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ELIZABETH FARNSWORTH: The Africa/AIDS catastrophe has many faces: The sick and dying; The mourners at graveside; Orphans who sing longingly about waking up the dead; The volunteers who try to help. These scenes are from Botswana and Malawi, but they could be almost any country in sub-Saharan Africa, where 25 million people are infected with the virus that causes AIDS. Seventeen million people in Africa have already died of AIDS, and millions more are dying now.
MARYLINE MULEMBA: If you would say, “tomorrow one million people will die because of an earthquake,” everybody would rush here and bring help. But these people will die slowly and in silence, more or less. The help coming in is still very small.
ELIZABETH FARNSWORTH: The response from African governments has varied greatly. Malawi is pushing hard on prevention, but the government lacks resources to do much in the way of treatment. Botswana, with its diamond wealth and with help from abroad, is about to offer life- saving anti-retroviral drugs to all who need them. South Africa’s President Tabo Mbeki has raised questions about the causes of aids and the link between HIV and the disease. But his government has also taken steps to access cheaper generic AIDS drugs and the technology to manufacture them. About 4.5 million people in South Africa are HIV-positive.
Internationally, a campaign by AIDS activists succeeded last year in getting drug companies to lower prices for the anti- retroviral medications. But even at prices 90 percent lower than in the U.S., drugs are still beyond the reach of most Africans, and there is a debate among those working on AIDS in Africa and elsewhere about whether the current emphasis on drugs is taking the spotlight off prevention, where it should be. Earlier this month, President Bush, flanked by Nigerian President Obasanjo and UN Secretary-General Kofi Annan, promised $200 million for a global AIDS fund first proposed by Annan in April. The Secretary-General is hoping to raise $7 billion to $10 billion to prevent the further spread of the epidemic and treat those who are already sick.
PRESIDENT GEORGE W. BUSH: We have the power to help. The United States is committed to working with other nations to reduce suffering and to spare lives, and working together is the key.
PRESIDENT OLUSEGUN OBASANJO, Nigeria: All nations, governments, foundations, private individuals and private sector, and indeed all humankind who are stakeholders in the health of humanity are challenged and called upon to make contributions to the global trust fund for HIV, AIDS, and related diseases.
ELIZABETH FARNSWORTH: The trust fund would apply not just to Africa, but also to the rest of the underdeveloped world. AIDS experts worry that HIV is also spreading rapidly in heavily populated India and elsewhere in Asia.
ELIZABETH FARNSWORTH: Now, the views of five people who’ve been involved in confronting the epidemic worldwide. Jeffrey Sachs is director of the Center for International Development at Harvard University and chair of the World Health Organization’s Commission on Macroeconomics and Health; Stephen Morrison is director of the Africa program at the Center for Strategic and International Studies; Dr. Helene Gayle is the director of the National Center for HIV, STD and TB Prevention at the Centers for Disease Control and Prevention, in September she will become a senior adviser to the Gates foundation; Dr. Peter Lamptey is the executive vice president of AIDS programs for Family Health International, a non-profit organization that focuses on reproductive health issues in developing countries; and Ambassador Sally Grooms Cowal is the former deputy director of UNAIDS.
Jeffrey Sachs, you’ve been involved in getting this global AIDS fund off the ground. Before we get into how the money should be spent, tell us just briefly how it will function and who will make decisions.
JEFFREY SACHS: I think this is potentially a very big breakthrough because for the first time the world is getting together in a unified way to fight the three main killer disease epidemics right now: AIDS, tuberculosis and malaria. The idea is that the rich countries will pool their funds for the first time into one global trust fund, countries will make proposals to access that money — that’s both governments and civil society within those countries.
The plans that are submitted to the fund will be reviewed by independent experts so that we’ll have a scientific and evidence-based approach for fighting the diseases. And then finally — and this is what is still missing — we’ll have the scale of resources to finally confront these diseases, which have been running out of control with so little resource available to fight them that the pandemics have just been running wild with the kinds of shocking numbers that we just saw in your report.
ELIZABETH FARNSWORTH: Dr. Lamptey, what should be the key priorities for spending the money that is raised?
DR. PETER LAMPTEY: Well, I believe that prevention is probably one of the most important needs. We have to remember that despite the fact that there are 25 million people infected, the vast majority of people are still… infected and we need to prevent them from being infected. But there is also an urgent and desperate need for care. Some of the most important, for example, is making sure that enough people know about HIV testing and so counseling and testing and preventing the infection in infected mothers and providing basic care for those who are already infected.
We always forget that because of the need for antiretroviral therapy, we forget that most people with HIV/AIDS don’t even have the basic care and 30-40 percent of people with AIDS are dying from tuberculosis, something that is preventable and treatable. And eventually when we have enough drugs and enough resources, antiretroviral therapy is important especially for the 25 million people who are already infected.
ELIZABETH FARNSWORTH: Dr. Gayle, what would you add or subtract from that?
DR. HELENE GAYLE: I think that’s an important summary. I think it’s clear that we have to have a comprehensive approach. It’s not either prevention or care. It’s both. And they need to be integrated. We know from global experience that prevention and care actually reinforce each other. So somebody is going to be more motivated to protect their family and friends and loved ones from getting HIV if they’re HIV-infected if they feel that their needs are being taken care of.
So it’s not an either/or, but as Dr. Lamptey said, it’s important to build upon a base of prevention and then add to it components of care including care for TB, tuberculosis, and other opportunistic infections, as well as more sophisticated care using antiretroviral therapies. But it’s a comprehensive approach.
ELIZABETH FARNSWORTH: Ambassador Cowal, do you worry that because the spotlight has been on getting the antiretroviral drugs to some people and to more people that it’s taken the spotlight off of prevention a little bit?
AMB. SALLY GROOMS COWAL: Well I certainly agree with both Dr. Gayle and Dr. Lamptey that you can’t separate prevention and care. But I think the most important thing that hasn’t yet been mentioned here is the need for real high-level political commitment. Without that, by all governments overcoming denial where that still occurs, overcoming complacency in places like the United States where that still occurs, we won’t really tackle this epidemic until we get that political commitment. It’s a real chance for the Bush administration to provide some leadership in a place where it’s unexpected.
ELIZABETH FARNSWORTH: And Stephen Morrison, where do you come down on how to spend the money or anything else that’s been raised?
STEPHEN MORRISON: Well, I would say that the trust fund is going to be a source of anxiety and skepticism for some time until it’s able to demonstrate some effect. It needs to get a governing structure that works and that is transparent and that is very fast and doesn’t interfere with existing mechanisms and brings forward the sort of resources that are out there. This is a major shift towards some new global architecture on health.
And as Jeff pointed out, I think this is a major step forward. It now needs to be made to work without losing sight also of the absence of health infrastructure, of delivery mechanisms in many of the most acutely affected countries. We have this global mobilization effort underway that’s very important. It’s historic. It’s risky. There’s a lot of uncertainty surrounding it at the moment but there’s also a considerable uncertainty in the most acutely affected countries.
ELIZABETH FARNSWORTH: Jeffrey Sachs, where do you come down on this question of how you weight the money: Prevention, drugs?
JEFFREY SACHS: I think what you hear and what’s very important to understand is that everybody that has been involved intensively in this is in a central consensus right now: You need prevention and you need treatment. The idea that we’ll just do prevention but treatment is too expensive I think has been dismissed by all who really know the situation. Prevention without treatment doesn’t work.
ELIZABETH FARNSWORTH: Excuse me. I want to interrupt you one second there. Explain a little bit more specifically why that’s the case — why people don’t want to be tested for example, some people if there’s not treatment.
JEFFREY SACHS: It’s estimated that only about 5 percent of the 25 million Africans that are HIV infected even know their status right now. If they come forward and find out that they’re HIV infected, unlike the situation in the United States where they would then go on to get care, they are marked for death. They’re also marked for stigmatization, they may lose their jobs, they may be isolated from the community, they may be accused of all sorts of things, even witchcraft and poisonings and so forth. There’s no reason right now for people to get tested to enter into that process because up until now there has been no treatment whatsoever available.
And I think it’s important, as you’ve mentioned a couple of times, that perhaps the spotlight is too much on antiretrovirals. It is crucial to keep in mind that until this moment almost nobody actually has been getting access to antiretrovirals. It’s not that the pendulum shifted so far the other way. We’re just trying to get treatment started. It’s estimated that of the three or four million Africans with advanced HIV/AIDS disease right now, perhaps 10,000 are on antiretroviral therapy and the rest are dying.
ELIZABETH FARNSWORTH: But, Mr. Sachs, if only say, $2 billion is raised, there’s no money to help provide antiretrovirals, is that right? So that only Botswana that has diamond wealth and maybe one or two other countries can give it. Am I wrong about that?
JEFFREY SACHS: I think that if we continue on the track where we are right now where the United States is pledging $200 million rather than the $2 billion that we ought to be pledging, which after all would be about $8 per American per year, $200 million is about 75 or 80 cents per American per year. It’s not a meaningful contribution yet. If we’re on the current track, then you’re right, the resources won’t be there. But the point is that for a few dollars per year of people in the rich countries, millions and millions of lives could be saved. Millions of orphans could be spared in Africa. These societies would have a chance to get back on their feet, which they won’t have if the resources are not raised.
ELIZABETH FARNSWORTH: Dr. Gayle, would you assume for the purposes of this discussion that not tiny amounts are raised but also not large amounts, somewhere in the $2 billion range, what do you do then?
DR. HELENE GAYLE: Well, I think we need to apply what we already know works. We know a lot about what it takes to change behaviors, to get services to people, prevention services like access to treatment for sexually transmitted diseases, access to condoms, voluntary counseling and testing. So we know outreach programs to groups at highest risk. We know what we can do, and we’ve already demonstrated that those things can make a difference in slowing down new HIV infections. What we haven’t done is taken that to scale. And so we have small examples of how you can make a difference. And I think we need to take to scale the things that we already know can make a difference in this epidemic.
I think at the same time we do need to start having activities that give us experience and help develop the infrastructure for treating people not only with antiretroviral therapies but just treating common infections that people with HIV have. Even that I think will be a very important motivating factor to get people into the systems of care for tuberculosis, the common infections, as well as the symptoms that people have from HIV infection. So I think we need to take it incrementally, use what we have, show that we can make a difference. And I firmly believe that if we continue to be able to show we can make a difference in this epidemic, resources will come.
ELIZABETH FARNSWORTH: Stephen Morrison, weigh in the factor of leadership in Africa. If a country, for example, has not come up with a good AIDS plan because the government isn’t involved in something else like a war, does that mean its people won’t get treated under this?
STEPHEN MORRISON: It means they won’t get the optimal response, clearly. If you look at some of the conflict… most conflicted states in Africa — Angola, Congo, Kinshasa, and others — there’s very, very weak data, there are very, very weak programs.
ELIZABETH FARNSWORTH: And the global AIDS fund wants the government to be the one that is putting forward the plan, right?
STEPHEN MORRISON: Yes, yes indeed, and they want to be able… they want to reliably feel that they can move in and have effective programs and have counterpart institutions that are competent and free of gross corruption and not distracted by internal wars.
ELIZABETH FARNSWORTH: So inevitably some people aren’t going to get helped under this, you think.
STEPHEN MORRISON: Well look at what has happened in the last year. In the case of Botswana, Botswana did a radical turn-around in its leadership position to a very assertive campaign to educate its own citizenry, to engage donors and foundations and the like. Look who is there now. You’ve got the Gates Foundation, Harvard AIDS Institute. You’ve got lots of other actors coming in and they are moving ahead very, very rapidly. It’s a good instance of money and talent moves to… into the crisis zone where it’s possible to begin to show results. That doesn’t mean they’re going to ignore altogether the places that are more conflicted and more unstable and more… less reliable.
ELIZABETH FARNSWORTH: Dr. Lamptey, weigh in on this, the question of leadership and the role of leadership.
DR. PETER LAMPTEY: I think it’s critical and unfortunately in the past 10 or 15 years we haven’t had adequate African leadership. The situation is improving but we’re still not completely there yet. The countries — I mean Uganda is a good example, Senegal is another — where there has been good leadership and that’s the reason for the decline there. It’s again unfortunate that some leaders wait until the problem gets completely out of hand before they respond. Hopefully with the new approaches that we are taking, we should be able to governize the… more leadership support in countries where governments are not ready to move, we work through the civil society and the private sector to be able to make a difference.
ELIZABETH FARNSWORTH: Ambassador Cowal, what’s your view of this leadership question?
AMB. SALLY GROOMS COWAL: I think this is a very unique moment. We now have a landscape that we haven’t had in the past ten years. We have some money available, perhaps not all the money. We have African governments committed. We have the United Nations committed which was… came only very slowly. Now you have the secretary general leading the effort. You have the Security Council engaged, recognizing that AIDS is not just a threat to public health but really to national security and to international security.
And I think in the Bush administration, hopefully is going to both respond and provide some leadership in these efforts. So it could be a very unique time. We also have the pharmaceutical companies, the difficulties in negotiations are well known but I think the companies themselves are recognizing that they need to respond. So it’s a unique moment and one we should seize and take advantage of.
ELIZABETH FARNSWORTH: Let me ask you, Ambassador Cowal, and I’m going to ask everybody this, so please respond fairly briefly. Do you think, given what you just said I think you do, that the world is going to respond adequately to this? I have in my mind what Maryline Mulemba, the nurse said, from Doctors Without Borders. Are these people going to die in silence and without much help, or really is there going to be this huge, huge response that is necessary?
AMB. SALLY GROOMS COWAL: Well, I think we need this triumph of hope over fear. And I think it could go either way. But I’m… I think there’s leadership that has not been there before. I’d like to believe that that was going to make a difference. Programs like this make a difference.
ELIZABETH FARNSWORTH: Dr. Gayle.
DR. HELENE GAYLE: I would wholeheartedly agree. I think we are at a very important moment in the history of this epidemic. I think we’re seeing unprecedented commitment. There’s an African proverb that goes, the best time to plant a tree is 20 years ago; the second best time is now. I think that’s what we’re seeing. If we put the effort in now, we are going to see that we can make a big difference. And I think that that commitment is growing and will continue to grow as we show evidence of making a difference.
ELIZABETH FARNSWORTH: Jeffrey Sachs, answer the question briefly, and tell me what your main worry is at this point, just briefly.
JEFFREY SACHS: The African leaders are crying for help. The question for us is whether we’re prepared to put a few dollars per year from each of us into this, with a billion people in the rich countries, a few dollars, $5 from each of us makes the $5 billion that we need to provide the treatment and keep people alive. My main worry is whether the resources are going to come. And I think if the American people understand that it’s such a small amount needed from each of us to do so much, we will get there.
ELIZABETH FARNSWORTH: Dr. Lamptey.
DR. PETER LAMPTEY: Well I’m hopeful but rather disappointed and skeptical about whether the right amount of money will be raised. The $200 million the U.S. pledged is certainly a start but it’s a drop in the bucket. If we get the same response rate, I don’t think we’ll be able to raise funds to save the people who are dying or to monitor an adequate prevention effort to prevent this epidemic from spreading.
ELIZABETH FARNSWORTH: Stephen Morrison.
STEPHEN MORRISON: I think the greatest risk that we face is that we do not have results within the next two to three years in Africa in the most acutely affected states. And that creates disaffection and skepticism and the momentum that has been building within Congress and among the American people and beyond begins to shift, begins to soften or shift to some of the other states that are on the edge of the pandemic that are outside of Africa. We are… we have a window of two to three years.
ELIZABETH FARNSWORTH: Got to go. ….
STEPHEN MORRISON: To take effective action in Africa.
ELIZABETH FARNSWORTH: Thank you. Sorry, we’re out of time. Thank you all very much.