TOPICS > Health

AIDS in Africa

July 10, 2003 at 12:00 AM EDT
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RAY SUAREZ: For more now on the challenges faced in Botswana, South Africa, and the rest of the continent, we get three perspectives. Caesar Lekoa is Botswana’s ambassador to the U.S. Dr. Mamphela Ramphele is originally from South Africa, and a managing director for health and education at the World Bank. And Josh Ruxin is a professor of public health at Columbia University, and a coordinator on the U.N. Millennium Project taskforce focused on HIV and AIDS. He’s worked extensively on the African continent, and recently returned from Rwanda.

Well, Mr. Ambassador, just a few moments ago we saw President Bush with your President Mogae, promising a partner with Botswana in the fight against AIDS, and eventually funding as well. Does this give you what you need to continue the fight?

CAESAR LEKOA: Yes, it does. In Botswana, we think HIV/AIDS is a big problem, and that really – at least speaking for Botswana — it will be very, very difficult for the country to deal with the problem on its own. We need all the friends that we can get, including the United States. So any assistance promised or pledged by the president is welcome.

RAY SUAREZ: Professor Ruxin, does the Bush initiative really change the prognosis, or does it call attention in a way that hadn’t been before?

JOSH RUXIN: Absolutely, Ray. For the past few years, we have been dreaming of hundreds of millions of dollars to combat this virus in the world. Today we’re now talking about billions of dollars, so that’s a great step forward. However, it’s important to point out that it’s still a small fraction of what would be needed, which would be in excess of $10 billion a year.

RAY SUAREZ: And Dr. Ramphele, in the way these things work in the world community, does a country like the United States putting down its marker, so to speak, on an issue like this one, help create consensus, help create coalitions?

DR. MAMPHELA RAMPHELE: It certainly does. And I think it’s particularly exciting coming at the back of the Abuja conference last year. We must remember it was African leaders, convened by the secretary general of the United Nations, who made a commitment that they would like to tackle this issue. They wanted to ban the silence that had been allowing this epidemic to grow. And now, with partners coming to support African leaders to tackle this epidemic, I’m very encouraged.

RAY SUAREZ: Professor Ruxin, looking over the continent as a whole, give us the state of the epidemic right now.

JOSH RUXIN: Well, Ray, I think it’s pretty much a catastrophe, I’m sad to report right now, with 30 million HIV-Infected, and those 30 million infections having occurred during the past seven years.

We’re still very much behind the epidemic, whether in Botswana or in other countries. But I think Botswana really does offer some rays of hope. They’ve got 6,000 people on anti-retroviral drugs. They’re demonstrating, with a good public healthcare system, that you actually can treat people and you can avert death and allow people to live healthy lives.

When you look at poorer countries like Rwanda, where I recently was, you find that there’s enormous political leadership. People are really coming together, but the finances are not necessarily yet in place, which is why the Bush proposal is so promising right now, though I would like to emphasize that dollars are not enough. You can’t clean up a puddle with a dollar bill. And you really do have to focus on health infrastructure and capacity and training. This is a fight and an effort that is going to take many decades before we overcome it.

RAY SUAREZ: Well, Mr. Ambassador, you just heard the professor cite Botswana as a positive example because now 6,000 people are on drug treatment. But even that 6,000 is only a small percentage of your overall infected population. How do you get to where you need to be?

CAESAR LEKOA: I think, like the professor says, we recognize that it is a drop in the ocean, but still that it is a good start. The government’s intention is to expand in the first place the physical infrastructure in terms of upgrading and improving facilities in the existing hospitals, and secondly and most importantly, building human resource capacity. That is the main constraint for the government. But we think that once we get some of these things in place, we’ll be able to move the program much faster than it is at the moment.

RAY SUAREZ: As a result of all the things you’re doing in Botswana, will your countrymen and women, who are not HIV- positive, be anymore likely to see doctors regularly, to get drugs for other illnesses regularly? Is this lifting the entire public health system in effect, this crisis?

CAESAR LEKOA: It is I think, because, especially with the launching of the IRV Program, whereas in the past there was no need in the view of the people that were being encouraged to go for testing. There was no need to go and test, because one was going to die anyway.

With the launching of the – or the introduction of – the anti-retroviral drugs it gives us a hope and a reason for testing. So we see a lot of encouraging signs in terms of the response to the testing, because then they know that there will then be a remedy, and at least the affected…infected people could live normal lives.

RAY SUAREZ: Well, Dr. Ramphele, Botswana is being held up as an example. It’s small. Its caseload is relatively small. And it’s also a single-language, largely single-ethnic-group state, as opposed to South Africa, which is big, multilingual, multi-ethnic, and has many times more cases. How does this make your job tougher, and what is South Africa doing?

DR. MAMPHELA RAMPHELE: I believe that both Botswana and other countries in Africa offer both the challenge and the opportunities. You’ve talked about Botswana. In South Africa, we have an interesting situation – sad in that the problem of HIV/AIDS is two decades old in South Africa.

All governments up to date have really not taken off at the level in terms of attacking this fight that they could have. And there is something about South Africa which I think is important to highlight, which is the depth of research, the depth of the health system in South Africa, the depth of the civil society in South Africa, the private sector. So South Africa, in an interesting way, is turning this adversity into an opportunity for people to work together at different levels.

So even though the national program could be better, could be stronger, many more provinces now have got a comprehensive package ranging from awareness creation right through to treatment, and the results are very encouraging.

RAY SUAREZ: So you can make up for some of the time lost in that slow start?

DR. MAMPHELA RAMPHELE: It’s unfortunate that you can’t make up for the people who have died unnecessarily, but what I do feel very encouraged by is that we are now making up for lost time for those who are still alive. We have cases in [Kailita], one of the poorest townships, where people who are HIV-positive and giving up hope last year are now up and walking.

Because of the interventions by a combination of the provincial administration and civil society, people are becoming willing to come forth for testing, to actually go on to treatment, and keep with it. The fear that was there for resistance among poor people because there would be unreliable intake in their treatment has actually proven not to be the case. People, once they’re given hope, hang on to it.

RAY SUAREZ: Professor Ruxin, during the week that the president’s in Africa, we’re seeing countries where the HIV Infection rate is well into the double digits at some breathtaking levels, but also seeing some countries like Senegal with only a 2 percent infection rate, Uganda with an 8 percent infection rate. How do we understand the differences between these two countries? What’s different about the countries where they’ve managed to keep the infection rate fairly low?

JOSH RUXIN: Well, Uganda previously did have a rather high infection rate, and a couple of things happened. Firstly, they implemented a pretty comprehensive prevention and treatment program. And we should note that you have to have those two together. When people know that they’ll have access to treatment, they’re more likely to go in to be tested. They’re more likely to be open to listening to prevention messages. But, unfortunately, in Uganda, a lot of people had to die before that program was put fully in place.

I think that if there were any one characteristic you could look to, it would be transparency in the government and an enormous level of political leadership in places like Senegal and Uganda.

RAY SUAREZ: And I guess that doesn’t bode well, you might say, for the people who unfortunately live in countries where the government is going through some turmoil now?

JOSH RUXIN: Well, I think when we look at countries like South Africa, for example, which according to one documentary maker is in a state of denial right now, at least as far as the president and the minister of health are concerned, regarding the AIDS crisis there, we see some very worrying signs.

And when you run your hand around the world, I think you see similar signs in places like China and India. And of course, there are always leaders who are ready to step forward and take on the fight, but we don’t have enough leaders who are really willing to push this to the very top of the agenda.

RAY SUAREZ: Well, Mr. Ambassador, how an African experiences the medical system, how an African experiences treatment once he or she realizes they’re infected, is quite different from what somebody in Toronto or Chicago might face.

Should the ambition be, for those who are HIV positive, to receive treatment that is more similar to that received in other places in the world, or to find an African solution that, given the much smaller budgets, the much smaller public health systems, does the best you can with what you’ve got?

CAESAR LEKOA: Well, I think, given the resource constraints of African countries — at least talking about my country — I think we could do with, not necessarily inferior drugs in terms of quality, but drugs that are reduced in cost. How we arrive at the formula of reduced cost is something else, but I think to provide affordability, at least in my country, we could do with cheaper drugs.

RAY SUAREZ: And aren’t you getting cheaper drugs as part of the program that Botswana is one of the pilots, the pioneers in developing?

CAESAR LEKOA: Yes, we are, through the partnership with MERCK and Bill and Melinda Gates.

RAY SUAREZ: But I guess the money isn’t there quite yet, Dr. Ramphele, to make that access to cheaper drugs universal?

DR. MAMPHELA RAMPHELE: I think the question of cost of drugs is both money as well as the extent to which the pharmaceutical industry works in partnership with the rest of us. The World Bank, for example has committed in Africa a billion dollars for multi-country assistance to countries that are poorer than Botswana. And that money is to cover everything from awareness-creation up to anti-retrovirals.

And I believe that the availability of that kind of money coming alongside the strengthening of health systems, the building of the capacity of people to actually tackle this, is going to create a larger market. And over time, there will be a reduction in the cost of drugs.

But we also have to remember that there is a place for generic drugs. We have seen in the case of Brazil which has, in fact, developed a local generic drug industry that has helped them to sustain coverage of their populations with anti-retrovirals drugs, so they are a multiplicity of opportunities that we have. We also have the world trust fund that is bringing cash and grant money on to the scene.

In the case of countries like Botswana, Swaziland and others that don’t qualify for World Bank grants and cheaper credits, we are working in partnership with the Global Trust Fund to be able to complement their cash with our implementation and other support, so that we can in every country at the end of the next five or ten years, really in a much stronger position than they are right now in terms of their health systems, the human capabilities, and, of course, healthier people.

RAY SUAREZ: Guests, thank you all very much.