
country political leaders and of various segments of civil society are key to
success. Moreover, resources provided by the US Government need to
help leverage, and to be coordinated with, those of other donors, the
private sector, and national governments to ensure synergy and to
maximize impact. Building partnerships with key stakeholders in support
of effective action at the community level is our greatest hope for
progress.
This initiative will pursue a variety of strategic opportunities for
challenging other partners to join in an enhanced effort, including:
Leadership Meeting On September 7, 1999, First Lady Hillary Rodham
Clinton will convene a meeting of key US officials, The World Bank, UNAIDS,
as well as heads of foundations, corporate CEOs, and others to discuss how
best to enhance AIDS prevention and treatment efforts in Africa and around
the world. The meeting will focus not only on leveraging additional resources,
but also on establishing priorities, identifying effective public/private
partnerships, and identifying targets for action to combat the crisis of
HIV/AIDS.
African Leaders Summit We propose hosting a high-level meeting with
Africa government and community leaders within the next ten months. This
meeting will highlight the critical role of leadership in arresting the epidemic
and will work to encourage increased leadership efforts. Topics will include the
economic impact of HIV/AIDS, examination of models of success in reducing
the transmission of HIV, and addressing the need for increased investment in
health programs. Additional topics will include AIDS care and treatment and
support for children orphaned by AIDS.
UN Conference on Children Orphaned by AIDS On December 1, 1999
(World AIDS Day), the United Nations in conjunction with the National Black
Leadership Commission on AIDS, The White House Office of National AIDS
Policy, The Magic Johnson Foundation and a variety of NGOs, will organize a
conference to focus attention on the growing number of children orphaned by
AIDS worldwide. Special emphasis will be placed on assessing the needs of
orphaned children in sub-Saharan Africa and the Americas. Participants will
include noted experts on the priority issues identified by UNAIDS, UNICEF,
and other UN agencies.
Business The Department of Commerce will facilitate a meeting of business
leaders active in Africa to encourage them to increase their efforts to rise to
the AIDS challenge. Given the impact that AIDS is having on businesses as
well as the overall economic-impact on African countries, such a meeting will
seek enhanced business commitment and involvement in AIDS programs.
The Commerce Department will work with American Chambers of Commerce
abroad and other business organizations to publicize the successful AIDS
efforts of US firms in Africa and to support others taking similar action. In
addition, the Department will direct work to promote closer coordination in
Africa between Commercial Service Offices, other USG agencies, the
business community, and African NGOs in a united effort to promote corporate
partnership in AIDS programs.
Labor The Secretary of Labor will facilitate a meeting of US and African labor
leaders, and will be co-chaired by the AFL-CIO. The success of the AFL-CIO
and its Solidarity Center in South Africa (supported by USAID) in working with
the South African Trade Union Federations to include AIDS as a key labor
outreach and policy issue provides a model for similar action elsewhere.
Outcomes include assisting labor organizations in educating their members
and securing commitments to develop workplace-based AIDS education and
prevention programs, including outreach to youth.
Religious Leaders Summit The US government will facilitate a meeting of
African, American, and other religious leaders to discuss the important role of
communities of faith in the fight against AIDS. In Uganda and Senegal, the
involvement of religious communities and leaders had a dramatic impact on
the ability of these two countries to reduce HIV incidence and to maintain it at
low levels over time. The outcome of such a meeting would be to increase
attention to the need for involving religious communities, to mobilize these
organizations and leaders in the fight against AIDS, and to identify ways to
support their efforts.
Diplomatic Initiatives The Department of State, NSC, and ONAP will work
with US and African ambassadors to increase attention to AIDS within the
diplomatic community. The NSC, the Department of State, and USAID will
work with G-8 and other donors, and challenge them to match the increased
investment put forward in this initiative.
"Joining Forces for LIFE: Leadership and Investment in Fighting an Epidemic" is an excerpt from Report
on the Presidential Mission on Children Orphaned by AIDS in sub-Saharan Africa: Findings and Plan of
Action, The White House, June 19, 1999.
AIDS Initiative: Qs & As
For Internal Use Only
&
Is this initiative a response to the recent problems facing the Vice
President on international patents in South Africa?
A:
No. The President, the Vice President and others throughout this Administration
recognize the critical nature of this pandemic and is committed to helping the
African people combat AIDS. This effort began on December 1, 1998 (World
AIDS Day) when the President and Vice President focused attention on this
issue and directed AIDS czar Sandy Thurman to lead a fact finding mission to
sub-Saharan Africa and report back with recommendations. Today we are
releasing a report from Director Thurman and moving forward on the Plan of
Action.
The Vice President has worked with President Mbeki and other African leaders
to address the crisis of AIDS and worked with Director Thurman and others to
assure that the Administration responded to the recommendations of Director
Thurman's report. The Vice President looks forward to continuing to work to find
ways to address this problem.
&
How is the budget amendment being paid for?
A:
This new proposed investment of $100 million is fully paid for. The Office of
Management and Budget worked with many agencies to come up with a series
of reasonable offsets, such as areas where appropriated funds are in excess of
what is needed. These include:
$40 million comes from unspent activities at the Department of Justice for
enforcement activities against unlawful diversion of prescription drug
medications.
$30 million in unobligated balances from the National Institutes of Health
Buildings and Facilities still available because they were not spent last year.
$10 million in balances from the Agency for International Development
Sustainable Development Assistance Account in appropriated funds. (IF
PRESSED: Typically, in the course of a given year, due to changing conditions,
a small portion of AID funding is available to be shifted from one program to
another. This year, there will be a shift toward prevention and treatment in
Africa.)
$10 million comes from a small percentage of unobligated commodity funding in
the International Assistance Programs.
$10 million from the Department of Defense from sales of excess raw minerals.
&
Are any of these funds being taken from existing AIDS programs, Africa
programs, or programs to support orphans?
A:
None of the funds are being shifted away from AIDS, Africa or programs which
provide support to orphans. These funds are additional to what is currently being
spent on both AIDS and Africa.
Ö
Does this initiative really double funding for prevention and treatment in
Africa?
A.
The United States Government currently spends $81 million in prevention and
treatment in Africa. This new $100 million proposed for FY2000 represents a
more than doubling of our investments in this area. We also are hopeful that this
level of commitment will encourage other nations to step up their efforts. We
need many nations and private sector commitments to address a problem of this
magnitude.
Q:
How much of the $100 million goes towards prevention? towards treatment?
A: $48 million will primarily go towards prevention and $23 million for treatment of sexually
transmitted diseases and opportunistic infections. Of the remaining dollars, $10 million
will provide care for children orphaned by AIDS and $19 million will strengthen
prevention and treatment by augmenting planning, infrastructure, disease surveillance and
capacity development.
Q:
How will you determine which countries receive funding?
A: Countries will be chosen based on a combination of factors. The most important factor is the
receptivity of host countries to partnering. Other factors to be considered include the adult
HIV prevalence rates, the potential for impact, the rate of increase in HIV, the status of
ongoing programs, the political commitment of governments and the opportunity for
innovation. Some of the countries which are currently under consideration are: South
Africa, Nigeria, Kenya, Uganda, Mozambique, Zimbabwe, Senegal, Malawi, Zambia,
Rwanda, Cambodia, and India. In addition, two regional programs (West/Southern
Africa Programs) may be necessary to target migrant workers, and other trans-border
issues.
Q:
How will the US Government accomplish the goals described with only $100 million
in FY2000?
A: The goals are part of a larger strategy to battle AIDS outside the U.S., primarily in Sub-
Saharan Africa. Our initiative seeks to link the US comparative advantage in assisting developing
countries battle AIDS with that of other bilateral and multilateral donors, as well as on the host
countries themselves. The battle against AIDS can not be won by the US alone or in one year.
Although US leadership is a critical component of the effort, there must be a substantial effort on
the part of other donors and the African nations themselves. The goals of the initiative,
developed in coordination with UNAIDS, are part of a five year strategy. The global effort of all
parties must be sustained over time to address this urgent problem.
&
Has funding been allocated for FY2001?
A:
It is clear that the difficult battle against AIDS will require sustained attention
from the US government, other bilateral and multilateral donors and especially
from the African nations themselves for many years. Our goals, which are
coordinated with the UNAIDS program goals, are five year goals. We are
committed to working towards reaching these important goals.
(IF PRESSED:) Today we are making a commitment for $100 million in the
global battle against AIDS. We have not made any funding commitments
beyond this. However, recognizing the extreme need, we anticipate future
funding commitments will be part of our sustained effort.
1999-SE-005934
(TUE) 6.
(COPY)
NO. 4260895443 P
1
the World Bank
Washington, D.C. 20433
U.S.A.
JAMES D. WOLFENSOHN
President
May 27, 1999
The Honorable
William J. Clinton
The President
United States of America
The White House
1600 Pennsylvania Avenue
Washington, D.C. 20500
Dear Mr. President:
The AIDS epidemic is reversing decades of progress in improving the quality of
life in developing countries. More than 33 million men, women, and children are
infected with HIV worldwide, and more than 90 percent of those infected live in
developing countries-two-thirds in Sub-Saharan Africa. In the hardest-hit African
countries, life expectancy is now 10-20 years shorter than it would have been without
AIDS. Meanwhile 16,000 more people worldwide become infected each day.
AIDS has therefore become a core development issue, and confronting the AIDS
epidemic in developing countries has become critical to all our efforts for poverty
reduction, growth, and improved quality of life. I welcome the strong concern G8 leaders
have shown at past meetings, but I believe we now have to move together to a new level
of action, on three fronts:
First, we must reinforce political commitment and active leadership in preventing
HIV/AIDS. There is no cure for AIDS and no vaccine, but there are educational and
behavioral interventions that work now to curb its spread. Half of the population of
developing countries-3.5 billion people-live in countries or areas where there is still
time to prevent an epidemic. Top-level, visible political leadership can make a critical
difference in bringing AIDS to the top of the social and political agenda.
Second, we must urgently find low-cost, effective therapies that are within the
reach of developing countries-for example to prevent mother-child transmission and to
fight AIDS-related infections like TB-and strengthen health systems to deal with the
increased demand for health care. This is particularly acute in Sub-Saharan Africa, where
the largest number of AIDS patients live, health systems are weak, and the ability to pay
is very low.
FROM WORLD BANK FRMRP 202 522 2515
(TUE) 6. 1'99 :14/ST. 12:13/NO. 4260895443 P 2
-2-
Third, we need to recognize that there is an emerging set of global health issues
for which we need new approaches and instruments: accelerating the development of an
HIV/AIDS vaccine that is affordable and effective in developing countries is a crucial
instance. An AIDS vaccine for low-income countries is an international public good
which is not likely to happen without innovative international public action. Private
industry must play the critical role in developing and marketing a vaccine, but the private
sector currently does not have the incentives to develop an AIDS vaccine for the strains
of the virus and the health system capabilities of developing countries. There is growing
consensus on the need for global partnership to ensure that AIDS vaccine development
will move swiftly-but it will take a number of years, and much longer unless we act
now.
The Bank is already hard at work on this through a special task force charged with
developing new partnerships and financing instruments which bring the private and
public sectors worldwide together to speed the advent of an AIDS vaccine. In this, we
are working closely with UNAIDS, WHO, the International AIDS Vaccine Initiative, and
other international partners. And we are starting a major program to push much greater
deployment of existing vaccines, which will be good for poor people's health now, and
will also encourage industry to bring new vaccines onstream.
The World Bank has lent more than US$765 million since 1986 to help developing
countries deal with the AIDS epidemic, and in recent years has been lending about $1.6
billion annually for programs to strengthen health systems. But this is not enough. We
are developing a new initiative of intensified action against AIDS in Africa, and I am
determined that we will dramatically increase our response to this global epidemic. On
all these fronts, we will work closely with our partner institutions of the UNAIDS
coalition.
It is time to take collective action on the G8 communiqués from Denver and
Birmingham to spur the development of an AIDS vaccine, and perhaps to link this effort
to other global health challenges, such as the need for new therapies and a vaccine for
malaria. The international community, including the developing countries, urgently
needs to elaborate a global strategy for advancing this effort, an understanding of what
different actors are already doing, and where there are gaps that need to be filled. The
World Bank is ready to play its part in bringing it to fruition.
We will warmly welcome your support and ideas, and your commitment to urgent
international action.
in with
Sincerely yours,
/in
James D. Wolfensohn
cc:
Hon. Robert Rubin, Secretary of the Treasury
Attachment
FROM WORLD BANK FRMRP 202 522 2515
(TUE) 6. 1'99 12:14/ST. 12:13/NO. 4260895443 P 3
Global Overview of the HIV/AIDS Epidemic
HIV/AIDS is now the number one overall cause of death in Africa, and has moved up to fourth
place among all causes of death worldwide, according to the latest annual World Health Report.
An estimated 33.4 million people are living with HIV/AIDS worldwide and almost 14 million people
already have died of AIDS (1998).
16,000 individuals are newly infected with HIV each day.
Greater than 8.2 million children have been orphaned by HIV/AIDS. This figure may increase to 40
million HIV/AIDS orphans by 2010.
Of all global regions, Sub-Saharan Africa has been hardest hit by the epidemic. The 21 countries
possessing the highest HIV/AIDS prevalence rates in the world are all in this region. Two-thirds
(22.5 million) of all those living with HIV/AIDS globally are from Sub-Saharan Africa
The Asian HIV/AIDS epidemic is building momentum, with South and Southeast Asia experiencing
the most dramatic increases in HIV infection. About 6.7 million people are presently living with
HIV/AIDS in South and Southeast Asia.
There is also a rapid rise in the epidemic in Eastern Europe and Central Asia. HIV/AIDS
infection rates have increased six-fold between 1990-1997.
Over 1.7 million people are living with HIV/AIDS in Latin America and the Caribbean.
North Africa and the Middle East still possess relatively low epidemic levels, although much is
still unknown about the status of the HIV/AIDS epidemic in this region.
Number of Adults and Children
Living with HIV/AIDS, 1998
FROM WORLD BANK FRMRP 202 522 2515
Eastern Europe
and Central Asia
North America
Western Europe
mm
<<<<<<<<<<
***********
270,000
********
550,000
890,000
Eastern Asia, South
Asia and the Pacific
North Africa and the Middle East
Caribbean
IIII
MMU
210,000
330,000
Sub Saharan Africa
Latin America
**********
mmmm
7,260,000
YYYYYY
1,400,000
Australia & New Zealand
12,000
(TUE) 6. 1'99 12:15/ST. 12:13/NO. 4260895443 P 4
mmmm
22,500,000
1 = 50,000 persons living with HIV/AIDS
August 31, 1999
SENSITIVE
For U.S. Government Use Only
South Africa
Intellectual Property Rights
ISSUE:
The SAG has undertaken to extend adequate and affordable healthcare to all South Africans. The
USG supports this goal. In 1997, the South African National Assembly amended prior legislation
in an attempt to ensure the supply of affordable medicines. The effect was to grant the Health
Minister broad, ill-defined powers to abrogate the patent rights of pharmaceuticals companies.
The pharmaceutical industry and their Congressional advocates have urged the USG to pressure
the South African Government (SAG) through use of U.S. trade laws and diplomatic channels
into repealing or amending the Medicines Act. At the same time, a coalition of South African and
foreign pharmaceutical companies is challenging the legislation as unconstitutional in South
African courts while also trying to negotiate a compromise directly with the SAG. Recently, a
coalition of consumer and AIDS activists has been pressuring the USG especially the Vice
President to stop pursuing the issue with South Africa in view of its HIV/AIDS epidemic.
In our efforts to resolve this issue, we have recognized that the HIV/AIDS crisis in South Africa
is a special situation that may require special measures. Thus, we informed the SAG and stated
publicly that while we do not believe that compromising intellectual property rights is the solution
to the greater problem, contrary to our general policy, we will raise no objection to compulsory
licensing or parallel importing of pharmaceuticals (described below) on the part of South Africa,
as long as it is done in a way that complies with the SAG's international trade obligations under
the World Trade Organization Agreement on the Trade-Related Aspects of Intellectual Property
Rights (TRIPS).
BACKGROUND:
Actions by the Administration
Under the Special 301 provisions of the Trade Act of 1974, the Office of the U.S. Trade
Representative is required annually to identify foreign countries that deny adequate and effective
protection of intellectual property rights and to issue a public report to this effect at the end of
each April. South Africa was named to the Special 301 "Watch List" (the report's lowest
category) in 1998 over concern about the authority granted the Minister of Health to abrogate
patent rights as well as other intellectual property issues. During this year's Special 301 review,
U.S. industry recommended we designate South Africa as a "Priority Foreign Country" (the
report's highest category), which could have resulted in trade sanctions. We chose not to do so,
however, because we had already developed a framework to resolve our differences. As a result,
South Africa was maintained on the Watch List.
The framework the Administration proposed for the resolution of our differences with South
Africa was through the Binational Commission, chaired by Vice President Gore and then deputy
President Mbeki. The intent of the proposal was to bring together an experts group including all
relevant decision makers - trade, health, and intellectual property - to reach a mutual goal of
bringing better healthcare to the people of South Africa while assuring effective and adequate
protection of intellectual property. Discussions have continued since the framework's acceptance.
A number of South African officials have recently stated that the Medicines Act will only be used
to compulsory license and parallel import pharmaceutical in a manner consistent with South
Africa's international trade obligations. We are now working to obtain satisfactory assurances
that the Medicines Act will be implemented in this manner so that this issue can be removed from
our bilateral agenda.
U.S. industry has expressed concern that any government-to-government settlement at this time
could undermine their efforts to negotiate a settlement with the new government.
Congress
In the closing days of last year's budget process, Congressman Frelinghuysen of New Jersey
inserted into the foreign aid bill a provision that blocked U.S. aid to the central Government of
South Africa until the State Department provided a report explaining the Administration's efforts
to obtain the repeal of the Medicines Act. Dissatisfied with State's first report, Congress asked
for a revised report. The final report contains language that portrays U.S. efforts as being more
aggressive. Congressional critics of the Administration's approach and consumer and AIDS
activists have now seized on this report, as well as USTR's Special 301 report, as evidence of the
Administration's heavy-handedness on the issue.
On June 25, in a response to a letter from the Chairman of the Congressional Black Caucus, the
Vice President responded stating that he supports "South Africa's efforts to enhance health care
for its people -- including efforts to engage in compulsory licensing and parallel importing of
pharmaceuticals -- so long as they are done in a way consistent with international agreements."
On July 21, the Office of the United States Trade Representative testified before the House
Committee on Government Reform's Subcommittee on Criminal Justice, Drug Policy and Human
Resources chaired by Congressman Mica. In that testimony, USTR stated that, contrary to our
general approach, we will raise no objection to compulsory licensing or parallel importing of
pharmaceuticals on the part of South Africa, as long as it is done in a way that complies with
TRIPS.
U.S. Policy
The Administration's approach to patent protection for pharmaceuticals is to ensure that the
necessary incentives are provided to promote rapid innovation of new drug therapies and to
safeguard the protection of the medicines that now exist. We generally do not support policies
that allow for the parallel importation or compulsory licensing of pharmaceuticals because such
practices compromise intellectual property rights and raise concerns about the safety and efficacy
of imported drugs. Under U.S. law, compulsory licensing and parallel importing of
pharmaceuticals is generally prohibited. However, the TRIPS Agreement does allow for these
practices under certain conditions. We will not object to South Africa's efforts to compulsory
license and parallel import pharmaceuticals, but want South Africa to abide by the TRIPS
Agreement.
Our policy approach has been responsive to both sides in this debate. On the one hand we seek to
ensure that South Africa honors its international obligations with respect to intellectual property
but on the other hand are demonstrating flexibility in the application of U.S. trade policy to
address concerns about South Africa's HIV/AIDS crisis.
Compulsory Licensing
In this situation we are concerned that the South African Government would grant a compulsory
license to one or more domestic manufacturer(s) for the purpose of allowing it (or them) to
produce a patented drug for sale in the domestic market without the consent of the patent holder.
TRIPS imposes a number of disciplines on compulsory licensing including, for example:
the requirement that authorization of such use shall be considered on a case-by-case basis;
such use shall be authorized predominantly for the supply of the domestic market;
the right holder shall be paid adequate remuneration; and
such use may only be permitted if, prior to such use, the proposed user has made efforts to
obtain authorization from the right holder on reasonable commercial terms and such
efforts have not been successful within a reasonable period of time.
The last requirement (but not the others) may be waived in a national emergency. However, none
of these conditions are included in the Medicines Act.
Parallel Imports
Parallel imports of pharmaceuticals are pharmaceuticals that are produced by, or with the
authorization of, the patent holder and intended for sale in one market, for example Kenya, but
that are diverted from the designated market, away from authorized distribution channels, and
imported into another market, such as South Africa, without the authorization of the patent
holder. The diversion occurs in many instances because the drugs are offered for sale in the
intended market at a lower price than the market to which they are diverted. It is difficult to
ensure the safety and efficacy of drugs that are parallel imported because they were not handled
by authorized distributors. Thus, parallel importing of pharmaceuticals is generally prohibited in
the United States and the European Union as well as Kenya.
The
Bernard
Economist
AUGUST 1999
Editorial
Helping the poorest
O
NE world, two fates. Of children who die
ny spends millions to develop a vaccine, it
before their fifth birthday, 98% are in the
wants an economic return.
developing world. Of people who are HIV
The machinery that might guarantee such
positive, some 95% are in poor countries. Of
a return is now taking shape. The World Bank,
the millions who die prematurely of tuber-
the World Health Organisation and other do-
culosis, malaria, measles, tetanus and whoop-
gooding bodies have formed alliances with
ing cough, all but a few thousand live in the
the pharmaceutical industry to promote re-
poor world. Indeed, tuberculosis alone kills
search on affordable drugs for neglected trop-
more people each year than lung cancer, the
ical ailments. Legislation under consideration
most prevalent cancer and the terror of the
in the American Congress and to be proposed
West. The gap is widening between rich and
by the European Commission would also
poor countries, especially between the very
give a helping hand. All this talk still needs to
richest and the very poorest. Although that
be backed by money, though. Others need to
has happened for a century or more, the con-
emulate Bill Gates's medical philanthropy.
tinued early deaths of the poor and their chil-
Important though such initiatives are,
dren are a reproach to us all. What is to be done to save those
they are not enough to heal the poor. The remarkable fall in
millions of young lives?
mortality. rates in Europe and North America a century ago
The good news is that there is some new thinking about
owed little to drugs and almost everything to improved nutri-
ways to respond to this challenge. Aid agencies and drug com-
tion and better public health arrangements: reliable water
panies are talking to each other in more constructive ways
supplies, safe drains, regular rubbish collection. Yet one in six
than they once did. For donor countries, this is not mere altru-
of the world's people lack safe drinking water; most of the gi-
ism: as international travel grows, rich-world governments ac-
ant cities of Africa and Asia have no sewerage system; and
quire a direct interest in halting diseases such as tuberculosis,
rubbish collection is so disorganised that between a third and
which may otherwise infect their own citizens. But affordable
half of their garbage lies uncollected. The main answers lie in
drugs are only part of the cure. Developing-country govern-
making local government more efficient and more account-
ments can do more to improve the health of their people than
able. Another is money-although appropriate technology
simply getting hold of western money and ingenuity.
can cut costs. It is quicker to help the poor by ensuring that the
Part of the new thinking lies in the application of econom-
water sellers on whom they rely have access to safe water
ics to what has too often been a purely emotional pitch for
than by struggling to install expensive piped supplies to the
aid. Since it published an influential report on health in 1993,
home; and wiser to arrange for septic tanks to be emptied
the World Bank has consistently advanced the argument that
promptly than to build water-borne sewerage systems.
unhealthy countries are condemned to slow growth. The idea
that ill health reinforces poverty is less familiar than the view
Education for health
that poverty causes ill health, but equally true. However, one
With some of the diseases that kill the poor, the surest answer
of the main virtues of the World Bank's argument is that it al-
is to change habits. No single change would save more lives
lows multinational aid donors to talk straight to developing-
than if people routinely washed their hands before touching
country finance ministers, who typically have more clout in
food. They need, too, to filter what they drink, to feed babies
the allocation of resources than do their colleagues in the
hygienically, to use mosquito nets, to avoid drunken driving-
health ministry.
and to practise safe sex. One success story is sex education in
Now, economists are tackling-or struggling with-anoth-
Senegal: along with condom distribution and prompt treat-
er aspect of the health of the poor: their lack of access to
ment of other sexually transmitted diseases, this has helped to
drugs. Jeffrey Sachs, a Harvard economist, has drawn atten-
keep HIV infection rates in Dakar below 2%, compared with
tion to the scale of the problem: poor countries cannot afford
20% in Kenya's Nairobi.
expensive medicines, and drug companies naturally tend to
Spreading such messages needs government enthusiasm.
focus their research on finding cures for the ills of the rich (see
But education ministers may not think it their job to teach
pages 17-20 and 63) rather than the afflictions of the poor.
personal hygiene, while politicians may prefer building hospi-
Americans and Europeans rarely suffer from schistosomiasis,
tals to preaching the virtues of hand-washing. In fact, good
which afflicts 200m people worldwide, or lymphatic filariasis,
health care also entails reorganising national systems so that
which makes life miserable for another 120m. So the market is
they concentrate on primary care for the poor, rather than
said to be too small to attract research. Gone are the days
five-star clinics for those, like the president and his cronies,
when Jonas Salk refused to patent polio vaccine, saying that to
who ought to pay for their own care.
do so would be "like patenting the sun". When a drug compa-
Even drug-buying could be done more effectively. Poor-
THE ECONOMIST AUGUST 14TH 1999
11
LEADERS
country governments need to make existing cheap medicines,
drugs in Kenya was recently withdrawn by donors exasperat-
such as oral rehydration salts and childhood vaccines, more
ed by corruption, inertia and political chicanery. And there's
available. They also need to care better for those drugs they
the rub. As Professor Sachs says in his article, getting good
get: all too often part of the consignment ends up on the black
government is not the whole answer. But of all the ills that kill
market or spoiled by bad storage. Foreign aid for malarial
the poor, none is as lethal as bad government.
THE WHITE HOUSE
Office of the Press Secretary
(Cologne, Germany)
For Immediate Release
June 18, 1999
STATEMENT BY THE PRESIDENT
The G-7 agreement we reached today is an historic step to help
the world's poorest nations achieve sustained growth and
independence while targeting new resources for poverty
reduction, education and combatting AIDS. It represents a
sound, humane effort to promote widely shared prosperity in the
new milennium.
30-30-30
Bernast
THE WHITE HOUSE
Office of the Press Secretary
(Cologne, Germany)
For Immediate Release
June 18, 1999
FACT SHEET
The Cologne Debt Initiative
The G-7 leaders have endorsed a new Initiative to enable Heavily
Indebted Poor Countries (HIPCs) to receive deeper, broader and
faster debt relief in return for firm commitments to channel the
benefits into improving the lives of all their people. The HIPC
Initiative was created in 1996 to provide deeper multilateral
debt reduction for poor countries with unsustainable debt
burdens.
New focus on poverty: The Cologne Initiative calls on the
International Financial Institutions to develop a new framework
for linking debt relief with poverty reduction that centers
around better targeting of budgetary resources for priority
social expenditures, for health, child survival, AIDS
prevention, education, greater transparency in government
budgeting, and much wider consultation with civil society in the
development and implementation of economic programs.
Substantially deeper relief: Together with earlier debt relief
commitments, the Cologne Initiative provides for reduction of up
to 70 percent of the total debts for these countries, (reducing
the stock) from about $127 billion today to as low as $37
billion with the cancellation of official development assistance
(ODA) debt by G-7 and other bilateral creditors. In today's
dollars (net present value -- NPV terms), this would more than
triple the amount of relief to be provided from $13 billion
under the current HIPC framework to as much as $50 billion.
This would be accomplished by reducing the HIPC program target
ratios for the NPV of outstanding debt to 150 percent of
exports, and 250 percent of government revenues, with fiscal
thresholds of 30 percent exports to GDP and 15 percent revenues
to GDP, and by providing full cancellation of ODA debts.
Faster relief: Relief will be available significantly faster
than under the current framework by providing early cash flow
relief ("Interim Relief") and allowing earlier stock reduction.
2
Broader participation: The number of countries expected to
qualify for HIPC relief would rise from 26 to 33, meaning that
more than 430 million people could ultimately be affected.
Releasing resources for priority needs: For the average HIPC
country, the share of scarce government revenue devoted to debt
service could fall by 10 percentage points to a ratio for debt
service to revenues of well below 20 percent and close to 10
percent in some cases. This is equivalent to a reduction in
actual payments of about 25 percent. Mozambique's debt will be
reduced by some $3.5 billion ($1.7 billion in NPV terms), for
example, which could cut in half the share of government
revenues allocated to external debt service from over 30 percent
to about 15 percent in 1999 and free about $30 million in
budgetary resources each year. These savings are equivalent to
over half the health budget in 1999 in a country where children
are 3 times more likely to die before the age of five than they
are to go to secondary school.
In proposing this Initiative on March 16, President Clinton
stated that "Our goal is to ensure that no country committed to
fundamental reform is left with a debt burden that keeps it from
meeting its people's basic human needs and spurring growth. We
should provide extraordinary relief for countries making
extraordinary efforts to build working economies." On June 16,
the President pledged "to work to find the resources so we can
do our part and contribute our share toward an expanded trust
fund for debt relief."
SACHS ON DEVELOPMENT
Sach's
Helping the world's poorest
gious than any defaults by impoverished
HIPCS. The broader American neglect of the
UN agencies that assist impoverished coun-
tries in public health, science, agriculture and
the environment must surely rank as anoth-
er amazingly misguided aspect of current
American development policies.
The conditions in many HIPCS are wors-
Jeffrey Sachs, a top academic economist, argues that rich countries must
ening dramatically, even as global science
mobilise global science and technology to address the specific problems which
and technology create new surges of wealth
help to keep poor countries poor
and well-being in the richer countries. The
problem is that, for myriad reasons, the tech-
I are nearly invisible. Seven hundred mil-
OUR Gilded Age, the poorest of the poor
nological gains in wealthy countries do not
BY INVITATION
readily diffuse to the poorest ones. Some bar-
lion people live in the 42 so-called Highly In-
riers are political and economic. New tech-
debted Poor Countries (HIPCS), where a
Jeffrey Sachs is direc-
nologies will not take hold in poor societies if
combination of extreme poverty and finan-
tor of the Centre for
investors fear for their property rights, or
cial insolvency marks them for a special
International Devel-
even for their lives, in corrupt or conflict-rid-
kind of despair and economic isolation.
opment and professor
den societies. The Economist's response to
They escape our notice almost entirely, un-
of international trade
the Cologne Summit ("Helping the Third
less war or an exotic disease breaks out, or yet
at Harvard University. A prolific
World", June 26th) is right to stress that aid
another programme with the International
writer, he has also advised the
without policy reform is easily wasted. But
Monetary Fund (IMF) is signed. The Cologne
governments of many develop-
the barriers to development are often more
Summit of the G8 in June was a welcome ex-
ing and East European countries.
subtle than the current emphasis on "good
ception to this neglect. The summiteers ac-
governance" in debtor countries suggests.
knowledged the plight of these countries, of-
Research and development of new tech-
fered further debt relief and stressed the
and World Bank to be more sensitive to so-
nologies are overwhelmingly directed at
need for a greater emphasis by the interna-
cial conditions is merely an indicative nod.
rich-country problems. To the extent that the
tional community on social programmes to
A much more important challenge, as
poor face distinctive challenges, science and
help alleviate human suffering.
yet mainly unrecognised, is that of mobilis-
technology must be directed purposefully
The G8 proposals should be seen as a be-
ing global science and technology to address
towards them. In today's global set-up, that
ginning: inadequate to the problem, but at
the crises of public health, agricultural pro-
rarely happens. Advances in science and
least a good-faith prod to something more
ductivity, environmental degradation and
technology not only lie at the core of long-
useful. We urgently need new creativity and
demographic stress confronting these coun-
term economic growth, but flourish on an in-
a new partnership between rich and poor if
tries. In part this will require that the wealthy
tricate mix of social institutions-public and
these 700m people (projected to rise to 1.5 bil-
governments enable the grossly under-
private, national and international.
lion by 2030), as well as the extremely poor in
financed and underempowered United Na-
Currently, the international system fails
other parts of the world (especially South
tions institutions to become vibrant and ac-
to meet the scientific and technological
Asia), are to enjoy a chance for human bet-
tive partners of human development. The
needs of the world's poorest. Even when the
terment. Even outright debt forgiveness, far
failure of the United States to pay its UN dues
right institutions exist-say, the World
beyond the G8's stingy offer, is only a step in
is surely the world's most significant default
Health Organisation to deal with pressing
the right direction. Even the call to the IMF
on international obligations, far more egre-
public health disasters facing the poorest
countries-they are generally starved for
funds, authority and even access to the key
negotiations between poor-country govern-
ments and the Fund at which important de-
velopment strategies get hammered out.
The ecology of underdevelopment
If it were true that the poor were just like the
rich but with less money, the global situation
would be vastly easier than it is. As it hap-
pens, the poor live in different ecological
zones, face different health conditions and
must overcome agronomic limitations that
are very different from those of rich coun-
tries. Those differences, indeed, are often a
fundamental cause of persisting poverty.
Let us compare the 30 highest-income
countries in the world with the 42 HIPCS (see
table on next page). The rich countries over-
Poverty and its ills: better remedies required
whelmingly lie in the world's temperate
THE ECONOMIST AUGUST 14TH
17
For fast relief from malaria
for my family
rely on
NIVAQUINE
zones. Not every country in those bands is
the foundation of modern science. Global
technology of significance that was not nur-
rich, but a good rule of thumb is that temper-
capitalism is, of course, a set of social institu-
tured through public as well as private care.
ate-zone economies are either rich, formerly
tions-of property rights, legal and political
If technologies easily crossed the ecolog-
socialist (and hence currently poor), or geo-
systems, international agreements, transna-
ical divide, the implications would be less
graphically isolated (such as Afghanistan
tional corporations, educational establish-
dramatic than they are. Some technologies,
and Mongolia). Around 93% of the com-
ments, and public and private research insti-
certainly those involving the computer and
bined population of the 30 highest-income
tutions-but the prosperity that results from
other ways of managing information, do in-
countries lives in temperate and snow zones.
these institutions has its roots in the develop-
deed cross over, and give great hopes of spur-
The HIPCS, by contrast, include 39 tropical or
ment and applications of new science-based
ring technological capacity in the poorest
desert societies. There are only three in a sub-
technologies. In the past 50 years, these have
countries. Others-especially in the life sci-
stantially temperate climate, and those three
included technologies built on solid-state
ences but also in the use of energy, building
are landlocked and therefore geographically
physics, which gave rise to the information-
techniques, new materials and the like-are
isolated (Laos, Malawi and Zambia).
technology revolution, and on genetics,
prone to "ecological specificity". The result is
Not only life but also death differs be-
which have fostered breakthroughs in
a profound imbalance in the global produc-
tween temperate and tropical zones. Indi-
health and agricultural productivity.
tion of knowledge: probably the most pow-
viduals in temperate zones almost every-
erful engine of divergence in global well--
where enjoy a life expectancy of 70 years or
Science at the ecological divide
being between the rich and the poor.
more. In the tropics, however, life expectan-
In this context, it is worth noting that the in-
Consider malaria. The disease kills more
cy is generally much shorter. One big reason
equalities of income across the globe are ac-
than im people a year, and perhaps as many
is that populations are burdened by diseases
tually exceeded by the inequalities of scien-
as 2.5m. The disease is so heavily concentrat-
such as malaria, hookworm, sleeping sick-
tific output and technological innovation.
ed in the poorest tropical countries, and
ness and schistosomiasis, whose transmis-
The chart below shows the remarkable dom-
overwhelmingly in sub-Saharan Africa, that
sion generally depends on a warm climate.
inance of rich countries in scientific publica-
nobody even bothers to keep an accurate
(Winter may be the greatest public-health in-
tions and, even more notably, in patents fil-
count of clinical cases or deaths. Those who
tervention in the world.) Life expectancy in
ed in Europe and the United States.
remember that richer places such as Spain,
the HIPCS averages just 51 years, reflecting the
The role of the developing world in one
Italy, Greece and the southern United States
interacting effects of tropical disease and
sense is much greater than the chart indi-
once harboured the disease may be misled
poverty. The economic evidence strongly
cates. Many of the scientific and technologi-
into thinking that the problem is one of so-
suggests that short life expectancy is not just
cal breakthroughs are made by poor-coun-
cial institutions to control its transmission. In
a result of poverty, but is also a powerful
try scientists working in rich-country labora-
fact, the sporadic transmission of malaria in
cause of impoverishment.
tories. Indian and Chinese engineers ac-
the sub-tropical regions of the rich countries
All the rich-country research on rich-
count for a significant proportion of Silicon
was vastly easier to control than is its chronic
country ailments, such as cardiovascular
Valley's workforce, for example. The basic
transmission in the heart of the tropics. Trop-
diseases and cancer, will not solve the prob-
point, then, holds even more strongly: global
ical countries are plagued by ecological con-
lems of malaria. Nor will the biotechnology
science is directed by the rich countries and
ditions that produce hundreds of infective
advances for temperate-zone crops easily
for the rich-country markets, even to the ex-
bites per year per person. Mosquito control
transfer to the conditions of tropical agricul-
tent of mobilising much of the scientific po-
does not work well, if at all, in such circum-
ture. To address the special conditions of the
tential of the poorer countries.
stances. It is in any event expensive.
HIPCS, we must first understand their
The imbalance of global science reflects
Recent advances in biotechnology, in-
unique problems, and then use our ingenui-
several forces. First, of course, science follows
cluding mapping the genome of the malaria
ty and co-operative spirit to create new
the market. This is especially true in an age
parasite, point to a possible malaria vaccine.
methods of overcoming them.
when technological leaps require expensive
One would think that this would be high on
Modem society and prosperity rest on
scientific equipment and well-provisioned
the agendas of both the international com-
research laboratories. Second, scientific ad-
Different ecologies
vance tends to have increasing returns to
Different resources
Rich
HIPCs*
countries
scale: adding more scientists to a community
Indicators of global science
(42)
(30)
does not diminish individual marginal pro-
1995, % of world totals
Advanced economies
Rest of world
PRPST:
1,187
18,818
ductivity but tends to increasei Therein lies
0
20
40
60
80
100
at birth/ yearst 951.5
76.9
the origin of university science departments,
Population
ecozones,
regional agglomerations such as Silicon Val-
55.6
ley and Route 128, and mega-laboratories at
GDP
0.7
3.7
leading high-technology firms including
Publications
17.6
Merck, Microsoft and Monsanto. And third,
and
snow
12.5
92,6
Patents (EU)
science requires a partnership between the
14.0
2.5
public and private sectors. Free-market ideo-
Patents (US)
*Highly Indebted poor countries Unweighted averages
Sources: J. Sachs; UNESCO
logues notwithstanding, there is scarcely one
18
THE ECONOMIST AUGUST 14TH
munity and private pharmaceutical firms. It
such a pledge could galvanise the world of
world in which science is a rich-country pre-
is not. A Wellcome Trust study a few years
private-sector pharmaceutical and biotech-
rogative while the poor continue to die, the ni-
ago found that only around $80m a year was
nology firms. Malaria vaccine research
ceties of intellectual property rights are likely
spent on malaria research, and only a small
would suddenly become hot. Within a few
to prove less compelling than social realities.
fraction of that on vaccines.
years, a breakthrough of profound benefit to
There is no shortage of complexities
The big vaccine producers, such as
the poorest countries would be likely. The
ahead. The world needs to reconsider the
Merck, Rhône-Poulenc's Pasteur-Mérieux-
costs in foreign aid would be small: a few
question of property rights before patent
Connaught and SmithKline Beecham, have
hundred million dollars a year to tame a kill-
rights allow rich-country multinationals in
much of the in-house science but not the bot-
er of millions of children. Such a vaccine
effect to own the genetic codes of the very
tom-line motivation. They strongly believe
would rank among the most effective
foodstuffs on which the world depends, and
that there is no market in malaria. Even if
public-health interventions conceivable.
even the human genome itself. The world
they spend the hundreds of millions, or per-
And, if science did not deliver, rich countries
also needs to reconsider the role of institu-
haps billions, of dollars to do the R&D and
would end up paying nothing at all.
tions such as the World Health Organisation
come up with an effective vaccine, they be-
Malaria imposes a fearsome burden on
and the Food and Agriculture Organisation.
lieve, with reason, that their product would
poor countries, the AIDS epidemic an even
These UN bodies should play a vital role in
just be grabbed by international agencies or
weightier load. Two-thirds of the world's
identifying global priorities in health and
private-sector copycats. The hijackers will
33m individuals infected with the HIV virus
agriculture, and also in mobilising private-
argue, plausibly, that the poor deserve to
are sub-Saharan Africans, according to a UN
sector R&D towards globally desired goals.
have the vaccine at low prices-enough to
estimate in 1998, and the figure is rising.
There is no escape from such public-private
cover production costs but not the preceding
About 95% of worldwide HIV cases are in the
collaboration. It is notable, for example, that
R&D expenditures.
developing world. Once again, science is
Monsanto, a life-sciences multinational
The malaria problem reflects, in micro-
stopping at the ecological divide.
based in St Louis, Missouri, has a research
cosm, a vast range of problems facing the
Rich countries are controlling the epi-
and development budget that is more than
HIPCS in health, agriculture and environ-
demic through novel drug treatments that
twice the R&D budget of the entire world-
mental management. They are profound, ac-
are too expensive, by orders of magnitude,
wide network of public-sector tropical re-
cessible to science and utterly neglected. A
for the poorest countries. Vaccine research,
search institutes. Monsanto's research, of
hundred IMF missions or World Bank
which could provide a cost-effective meth-
course, is overwhelmingly directed towards
health-sector loans cannot produce a malar-
od of prevention, is dramatically under-
temperate-zone agriculture.
ia vaccine. No individual country borrowing
funded. The vaccine research that is being
from the Fund or the World Bank will ever
done focuses on the specific viral strains
People, food and the environment
have the means or incentive to produce the
prevalent in the United States and Europe,
Public health is one of the two distinctive cri-
global public good of a malaria vaccine. The
not on those which bedevil Africa and Asia.
ses of the tropics. The other is the production
root of the problem is a much more complex
As in the case of malaria, the potential devel-
of food. Poor tropical countries are already
market failure: private investors and scien-
opers of vaccines consider the poor-country
incapable of securing an adequate level of
tists doubt that malaria research will be re-
market to be no market at all. The same, one
nutrition, or paying for necessary food im-
warded financially. Creativity is needed to
should note, is true for a third worldwide
ports out of their own export earnings. The
bridge the huge gulfs between human needs,
killer. Tuberculosis is still taking the lives of
HIPC population is expected to more than
scientific effort and market returns.
more than 2m poor people a year and, like
double by 2030. Around one-third of all chil-
malaria and AIDS, would probably be sus-
dren under the age of five in these countries
Promise a market
ceptible to a vaccine, if anyone cared to in-
are malnourished and physically stunted,
The following approach might work. Rich
vest in the effort.
with profound consequences throughout
countries would make a firm pledge to pur-
The poorer countries are not necessarily
their lives.
chase an effective malaria vaccine for Afri-
sitting still as their citizenry dies of AIDS.
As with malaria, poor food productivity
ca's 25m newborn children each year if such
South Africa is on the verge of authorising the
in the tropics is not merely a problem of poor
a vaccine is developed. They would even
manufacture of AIDS medicines by South
social organisation (for example, exploiting
state, based on appropriate and clear scien-
African pharmaceutical companies, despite
farmers through controls on food prices). Us-
tific standards, that they would guarantee a
patents held by American and European
ing current technologies and seed types, the
minimum purchase price-say, $10 per
firms. The South African government says
tropics are inherently less productive in an-
dose-for a vaccine that meets minimum
that, if rich-country firms will not supply the
nual food crops such as wheat (essentially a
conditions of efficacy, and perhaps raise the
drugs to the South African market at afford-
temperate-zone crop), rice and maize. Most
price for a better one. The recipient countries
able prices (ones that are high enough to meet
agriculture in the equatorial tropics is of very
might also be asked to pledge a part of the
marginal production costs but do not include
low productivity, reflecting the fragility of
cost, depending on their incomes. But noth-
the patent-generated monopoly profits that
most tropical soils at high temperatures
ing need be spent by any government until
the drug companies claim as their return for
combined with heavy rainfall. High produc-
the vaccine actually exists.
R&D), then it will simply allow its own firms
tivity in the rainforest ecozone is possible
Even without a vast public-sector effort,
to manufacture the drugs, patent or no. In a
only in small parts of the tropics, generally
THE ECONOMIST AUGUST 14TH
19
on volcanic soils (on the island of Java, in In-
with disturbing frequency.
technological reach. Similar efforts to merge
donesia, for example). In the wet-dry tropics,
The United States feels aggrieved that
public and private science activities will be
such as the vast savannahs of Africa, agricul-
poor countries are not signing the conven-
needed in agricultural biotechnology.
ture is hindered by the terrible burdens of
tion on climatic change. The truth is that
Third, just as knowledge is becoming
unpredictable and highly variable water
these poor tropical countries should be call-
the undisputed centrepiece of global pros-
supplies. Drought and resulting famine have
ing for outright compensation from America
perity (and lack of it, the core of human im-
killed millions of peasant families in the past
and other rich countries for the climatic
poverishment), the global regime on intellec-
generation alone.
damages that are being imposed on them.
tual property rights requires a new look. The
Scientific advances again offer great
The global climate-change debate will be
United States prevailed upon the world to
hope. Biotechnology could mobilise genetic
stalled until it is acknowledged in the United
toughen patent codes and cut down on intel-
engineering to breed hardier plants that are
States and Europe that the temperate-zone
lectual piracy. But now transnational corpo-
more resistant to drought and less sensitive
economies are likely to impose heavy bur-
rations and rich-country institutions are pat-
to pests. Such genetic engineering is stymied
dens on the already impoverished tropics.
enting everything from the human genome
at every point, however. It is met with doubts
to rainforest biodiversity. The poor will be
in the rich countries (where people do not
New hope in a new millennium
ripped off unless some sense and equity are
have to worry about their next meal); it re-
The situation of the HIPCS has become intol-
introduced into this runaway process.
quires a new scientific and policy frame-
erable, especially at a time when the rich
Moreover, the system of intellectual
work in the poor countries; and it must
countries are bursting with new wealth and
property rights must balance the need to
somehow generate market incentives for the
scientific prowess. The time has arrived for a
provide incentives for innovation against
big life-sciences firms to turn their research
fundamental re-thinking of the strategy for
the need of poor countries to get the results
towards tropical foodstuffs, in co-operation
co-operation between rich and poor, with
of innovation. The current struggle over AIDS
with tropical research centres. Calestous Ju-
the avowed aim of helping the poorest of the
medicines in South Africa is but an early
ma, one of the world's authorities on bio-
poor back on to their own feet to join the race
warning shot in a much larger struggle over
technology in Africa, stresses that there are
for human betterment. Four steps could
access to the fruits of human knowledge. The
dozens, or perhaps hundreds, of underused
change the shape of our global community.
issue of setting global rules for the uses and
foodstuffs that are well adapted to the trop-
First, rich and poor need to learn to talk
development of new technologies-espe-
ics and could be improved through directed
together. As a start, the world's democracies,
cially the controversial biotechnologies-
biotechnology research. Such R&D is now all
rich and poor, should join in a quest for com-
will again require global co-operation, not
but lacking in the poorest countries.
mon action. Once again the rich G8 met in
the strong-arming of the few rich countries.
The situation of much of the tropical
1999 without the presence of the developing
Fourth, and perhaps toughest of all, we
world is, in fact, deteriorating, not only be-
world. This rich-country summit should be
need a serious discussion about long-term fi-
cause of increased population but also be-
the last of its kind. A G16 for the new millen-
nance for the international public goods
cause of long-term trends in climate. As the
nium should include old and new democra-
necessary for HIPC countries to break
rich countries fill the atmosphere with in-
cies such as Brazil, India, South Korea, Nige-
through to prosperity. The rich countries are
creasing concentrations of carbon, it looks
ria, Poland and South Africa.
willing to talk about every aspect except
ever more likely that the poor tropical coun-
Second, rich and poor countries should
money: money to develop new malaria, tu-
tries will bear much of the resulting burden.
direct their urgent attention to the mobilisa-
berculosis and AIDS vaccines; money to spur
Anthropogenic global warming, caused
tion of science and technology for poor-
biotechnology research in food-scarce re-
by the growth in atmospheric carbon, may
country problems. The rich countries should
gions; money to help tropical countries ad-
actually benefit agriculture in high-latitude
understand that the IMF and World Bank are
just to climate changes imposed on them by
zones, such as Canada, Russia and the north-
by themselves not equipped for that chal-
the richer countries. The World Bank makes
em United States, by extending the growing
lenge. The specialised UN agencies have a
mostly loans, and loans to individual coun-
season and improving photosynthesis
great role to play, especially if they also act as
tries at that. It does not finance global public
through a process known as carbon fertilisa-
a bridge between the activities of advanced-
goods. America has systematically squeezed
tion. It is likely to lower tropical food produc-
country and developing-country scientific
the budgets of UN agencies, including such
tivity, however, both because of increased
centres. They will be able to play that role,
vital ones as the World Health Organisation.
heat stress on plants and because the carbon
however, only after the United States pays its
We will need, in the end, to put real re-
fertilisation effect appears to be smaller in
debts to the UN and ends its unthinking hos-
sources in support of our hopes. A global tax
tropical ecozones. Global warming is also
tility to the UN system.
on carbon-emitting fossil fuels might be the
contributing to the increased severity of
We will also need new and creative insti-
way to begin. Even a very small tax, less than
tropical climatic disturbances, such as the
tutional alliances. A Millennium Vaccine
that which is needed to correct humanity's
"one-in-a-century" El Niño that hit the trop-
Fund, which guaranteed future markets. for
climate-deforming overuse of fossile fuels,
ical world in 1997-98, and the "one-in-a-cen-
malaria, tuberculosis and AIDS vaccines,
would finance a greatly enhanced supply of
tury" Hurricane Mitch that devastated Hon-
would be the right place to start. The vaccine-
global public goods. No better time 10 start
duras and Nicaragua a year ago. Once-in-a-
fund approach is administratively straight-
than as the new millennium begins.
century weather events seem to be arriving
forward, desperately needed and within our
20
THE ECONOMIST AUGUST 14TH
SCIENCE AND TECHNOLOGY
pharmaceutial
ket. But as Patrice Trouiller. a consultant with
Médecins sans Frontières (MSF), an aid
group, points out, only 11 of them were de-
signed for tropical diseases.
The problem is not merely one of human
welfare, important though that is. Many eco-
nomists, among them Jeffrey Sachs of Har-
vard University (see pages 17-20), believe it is
also an issue of economic development. Bet-
ter access to better medicines is not the only
way to improve the health of poor countries,
but it is a significant one. And creating new
drugs and vaccines is such a technology-
intensive business that the developing world
is likely to remain dependent on western
pharmaceutical firms for years to come.
New pills, old ills
Encouraging the development of new med-
icines is difficult because it requires both the
push of financial incentives (to offset the risk
Balms for the poor
of research in largely uncharted fields) and
the pull of secure funding (to ensure that
there is a paying market once the drugs are
ready). Recently, however, some new ideas
about how to solve these problems have
emerged, based on new alliances between
industry and the public sector.
One approach is that being taken by the
Infectious diseases hinder developing countries from developing. Making
new Medicines for Malaria Venture (MMV),
existing drugs cheaper there would help. Making entirely new drugs would
which brings together public-sector organi-
help even more
sations and drug companies under the um-
brella of the WHO. Robert Ridley, director of
P
EER over the counter at a pharmacy in
supermodels than charities: they won't get
MMV, sees the venture as a "not-for-profit
America, Europe or Japan and you see a
out of bed and into work for less than $350m
virtual drug company", combining public-
wealth of drugs. Americans and Europeans
in annual sales for any given product. This is
and private-sector research through funding
spend more than $220 billion a year on pre-
because turning a gleam in a researcher's eye
collaborative discovery and development
scription medicines for everything from
into a handful of useful pills is an expensive
projects. Drug companies have millions of
high blood pressure to low mood-a power-
and time-consuming business: on average, it
molecules in their chemical libraries created
ful incentive for pharmaceutical companies
costs $300m and takes more than a decade.
for more lucrative diseases such as cancer,
to keep them supplied with current reme-
Between 1975 and 1997, an impressive 1,223
along with thousands of old drugs currently
dies and to concoct new ones (see chart). Of
new compounds were launched on the mar-
used for other ailments, which could be de-
course, drugs for such diseases as river blind-
veloped for malaria at roughly a tenth of the
ness and sleeping sickness are not routinely
Overdosed
cost of starting from scratch.
found on western shelves since there is little
Pharmaceuticals market, 1999
But finding the money to finance the re-
demand for them. But walk into a dispen-
$bn
search is not easy. MMV aims to register one
sary in, say, Cameroon, and you discover
North America
8.6
new antimalarial product every five years,
that such drugs are equally scarce there-not
and is likely to need $30m a year to do so. The
because they are not needed, but because
Europe
5.3
drug companies' gifts-in-kind are worth mil-
nobody can afford them.
Japan
0.2
lions, but the bulk of the required money is
Lack of money not only restricts access
Latin America
7.2
still expected to come from public funds and
to existing drugs and vaccines and means of
South-East Asia,
philanthropic institutions. Initial promises
dispensing them; it also offers little incentive
China
11.1
of $5m have enabled MMV to begin the pro-
for drug companies to develop new medi-
Middle East
10.4
cess of project selection, and the venture will
cines for people in poor countries. Globally,
Eastern Europe
9.4
be formally launched later this year.
the World Health Organisation (WHO) esti-
Seth Berkley, head of the International
mates that more than $56 billion a year is
Indian subcontinent
7.9
AIDS Vaccine Initiative (IAVI), is hoping to do
spent on health research-but less than 10%
Africa
3.2
something similar for AIDS vaccines. Rough-
of that sum is directed toward diseases that
ly $2 billion a year is spent on research into
Australasia
afflict 90% of the world's population.
Annual
9.2
change,
AIDS treatments, most of which are either
As Piers Whitehead of Mercer Consult-
CIS
1999-2003
6.1
too costly or too complicated for use in poor
ing notes, large drug companies are more like
Source: IMS HEALTH
ALL
countries. But IAVI estimates that only
THE ECONOMIST AUGUST 14TH 1999
63
SCIENCE AND TECHNOLOGY
Flying high
control circadian rhythm-also lack
heightened responses to cocaine even after
multiple doses. In fact, "Doubletime" mut-
C
OCAINE, as addicts well know, has
Other experiments on mice and flies have
ants proved particularly resistant to the
curious effects on the body. One of
shown that dopamine is also involved in
drug, requiring substantially higher quan-
them is "reverse tolerance": rather than be-
cocaine sensitisation. So the researchers
tities before behaving strangely.
coming accustomed to cocaine with in-
put the two together and decided to see
In fruit flies, a biochemical called tyra-
creasing exposure (as happens with, say,
whether disrupting the body's internal
mine seems to be responsible for such drug
alcohol), the brain becomes more sensitive.
clock might also affect cocaine craving.
responses, and Dr Hirsh thinks that tyra-
With each hit, responses, such as fidgeting,
When exposed to purified "freebase"
mine regulation is the chemical link bet-
are more exaggerated. This sensitisation is
cocaine, fruit flies behave surprisingly like
ween these two very different processes.
thought to be a first step in creating an over-
junkies. They twitch, gnaw and groom
After a single cocaine dose, the enzyme
whelming craving for the drug that eventu-
themselves compulsively while wandering
that makes tyramine becomes more active
ally leads to addiction.
about in circles. As the drug dose rises, such
in normal flies. In the circadian-gene mut-
In humans, studying cocaine sensitisa-
erratic movements become more severe
ants, however, the enzyme's activity stays
tion is tricky since most governments have
until the fly is paralysed and drops dead.
steady after a dose of the drug, so tyramine
strong views on giving drugs to the uniniti-
Ordinarily, one cocaine hit is enough to
levels remain low. The absence of the circa-
ated, and tend to enforce them with leng-
sensitise a fly. But Dr Hirsh's team found
dian genes, which seem to regulate the
thy prison sentences. So instead research-
that mutant Drosophila lacking genes
release of tyramine, prevents flies from
ers have turned to creatures such as the
called "Clock", "Period", "Cycle" and
becoming more responsive to cocaine.
fruit fly, Drosophila melanogaster, to
"Doubletime"-all of which are known to
Whether sky-high flies can teach scien-
probe the cellular basis for co-
tists much about human addic-
caine craving. In this week's issue
tion remains to be seen. Only
of Science, biologists Jay Hirsh,
about a fifth of the people who
Sarah Chaney and Rozi Andretic
use cocaine actually become ad-
of the University of Virginia re-
dicted to it: the puzzle lies in un-
port that an appetite for cocaine
derstanding what distinguishes
seems to be connected to the
the casual user from the hard-
mechanisms which control circa-
core addict. But if the propensity
dian rhythm-the so-called
to addiction is also genetically
"body clock".
controlled in humans, it could
Fruit flies, like humans, have
provide a mechanism to address
an internal biological clock that
the problem at the cellular level,
governs their activity over a 24-
by regulating tyramine or its ver-
hour cycle. Ms Andretic recently
tebrate equivalent. It might then
found that the brain makes use of
be possible to treat cocaine addic-
a biochemical called dopamine
tion as a disease, rather than a
to regulate its circadian rhythm.
Fruit flies on the rocks
criminal activity.
$250m is spent creating vaccines, few of
as well. Another proposal is to allow compa-
of 1999, introduced by Nancy Pelosi, aims to
which are potentially useful for poor coun-
nies that agree to develop an HIV vaccine a
encourage drug makers to develop vaccines
tries where about 95% of HIV infections oc-
limited extension to their patents on block-
for malaria, tuberculosis and HIV, which to-
cur. Dr Berkley wants to make life as easy as
buster drugs in their most lucrative markets.
gether kill almost 8m people each year. The
possible for potential vaccine developers by
A different approach, being cham-
legislation proposes substantial tax credits
mustering expertise and money to help com-
pioned by MSF, is to make a virtue of the rar-
on research and development expenses, and
panies negotiate regulatory hurdles and or-
ity of tropical diseases in the West. Since 1983
would cost about $25m a year.
ganise clinical trials in developing countries.
America has offered incentives in the form
But while the bill has received backing
IAVI is also trying to use the tricky issue of
of tax credits and marketing monopolies to
from both politicians and industry execu-
intellectual property to expand access to
companies willing to develop drugs for "or-
tives for its tax credits, it may face opposition
new vaccines. Patents have long been a sore
phan" diseases, which afflict fewer than
to its explicit endorsement of "tiered pric-
point between the companies which own
200,000 people and so offer markets too
ing"-the simple idea that poor countries be
them and developing countries (such as
small to attract much attention from phar-
charged less than rich ones for drugs. In the
South Africa) which want to get their hands
maceutical companies. The European Com-
past, American congressmen have com-
on nifty new medicines and resent having to
mission is preparing similar legislation, and
plained that it is "unfair" that their voters
pay the premiums which patent-holders ex-
Dr Trouiller of MSF is lobbying for tropical
should pay 100 times more for a measles vac-
pect as a reward for their innovation. IAVI
diseases to be included in it. But although or-
cine than, say, a mother in Bangladesh.
will invest in drug companies if they prom-
phan drug legislation has been a boon to
Such opposition to tiered pricing alarms
ise to provide their vaccines to poor coun-
America's biotech companies, which can
drug companies, according to Amie Batson, a
tries (though not rich ones) at just above
use the prospect of a market of a few million
vaccine consultant with the World Bank.
manufacturing cost, rather than including
dollars to lure investors, that is scarcely loose
Even more worrying, says Walter Vanders-
the usual hefty margin. If they do not, IAVI
change for large pharmaceutical firms. And
missen, head of government affairs at Smith-
has the right to transfer the patent to another
since only big firms can manufacture drugs
Kline Beecham Biologicals, is the prospect
producer. IAVI has already struck a deal with
in large quantities, it is crucial to engage their
that rich countries might allow the import of
one biotech company, Alphavax of North
interest too.
discounted drugs from poor countries, and
Carolina, along these lines and is hoping to
A bill now before Congress could do just
undercut the drug industry's sales in their
do business with large pharmaceutical firms
that. The Lifesaving Vaccine Technology Act
profitable markets. (At the moment, America
64
THE ECONOMIST AUGUST 14TH 1999
and the European Union strictly control im-
ports of drugs made outside their borders.)
Though many in the pharmaceutical in-
dustry are impressed by these proposals,
some feel that there are now too many com-
peting "initiatives" and that they all fall
short of inspiring novel drug development.
Mr Vandersmissen considers them "interest-
ing think-tank exercises". The best way to
stimulate new research, he believes, is to
prove that sustainable markets can be creat-
ed for relatively expensive medicines al-
ready on the shelf. This is the aim of a new in-
ternational consortium, the Global Alliance
for Vaccines and Immunisation, to be
launched next year. It brings together the
World Bank, the WHO, wealthy donor coun-
tries, poor recipient ones, philanthropic or-
ganisations and the drug industry, with the
aim of improving access to existing vaccines
and developing new ones.
According to Geoffrey Lamb, head of
"resource mobilisation" at the World Bank,
one way to finance such a programme is
through a global trust fund for vaccines for
needy countries. But wealthy donor govern-
ments are not keen to tie up large sums of
money for long periods of time on uncertain
odds. A more likely prospect, in Mr Lamb's
view, is "contingent lending", in which do-
nors promise to give money and needy
countries promise to buy a vaccine if and
when a useful one appears.
Ultimately, says Tim Evans, director of
health sciences at the Rockefeller Founda-
tion, rich donor countries prefer to give their
money to projects (such as drug donation
and immunisation programmes) which
show results in a couple of years, rather than
put up with the long and uncertain slog of
developing new medicines. But some donors
are prepared to take a more long-term view.
The biggest splash has been made by the Bill
and Melinda Gates Foundation. Since last
December, the foundation has given $50m
for malaria vaccine development, $25m for
AIDS vaccine research and $100m to the
Gates Children's Vaccine Programme which
aims to improve access to expensive new
shots against hepatitis-B, Haemophilus in-
fluenzae and rotavirus.
Though such contributions are wel-
comed by international health workers, they
are, in Mr Evans's view, largely "catalytic"-
enough to kickstart a reaction among drug
developers and public health authorities,
but not enough to sustain it. He would like to
see a new group of donors: multinational
corporations whose business in poor coun-
tries depends on a healthy workforce, who
would benefit from novel drugs for their old
ailments. In the end, developing new medi-
cines for the world's poorest will depend on
appeals to both altruism and self-interest.
Balancing the two may prove the toughest
trick of all for the new alliances between the
public and private sector.
THE ECONOMIST AUGUST 14TH 1999
INTERNATIONAL
AIDS orphans
dren and 68% of rural orphans in Zambia do
not attend any classes at all. In Ndola, unem-
ployment has become the norm as the cop-
per mines, mismanaged for decades, are
now sacking workers by the thousand. Hun-
dreds of families face eviction from mine-
owned houses. In the recently expanded
cemeteries around Ndola, several graves
have been dug up: local thieves are so des-
perate that they strip fresh corpses of the
smart suits in which they are buried.
State welfare payments reach less than
2% of Zambians; charitable organisations
help only a tenth. Almost the entire burden
of coping with the orphan problem falls on
the extended family. Zambian families have
adapted impressively to the crisis. According
to one study, 72% of Zambian households
care for one or more orphans. Zambia's old
socialist regime preferred to put orphans
into state institutions, but the current gov-
ernment, arguing that orphanages are an ex-
pensive way of making children miserable,
has closed almost all of them.
Orphans of the virus
Most orphans are now fostered by rela-
tions, who offer more love and pumpkin-
leaf stew than the government ever could.
But extra mouths mean less food to go
round, so many fostered children are made
to work for their keep. And since fostering is
NDOLA, ZAMBIA
informal, orphans usually enjoy fewer legal
rights than other children. Formal adoptions
The AIDS epidemic is leaving a horrifying number of African children
require paperwork and the co-operation of
without their parents
sluggish bureaucrats, so they are rare: in 1996
there were only 18 in the whole of Zambia.
T
WO-THIRDS of the patients at the main
mates of the proportion of Zambian chil-
The unlucky ones receive no care at all.
hospital in Ndola, in the copper-mining
dren under 15 who have lost one or both par-
Babies born H1V-positive in Zambia usually
region of northern Zambia, are dying of AIDS.
ents (usually but not always from AIDS)
die within a year. Uninfected babies should
Some have lost so much weight that their
range from 13% to as high as 50%. Even at the
be able to survive, but, if the mother dies, her
arms look like broken broom handles and
lowest estimate, this is a dozen times higher
relations sometimes wrongly think the baby
their tattoos are shrivelled and illegible.
than the level in industrialised countries.
too is doomed, and so do not waste scarce
Their immediate wish is not for costly anti-
It is not only children who are hit. Faides
food delaying the inevitable. The disease has
retroviral drugs, but for food. In theory, the
Zulu, a grandmother from a shanty town
led to a dramatic increase in the number of
state-run hospital provides meals for all pa-
outside Ndola, was supported by her daugh-
homeless children: perhaps 90,000 live on
tients, but several complain that they have
ter until she and her husband both died.
Zambia's streets or in the bush, scratching a
not eaten all day, and beg for 100 kwacha
Suddenly, Mrs Zulu had lost her only source
living by recycling broken bottles or through
(four American cents) for breakfast.
of income and gained five new dependants.
petty theft. Too poor to afford glue to dull the
Poverty hastens death among AIDS suf-
Despite her age (she is old enough to have no
evening chill, they sniff fermented sewage.
ferers. And in Zambia, as in much of Africa,
idea when she was born) and frailty, she has
Other African countries' statistics on
the sheer number of AIDS deaths aggravates
resumed the heavy task of growing vegeta-
AIDS orphans are even less reliable than
the poverty of those who survive. The dis-
bles in her small plot and carrying them to
Zambia's. But a study of 19 sub-Saharan
ease in Zambia is so common that it has lost
market. Hand-outs from a local charity cover
countries by USAID reckoned they would
its social stigma. The Zambian health minis-
clothes and the $7-a-year school fees for
have 40m orphans by 2010, largely because
try estimates that half the country's popula-
each child. She says that without the 25kg of
of AIDS. According to the UN, there were 35
tion will eventually die of it. Only tycoons
maize meal she is given each month, the fam-
countries (all poor) where the proportion of
and cabinet ministers can afford proper
ily would starve.
orphans doubled, tripled or quadrupled bet-
treatment. The death toll is worse than any-
Many are less fortunate. About half of all
ween 1994 and 1997. However good the care
thing Peter McDermott, who runs the Zam-
Zambian children are malnourished to the
of these children, it is hard to imagine robust
bian office of Unicef, the UN'S agency for
point of being stunted, a fifth severely so.
economic growth where so many adults are
children, has seen in the numerous war
Lack of food hinders these children's mental
dying in their productive prime, leaving the
zones where he has worked. Most of those
development. Lack of education retards
very young and the very old to cope alone.
who die are mothers or bread-winners. Esti-
young brains still further: half of rural chil-
35
THE ECONOMIST AUGUST 14TH 1999
THE NEW YORK TIMES EDITORIALS/LETTERS MONDAY, AUGUST 23, 1999
Drugs for AIDS in Africa
The average African nation spends less than
to recover the research and development costs of
$10 per person each year on health care. The mix of
all their projects, even the unsuccessful ones.
drugs, including the new protease inhibitors, neces-
The drug companies, and the Clinton Adminis-
sary to turn AIDS from a death sentence into a
tration's trade negotiators, have fought the efforts
chronic disease costs at least $12,000 per person
of third-world countries to manufacture or import
each year. That disparity virtually guarantees that
cheap versions of still-patented drugs. American
most of the 22 million Africans infected with the
trade pressure on Thailand throughout the 1990's,
AIDS virus will not get the best available treatment.
for example, caused the country to put restrictions
Few will even be able to afford less expensive life-
on its manufacture of cheap patented drugs and ban
prolonging drugs such as AZT or ddI or - far
their import, which AIDS doctors say reduced the
cheaper and just as crucial - medicines to fight the
country's ability to fight the disease.
infections that accompany AIDS.
What really worry the drug industry today,
Washington is now arguing with South Africa
however, are the new intellectual property rules of
about a new law in that country that could allow
the World Trade Organization. Over Washington's
South Africa to make cheap versions of still-patent-
objections, poor nations won the right to make
ed drugs or import them at less than the manufac-
patented drugs in certain situations, especially
turers want to charge. The debate is important, and
when there is a "national emergency." While Wash-
it has revealed the need to broaden the Administra-
ington says it objects to technicalities in the new
tion's policy, which has been dominated by trade
South African law, the larger reason trade officials
issues and the desire to protect American pharma-
have pressed so hard is that the industry fears
ceutical patents. Washington should stop pressuring
South Africa could set precedents, within the
South Africa to change the law, but even then far
world's trade rules, for the manufacture of cheap
more will need to be done to get lifesaving medi-
drugs. Drug makers have sued in South African
cines to poor Africans with AIDS.
courts to block the law.
While defending intellectual property is impor-
tant, the narrowness of the Administration's views
Part of the challenge is to increase the avail-
is dismaying. Pharmaceutical companies would
ability of already affordable drugs. Last month, the
lose little if they found legal and controllable ways
Administration announced a $100 million effort to
to let poor countries - which offer scant market
fight AIDS in Africa. It will buy and help countries
anyway - reproduce drugs or buy them cheaply.
use some cheap treatments, like medicines for
In addition, some of the most important AIDS
tuberculosis and other AIDS-related infections and
drugs were discovered in the National Institutes of
drugs to prevent mother-child transmission.
Health, or with Government grants. Two examples
While some pharmaceutical manufacturers,
are ddI and the protease inhibitor Norvir. That
most recently Bristol-Myers Squibb, are making
financing may well give Washington the right to
substantial donations to fight AIDS in poor coun-
allow the World Health Organization to license the
tries, they want to see governments or health
drugs' manufacture, for sale only in poor nations in
organizations bear the cost of AIDS drugs. But most
case of emergency. The Administration should ex-
of the newer ones are far too expensive. Many third-
plore this option for all such vital medicines devel-
world countries have long responded to the high
oped at taxpayer expense. The desires of America's
cost of patented drugs by copying them, sometimes
pharmaceutical companies have been the over-
for a tenth of the patented price. The pharmaceuti-
whelming force driving American policy on the
cal industry argues that this pirating discourages
issue of drugs in poor nations. Surely the needs of 35
the search for new medicines, as patented drugs
million people infected with H.I.V. worldwide should
are priced high in part to allow manufacturers
count for more.
Princeton N. Lyman
Facing a Global AIDS Crisis
Washington Post
vsbc
noffhe toll from the HIV/AIDS epidemic is
or intellectual property protection. The
companies and African and other nations
relatively low-cost medicine available free
becoming more evident each day. Last year
South African challenge is technically not
under siege. This is the discovery of a
or at least at cost, and the governments of
close to 2 million people worldwide died
aimed at AIDS medicines per se. But the
relatively simple means of interrupting the
Asia and Africa to launch and oversee the
from the disease. The number of AIDS
confrontational attitude behind these chal-
transmission of HIV from an infected
program.
orphans is horrifying: 8.3 million children,
lenges has its origins in the AIDS crisis.
mother to the unborn child. At least this
This is still a small step toward control-
according to UNICEF.
Most African countries would be unable
much could be addressed now.
ling this disease. Some day, a much greater
Less well reported is the growing eco-
to administer the complex use of AIDS
Such a partnership would involve major
partnership will be needed to administer a
nomic impact. In Zimbabwe, companies
"cocktails" even if the price were within
donors, such as the United States, to cover
vaccine, once it is developed. For now,
report training seven workers for each job,
as the death roll is so great. In Zambia,
reach. But a new development has offered
the administrative costs, UNICEF to en-
however, pharmaceutical companies,
colleges graduated 300 new teachers last
the prospect of a partnership between the
sure proper ministration of the medicine,
which have been notoriously insensitive to
year; but AIDS took the lives of 600. In
the pharmaceutical companies to make this
the underlying crisis when vigorously de-
international community, pharmaceutical
fending their patent rights (Bristol-Myers
South Africa, analysts predict that the
being a welcome exception), can demon-
epidemic could kill up to 10 percent of the
strate concern in a tangible way.
mitting work force each year. AIDS will
For Vice President Al Gore, dogged by
drive up the payroll costs of this critical
protesters over his alleged defense of the
industry in South Africa by 45 percent, an
pharmaceutical industries' claims against
industry already racked by falling world
South Africa, this would be a most appro-
prices.
priate initiative to lead. It would have far
While the impact today is greatest in
more impact than the extra $100 million
Africa, the rate of spreading infection in
request for HIV/AIDS he recently an-
South Asia is one of the most rapid in the
nounced with Archbishop Desmond Tutu,
world, threatening havoc in that already
as welcome as that is.
volatile region within a decade.
The HIV/AIDS epidemic is perhaps the
Faced with this devastating epidemic,
most serious source of future social and
African countries have become increas-
economic upheaval in large parts of the
ingly frustrated with the gap between the
world today. It demands initiatives far
industrialized countries' ability to treat
greater than anything done so far. A
AIDS patients, and thus lower death rates,
and their own lack of the resources to do
public-private partnership as described
here could be the forerunner of the kind
SO. This has led to attacks on the patent
rights of pharmaceutical companies, by
that eventually will be needed.
South Africa in particular, and challenges
to these rights by others in the World
The writer, a former U.S.
Health Organization.
ambassador to South Africa, is a
Led by Zimbabwe, countries are arguing
visiting fellow at the Overseas
that health should take priority over trade
ASSOCIATED PRESS
Development Council.
AIDS IN THE THIRD WORLD
Bernard gand, 1999
AIDS was already devastating Africa.
So far, the worst-hit areas are east and
southern Africa. In Botswana, Namibia,
Swaziland and Zimbabwe, between a fifth
and a quarter of people aged 15-49 are af-
flicted with HIV or AIDS. In Botswana, chil-
dren born early in the next decade will
have a life expectancy of 40; without AIDS,
it would have been nearer 70. Of the 25
monitoring sites in Zimbabwe where preg-
nant women are tested for HIV, only two in
1997 showed prevalence below 10%. At the
remaining 23 sites, 20-50% of women were
infected. About a third of these women will
pass the virus on to their babies.
The region's giant, South Africa, was
largely protected by its isolation from the
rest of the world during the apartheid years.
Now it is host to one in ten of the world's
new infections-more than any other coun-
try. In the country's most populous prov-
ince, KwaZulu-Natal, perhaps a third of sex-
ually active adults are HIV-positive.
Asia is the next disaster-in-waiting. Al-
ready, 7m Asians are infected. India's 930m
people look increasingly vulnerable. The
Indian countryside, which most people
imagined relatively AIDS-free, turns out not
A global disaster
to be. A recent study in Tamil Nadu found
over 2% of rural people to be HIV-positive:
500,000 people in one of India's smallest
states. Since 10% had other sexually trans-
mitted diseases (STDS), the avenue for fur-
PIETERMARITZBURG, HARARE, KAMPALA
ther infections is clearly open. A survey of
female STD patients in Poona, in Maha-
The AIDS virus has infected 47m people, and shows no signs of slowing. It
rashtra, found that over 90% had never had
cannot be cured. Can it be curbed?
sex with anyone but their husband; and yet
13.6% had HIV. China is not far behind.
I
N RICH countries AIDS is no longer a
diarrhoeal disorders and tuberculosis. It
No one knows what AIDS will do to
death sentence. Expensive drugs keep
now claims many more lives each year
poor countries' economies, for nowhere
HIV-positive patients alive and healthy,
than malaria, a growing menace, and is still
has the epidemic run its course. An op-
perhaps indefinitely. Loud public-aware-
nowhere near its peak. If India, China and
timistic assessment, by Alan Whiteside of
ness campaigns keep the number of in-
other Asian countries do not take it seri-
the University of Natal, suggests that the ef-
fected Americans, Japanese and West Euro-
ously, the number of infections could reach
fect of AIDS on measurable GDP will be
peans to relatively low levels. The sense of
"a new order of magnitude", says Peter Piot,
slight. Even at high prevalence, Mr White-
crisis is past.
head of the UN'S AIDS programme.
side thinks it will slow growth by no more
In developing countries, by contrast,
The human immuno-deficiency virus
than 0.6% a year. This is because so many
the disease is spreading like nerve gas in a
(HIV), which causes acquired immune defi-
people in poor countries do not contribute
gentle breeze. The poor cannot afford to
ciency syndrome (AIDS), is thought to have
much to the formal economy. To put it even
spend $10,000 a year on wonder-pills. Mil-
crossed from chimpanzees to humans in
more crudely, where there is a huge over-
lions of Africans are dying. In the longer
the late 1940s or early 1950s in Congo. It
supply of unskilled labour, the dead can
term, even greater numbers of Asians are at
took several years for the virus to break out
easily be replaced. Some people argue that
risk. For many poor countries, there is no
of Congo's dense and sparsely populated
those who survive the epidemic will benefit
greater or more immediate threat to public
jungles but, once it did, it marched with
from a tighter job market. After the Black
health and economic growth. Yet few po-
rebel armies through the continent's nu-
Death killed a third of the population of
litical leaders treat it as a priority.
merous war zones, rode with truckers from
medieval Europe, labour scarcity forced
Since HIV was first identified in the
one rest-stop brothel to the next, and even-
landowners to pay their workers better.
1970S, over 47m people have been infected,
tually flew, perhaps with an air steward, to
Other researchers are more pessimistic.
of whom 14m have died. Last year saw the
America, where it was discovered in the
AIDS takes longer to kill than did the
biggest annual death toll yet: 2.5m. The dis-
early 1980s. As American homosexuals and
plague, so the cost of caring for the sick will
ease now ranks fourth among the world's
drug injectors started to wake up to the
be more crippling. Modern governments,
big killers, after respiratory infections,
dangers of bath-houses and needle-sharing,
unlike medieval ones, tax the healthy to
42
THE ECONOMIST JANUARY 2ND 1999
AIDS IN THE THIRD WORLD
help look after the ailing, so the burden will
ous, AIDS could break budgets and hobble
War. Refugees, whether from genocide in
fall on everyone. And AIDS, because it is sex-
the provision of services. In South Africa,
Rwanda or state persecution in Myanmar,
ually transmitted, tends to hit the most en-
an estimated 15% of civil servants are HIV-
spread HIV as they flee. Soldiers, with their
ergetic and productive members of society.
positive, but government departments
regular pay and disdain for risk, are more
A recent study in Namibia estimated that
have made little effort to plan for the com-
likely than civilians to contract HIV from
DS cost the country almost 8% of GNP in
ing surge in sickness. Education, too, will
prostitutes. When they go to war, they infect
6. Another analysis predicts that Ke-
suffer. In Botswana, 2-5% of teachers die
others. In Africa the problem is dire. In
nya's GDP will be 14.5% smaller in 2005
each year from AIDS. Many more take ex-
Congo, where no fewer than seven armies
than it would have been without AIDS, and
tended sick leave.
are embroiled, the government has accused
that income per person will be 10% lower.
At a macro level, the impact of AIDS is
Ugandan troops (which are helping the
felt gradually. But at a household level, the
Congolese rebels) of deliberately spreading
The cost of the disease
blow is sudden and catastrophic. When a
AIDS. Unlikely, but with estimated HIV
In general, the more advanced the econ-
breadwinner develops AIDS, his (or her)
prevalence in the seven armies ranging
omy, the worse it will be affected by a large
family is impoverished twice over: his in-
from 50% for the Angolans to an incredible
number of AIDS deaths. South Africa, with
come vanishes, and his relations must de-
80% for the Zimbabweans, the effect is
its advanced industries, already suffers a
vote time and money to nursing him.
much the same.
shortage of skilled manpower, and cannot
Daughters are often forced to drop out of
Sexism. In most poor countries, it is hard
afford to lose more. In better-off developing
school to help. Worse, HIV tends not to
for a woman to ask her partner to use a con-
countries, people have more savings to fall
strike just one member of a family. Hus-
dom. Wives who insist risk being beaten
bands give it to wives, mothers to babies.
AIDS, the killer
This correspondent's driver in Kampala
Life expectancy, years
lost his mother, his father, two brothers and
Africa, the target
70
Adults and children estimated to be living
their wives to AIDS. His story is not rare.
with HIV/AIDS, end 1998, m
Botswana
65
Sub-Saharan
South &
South Africa
60
Obstacles to prevention
Africa 22.5
South-East Asia 6.7
Swaziland
The best hope for halting the epidemic is a
South America &
55
cheap vaccine. Efforts are under way, but a
Caribbean 1.73
Zimbabwe
50
vaccine for a virus that mutates as rapidly
North America 0.89
45
as HIV will be hugely difficult and expen-
Europe &
40
sive to invent. For poor countries, the only
Central Asía 0.77
35
practical course is to concentrate on pre-
East Asía &
Australasia 0.57
s
vention. But this, too, will be hard, for a
1993
94
95
96
97
plethora of reasons.
North Africa &
98
Middle East 0.21
Sources: UNDP; US Bureau of the Census
f'cast
Sex is fun Many feel that condoms
Sources: UNAIDS; WHO
make it less so. Zimbabweans ask: "Would
back on when they need to pay medical
you eat a sweet with its wrapper on?"
up. Rape is common, especially where wars
bills. Where people have health and life in-
and discussion of it often taboo. In Ke-
rage. Forced sex is a particularly effective
surance, those industries will be hit by big-
nya, Christian and Islamic groups have
means of HIV transmission, because of the
ger claims. Insurers protect themselves by
publicly burned anti-AIDS leaflets and con-
extra blood.
charging more or refusing policies to HIV-
doms, as a protest against what they see as
Drinking. Asia and Africa make many ex-
positive customers. In Zimbabwe, life-in-
the encouragement of promiscuity. A study
cellent beers. They are also home to a lot of
surance premiums quadrupled in two
in Thailand found that infected women
people for whom alcohol is the quickest es-
years because of AIDS. Higher premiums
were only a fifth as likely to have discussed
cape from the stresses of acute poverty.
force more people to seek treatment in pub-
sex openly with their partners as were unin-
Drunken lovers are less likely to remember
lic hospitals: in South Africa, HIV and AIDS
fected women.
to use condoms.
could account for between 35% and 84% of
Myths abound. Some young African
public-health expenditure by 2005, accord-
women believe that without regular infu-
How to fight the virus
ing to one projection.
sions of sperm, they will not grow up to be
Pessimists look at that list and despair. But
Little research has been done into the
beautiful. Ugandan men use this myth to
three success stories show that the hurdles
effects of AIDS on private business, but the
seduce schoolgirls. In much of southern Af-
to prevention are not impossibly high.
anecdotal evidence is scary. In some coun-
rica, Hrv-infected men believe that they can
First, Thailand. One secret of Thai-
tries, firms have had to limit the number of
rid themselves of the virus by passing it on
land's success has been timely, accurate in-
days employees may take off to attend fu-
to a virgin.
formation-gathering. HIV was first detected
nerals. Zambia is suffering power shortages
Poverty. Those who cannot afford televi-
in Thailand in the mid-1980s, among male
because so many engineers have died.
sion find other ways of passing the evening.
homosexuals. The health ministry immedi-
Farmers in Zimbabwe are finding it hard to
People cannot afford antibiotics, so the un-
ately began to monitor other high-risk
irrigate their fields because the brass fit-
treated sores from STDS provide easy open-
groups, particularly the country's many
tings on their water pipes are stolen for cof-
ings for HIV.
heroin addicts and prostitutes. In the first
fin handles. In South Africa, where employ-
Migrant labour. Since wages are much
half of 1988, HIV prevalence among drug
ers above a certain size are obliged to offer
higher in South Africa than in the sur-
injectors tested at one Bangkok hospital
generous benefits and paid sick leave, com-
rounding region, outsiders flock in to find
leapt from 1% to 30%. Shortly afterwards, in-
panies will find many of their staff, as they
work. Migrant miners (including South Af-
fections soared among prostitutes.
sicken, becoming more expensive and less
ricans forced to live far from their homes)
The response was swift. A survey of Thai
productive. Yet few firms are trying to raise
spend most of the year in single-sex dormi-
sexual behaviour was conducted. The re-
awareness of AIDS among their workers, or
tories surrounded by prostitutes. Living
sults, which showed men indulging in a
considering how they will cope.
with a one-in-40 chance of being killed by a
phenomenal amount of unprotected com-
In the public sector, where pensions
rockfall, they are inured to risk. When they
mercial sex, were publicised. Thais were
and health benefits are often more gener-
go home, they often infect their wives.
warned that a major epidemic would strike
THE ECONOMIST JANUARY 2ND 1999
43
AIDS IN THE THIRD WORLD
if their habits did not change. A "100% con-
barely literate. President Yoweri Museveni
Contrast these three with South Africa.
dom use" campaign persuaded prostitutes
recognised the threat shortly after becom-
On December 1st, World AIDS Day, Presi-
to insist on protection 90% of the time with
ing president in 1986, and deluged the
dent Nelson Mandela told the people of
non-regular customers.
country with anti-AIDS warnings.
KwaZulu-Natal that HIV would devastate
By the mid-1990s, the government was
The key to Uganda's success is twofold.
their communities if not checked. The
ending $80m a year on AIDS education
First, Mr Museveni made every govern-
speech was remarkable not for its quality-
and palliative care. In 1990-93, the propor-
ment department take the problem seri-
Mr Mandela is always able to move audi-
tion of adult men reporting non-marital
ously, and implement its own plan to fight
ences-but for its rarity. Unlike Mr Musev-
sex was halved, from 28% to 15%; for
the virus. Accurate surveys of sexual behav-
eni, South Africa's leader seldom uses his
women, it fell from 1.7% to 0.4%. Brothel vis-
iour were done for only $20,000-30,000
authority to encourage safer sex. It is a tragic
its slumped. Only 10% of men reported see-
each. Second, he recognised that his govern-
omission. Whereas the potholed streets of
ing a prostitute in 1993, down from 22% in
ment could do only a limited amount, so
Kampala are lined with signs promoting fi-
1990. Among army conscripts in northern
he gave free rein to scores of non-govern-
delity and condoms, this correspondent
Thailand, a group both highly sexed and
mental organisations (NGOS), usually for-
has, in eight months in South Africa, seen
well-monitored, the proportion admitting
eign-financed, to do whatever it took to
only two anti-AIDS posters, both in the UN'S
to paying for sex fell from 57% in 1991 to
educate people about risky sex.
AIDS office in Pretoria.
24% in 1995. The proportion claiming to
The Straight Talk Foundation, for exam-
have used condoms at their last commer-
ple, goes beyond simple warnings about
How to dither and die
cial entanglement rose from 61% in 1991 to
AIDS and deals with the confusing com-
South Africa has resources and skills on a
93% in 1995.
plexities of sex. Its staff run role-playing ex-
scale that Uganda can only marvel at. It
People lie about sex, so reported good
ercises in Uganda's schools to teach adoles-
even has an excellent AIDS prevention
behaviour does not necessarily mean ac-
cents how to deal with romantic situations.
plan, accepted by the new cabinet in 1994.
tual good behaviour. But tumbling infec-
Its newsletter, distributed free, covers every-
But the plan was never implemented. The
tions suggest that not everyone was fibbing.
thing from nocturnal emissions to what to
government likes to consult every conceiv-
The number of sexually transmitted dis-
do if raped. Visiting AIDS workers from
able "stakeholder", so new plans are eter-
eases reported from government clinics fell
South Africa and Zimbabwe asked the
nally drafted and redrafted. Local authori-
from over 400,000 in 1986 to under 50,000
foundation's director, Catharine Watson,
ties cannot act without orders from the
in 1995. Among northern conscripts, HIV
how she won government permission to
central government. NGOS, many of them
prevalence fell by half between 1993 and
hand out such explicit material, and were
dependent on the powers-that-be for their
1995, from over 7% to under 3.5%.
astonished to hear that she had not felt the
finance, waste months making sure that
Most striking was the government's suc-
need to ask.
enough of their senior management posts
cess in persuading people that they were at
The climate of free debate has led Ugan-
are filled with blacks to satisfy the ruling Af-
risk long before they started to see acquaint-
dans to delay their sexual activity, to have
rican National Congress. And they have
ances die from AIDS. There was no attempt
fewer partners, and to use more condoms.
minimal freedom to experiment.
to play down the spread of HIV to avoid
Between 1991 and 1996, HIV prevalence
"There's an idea that if you disagree
scaring off tourists, as happened in Kenya.
among women in urban ante-natal clinics
with the government, you are betraying the
Thais were repeatedly warned of the dan-
fell by half, from roughly 30% to 15%.
liberation struggle," says Mary Crewe, head
gers, told how to avoid them, and left to
Third, Senegal. If Uganda shows how a
of the Greater Johannesburg AIDS project.
make their own choices. Most decided that
poor country can reverse the track of an epi-
As a result, soldiers in the South African
a long life was preferable to a fast one.
demic, Senegal shows how to stop it from
army are so ignorant that they snip the tips
Second, Uganda. Thailand shows what
taking off in the first place. This West Afri-
off their free condoms, and HIV has spread
is possible in a well-educated, fairly pros-
can country was fortunate to be several
through South Africa as fast, according to
perous country. Uganda shows that there is
thousand miles from HIV'S origin. In the
Dr Neil McKerrow of Grey's Hospital in Pie-
hope even for countries that are poor and
mid-1980s, when other parts of Africa were
termaritzburg, as if no preventive measures
already blighted, Senegal was
at all had been taken.
still relatively AIDS-free. In
Such bungling is not unique to South
concert with non-govern-
Africa. Most governments have been slow
mental organisations and the
to recognise the threat from AIDS. From Bu-
press and broadcasters, the
lawayo to Beijing, apathy and embarrass-
government set up a national
ment have hamstrung preventive efforts.
AIDS-control programme to
In anarchic countries, such as Congo
keep it that way.
and Angola, there have been almost no pre-
In Senegal's brothels,
ventive efforts. Many people believe that
which had been regulated
the cause-a bid to restrain one of the most
since the early 1970s, condom
basic human instincts-is hopeless. As a
use was firmly encouraged.
Zimbabwean novelist, Chenjerai Hove,
The country's blood supply
puts it with disturbing fatalism: "Since our
was screened early and effec-
women dress to kill, we are all going to die."
tively. Vigorous education re-
But if the sexual drive is basic, so is the de-
sulted in 95% of Senegalese
-sire to live. If governments in poor coun-
adults knowing how to avoid
tries wake up to the need to persuade their
the virus. Condom sales
citizens that unprotected sex is Russian
soared from 800,000 in 1988
roulette, Mr Hove could be proved wrong.
to 7m in 1997. Senegalese lev-
els of infection have re-
This article is indebted to a number of UNAIDS reports,
mained stable and low for a
including AIDS epidemic update (December 1998), AIDS
in Africa (November 1998), and "A measure of success in
decade-at around 1.2%
Uganda" (May 1998).
among pregnant women.
44
THE ECONOMIST JANUARY 2ND 1999
In Africa, a Deadly Silence About AIDS Is Lif.
Page 1 of 6
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Yellow
The Dead Zones: AIDS in Africa
Looking for the Light: The AIDS Epidemic
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By LAWRENCE K. ALTMAN, M.D.
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E
arlier this year, AIDS became the leading killer in Africa, a
mere 18 years after the infection was first recognized. But if
Update
political and religious leaders had responded with effective
LIFE
public health programs much earlier, they might have prevented
Food
hundreds of thousands, if not millions, of deaths.
Home
Fashio
Some leaders simply denied the scientific evidence that H.I.V. was
Health
How to
being transmitted in their countries. Others mistakenly believed
they had more pressing health problems to address.
NEIGH
Near M
Now, as the epidemic in Africa
Near M
becomes an even greater catastrophe,
Other A
Dr. Peter Piot, Assistant Secretary
General of the United Nations and head
NEWYC
of its AIDS programs, says he sees
signs of momentum among African
AD
leaders to fight the disease. The
momentum promises to slow the
relentless transmission of H.I.V.,
conveyed on the continent primarily
through heterosexual sex, Dr. Piot said
in an interview.
Nelson Mandela, the former President
of South Africa; his successor, Thabo
Ruby Washington/ The New York
Mbeki, and Dr. Negasso Gidada, the
.
Times
President of Ethiopia, are among the
Dr. Peter Piot, the Assistant
leaders of countries with high infection
Secretary General in charge
of the United Nations AIDS
rates to speak out on AIDS for the first
program, said he is finding a
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7/13/99
In Africa, a Deadly Silence About AIDS Is Lif.
Page 2 of 6
time recently in their own countries and
program, said he is finding a
new attitude toward the
to put more money into prevention
disease among African
efforts.
leaders.
And, in May, at their annual meeting in Addis Ababa, Ethiopia,
African finance ministers for the first time called AIDS a major
threat to economic and social development.
The United Nations General Assembly recently called for a 25
percent reduction in new H.I.V. infections among young people
over the next five years in the countries most affected by AIDS.
And the Clinton Administration, appalled by the staggering
dimensions of the African AIDS epidemic, is planning an
initiative to help, Dr. Piot said.
Large-scale efforts clearly are needed. In sub-Saharan Africa,
H.I.V. has infected 34 million people and killed 11.5 million since
1981, dwarfing malaria and tuberculosis. Last year, AIDS
accounted for 1.8 million deaths in sub-Saharan Africa, nearly
double the 1 million deaths from malaria and about nine times the
209,000 deaths from tuberculosis, according to Dr. Piot's agency,
which has headquarters in Geneva.
B
ased on meetings with leaders of 10 African countries this
year, Dr. Piot says he has noted a striking change in attitudes
toward AIDS: at earlier meetings, he initiated discussions
about AIDS; at the recent sessions, African leaders admitted their
problems and asked for help.
"It is such a big change," Dr. Piot, a 50-year-old Belgian and a
pioneer in AIDS research in Africa, said in a brief visit to New
York. In years past, Dr. Piot said, even meeting with an African
head of state was difficult.
He recalled an incident about 15 years ago when he and another
AIDS expert waited nearly a day in the office of the Kenyan
Minister of Health while officials debated whether to expel the
two because they had talked to reporters about AIDS in Kenya.
In 1985, Zaire refused to give me a visa to report on AIDS, and
the Government of Kenya confiscated issues of The International
Herald Tribune, which carried my articles, because of its
displeasure with my coverage of AIDS there.
African political leaders remained silent even when AIDS was
killing members of their own families.
In 1985, the press secretary to Kenneth D. Kaunda, then the
President of Zambia, denied my request for an interview about
AIDS. The press secretary threatened to expel me for reporting on
what he called an American disease. A year later, Kaunda lost a
son to AIDS.
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In Africa, a Deadly Silence About AIDS Is Lif.
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In 1989, Kaunda was one of the first to speak out. In describing
his family's loss at an international AIDS meeting in Montreal,
Kaunda said that if scientists failed to cure AIDS, the epidemic
would become "a soft nuclear bomb on human life." But in the
years of Kaunda's silence, hundreds of thousands of Africans
became infected.
Yet even now realism has not fully set in. Dr. Piot still encounters
government officials who "ask why I use the word epidemic," he
said.
t takes an average of nine years for H.I.V. to progress to AIDS,
and the virus spread widely and silently for a decade before
being discovered. Yet even with the undetected early spread,
there was time to initiate programs to prevent subsequent
infections, as was done effectively among gay men in the United
States and other developed countries.
In South Africa, H.I.V. rates soared during Nelson Mandela's
Administration, a fact that he later acknowledged.
"It's the silence that is letting this disease sweep through the
country," Mandela said on World AIDS Day in December. "It is
time to break the silence."
Dr. Piot applauded Mandela and Mbeki, his successor, for calling
national attention to AIDS, but said, "It took a long time, and a lot
of deaths could have been prevented if they had spoken out
earlier."
Today, AIDS continues to thin the ranks of Africa's small middle
class, killing at least one teacher a day in Malawi and the Ivory
Coast. It is devastating already weak economies across Africa and
forcing children to drop out of school to till the farms and care for
sick parents.
Dr. Piot challenged African finance ministers at their annual
meeting in Addis Ababa in May to learn more about how AIDS
was devastating their economies.
"After my speech, there was dead silence," Dr. Piot said. "I
thought, another of those moments of supreme denial."
But then, he added, "One after the other, the finance ministers
spoke, often making personal references to AIDS in the family or
a colleague."
That evening, many joined him for a drink.
"The problem was how to stop the discussions," Dr. Piot said.
"That was a great moment for me."
The next day, Dr. Gidada, the President of Ethiopia, and His
Holiness Abune Paulos, the Patriarch of the Ethiopian Orthodox
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In Africa, a Deadly Silence About AIDS Is Lif.
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Church, shook hands as they met publicly for the first time with
H.I.V.-infected Ethiopians, Dr. Piot said.
"That may have been a small thing, but it was highly symbolic in
Africa," he added. Yet it was a gesture that political leaders
elsewhere had made in the 1980's.
Uganda, which acted early, showed that educational programs
could change sexual behavior after AIDS had struck in vast
numbers.
Senegal and Brazil also thwarted the assault of AIDS, Dr. Piot
said, taking "vigorous action" on sex education, AIDS prevention
and condom promotion to keep the infection rate below 2 percent.
"It is a major political challenge to invest in AIDS prevention
when there is not a huge problem," Dr. Piot said, "yet that is
exactly what Senegal has done."
Through programs that political and religious leaders encouraged,
the Senegalese postponed having first sexual intercourse, used
condoms more often and had sex with fewer partners and less sex
with prostitutes, surveys there showed.
Nigeria, Africa's most populous country, stands in stark contrast,
with an infection rate of about 9 percent and rising. A new regime
appears to be willing to tackle the AIDS problem in Nigeria,
which the previous regime denied, Dr. Piot said.
D
r. Piot's team has a budget of $60 million a year, only enough
to act as a catalyst for others to undertake prevention efforts.
His AIDS team, for example, calls on African leaders to urge
drastic efforts to fight the epidemic.
The latest figures show that international aid paid for $150 million
of the $165 million spent on AIDS prevention in Africa in 1997.
Uganda accounted for much of the $15 million that the African
countries spent.
"It's a scandal that African countries have not spent more," Dr.
Piot said.
Although the World Bank and other international agencies make
money available for projects in Africa, much of it goes unspent
because of bureaucratic complexities and other problems.
Dr. Piot said his agency was trying to identify untapped funds to
direct toward prevention efforts, while recognizing that those
nations "cannot afford everything for AIDS, certainly not lifetime
anti-retroviral drugs."
Taken in combination, those drugs can cost $15,000 a year for a
single patient, require adherence to rigid schedules, and often
demand sophisticated monitoring tests unavailable in developing
countries. That means few Africans can benefit from the drug
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In Africa, a Deadly Silence About AIDS Is Lif...
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cocktails, which are prolonging lives and often restoring health
among H.I.V.-positive people in developed nations.
To reach a largely captive audience, and one in its sexual prime,
Dr. Piot is encouraging governments to spend more of their
military budgets, which usually receive high priority, on AIDS
prevention.
In Uganda, the infection rate is about 10 percent in the general
population and up to 30 percent in the military. "There are African
countries where it is said that more than 50 percent of all the
military are H.I.V. infected," Dr. Piot said, "and that is a problem
of national security."
It also means that many spouses and children are infected. So Dr.
Piot's team aims to encourage teachers' unions, school systems and
youth groups to join prevention programs in Africa.
In some West African countries, for example, Scouting groups
have created an AIDS badge for those who do good deeds for
people with H.I.V., Dr. Piot said.
His agency has also teamed on AIDS efforts with Caritas, a
Catholic health agency based in the Vatican that is responsible for
health care in many African countries, Dr. Piot said.
Although the Vatican does not approve of the use of condoms, Dr.
Piot said that he had seen many Catholic priests, nuns and
organizations promote condom use in Africa.
n June 1998, Dr. Piot's agency issued the first
country-by-country analysis of H.I.V. It showed that one in four
adults was infected with H.I.V. in certain parts of Africa and
that AIDS was hitting so fiercely that it compared to the greatest
epidemics of history. The report was a crucial factor in changing
political attitudes, Dr. Piot said.
Dr. Piot said he was criticized for the report by many Western
epidemiologists and health workers, who called the figures
exaggerated.
"A lot of the criticism had to do with turf battles, from scientists
who believe their disease is more important than someone else's,"
Dr. Piot said, "and it's the type of nonsensical competition that
exists in all countries."
But now, the criticism has come full circle. In 1992, a team headed
by the late Dr. Jonathan M. Mann at the Harvard School of Public
Health, published estimates of H.I.V. infections in sub-Saharan
Africa ranging from 20.8 million to 33.6 million by 2000.
The World Health Organization criticized Dr. Mann's estimates as
excessive. Now, academic scientists are criticizing the figures of
Dr. Piot's team. "When we look at the figures today, they are
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In Africa, a Deadly Silence About AIDS Is Lif.
Page 6 of 6
worse than the scenarios Jonathan had published," Dr. Piot said.
L
arger budgets are needed. But pumping money into a country
where AIDS is a low priority will not end the epidemic. "If a
country does not recognize that it has an AIDS problem, then
it is not willing to take on the tough questions," Dr. Piot said.
"Outside support for something that can only be solved from the
inside will not work.
"We can only win," he added, "if there is a mass movement."
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http://www.nytimes.com/library/national/science/aids/071399hth-doctors.html
7/13/99
ANNEX 2. HIV/AIDS PREVALENCE RATES FOR SSA
Adult (15-49 Years) HIV/AIDS Prevalence Rates, Sub-Saharan Africa, December 1997
Rank
Country
Adult HIV/AIDS
Rank
Country
Adult HIV/AIDS
rate (percent)
rate (percent)
1
Zimbabwe
25.84
23
Democratic Republic
4.35
of Congo
2
Botswana
25.10
24
Gabon
4.25
3
Namibia
19.94
25
Nigeria
4.12
4
Zambia
19.07
26
Liberia
3.65
5
Swaziland
18.50
27
Eritrea
3.17
6
Malawi
14.92
28
Sierra Leone
3.17
7
Mozambique
14.17
29
Chad
2.72
8
South Africa
12.91
30
Ghana
2.38
9
Rwanda
12.75
31
Guinea-Bissau
2.25
10
Kenya
11.64
32
Gambia, The
2.24
11
Central
African
10.77
33
Angola
2.12
Republic
12
Djibouti
10.30
34
Guinea
2.09
13
Côte d'Ivoire
10.06
35
Benin
2.06
14
Uganda
9.51
36
Senegal
1.77
15
Tanzania
9.42
37
Mali
1.67
16
Ethiopia
9.31
38
Niger
1.45
17
Togo
8.52
39
Equatorial Guinea
1.21
18
Lesotho
8.35
40
Mauritania
0.52
19
Burundi
8.30
41
Somalia
0.25
20
Republic of Congo
7.78
42
Comoros
0.14
21
Burkina Faso
7.17
43
Madagascar
0.12
22
Cameroon
4.89
44
Mauritius
0.08
Note: Adult rates (percent) are derived from the number of adults (15-49 years) living with HIV/AIDS at the end of
1997 divided by the 1997 adult population.
Source: UNAIDS, 1998a.
56