The Age of Aids [home page]

interview: jeffrey sachs

[photo of Jeffrey Sachs]

Although he had worked in global development for years and followed news stories about the AIDS pandemic, economist Jeffrey Sachs didn't truly understand its magnitude until he arrived in Zambia in the mid-1990s and learned that eight of the 30 colleagues he would have worked with at the Ministry of Finance and Central Bank there had died of AIDS over the previous few years. He realized that the message the West was sending Africa -- a message of market reform and structural adjustment that he had helped develop for Eastern Europe after the end of the Cold War -- did not take into account the underlying reality that "ill health is one of the most profound, pernicious poverty traps." During a 2000 speech at the International AIDS Conference in Durban, South Africa, Sachs floated the idea of a global fund that would buy drugs at cost and provide them to the poorest people in the poorest countries for free. His idea eventually became the Global Fund to Fight AIDS, Tuberculosis and Malaria, announced by U.N. Secretary-General Kofi Annan in 2001. Here, Sachs, author of The End of Poverty: Economic Possibilities for Our Time, describes the evolution of his thinking, his conversations with Condoleezza Rice and other Bush administration officials, and his disappointment that instead of giving money to the Global Fund, the president decided to create his own $15 billion fund, the President's Emergency Plan for AIDS Relief (PEPFAR). This is the edited transcript of an interview conducted March 16, 2005.

When did you first encounter HIV, and what got you so passionate about this?

Of course, like everyone else, I was reading about this new and terrible disease, basically from the start of the public announcements, and understanding and watchful of what was happening in the United States. But I did not think very much about AIDS in my professional capacity until I started working in Africa. That was in the mid-1990s.

One of the first stops for me as a newcomer to Africa was in Zambia. Harvard University at the time had a project with the Central Bank and Ministry of Finance in Zambia, and when I got to Lusaka, my colleagues there told me that eight of the 30 counterparts or so had died of AIDS in the past couple of years. I was dumbfounded, of course. I had never experienced anything like this in an economic development project. This was something completely new, utterly shocking. And this was for me the jolt to begin to understand what was really happening in Africa.

Over time I started to look more deeply, of course. I said, well, why is it that people just don't show up to work at some point and then they're quickly dead? ... It was only then that I began to understand there is no health system; there are no doctors; there is no medicine. This was my way into the shocking realization of how hundreds of millions of people live essentially without health care, what it means to have a health system that spends $2 or $5 or $7 per person per year on all health compared to the United States, where maybe $5,000 or $6,000 [is spent] per person, per year.

So these are things I found hard to imagine. I certainly didn't imagine them until I started to see them close up. I learned over time it's not just AIDS. It's malaria; it's TB; it's thyroid disease; it's respiratory infection. It's many killers that are unattended to. The poorest people in the world can't afford health care. Their governments are impoverished, debt-strapped. They don't provide health care. This has been one of the most shocking aspects of my understanding in my whole career, what extreme poverty really means and what AIDS means in the context of extreme poverty.

It sounds like it was a very defining moment for you personally.

Each place that I've worked has been a defining moment on certain things, but for Africa, the defining aspect of African economic development, and underdevelopment, is the struggle to survive; is life and death. This is ... part of our global society, where life expectancy is 40 years or less in many places, compared to the 80 years of the rich world; where death is everywhere; where the villages have been decimated of the mothers and the fathers; where the grandmothers are looking after their grandchildren. ...

So how did you make sense of what we call the two worlds of AIDS?

I started to see the mass death. I began to understand it. So I began to ask two questions about AIDS, about malaria and other diseases as well. First, what's actually being done? Second, what's the consequence of our inaction? As I started to look at the question, [I began to ask] what are the donors doing? What are the rich countries doing to help Africa? This was the time when combination therapy was being starting, when the antiretrovirals had proven their efficacy, when there was a major, major breakthrough in the United States. Of course there was nothing like that in Africa.

I was part of the market reforms in Eastern Europe, but actually, that gave me the perspective to understand: Don't go there in Africa's health care in the middle of the AIDS pandemic. Yet that's what Washington was doing.

As I began look more closely, there was basically nothing happening in Africa. So I did one of the first studies to ask how much is actually being spent by donors for Africa to control AIDS, malaria and other diseases. It was so amazing; we couldn't imagine that the numbers were right. Looked again, verified. Looked again, verified.

It turned out that at the end of the 1990s, the world was giving in aid to fight AIDS in Africa about $75 million a year total, and this is a time with 25 million HIV-infected individuals -- $3 per HIV-infected individual for treatment. Of course there was none for prevention, for everything around AIDS. Essentially, this pandemic was running its complete natural course without any intervention from the rich world.

The surprising thing, and the thing that's not so easy to figure out, is that there's lots of talk going on. There's speeches; there's hand-wringing; there's pronouncements; there's summits. So you imagine with all that noise that there's actually some action. You have to parse through all of the fog that's intentionally thrown up to find out there is nothing there. There is no treatment. There is no health promotion. There's almost nothing. That's what I discovered at the end of the 1990s to be the case. Officialdom doesn't exactly hold up a sign that says, "We're doing nothing." And they're not so happy when anyone else holds up a sign, either.

president bush and bono

Part Two: Chapter Five Financing the Battle

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So I started to circulate this reality, to give these speeches. There was pushback. Oh, the World Bank said, "We're doing dozens of programs; they're just not called AIDS programs." "Oh, show me." So you get a mountain of materials. You start going down into the mountain of materials. Oh, AIDS is mentioned somewhere on page 26, maybe some thousands of dollars, maybe even a million dollars over the life of a loan. But a real AIDS control effort? No, it wasn't there. The World Bank didn't make a single loan for a sub-Saharan African country or a grant for a sub-Saharan African country between 1995 and 1999. ...

So I published those numbers and started, of course, to try to figure out really what should be done. Remember, I'm coming as a macroeconomist, not as an AIDS specialist. I'm trying to understand this shocking reality. Now, at the same time I was trying to understand what all this disease and death means for the economies of Africa, and I began a series of studies [on] the effect of disease on not only poverty, but on the failure of economic development and the poverty traps, so-called, where poverty leads to disease, leads to more poverty, and you can't get out of the mess. At the time, this was also shockingly not exactly a matter of polite discussion in polite company. There were no papers being written on these issues.

The idea that the AIDS pandemic and malaria and other killers were fundamental reasons for Africa's deepening crisis [was] not part of the discourse. What Africa was being told to do was not to control AIDS and malaria and give them help to do so, but to privatize the sugar mill. It was all markets. It was all tighten the belt. It was all what came to be called structural adjustment, actually cutting the size of the health sector, cutting the size of the education sector in the middle of a pandemic. ...

That was also a time, in the '90s, where there was a lot of talk about free markets, free trade and this as well, and applying those theories to Africa. This is exactly what you just mentioned. Was there something wrong with that concept, or was it just not enough?

Well, for me it was quite strange. I was the leading adviser in Poland, for example, at the beginning of the economic transformation. Poland had electricity; it had roads; it had an infrastructure; it had a health system; it had doctors. It didn't have malaria; it didn't have an AIDS pandemic. The main issue that Poland faced in 1989, in a collapsed and a hyperinflation-ridden economy, was market reform. I became known as promoting market reforms. When the key thing that you're missing is markets, you promote market reform.

I came to Africa. What was the issue there? As I began to understand it, it was AIDS; it was malaria; it was drought; it was the absence of roads, electricity, basic power clinics, schools, safe drinking water. And yet, all of the sudden, I hear it's all about market reform; it's all about privatizing the sugar mill; it's all about tweaking the exchange rate. I said to myself, this is weird, you know. Yeah, in Poland that's right. Poland had all the infrastructure. Poland had the basic health care. Poland had 70 years' life expectancy. But don't these guys in Washington understand that in Africa it's different issues? Is every patient in the clinic facing the same health issues? Does the doctor have one approach? Or in Poland do you recommend one thing, and in Africa, recommend a different thing?

What I found was, of course, the more I understood the agenda, that priorities, the urgency was in a completely different area. Yet the rhetoric of Washington was in overdrive. It was just markets, markets, markets. Now, even in a market economy -- even in our own market economy in the United States -- the role of the public sector and the budget in health care is fundamental. It's enormous, whether it's Medicare or Medicaid or prescription drugs or Social Security. This is government. In other countries, it's 100 percent virtually, in very successful countries [in] Europe or in single-payer Canada. These are public systems that are providing health care.

Not only, however, were the Washington institutions prescribing belt-tightening, cutting the public sector, not recognizing the pandemic disease crisis, in overdrive on market reform. They were also recommending, shockingly, privatization of the health sectors -- that which is public, even in our own country. So this whole market-reform issue was taken to such a dangerous, preposterous, actually devastating extreme.

Now, I was part of the market reforms in Eastern Europe, but actually, that gave me the perspective to understand: Don't go there in Africa's health care in the middle of the AIDS pandemic. Yet that's what Washington was doing.

Is it the Clinton administration?

This was the Clinton administration. This was the tail end of what was called the structural adjustment era. It's over and gone, and it was a massive failure with regard to the poverty needs of controlling disease, hunger for the poorest of the poor. The market doesn't come to rescue people dying of AIDS and malaria and without access to safe drinking water and without enough food to eat, and yet Washington was promoting privatization, belt-tightening and austerity right through the 1990s.

So then you began to formulate some options. What was the evolution of your thinking?

In 1999, after I had been speaking, writing and opening my own eyes, and trying to open others' eyes, to this reality in Africa, I was approached by the most remarkable world leader, Dr. Gro Harlem Brundtland, who had been prime minister of Norway and then was head of the World Health Organization. She knew something very key from her experience as prime minister. ...

She asked me to head what became known as the Commission on Macroeconomics and Health, which served for two years, in the year 2000 and 2001, and it was charged with bringing together the worlds of finance and health to do two things: one, to understand what are the implications of uncontrolled disease and poor health and economic development -- in other words, why should finance ministers care; second, what could be done about it?

What we found was, indeed, that ill health is one of the most profound, pernicious poverty traps. These disease pandemics overwhelm society, and yet, at the same time, they can be controlled. But the irony is they can't be controlled only with the resources at hand in the impoverished countries themselves. You want to control the disease, but you don't have the means to do it on your own. To get out of the trap, someone has to give you the help, control the disease. That will raise your economy; then you'll be on your way. You'll be sprung from the poverty trap. That was the conclusion that the commission reached in the course of its work, involving hundreds of experts and multiple studies and detailed analyses of what could be done, what it would cost, who could pay.

Now, in the middle of that work, of course, AIDS was at the central focus, and we were making sure that we understood the enormity of this burgeoning pandemic, and [were] using the commission to help bring to the world's attention the financial needs in order to get this under control. In that context, I traveled to Durban, [South Africa], in 2000, to the World AIDS Conference, in the summer of 2000, and came with the message that I had learned over the preceding years. ...

Here we are in the middle of 2000. We've had the breakthrough of highly active antiretroviral therapy. HAART is saving vast numbers of lives in the rich world, but the poor are not being attended to at all. The activists, of course, are starting to make a very loud noise, completely appropriately. Ironically, they were mainly attacking the pharmaceutical companies, but rather than putting together the financial strategy, the model of the production, and the distribution to actually get what could be done in place -- because I think that all sides didn't quite see that the issues were simply what the companies were doing. But even if these drugs were available at cost -- they were coming to be -- poor companies couldn't afford them, and poor people couldn't afford them, so one needed a financial strategy to translate the new technology into saving people.

In my presentation in Durban in 2000, I raised the idea of a global fund and gave a speech one night where I said that the World Bank isn't doing its job; the donors aren't doing their job. The amounts of money going into this are $3 per person per year. There is mass death, and yet here are drugs. I said that it would be perhaps $1,000 per patient per year. ... I made a calculation that showed that for a few billion dollars a year, it would be possible to make a huge step in actually putting people on treatment.

The proposition was that the drug companies, whether those that held the patents or generic producers that were starting to produce these drugs, would provide these drugs essentially at cost. A fund would be established to buy the drugs at cost and make them available to the poorest people in the poorest countries, and I envisioned for free, because precisely those people could not afford that, and that for a few billion dollars a year, we could have a breakthrough.

Well, this created a lot of excitement on the one side, but a lot of official consternation, as usual, on the other side. ... But the idea stuck. It did take hold. Our commission worked on it in the following months. At the end of 2000 -- indeed, it was early 2001 that my good friend and our wonderful inspiration, Paul Farmer, the doc who worked in the central plateau of Haiti, brought me to his clinic in the central plateau, and it was one of these most amazing moments one is lucky to experience in life. The ideas of putting people on treatment that I had been promoting there I could see. Because of Farmer's brilliance and his drive and his nerve, he was doing it without anyone in WHO or World Bank or U.S. government, or anyone else having given him the permission. He had just scraped and scrounged and did whatever he could to get some drugs from Boston patients or from philanthropists and others to bring them to Haiti. People were on treatment, a few dozen. We went out to their farms, and there were people that I had seen their pictures at death's door, and there they were looking wonderful, out on their farm, inviting us to sit down to join them for some fruit, the children running around. These were people who would have been dead but for what Paul was doing.

On that basis, we took the idea of the global fund; we took Paul's experience. We went back to our colleagues at the Harvard Medical School, the Harvard School of Public Health, and we put together a roughly 25-, 35-[page] description of how one could scale up treatment in impoverished areas. What are the medical protocols? What kind of drug regimens? Who should do them? How do you do them? What does it cost? I added the economic side of if you scale it up, what does this really mean on a macroeconomic scale? That became the cornerstone for how an actual global fund could get set up, do its technical reviews, and actually get things started.

It was amazing to me. One thing that was amazing is 140 Harvard colleagues quickly agreed to sign on to this. For those in academia, it's amazing enough when you get consensus among your colleagues. But everybody appreciated how urgent it was. And it was quite stunning for the world that a very large number of the world's leading scientists and AIDS practitioners at the great hospitals of the Harvard teaching system all signed on to a very, very strong statement. We can move, we should move, and so on. So it had a big impact.

Of course there was resistance. Immediately there was pushback. Oh, the pendulum is swinging too far from prevention to treatment, some foundations said. I was shocked, because how can you say the pendulum swung? Not one person yet was on treatment from actual donor dollars. The rich world had not treated one person on a donor project up until the middle of 2001. This was the reality -- millions dying, drugs available, proven successes, and nobody being treated by the rich countries. It's the most shocking reality.

But after this statement and the noise it created, [U.N.] Secretary-General Kofi Annan, who has been unique in his global leadership in this issue, said: "Let's do this. Let's get this global fund going. Let's get it established." He gave the launch speech in Abuja, Nigeria, in April.

Did he talk to you? Did he come to you directly?

Oh, we talked, of course, a great deal about the details and the specifics, and I worked closely with him and his office. He gave the launch of the Global Fund [To Fight AIDS, Tuberculosis and Malaria] April 2001. What is amazing, actually heartening, is that the month follow[ing], in May, one month after the speech, there was Secretary-General [Annan], President [Olusegun] Obasanjo of Nigeria and President Bush in the Rose Garden, when the United States became the first country to announce that it would join this new global fund that the secretary-general had called for. Of course, in some ways that was the high point for the U.S., because the levels of funding that U.S. should be providing have not yet been forthcoming to the Global Fund. Someday they will be, but the administration, though it was the first to join the fund, did not follow through with the most basic arithmetic of how to support the fund adequately. ...

How is it possible that the situation you described came as being that no funds had been given for treatment until 2001? You seem very impassioned about that. How is it possible that that was the case?

The world is a mysterious place. The things we don't do are absolutely mind-boggling, hard to understand. Here we're talking about AIDS, and there is now a scaling-up of the fight against AIDS, and yet malaria, which will kill around 3 million children this year, is not being controlled. It could quite easily be controlled. It's a much easier disease to control than the AIDS pandemic, in fact. Effective bed nets treated with insecticide, effective medicines could save a million or more lives per year with just straightforward application of those technologies. I'd said it endless numbers of times; others have said it. The world doesn't move. ...

You went to see [then-National Security Adviser Condoleezza] Rice … in early 2001. Were you talking about the Global Fund then, and what was her reaction?

I came in to the White House, the first year of the Bush administration. I came in to see Condoleezza Rice, with whom I worked in 1989 when I was advising the new post-Communist Polish government, and she was in the National Security Council. ... I went in 2001 to say, "Here's another chance for a wonderful initiative; we need to help treat people that are dying of AIDS; ... here's a $3 billion-a-year plan," and put it forward.

It was interesting, the reaction. Well, first Condoleezza Rice said, "The president is interested in this." Thank goodness. And "It's interesting to hear you discuss this, but our experts tell us that people can't be treated." And I said: "Well, that's not true. Not only have I seen it with my own eyes, but I'm lucky to have as colleagues some of the world's leading scientists and clinicians in AIDS, and they've all just agreed on the fact that treatment is feasible, and it's even feasible in the clinical conditions you would find in impoverished places." Well, there was lots of philosophical argument -- no, it's only cost-effective to do prevention, and all sorts of misunderstandings. ...

I was utterly shocked, I think, completely stunned, when the newly appointed head of USAID [United States Agency for International Development], Andrew Natsios, then made the most remarkable and chilling set of statements about all of this as he was coming into office. He said: "Well, you can't treat Africans. Africans don't know Western time. They won't know the time to take their medicines." He said: "They may know mornings; they may know noon; they may know night. But they don't know Western time." Hard to fathom, actually, how a senior American official could ever make such a statement. But that was the statement of the USAID agency -- in his early days, admittedly, but absolutely shocking. And I talked to [then-Secretary of State] Colin Powell and others, and of course Secretary Powell said: "I've been to hospitals all over Africa. This statement is not our policy." But it showed how steep the hill was going to be with this administration.

The upshot of all of this: Well, they joined, a small initial contribution, but as the first member of the Global Fund, that was a real breakthrough. But the idea of a major effort, which I was hoping would go through the Global Fund when I made those calculations, my presumption was the United States would contribute $3 billion to the Global Fund. That would be roughly a third or a fourth of something like $10 billion a year to fight AIDS, TB and malaria from a pooled fund, which would engage Japan and Europe as well.

As events unfolded, the first shock was that the United States was not thinking in that order of magnitude. The amount of initial contribution was roughly a 10th of that. The fact of the matter is, they just don't do arithmetic in Washington, at least not on these things. They don't really calculate need, cost, multiply them together -- how many patients, how much treatment -- to get at the number. Even the most [simple] kinds of calculations are just obfuscated. Numbers come out of thin air, very small, and that somehow is announced. And when you say, "Well, that's not enough," they say, "Well, we're just getting started." But the numbers are just pulled out of some OMB [Office of Management and Budget] accountant's head, not out of any sensible policy that links actual needs to actual costing.

Well, certainly I continued the fight. Our commission worked until -- through the end of 2001. I helped to see through and behind the scenes in the launch of the Global Fund, with our report and in fact several reports at hand from the commission. I was pounding the pavement in Washington continuously in 2002. ...

Then politics did advance a bit. My good friend and remarkable, remarkable leader in all this, [lead singer of the Irish band U2] Bono, had a remarkable breakthrough. This was the time that Bono made quite intensive contact with the evangelical community in the United States, with [Samaritan's Purse President] Franklin Graham, with [North Carolina Sen.] Jesse Helms, with some very conservative congressmen and senators. He read Scriptures with them; they talked about religious faith; they talked about religious obligation. They talked about how Jesus would view the poor, the suffering and the dying. And they came around to Bono's point of view, and they came around to the right point of view; that it was horrendous, contrary to their own faith; that millions and millions of people are suffering and dying, and we're not acting. And Jesse Helms said, "I want to help you, Bono, to get this done."

This was, I believe, the great turning point inside the Bush administration. From a public health issue -- that they didn't want to look at these numbers, and where OMB wasn't very interested, and no one wanted to do arithmetic, and you didn't know if Africans could tell time, and all of that, all of that fog, in a way obfuscation, and difficulty of moving anything -- in came the evangelical community, the religious core constituency of the Bush administration, and they started telling the White House that we need to do something. I believe this was a fundamental turning point, a very basic turning point, because here was a most important constituency saying not only is this bad politics, [but] "We need to do this."

Discussions accelerated towards the end of 2002, and in early 2003 there was more movement, and then I'll never forget -- for me, the amazement that the secretary-general called me, the day of the 2003 State of the Union address of President Bush, and he said: "Jeff, the White House just called, and they said it would be interesting for us to watch tonight. There's going to be an announcement done on AIDS." The president made a remarkable statement that night. He said there are medicines available, yet people go to hospitals and they die because they don't have access to these medicines. This is not how the world should be. You dream of the president making such a clear statement. And he announced, lo and behold, a $3 billion-per-year program. ...

This was this PEPFAR program, the President's Emergency [Plan] for AIDS [Relief], and it is a breakthrough. It is important. It has, however, one of these hallmarks of this administration: It's unilateral; U.S. goes it alone. I was amazed the night of the speech, and then, of course, perplexed the next morning when the White House called me to brief me and give me the details, and explained that of that $15 billion over five years -- $3 billion a year over five years -- that only $200 million per year, or a billion of the total, roughly 1/15th, or about 6 percent, would go through the Global Fund. "The rest, we'll do it our way," says the White House. So yes, a breakthrough, yet again, more delay, more difficulty, more ineffectiveness by choosing to go it alone and not [taking] the course that would have been the way to really make the most dramatic, the most rapid, and I believe the most effective scaling up through a multilateral process centered on the Global Fund.

The Bush administration would say it was far more efficient to keep the money under U.S. control than to give it to the U.N. and have it be distributed also through different governments. ...

This administration has such a deep distrust of other governments and all international processes that they have a very hard time understanding that if we do things together in a cooperative and collegial manner, we can get a great more done than if we do it ourselves.

I mean, I have to say we have been to some of the CCMs [Country Coordinating Mechanisms, which disburse Global Fund money], and they don't always inspire confidence in their efficiency.

If the United States had given more direct help and pushed to enabling the Global Fund to get up and running, to be staffed properly, and to be as consequent and executive as it can be, the Global Fund itself would be doing more. As it is, the Global Fund has a vastly wider reach than PEPFAR. ... PEPFAR is only AIDS. The Global Fund is AIDS, tuberculosis and malaria. That's not just incidentally three diseases. These are three completely interacting diseases, and the idea that you just pick off one and you chose 14 countries and somehow you've done your thing is a huge mistake.

I believe that the Global Fund is a tremendous breakthrough. I believe that it could even be more effective. There are many things that could be done to enable the Global Fund to work even better than it does right now, and if the United States were showing real leadership and determination, through that multilateral instrument, we'd be far ahead of where we are. Yes, the PEPFAR is an important initiative. I think it's tremendous that we have it. It's not what it could be because of this unilateral approach, but it still is a tremendous policy initiative.

What about the emphasis about faith-based programs through PEPFAR? Is it too ideological?

Well, in general, there's a lot of ideology that drives a lot of PEPFAR, of course. The U.S. government wants to talk about abstinence; it doesn't want to talk about condoms. It doesn't necessarily get to the real realities of places that it's dealing [with], because it's pushing a faith agenda of some groups, or it's handing off the actual execution of policies to a faith group.

The pharmaceutical companies have weighed in too much, I believe, because of certain breakthroughs that could have come faster -- fixed those combinations, for example, where you so-called co-formulate the three medicines into one pill, [that] was done abroad faster than it was done by U.S. companies. And by relying [on] a U.S.-only approach, that slowed down the introduction of these fixed-dose combinations.

So I think there's a lot of ideology, and there's a lot of U.S. centrism, naturally, in U.S. programs. That's no doubt why they kept it inside the U.S. They want to do it their way, and our way is a way of part of a country that has 5 percent of the world's population; it's not the way of the whole world. Just pretending that our way is the way of the whole world is very often not the most effective way to approach the problems in other places. ...

PEPFAR is a little more than a dozen countries. It doesn't even pretend at comprehensive coverage. In Africa alone, in sub-Saharan Africa, you have 49 countries. Essentially all of them are battling AIDS, and many of them, many more of them than in PEPFAR, are in the midst of horrendous AIDS pandemics. Even if PEPFAR works brilliantly, and we certainly hope and wish it to, it doesn't even pretend to cover not only Africa, but also India, which has together with South Africa the most AIDS cases of all in the world. Of course, [HIV/AIDS is found in] a relatively small proportion of India's population, but with a vast base, that comes to an estimated 5 million HIV-infected people. PEPFAR has nothing to do with them. With China, with Russia, with other parts of the former Soviet Union, we need a multilateral approach under any circumstances. It's tremendously underfunded. It's hard to understand what the administration thinks it's doing. Do they just want spin and headlines, or do they actually want to solve the problem? You wonder.

Solving the problem requires a global approach?

Solving the problem requires a global approach, and it requires arithmetic: How big is the challenge, in how many countries? What needs to be done? How much does it cost? How do you scale up? What's the time table? It requires a basic programming of a plan of action. ...

If you look at what happens in the sub-Sahara here in Africa, and then you look at the potential next-wave countries, particularly in Russia, India, China, can the problem be managed in those countries? ... Is what happened in Africa particularly going to be confined [there]?

The truth of the matter is that the scientists, especially in this case, the epidemiologists, do not understand the time profile of this pandemic. They don't understand really why [East] and Southern Africa is so much more extreme than [West] Africa. They don't really understand why Africa is so much more extreme than other parts of the world.

The basic idea is well, it's the sexual behavior; it's the sexual networks or the number of partners. All of those simple ideas are not correct, actually. They may play a role, but there's no basic explanation of the different time paths, the different levels of severity.

It no doubt has to do with many things. It does have to do with sexual behavior, sexual networks, sexual partnering. It has to do with the other disease co-factor, so-called. Is there a lot of other sexually transmitted disease around? Are there ulcerations or ways for the virus to get into the body of people through sex? It has to do with the issues of circumcision. It seems that circumcised males have some protection in transmission, so that in areas, Islamic populations, the transmission seems to be lower. It's been hypothesized that this may relate to men in Islamic society being circumcised. It may have to do with the subtypes of the virus, the so-called clades. It may have to do with population genetics. It may have to do with ... migration patterns, trucking patterns, mining communities where men are separated from their wives for long periods of time, to other cultural practices. The fact of the matter is we don't know. Some people say they know, but the studies don't really demonstrate it.

What does all of this mean? All of this means that when you see the epidemic in India, with, say, 1 percent prevalence, approximately, you could say, "Well, that could explode as it did in South Africa." But there are other places where it didn't explode, and not for any absolutely obvious reason. And of course, with that uncertainty, we need to put in place as many barriers as possible, as much public education, use of condoms, safe behavior in terms of sexual behavior, treatment, testing, other things that we know to be of a successful intervention when more people that are sick are actually treated. That helps to bring people in for testing; that helps to make people aware; that helps to actually do the prevention programs as well.

So what we can be sure of in these next-wave countries that there's a huge risk of a takeoff. But it's not right to say if we do nothing, we know how it's going to go. We don't. We don't really understand, in my opinion, in my understanding of the scientific evidence, we don't really understand the different time paths in different places. But we do understand that there are huge risks, and many of those risks are unattended to right now.

You've been working on this now for almost 10 years. Are you optimistic? And if the virus isn't brought under control, what are the stakes?

This pandemic is not under control. We have 40 million people infected, an estimated 5 million new cases, according to the most recent UNAIDS [Joint United Nations Programme on HIV/AIDS] estimates, more than 3 million people dying per year. The effort to control this terrible scourge has finally started. We're not on top of it yet. There are areas where we risk massive increase in numbers.

In Africa, we're seeing some glimmers of hope, perhaps the early signs of the prevalence rate starting to come down. It seems that in Kenya the rate is very high, may be starting to come down. It seems in Ethiopia maybe they're starting to come down. The same in some other countries.

But still, there's no sense where one could say we've turned the corner on this scourge. There is now a set of institutions, awareness technologies to control the disease, but the world has demonstrated during this 25 years of this pandemic an absolutely inexcusable and shocking capacity to avoid the real news. Unless we face the realities of this disease, we still stand the risk of it exploding, still further continuing its terrifying course around the world, and with it carrying massive burdens of impoverishment, other disease alongside AIDS, like the tuberculosis pandemic, and many other liabilities, of tens of millions of orphans. We have not yet controlled the pandemic.

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posted may 30, 2006

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