The United Nations and World Health Organization (WHO) report on AIDS paints a picture of devastation in Africa and warns of catastrophe in many other regions of the world, yet offers no solution to this raging epidemic.
Issued in preparation for the XIII World AIDS conference held last week in South Africa, “Report—On the Global HIV/AIDS Epidemic—June 2000” was intended to detail the extent of the worldwide epidemic and set the tone for the conference.
This, the second of two articles on the UN/WHO report, examines the crisis in health care and the proposals advanced by the UN/WHO. The first article, posted July 17, dealt with the extent of the destruction caused by HIV/AIDS, mainly in Africa, but also in other regions.
In regard to this latter section of the report, the reader gets the eerie feeling that those who drafted it had barely read the sections dealing with the extent of the epidemic. Even if fully implemented, the UN/WHO proposals would not halt the infection and death of millions of people each year.
An examination of the information provided in the UN/WHO report leads ineluctably to the conclusion that HIV/AIDS is not merely a health crisis, but a massive social crisis.
The UN/WHO report on the AIDS epidemic contains a glaring contradiction. Its opening sections provide a mass of statistics and other information documenting the catastrophic impact of the disease in sub-Saharan Africa, and the growing threat of similar conditions developing in other parts of the world. On the basis of the report, it is clear that what is occurring presently in much of Africa is a process of depopulation, without precedent since the black plague that devastated medieval Europe.
One might think that the authors of the report, in light of the disaster which they describe, would call for sweeping and far-reaching action by the world community to fight the epidemic. In fact, the report advances only the most minimal proposals, whose inadequacy is all too evident. The inability of the UN and WHO, which are, in the end, answerable to the most powerful capitalist nations and which dare not challenge existing property relations, to put forward a serious policy for dealing with a human crisis of historic proportions only underscores the social and political dimensions of the AIDS epidemic.
This tragedy is compounded by the fact that the scientific and medical knowledge exists to dramatically retard the spread of HIV/AIDS and effectively treat many of those already infected. A serious, comprehensive and internationally coordinated effort to fight the epidemic could save millions of lives.
One aspect of the latest UN/WHO report is of particular significance. In previous reports the UN has routinely pointed to the inequality between the rich and poor nations, and placed emphasis on the responsibility for the wealthy nations to provide aid. But today, when such assistance takes on unprecedented urgency, the report makes no such appeal. In fact, it does not propose that resources be marshaled on an international scale to develop a vaccine for AIDS, a project to which the major drug companies have been unwilling to commit the needed funds for reasons of commerce and profit.
Instead, the UN/WHO report issues a series of proposals that at best, even if fully implemented, would only slow the spread of the epidemic, while condemning the millions currently infected to certain death. Moreover, the report repeatedly implies that the major responsibility for dealing with the AIDS catastrophe rests with the very countries that are the most devastated.
Executive Director Peter Piot sets the tone for the entire report when he writes in the preface, “while international political, financial and technical support are important, lowering incidence and mitigating the epidemic's impacts must be a nationally driven agenda.”The health care crisis
The report restricts its proposals to a limited campaign of education, testing and pain relief for the afflicted, i.e., what is considered to be affordable for the most devastated countries. Yet, even these measures are beyond the means of many countries.
The lack of health care systems in sub-Saharan Africa capable of handling the AIDS crisis has compounded the impact of the disease. Public health centers and hospitals lack staff, and facilities for diagnosing HIV and related opportunistic diseases are inadequate. Drugs for treating HIV/AIDS are nonexistent, while millions of people go without drugs for tuberculosis and other infectious diseases.
A 1997 survey conducted by the UN of 22 university teaching hospitals in 19 African and 3 Asian cities found that the hospitals lacked the diagnostic facilities and medications for many of the infections that are common among AIDS patients. Patients had less than a 50 percent chance of being diagnosed and treated for Kaposi sarcoma, an HIV-related cancer. Only half of the hospitals had equipment and medication to provide relief for breathing difficulties, and only two-fifths of the hospitals had strong pain-killing drugs. As the report notes, these were the best staffed, equipped and stocked hospitals. In other facilities the situation is much worse.
Due to lack of medication, tuberculosis often goes untreated. Forty percent of AIDS patients acquire active tuberculosis. In Zambia, where TB cases increased 600 percent from 1992 to 1998, “proper treatment became increasingly problematic because health facilities kept running out of TB drugs.”
At the same time, the increase in the number of AIDS cases is crippling the treatment of other health problems. Rwanda spends more than 66 percent of its health care budget on treatment of people with AIDS, and Zimbabwe spends a quarter. AIDS patients occupy 40 percent of the beds in the Kenyatta National Hospital in Nairobi, Kenya and 70 percent of the beds in the South Africa. The hospital sector in Kenya has seen increased mortality among HIV-negative patients, who are being admitted at later stages of illness.
Furthermore the lack of proper diagnosis and treatment of AIDS has led to a disproportionately high death rate among health care workers themselves, further undermining treatment. Deaths among health care workers increased 13-fold between 1980 and 1990 at one hospital in Zambia, largely due to the AIDS crisis.
In sharp contrast, death rates in the advanced capitalist countries of North America and Europe, where the AIDS epidemic began about the same time as in Africa, have dropped dramatically, especially since the introduction nearly five years ago of a class of drugs known as highly active antiretroviral therapy. While not a cure, these drugs reduce the blood count of HIV to undetectable levels.
In Canada deaths from AIDS have fallen more than seven-fold between 1995 and 1999. In the United States the death rate from AIDS has fallen by more than half. However, it has fallen at an even greater rate among those with access to highly active antiretroviral therapy, while increasing for those without access.
The cost of these medications has blocked their use for millions of HIV-infected people in sub-Saharan Africa and other parts of the world. The average cost of the three-drug cocktail is $17,000 a year, not to mention the very advanced level of health care needed to administer the drugs and provide treatment for side effects. In many countries, the provision of antiretroviral drugs at current prices would cost more than their entire gross national product.
Moreover, drug companies and the US government have blocked countries from producing generic versions. When in 1997 South Africa passed a law for compulsory licensing of the medication, 30 drug companies in South Africa, Europe and the US filed suit and the Clinton administration threatened trade sanctions. The dispute was only resolved earlier this year when the makers of AZT agreed to cut its price by 85 percent. During this time, the percentage of those infected rose from 12 percent to 20 percent. In the rest of sub-Saharan Africa, inexpensive antiretroviral therapy has only been made available in a handful of local studies.Three levels of care based on wealth
The report proposes three levels or packages of treatment: the essential, intermediate and advanced packages. The report recommends that each country adopt the package that it can afford. Only the advanced package contains the triple antiretroviral therapy that has proven so effective in cutting the death rate in North America and Europe over the past few years.
The essential care and support package is limited to:
* Voluntary HIV counseling and testing
* Psychosocial support for HIV-positive people and their families
* Palliative (that is care without curing) care and treatment for pneumonia, oral thrush, vaginal candidiasis and pulmonary tuberculosis (DOTS)
* Prevention of infections with cotrimoxazole prophylaxis for symptomatic HIV-positive people
* Official recognition and facilitation of community activities that reduce the impact of HIV infection
Even if these measures were implemented in full in sub-Saharan Africa—no small feat since most countries could not afford them—at best they would reduce the rate of new infections, but would do nothing to save the lives of millions already infected with HIV/AIDS.
After Uganda implemented a strong prevention campaign, prevalence rates were brought down from 14 percent at their peak to about 8 percent. Zambia is also showing signs that HIV/AIDS prevalence rates may have peaked and are now being brought down by prevention campaigns.
While such programs are necessary components of an effective strategy against AIDS, their basic premise is to rely on fear. The report admits that the decline in prevalence is mainly due the fact that a generation of young people has grown up seeing what AIDS has done to their parents and older siblings, and have decided to abstain from sexual relationships for a longer period of time.
Moreover, the essential package does not provide at all for the treatment of HIV-infected pregnant women to prevent transfer of the virus to newborn children. Last year over half a million children became infected with HIV in Africa, the vast bulk of whom were infected from their mothers and will die before they reach their teens.
For several years, a program of AZT given to the mother during pregnancy combined with cesarean birth and bottle-feeding has been proven highly effective in preventing mother-child transmission of HIV. Such a program costs $1,000 a month, far beyond the current resources of most sub-Saharan countries. Moreover, women in these areas do not have access either to baby formula or clean water with which to mix it.
Only in the final sections of the UN/WHO report is the cost of drugs and treatment even addressed. Page 81 of a 103-page report contains one sentence that says:
“The high costs of antiretroviral drugs, and the sophisticated medical facilities required to track patients' progress and monitor side effects, have been major stumbling blocks to access for the vast majority of people with HIV in the developing world.”
In fact, a study conducted by the London-based Panos AIDS Programme estimates that it would cost $60 billion a year at current prices to treat the 12 million people with HIV worldwide who would benefit from the drugs. In Zambia alone the cost would rise to $2.7 billion a year, or 76 percent of the country's gross national product.
Continuing on the theme that solutions to the crisis must arise at the local level, the report's proposals center on countries negotiating price discounts with the major drug producers and debt forgiveness. It cites several cases in which countries have obtained reduced drug prices for specific trials. For example, Uganda was able to obtain AZT at $4.34 for a daily dose, compared to the $10.12 price charged in the US. But even at the reduced price, the drug is still out of the reach of the vast majority of people suffering from AIDS.
The Panos report estimates that drug prices would have to be cut by 95 percent for them to become affordable to the vast majority of those infected.