Editorial

Reclaiming the state: Advancing peoples Health, Challenging Injustice
EQUINET Steering Committee

In just over a month delegates from all over southern African will be converging at the third EQUINET Southern African Regional Conference on Equity in Health being held in Durban, South Africa on the theme ‘Reclaiming the state: Advancing peoples Health, Challenging Injustice’. This conference theme has been chosen to reflect the commitment by EQUINET to go beyond mapping the problems in and challenges to health equity and social justice in southern Africa and to proactively build the alternative vision, analysis, perspective and practice needed to meet those challenges.

The conference will debate the actions and systems needed to advance people’s health equitably, fairly and within the broader context of social justice. EQUINET proposes that such systems must integrate principles and practice:
- of public health, viz the protection and promotion of population health and prevention of ill health
- of providing relevant, quality health services and care for all according to need and financed according to ability to pay
- of building the human resources and knowledge to shape and deliver public health and health services, and
- of protecting and ensuring the social values, ethics and rights that underlie health systems, including to participation and involvement.

The conference will also review through various areas of work the proposal that health must be supported by redistribution of the resources for health in an equity oriented policy agenda supported by the state. The conference will explore options for policies and systems that are explicitly centred on rising investment in health through the state and public sector. What does it mean conceptually and practically at national and global level to reclaim the central role of the state for equitable health systems?

Efforts by states and citizens in the region to equitably meet the health needs of their people confront the challenge posed by a globalization process based on unfair global trade relations, dominance of transnational corporation interests, reduced role and authority of the state and political and economic marginalization of southern and low income populations. Such conditions contribute to a huge ‘brain drain’ of health personnel, growing household food insecurity, massive constraints in meeting the drug and other inputs to health care and privatization of essential services, all with damaging implications for equity in health.

The conference will present and discuss the perspectives, shared values and options for challenging the injustices undermining people’s health. We will draw from the experiences of work with government, parliaments and civil society. We will examine the rights and governance approaches that are needed to support such action for health.

We invite all those with ideas, issues and options to contribute to this process, whether or not you are coming to the conference! Send us your feedback, resolutions, and contributions with your name and institution to admin@equinetafrica.org and we will integrate it into the inputs to the conference resolutions and keep you informed on the outcome. What do you see as the major challenges and contributions to advancing people’s health in southern Africa? What policies and actions are needed to strengthen the role and performance of the state and public sector in health? How can southern Africans more effectively challenge the injustices that undermine health? What should EQUINET do, as a network based on shared vision and values of equity and social justice, to strengthen our analysis, actions and institutions to better deliver on our collective aspirations for health equity and social justice? What role would you like to play in this?

BRIEFING FROM THE EQUINET SECRETARIAT: EQUINET ANNOUNCES NEW WEBSITE
R. LOEWENSON, TARSC, FIROZE MANJI, FAHAMU

EQUINET is pleased to announce the launch of its new website.

Visit http://www.equinetafrica.org/

The new website has been designed with minimal graphics to make it easier for those with low bandwidth connections to access the website with ease.

The full range of EQUINET's publications are available online. You will find a searchable database of all our publications, including our monthly newsletter, Equinet News, and Briefings, with archives of all previous issues. Policy papers, discussion documents, and other essential materials for the struggle for equity and health - all can be found at this easy-to-use website.

Our Annotated Bibliography on Equity in Health in Southern Africa is now available online for the first time in a searchable database, and information will now be updated regularly by the EQUINET secretariat at TARSC and the steering committee.

You can find the latest information about EQUINET's activities, research grants, training courses and reports from theme and country coordinators.

We welcome submission of news and other information online. Please send us news of work on health equity, publications for the annotated bibliography, news, policies and reports of meetings and research within the theme areas, information on grants and training opportunities and other information on health equity work in the region.

Send your contributions for the website and publications
bibliography to admin@equinetafrica.org and send your news to editor@equinetafrica.org.

We hope that this makes the site more useful to you and helps you in your work. We hope that it contributes to a stronger, more informed and more organized region in support of health equity goals.

For general queries on Equinet please email admin@equinetafrica.org or visit the Equinet website at www.equinetafrica.org.

The EQUINET website has been developed and designed, and is maintained by:

Fahamu - learning for change (http://www.fahamu.org).

Fahamu uses information and communication technologies to serve the needs of organisations and social movements that aspire to progressive social change and that promote and protect human rights.

Ensuring universal treatment access through sustainable public health systems
Southern African Regional Network for Equity in Health (EQUINET) Discussion Paper

The Regional Network for Equity in Health in Southern Africa (EQUINET), Oxfam GB in co-operation with SADC, government, UN, civil society, health sector and international agency partners met in February 2004 to review the options for a sustainable and equitable path to realising the urgent imperative of making antiretroviral therapy (ART) available to southern Africans and the long term imperative of universal treatment access. The organisations identified principles to guide a sustainable and equitable response that would address the urgency of the need to act and the demand to do this in ways that build and do no harm to the already fragile public health systems in southern Africa. There is an opportunity for a virtuous cycle where programmes aimed at delivering ART strengthen health systems and thus widen access to ART. There is also a threat of a vicious cycle of programmes aimed at delivering ART diverting scarce resources from wider health systems and undermining long term access both to ART and to other critical public health interventions. These principles are the basis for the virtuous cycle. They are presented as a discussion document for wider dissemination, discussion and feedback. Feedback is welcomed! Please email your feedback to admin@equinetafrica.org.

1. WHY TREATMENT ACCESS THROUGH SUSTAINABLE PUBLIC HEALTH SYSTEMS?

- Approximately 15 million adults and children in southern Africa are currently infected with HIV and an estimated 700 000 - 1million currently have AIDS. With only one eligible person in 25,000 currently on treatment with antiretroviral therapy (ART), the shortfall is enormous, and widest for the low income communities using peripheral and rural health services. Responding to this scale of disease and shortfall will not be possible through scattered programmes and projects. It requires a comprehensive and co-ordinated approach that embeds treatment within an effective, accessible health system.
- Treatment is only one of the multiple responses to the risk environments and factors that produce HIV and to the many areas of household vulnerability due to AIDS. Household food security, access to primary health care, social security, gender equity and income security are important factors linked to HIV and AIDS in southern Africa. Treatment programmes may excessively shift attention to drugs as the response to AIDS if they do not reinforce the prevention, care and socio-economic programmes that deal with these factors influencing HIV infection and the impacts of AIDS.
- After decades of macroeconomic measures weakening health systems, the capacities lost to public health systems, including the human resources for health, need to be systematically rebuilt to plan, manage and use the significant global and international resources for treatment of AIDS coming into Africa. Treatment activism has opened a real window of opportunity for meeting rights of access to treatment and overcoming unjust barriers to ART. It now needs to join with broader public health activism to ensure that these goals can be realised for all through sustainable, effective and equitable health systems.
- All southern African Development Community (SADC) member states have policies on AIDS and treatment guidelines and some are developing explicit treatment access policies. While legal, clinical and pharmaceutical aspects of these policies are now developed, there is a gap in the health system aspects. This gap needs to be filled if treatment policies are to be implemented in the practical conditions found in southern Africa health systems and to reinforce wider health and social goals.

The current situation does not lend itself to prescription. Southern African countries vary widely in socio-economic status, health system development and in the availability and organisation of resources for health. The choices around how scarce resources are used need to be made in an informed, transparent and participatory manner at the national level. These guiding principles are thus intended to support fair country level processes to develop strategies based on the capabilities, resources and demands of national health systems.

2. PROPOSED GUIDING PRINCIPLES

2.1 Fair, transparent processes to make informed choices.
The choices to be made around use of resources, around the clinical, social and systems criteria for rationing and around opportunity costs and trade-offs call for governments and relevant international and national non-government organisations to provide clear, transparent and accountable mechanisms for public and stakeholder consultation and debate to develop policy and to make policy choices.

2.2 Joint public health and HIV/AIDS planning.
Strategic and operational plans as well as monitoring and evaluation frameworks at national and district levels should be produced through a process that integrates HIV / AIDS planning into broader public health planning. This includes integrating AIDS treatment programmes into HIV/AIDS prevention and social care programmes. Integrated planning should be supported by investments in public health leadership and in the management and monitoring capacities needed to implement plans.

2.3 Integrating treatment into wider health systems.
Governments, international and national agencies should integrate HIV and AIDS prevention, treatment and care programmes into a programme of health systems strengthening and development. Key elements of this programme include:
Strengthening inclusive public health systems:
· Prioritising district and primary level facilities and services as points of entry for ART services over tertiary level services.
· Locating treatment programmes within an effective District Health System, supported by effective district health management structures that provide all basic services for HIV and non-HIV related illness in an integrated and locally appropriate manner.
· Ensuring adequate human resources for treatment programmes integrated within district health systems.
· Co-ordinating and building national networking of information and experience from district sites.
· Services provided by non-profit organisations should be integrated in the public sector framework.
· Private sector provision should complement public provision and not compete for public funding.

2.4 Realistic targets for treatment access with clear guidelines and monitoring systems for ensuring equity in access and quality of care.
The rapid expansion of ART can be achieved through targeting HIV positive current users of the health system, (particularly PMTCT, TB and VCT clients) and certain social and occupational groups (such as those with medical insurance or health workers). Such rapid expansion options should take place with simultaneous and equal investments to build the district health system and PHC infrastructure in areas without the current capacity to sustain effective ART services within clear time frameworks for wider rollout.

2.5 Treatment resources integrated into regular budgets, supported by long term external commitments and through fair financing approaches
Dedicated AIDS funding should be integrated into regular budgets and comprehensive health sector plans. The transfer and use of earmarked funds for AIDS should be transparent. ‘Emergency transfers’ to meet specific system shortfalls should be time-limited with plans for their integration into regular budgets and comprehensive health sector plans.

Additional funds and resources dedicated to HIV/AIDS should be system supporting (covering prevention, treatment, district health system and PHC responses) and include expenditure on broader health care infrastructure where required. This calls for longer term commitments from international agencies (minimum 5 years), in support of joint national HIV/AIDS and health plans, linked to budget and sector wide support with agreed exit strategies. Global and international funds should build predictable, consistent, long term and co-ordinated funding. African governments should increase their health budgets to 15% of total budgets in accordance with the Abuja declaration, and strengthen their governance and management capacities for resource planning and management. Ministries of finance should now integrate health systems demands into financial planning and budget frameworks and review their Medium Term Expenditure Frameworks with the IMF to take account of additional resource inputs demanded for system strengthening.

2.6 Prioritise human resource development in the health sector.
Strategic plans, developed in consultation with health personnel, are required for the health personnel needs and commitments for a health systems approach to treatment access. This should include effective and sustainable in-service and institutional training approaches, provisions for clear career paths, effective human resource management (payroll management, supervision and training), incentives for health workers to work in under-staffed areas and provisions for safe work. Plans for treatment access should not involve deliberate policies of recruitment of staff from other African countries or diversion of scarce personnel from broader health systems into vertical programmes. Any proposed new investment in HIV/AIDS or treatment expansion should include resources and measures for the training, sustaining and retaining of relevant health personnel and for their safe work environments and infection control.

2.7 Strengthen essential drugs policies and systems at national and regional level.
National legislation should now take full advantage of the TRIPS flexibilities and the Doha declaration, particularly provisions for parallel importation and compulsory licensing. Drug regulatory and medicine control authorities should be strengthened, together with drug procurement and distribution systems. The expansion of ART should be included within the essential drugs programmes, through review and update of the essential drugs list. The essential drugs policy should cover the private sector and provide where necessary for mandatory generic substitution (available generic equivalent drug provided when brand name drug prescribed). SADC as a regional body should use TRIPS flexibilities and the Doha commitments to support regional strategies for procurement, price monitoring and negotiation, and quality control of drug supplies. Southern African governments and civil society should promote monitoring, regulation and advocacy within the region and internationally to prevent excessive profiteering and unfair monopolies in the pharmaceutical sector.

3. CONCLUSION

These principles are proposed as central to ensuring that actions to expand access to ART are reinforced, sustained and meet equity policy goals through strengthened health systems. They are proposed:
- for national debate,
- for translation into practical strategies and programmes,
- to gather and share evidence on options for good practice,
- to provide a wider framework for understanding the costs and benefits of approaches to ART access,
- to inform international agency policy and practice and
- to inform advocacy and activism.

They are proposed as a framework for monitoring and evaluating our efforts to expand treatment access. They are as important as targets and are more directly linked to our longer term capacities and aspirations to sustain and expand access to treatment for all those who need it.

Free trade agreements, Southern Africa and access to health services


* Treatment Action Campaign (TAC)/AIDS Law Project (ALP) Memorandum on the United States/Southern African Customs Union Free Trade Agreement Negotiations. Prepared by: Jonathan Berger (Law and Treatment Access Unit, AIDS Law Project) and Njogu Morgan (International Desk, Treatment Action Campaign.

Introduction

On 4 November 2002, United States Trade Representative (USTR) Robert Zoellick formally notified US Congressional leaders of President Bush's intention to initiate negotiations for a free trade agreement (FTA) with the Southern African Customs Union (SACU), which includes Botswana, Lesotho, Namibia, South Africa and Swaziland. These negotiations are now underway, with the next round scheduled for 23 February 2004 in Namibia. As far as we are able to ascertain, the negotiators plan to conclude their discussions in or around October 2004, with a US-SACU FTA being signed before the end of the year.

The Treatment Action Campaign (TAC) and the AIDS Law Project (ALP) believe that trade between nations, when conducted within the framework of a reasonable and fair set of rules that adheres to the triple-bottom line of environmental, social and commercial sustainability has the potential to act as a tool for attaining developmental priorities. Our support for the ongoing negotiations would therefore be predicated on the agreement strictly adhering to these principles. Yet the US position, as clarified in Mr Zoellick's correspondence with Congress, raises cause for concern.

In his letters to the Speaker of the House of Representatives and the President of the Senate, Mr Zoellick set out reasons for entering into such negotiations, as well as the USTR's “specific objectives for negotiations with the SACU countries”. In particular, Mr Zoellick raises the following US objectives:

“We plan to use our negotiations with the SACU countries to address barriers in these countries to U.S. exports - including high tariffs on certain goods, overly restrictive licensing measures, inadequate protection of intellectual property rights, and restrictions the SACU governments impose that make it difficult for our services firms to do business in these markets. We also see the negotiations as an opportunity to advance U.S. objectives for the multilateral negotiations currently underway in the World Trade Organisation (WTO)." In our view, a number of the specific objectives identified have the potential to undermine the financing and provision of health care services in SACU countries, both in the public and private health sectors, as well as the rights of people living with HIV/AIDS. In particular, if translated in binding commitments, many of these objectives have the potential to limit the ability of the South African government in discharging its constitutional obligations, primarily in respect of the right of access to health care services. In our view, such undertakings would be an unconstitutional exercise of power.

This memorandum highlights our concerns in respect of two key areas: intellectual property (IP) and trade in services.

Intellectual property

With respect to intellectual property rights, the US government's specific objectives are as follows:

" - Seek to establish standards that reflect a standard of protection similar to that found in U.S. law and that build on the foundations established in the WTO Agreement on Trade-Related Aspects of Intellectual Property (TRIPs Agreement) and other international intellectual property agreements, such as the World Intellectual Property Organisation Copyright Treaty and Performances and Phonograms Treaty, and the Patent Cooperation Treaty.

“ - Establish commitments for SACU countries to strengthen significantly their domestic enforcement procedures, such as by ensuring that government agencies may initiate criminal proceedings on their own initiative and seize suspected pirated and counterfeit goods, equipment used to make or transmit these goods, and documentary evidence. Seek to strengthen measures in SACU countries that provide for compensation of right holders for infringements of intellectual property rights and to provide for criminal penalties under the laws of SACU countries that are sufficient to have a deterrent effect on piracy and counterfeiting.”

Quite clearly, the US sees the SACU negotiations as an opportunity to extract standards of intellectual property protection in excess of what the Agreement on Trade-Related Aspects of Intellectual Property (or TRIPS) currently requires. This is consistent with its approach to other regional and bilateral trade negotiations. A review of a range of such trade negotiations initiated by the US indicates that it has sought to extract greater concessions than those provided under existing international trade rules, largely to the detriment of developing countries.

To meet "standards of protection similar to that found in U.S. law", SACU nations would be required to adopt a range of TRIPS-plus provisions, including limiting compulsory licenses to national emergencies or to governmental, non-commercial use only. This is clearly in conflict with the Declaration on the TRIPS Agreement and Public Health adopted at the WTO Ministerial Conference at Doha in November 2001, which unambiguously states that "[e]ach Member has the right to grant compulsory licences and the freedom to determine the grounds upon which such licences are granted". Further, SACU members would be required to bar parallel trade, to extend patent monopolies for administrative delays, to link drug registration rights to patent status, to enhance protections for clinical trial testing data and to adopt criminal enforcement for patent violations, including improvidently granted compulsory licenses.

In short, the specific objectives in respect of IP would significantly undermine the ability of SACU member states' to make use of the regulatory flexibilities and public health safeguards identified in the Doha Declaration. If implemented, the negotiating objectives would severely limit access to essential medicines used in the prevention and treatment of a range of health conditions, including but not limited to HIV/AIDS. In addition, by seeking to impose TRIPS-plus provisions on SACU members, the USTR would be violating the principal negotiating objectives in the US Trade Act of 2002, which require "respect [for] the Declaration on the TRIPS Agreement and Public Health, adopted by the World Trade Organisation at the Fourth Ministerial Conference at Doha, Qatar on November 14, 2001", as well as Executive Order 13155, which deals specifically with access to "HIV/AIDS pharmaceuticals or medical technologies".

Trade in Services

With respect to trade in services, the US government's specific objectives include pursuing "disciplines to address discriminatory and other barriers to trade in the SACU countries' services markets." As mentioned above, the US plans to use the negotiations to address "overly restrictive licensing measures" and "restrictions the SACU governments impose that make it difficult for our services firms to do business in these markets."

If implemented, these negotiating objectives would render a range of legislative provisions in the South African Medical Schemes Act, for example, as unlawful. Such provisions increase access to health care services, by ensuring that unfair discrimination on the basis of health status is prohibited and by ensuring that medical scheme beneficiaries are guaranteed a minimum package of care, regardless of financial contribution.

It is not only trade in health care services that is of concern to TAC and the ALP. Similar arguments apply with equal effect, for example, to any regulatory steps taken by the state to ensure access to financial services for people living with HIV/AIDS. In our view, the state has a constitutional obligation to regulate the insurance services industry in such a manner, to ensure that people with HIV/AIDS have access to life cover and funeral benefits, as well as access to insurance services necessary for accessing financing for housing.

Conclusion

The ALP and TAC are concerned that the US/SACU FTA negotiations have the potential to result in binding commitments on SACU member states that undermine access to health care services, the rights of people living with HIV/AIDS and the ability of such states to comply with their domestic, regional and international human rights obligations. In our view, such an agreement would not only unlawfully conflict with certain national constitutions and human rights instruments, but would also serve to advance the interests of the US at the expense of the health and welfare of the people of Botswana, Lesotho, Namibia, South Africa and Swaziland.

* Please send comments for publications in the Letters section of Equinet News to editor@equinetafrica.org

CALL FOR APPLICANTS FOR STUDENT RESEARCH GRANTS ON EQUITY IN HEALTH, FEBRUARY 2004
EQUINET SECRETARIAT BRIEFING, FEBRUARY 2004

FIRST CALL CLOSES ON MARCH 31 2004. THE BEST APPLICANT WILL QUALIFY FOR
SUPPORT TO ATTEND THE EQUINET JUNE 2004 CONFERENCE IN DURBAN SOUTH AFRICA

This briefing describes the new programme of student research grants in
EQUINET and invites applicants for the first round of grants.

The Regional Network for Equity in Health in Southern Africa (EQUINET)
promotes policies for equity in health across a range of priority theme
areas (See www.equinetafrica.org) EQUINET has over the years, organized its
work in various theme areas, including: economic and trade policy and
health; human rights, governance and participation, equity in health sector
responses to HIV/AIDS, human resources for health; monitoring and
surveillance and others. Within these areas of work EQUINET aims to
identify, recruit and build capacity and analysis. After a successful
pilot initiative in 2003 in co-operation with the Malawi Health Equity
Network member in the EQUINET steering committee, EQUINET has now launched a
programme of student research support that provides small research grants
for students at college or university in various programmes in east and
southern Africa. The programme will give priority to student research
applicants who propose projects in areas of research relevant to EQUINETs
priority areas of theme work, and who provide evidence of supervision from
expertise in these areas.

This first round of the EQUINET student research grant programme (SRGP) is
being implemented in February 2004. EQUINET will award a number of small
grants to post graduate students and undergraduate students in East and
Southern Africa for research proposals in the areas of
? Equity in Human Resources for Health
? Equity in health sector responses to HIV/AIDS and treatment access
? Using health rights as a tool for equity in health
? Health equity in economic and trade policies
? Fair financing in health
? Governance issues in health equity
? Understanding and analyzing policy processes
? Equity issues in food security and nutrition

The grants are for students to carry out supervised, small research projects
in the course of their studies and are set at a maximum of $750. Applicants
are requested to provide brief information in 2-3 pages on
? The name, institution, course and year of study of the student
? The name, department and institution and contact email/fax for the
proposed supervisor for the study
? The theme area of the proposal
? The hypothesis, research question or research objective(s)
? The methods to be used, and indicators / (quantitative, qualitative
information) to be collected and the intended analyses to be carried out
? The time frames and budget
The application should be made jointly by mentors / supervisors and their
students. The grants will be open to all EQUINET members, undergraduate
and postgraduate students, students from all disciplines. Applications
should be submitted to admin@equinetafrica.org with STUDENT GRANTS in the
subject line or by fax to 263-4-737220 by March 30 2004.

In this round the student providing the project proposal rated highest on
grounds of analytic and technical quality and relevance will qualify to be
supported to attend the EQUINET conference in Durban South Africa, June 8-9
2004 (see www.equinetafrica.org) and formally granted their award at the
Conference.

The selection of grants will be made on the basis of relevance of subject
area and quality of proposal but with some attention to ensuring equity in
the distribution of grants across countries in the region. Applications in
French or Portuguese will be considered.

EQUINET web based resources, newsletter and expertise in the theme areas
will be available to the students. The reports of the research projects
will be made available on the EQUINET website. Publication from the research
is encouraged, with acknowledgement of the support from EQUINET. EQUINET
will also have the right to use the research in its theme work and will
encourage the students participation in future EQUINET activities and
information exchange.

Focal points for queries on this programme are Dr R Loewenson/G Musuka at
the EQUINET Secretariat (TARSC) and Dr A Muula at the Malawi College of
Medicine/ Malawi Health Equity Network. Please send queries through
admin@equinetafrica.org. For general information on EQUINET and its work
please visit our website at www.equinetafrica.org or email the secretariat
at admin@equinetafrica.org.

Access to antiretroviral treatment in Africa
Rene Loewenson and David McCoy

The demand for people living with HIV and AIDS in Africa to access treatment cannot be ignored. At the same time the challenges to meeting this demand are many. They include the shortfalls in health services and lack of knowledge about treatment, making decisions about newer regimens, and the risk of resistance to antiretrovirals highlighted in the paper by Stevens et al (p 280). (1 2) The challenges also include ensuring uninterrupted drug supplies, laboratory capacities for CD4 monitoring, accessible voluntary counselling and testing, trained healthcare workers, and effective monitoring of resistance to antiretroviral drugs.(3) A series of papers produced in 2003 through the southern African regional network on equity in health raised further concerns about measures to ensure fairness in the rationing of scarce treatment resources and the diversion of scarce resources from strained public health services into vertical treatment programmes.(4-8)

The reasons for these challenges are not a mystery. They stem from the chronic under-resourcing of health systems, the underdevelopment of strategic public health leadership, the attrition of health personnel, and the high prevalence of poverty, factors that already limit the delivery of many less complex primary healthcare services.(5-7) Given this context, how should resources best be allocated to ensure access to treatment for HIV/AIDS in Africa?

Existing initiatives provide some indications of what to do and what not to do. Making treatment accessible through private and non-government sectors or through redeployment of personnel without addressing the staffing, pay levels, and working conditions of health personnel in public health services can further increase attrition from essential services and aggravate uncoordinated health planning. (7)

Providing treatment on a "first come, first served" system favours urban, higher educated people who are not poor. It also unfairly delegates frontline healthcare workers to decide who does and does not access treatment, resulting in inconsistencies and even corruption. (8)

Providing treatment at central hospitals without strong links to community outreach or primary healthcare services weakens the link between prevention and care. It also limits the benefits that treatment brings in reducing stigma to the higher income users of these hospital services. (5 7) Vertical programmes established to achieve rapid delivery against unrealistic targets can divert scarce resources from strained public health services and bring undesirable opportunity costs and inefficiencies through the creation of parallel management and administrative systems.

In contrast, approaches to expand access to treatment can simultaneously strengthen health systems; build synergies between treatment, prevention, and primary healthcare services; and reach vulnerable groups. For example, when treatment is linked to prevention of parent to child transmission of HIV, provided through maternal health services, the likelihood of women having enhanced access to treatment, reduced social stigma around AIDS in women, and strengthening general maternal health services for all women is greater.

Criteria for selecting patients that explicitly target low income groups or particular subgroups of the population such as health workers and teachers (because their job promotes services for poor people), or that involve communities in decisions about selecting patients, can enhance equity and prevent the development of patronage or corrupt practices around treatment. Community health workers have had an important role in Africa in nutrition, immunisation, maternal health, child spacing, and many interventions that enhance health and treatment related literacy. Developing their role in access to treatment could strengthen primary health care and should be further explored. (7)

Such approaches to treatment access on a national scale will be possible only if the health system is properly organised, coordinated, and managed, and if it is adequately resourced. Organisationally, the principles of a district health system should remain paramount as a remedy to the destructive effects of uncoordinated, disease focused, vertical interventions. For such systems to be functional, we need to address the growing shortfalls and maldistribution of personnel and resources in African countries. (8 9)

If effective, equitable, and sustainable approaches to treatment access are to be replicated, considerable new resources will need to be channelled to Africa's health systems, particularly for district level services. Such resources should come from national public budgets, overseas development aid, global funds, and from the cancellation of debt. The International Monetary Fund and World Bank medium term expenditure framework constraints currently limiting the uptake of increased resources in the public health sector also need to be revisited.

The global recognition of rights to treatment reflects a significant shift in mindset. Another shift is now needed to deliver on those aspirations. Health systems cannot be built from a patchwork of non-government, vertical, ad hoc services around a crumbling public sector core. For treatment access to become a reality for more than a minority, a further step needs to be taken towards an explicit global and national commitment to refinance Africa's public health sector and district health systems.

* For a list of references, please click on the link below. This article was an editorial in the 31 January issue of the British Medical Journal. http://bmj.bmjjournals.com

Further details: /newsletter/id/30256
Anti-trust Litigation For Public Health Advocacy: Lessons From The South African Competition Commission Case
Sanjay Basu

Two months ago, after heavy pressure (including non-violent street protest) from the Treatment Action Campaign (TAC), the South African government announced that it would provide antiretroviral treatment to 1.4 million people within the next five years. This massive victory for South Africans was followed by December’s announcement that two major pharmaceutical companies - GlaxoSmithKline (GSK) and Boehringer-Ingelheim (BI) - who own more than half of the world AIDS drug market, would allow production of three of their antiretrovirals by generic companies in South Africa. The licensing deal - which will substantially drop the price of drugs throughout sub-Saharan Africa - was a result of a settlement after TAC filed anti-trust complaints to the Competition Commission, a unique South African government body.

TAC’s complaint was more than generous, arguing that a “reasonable profit” for the two companies would be the average profit margin of the patent-based pharmaceutical industry. TAC calculated the “economic value” of each of the three drugs in question by adding the price of the lowest-priced generic equivalent (an estimate of production cost) to the cost of research and development, and adding to that number the average profit of the patent-based industry. Even when using this generous formula, TAC found that a 300mg pill of AZT was priced at 2.58 times its economic value and a 150mg pill of Lamivudine was priced at 4.01 times its economic value [1].

GSK and BI have monopoly patents on the drugs AZT, lamivudine and nevirapine; these patents would not have expired until 2005 (AZT) or 2010 (lamivudine and nevirapine). While all three drugs were produced through taxpayer funded- research at the National Institutes of Health (nevirapine and AZT) or Emory and Yale Universities (lamivudine), the NIH and universities gave the research to private entities for a 1 to 4% royalty, and the private companies sold the drugs at prices upwards of 173% of production cost without any form of competition to regulate prices [2].

The companies, in pursuing their own profit motives, were therefore smart to settle the case rather than allow it to go to the South African Competition Tribunal. Had the Tribunal heard the case, the two companies would have been forced to defend their pricing, and therefore would have had to reveal their true production costs (estimated to be below 98% of drug price in many cases) and their profit margins (which are nearly three times higher than the rest of the Fortune 500 industry when calculated as a percentage of revenue, making the industry the most profitable in the world) [3, 4]. The Tribunal’s hearing would have also affirmed the principles of the WTO’s “Doha Declaration on TRIPS and Public Health” (referring to the Trade-Related Aspects of Intellectual Property Rights agreement), which calls for patent rules to be subsumed in the case of public health needs (not only in emergency cases, as often wrongly stated) [5]. Thus, a precedent would have been created to allow for tighter regulation and increased competition to challenge the current global pharmaceutical monopoly. In settling the case with TAC, GSK and BI therefore agreed to some forms of regulation. The terms of the settlement required that:

1. GSK will grant licenses to four generic companies (including Aspen Pharmacare and Thembalami Pharmaceuticals) to produce and/or import, sell and distribute the antiretroviral medicines AZT and lamivudine. Before the agreement with GSK was concluded and signed, GSK had only granted a license to Aspen Pharmacare, which included a massive royalty to GSK (increasing the price of the generic version of the drug) and had required Aspen to market exclusively to NGOs and the public sector, which is inappropriate in any sub- Saharan African countries, where the lack of public infrastructure in the wake of neoliberalism means that even the poorest classes often see private providers.

2. BI will grant licenses to three generic companies to produce and/or import, sell and distribute the antiretroviral drug nevirapine. Before the agreement with BI was concluded and signed, BI had only granted a license to Aspen Pharmacare. This provision will produce competition between generics, likely lowering price.

3. The royalty fee on the licenses will be no more than 5% of net sales of the antiretroviral medicines. Before the agreements with GSK and BI were concluded and signed, the royalty fee that GSK requested was 30% and with BI it was 15%.

4. The licenses will be for both the private and public sectors. Before the agreements with GSK and BI were concluded and signed, the licenses granted by GSK and BI to Aspen were limited to the public sector only.

5. The agreements with GSK and BI will also allow licensees to export AZT, lamivudine and nevirapine that are manufactured in South Africa to all 47 sub- Saharan African countries. Before the agreements with GSK and BI were concluded and signed, exports to sub-Saharan African countries were not permitted.

6. The licensees will be able to manufacture AZT, lamivudine and/or nevirapine in combination with each other and/or any other medicines for which the licensees have contracts. This is critical because it will allow triple-drug fixed-dose combinations, currently manufactured by at least two generic producers, to come to the market, dramatically simplifying treatment protocols and reducing the number of pills that HIV+ persons have to take each week and the frequency of dosing.

These terms provide us with some insights about the power of threatening anti- trust litigation (if not actually using it in countries where such complaints are possible). But they also provide us with cautions about how such litigation must be constructed if it is to produce public health benefits. There are several terms of the South African settlement that are not ideal, giving evidence to the power of strong pharmaceutical company lawyers. As pointed out by James Love of the Consumer Project on Technology, we must wonder why the two companies still gain a royalty on taxpayer-funded research after gouging consumers in the context of a plague, and why the companies are allowed to choose their own competitors [6]. One of the most important generic companies - Cipla of India - has consistently operated under an “alternative” business model of producing near or below cost to provide several drugs as quickly and safely as possible to poor countries, but has been excluded from this arrangement, limiting the ability of countries to make use of Cipla’s excellent production capacities and to produce the sort of “free trade” that might actually benefit consumers.

Nevertheless, the settlement is clearly beneficial for those in need of AZT, lamivudine and nevirapine in sub-Saharan Africa. The irony is that the day after the settlement was announced, a major study of HIV therapies was published in The New England Journal of Medicine, revealing that the best combination of drugs to treat HIV infection for those persons not yet receiving treatment was AZT, lamivudine and efavirenz [7]. Efavirenz and nevirapine are members of the same class of drugs, but are unlikely to work in the same manner. Efavirenz is also produced by DuPont, and is not part of the South African settlement. Therefore, as pointed out by Rahul Rajkumar of the Yale Medical School, South African physicians and their patients will still not be able to make use of the latest research on HIV therapies; such research is only beginning to emerge, as large trials of different combination therapies have taken years to conduct and evaluate. Treatment decisions in South Africa and elsewhere will be guided by trade rules and a patchwork of litigation, not by best practices and new research [8].

The context of the settlement and of this limitation faced by South African physicians and patients parallels the sort of problems faced by public health advocates after the US Trade Representative (USTR) resisted the implementation of the Doha Declaration on TRIPS and Public Health. A year after signing the Doha Declaration, the USTR began a long process of adding stipulations to the agreement, which have excluded most countries from allowing generic drug competition into their markets, as I have described elsewhere [9, 10, 11]. The result was a stringent and complex series of rules requiring countries to demonstrate a public health need and then submit themselves to a WTO tribunal before regulating their own drug markets. And so both in the case of the Competition Commission settlement, and in the case of Doha, those persons attempting to lower the prices of pharmaceuticals - both for AIDS and for other diseases -will have to bend-over-backwards to enter into specific drug-by-drug litigation, or disease-by-disease WTO approval processes that are unlikely to succeed.

The lesson here is that anti-trust litigation is immensely helpful, as is reform of WTO processes; but both are limited currently because they are so specific to AIDS, or to individual AIDS drugs, that their specific rulings will limit the flexibility needed for appropriate system-wide health improvements. Therefore, an appropriate second step for AIDS activists, beyond the kind of litigation that TAC has been so successful at, is to examine more critically the new sets of trade rules that are being proposed through the free-trade agreements crafted by the USTR. Challenging these new agreements (some of which call for over three decades of patent protection for new pharmaceuticals) will require joining with already-mobilized forces working against the South African Customs Union (SACU) trade deal and its accompanying New Economic Partnership for African Development (NEPAD), as well as those currently working to expose and transform the Central American Free Trade Agreement (CAFTA), the Free Trade Area of the Americas (FTAA), and the Enterprise for ASEAN Initiative. I have reviewed the specifics of these agreements in a separate piece [10], and some student organisations have begun to join international NGOs to work on the issue (www.fightglobalaids.org, www.amsa.org/global).

Linking our work on drug prices to the larger scheme of trade-associated problems promoting the spread of infectious and non-infectious diseases (such as forced migration [12], factory-labour-associated illness [13], and the crash in primary commodity prices that precedes changes in food use and subsequent diabetes rates [14]) will likely take us to a new level of public health advocacy, one that will hopefully move beyond our behaviouristic and disease- specific leanings and onto effective system-wide critiques that can offer a good complement to the work of groups like TAC [15]. So while anti-trust litigation offers the precedent we need to push the line of acceptable outcomes, our activism on trade agreements can extend specific cases to larger themes and wider practices that currently limit the success of our interventions.

* Sanjay Basu is at the Yale University School of Medicine. http://omega.med.yale.edu/~sb493/

* This article was originally published on the website www.zmag.org and is reproduced here with permission of the author. Please send comments to editor@equinetafrica.org. Click on the link below for references.

Further details: /newsletter/id/30171
Can victory on AIDS medicines catalyse wider change?
Patrick Bond (http://www.zmag.org)

A rare activist-driven win for some of Africa's wretchedly poor women, men and children leaves me humbled. In June 2002, I wrote a Znet (www.zmag.org) column-'Corporate cost-benefit analysis and culpable HIV/AIDS homicide'-in which the main prediction proved partly wrong within a few weeks. I have been waiting for a chance to correct the mistake. My error, excessive pessimism, was compounded by another event I would not have considered possible: the November 19 announcement that the South African government will now finally begin providing anti-retroviral (ARV) medicines to hundreds of thousands of people who are HIV+.

Activists hope that five million infected, who now account for more than a quarter of South Africa's adult population, will eventually get the desperately needed medicines, notwithstanding some practical barriers to implementation. Exultant relief was expressed by South Africa's Treatment Action Campaign (TAC), along with allies including ACT UP, Oxfam and Medicins sans Frontiers, which is running successful treatment pilot projects in Cape Town township clinics, where compliance with treatment regimes is higher than 90%.

TAC also restrained itself from launching protests against president Thabo Mbeki's extraordinary comment in late September to the New York Times: 'Personally, I don't know anybody who has died of AIDS.' In mid-November, the hated health minister, Manto Tshabala-Msimang, also revealed her reluctance to attribute AIDS to the HI Virus, just as she announced the medicines roll-out. In previous statements, she has termed ARVs 'poison.' Given such attitudes, I didn't think Pretoria or its corporate friends would get this far along the path to civilised behaviour, this fast. For the chance to commit these errors, I am delighted, because far worse would have been to claim deadly accuracy.

My prediction was that at least three structural forces in South African capitalism would overwhelm the struggle capacity of AIDS treatment activists. Structure/struggle is always a dialectic, but it's wonderful to see history written from the bottom up, for a change. I will briefly rehearse the argument that I confidently made in mid-2002; some of that analysis is still valid, even if my main point-that the dynamics of state power and corporate profits tend to overwhelm progressive resistance-must be revised.

The first factor is the pressure exerted by international and domestic financial markets to keep Pretoria's state budget deficit to 3% of Gross Domestic Product. This pressure led Mbeki's spokesperson Parks Mankahlana (who died of AIDS three years ago) to remark to Science magazine in early 2000 that pregnant, HIV+ women would not be receiving Nevirapine to prevent mother-to-child transmission, because 'That mother is going to die and that HIV-negative child will be an orphan. That child must be brought up. Who is going to bring the child up? It's the state, the state. That's resources, you see.' Second is the multinational pharmaceutical corporations' interest in maintaining exclusive patents on ARVs so as to monopolize profits, profits which come from sales to wealthy markets, not low-price deals for Africa. As the actions of US Trade Representative Robert Zoellick prove, pharmacorp pressure remains intense, although some firms have offered cheap drugs, but mainly so as to head off the possibility of mass imports (or local production) of generics. To illustrate, staff at the Bill and Melinda Gates Foundation, which provides medicines to some African countries, certainly don't want to see the World Trade Organisation's protections on 'Trade in Intellectual Property Rights' undermined, for obvious reasons.

Third, South Africa's huge unemployed labour pool-more than 40% of the potential workforce-means that local capitalists can readily replace unskilled workers who start developing AIDS symptoms with desperate, jobless people. This is less expensive than providing medicines, with Anglo American Corporation's 2001 cost-benefit analysis demonstrating that only the highest-paid 12% or so of employees justified receiving AIDS medicines, given the cost of recruiting and training replacements at the higher end of the spectrum.

But within a few months, the calculus changed sufficiently for two of the largest employers in Africa, Anglo and Coca Cola. The main ingredient was protest-and in Anglo's case, I was reliably informed by insiders, the prospect of demonstrators at the August 2002 World Summit on Sustainable Development dragging up many other bits of dirty laundry. Coke's main bottler in South Africa has failed to insure two-thirds of its 4,000-strong workforce at a sufficient level to allow the HIV+ workers access to ARVs, and it too was subject to international protest over African AIDS policies.

However, even though the costs of HIV/AIDS-absenteeism, declining productivity, payouts for early death-have soared to as high as 25% of payroll, according to the Financial Times in a September 18 report this year, most employers are still hesitant to provide ARVs: 'Untreated, HIV typically takes four to five years to manifest itself as full-blown AIDS, and companies are reluctant to pay for a risk that they cannot see. Persuading managers to part with fees [AIDS treatment programmes] today for costs that will hit company earnings years down the line has been a hard sell.' In sum, all three structural factors are still deterrents to provision of treatment, though each has been mitigated recently. The budget deficit will climb this year from just over 1% of GDP to nearly 3%, allowing extra leeway for AIDS spending. Pharmacorps are cooperating with the World Health Organisation, Clinton Foundation and governments to lower prices for Africa, in part because Canada's outgoing prime minister Jean Chretien-spurred by UN advisor Stephen Lewis-has introduced legislation to promote generics. And employers are waking up, in part because of the dramatic rise of AIDS-related disability claims as a percentage of all disability claims, from 18% in 2001 to 31% last year.

What, specifically, was behind the November 19 Cabinet statement? Pretoria cited factors which included: 'a fall in the prices of drugs over the past two years; new medicines and international and local experience in managing the utilisation of ARVs; [sufficient] health workers and scientists with skills and understanding; and the availability of fiscal resources to expand social expenditure in general, as a consequence of the prudent macro-economic policies pursued by government.' However, these factors are, in my view, minor compared to intensive activist pressure, which Pretoria did not dare mention lest it encourage further protests. TAC's victory statement was explicit: 'The combination of the Constitutional Court decision on mother-to-child transmission prevention, the Stand Up for Our Lives march [of 15,000 people on parliament] in February, the civil disobedience campaign and the international protests around the world have convinced Cabinet to develop and implement an ARV rollout plan.' Another factor, of course, is the 2004 presidential election, which Mbeki is expected to win easily but which will be characterised by high levels of apathy and no-vote campaigning by the Landless Peoples Movement. An AC Nielsen survey in November confirmed that Mbeki's AIDS policy is hurting the ruling African National Congress' chances of turning out the vote.

High visibility is an important antidote, and the Cabinet promised that 'within a year, there will be at least one service point in every health district across the country and, within five years, one service point in every local municipality.' In addition to medicines, the state will provide an education and community mobilisation programme, promotion of good nutrition and traditional health treatments such as herbal remedies, support for families affected by HIV and AIDS, and funds for upgrading health infrastructure. The current health system is massively overextended, with far too few essential medicines, much less ARVs, available in South Africa's underfunded rural clinics.

The programme's resources-US$40 million through March, rising to US$680 million per year in 2007-are all new (not drawn from existing allocations to social programmes. The cost of medicines will rise from 20% to 33% of the programme budget.

Will ARV availability generate negative unintended consequences? One would be noncompliance with treatment regimes by poor people, and the concomitant emergence of drug-resistant strains. Another would be the black-market smuggling of cheap drugs to Europe and North America which would reduce access in Africa. Another is that although stigmatisation will decline given the availability of hope-giving drugs, so too might the practice of safe sex. These are all major challenges to TAC and other health-sector groups.

The Cabinet also repeated one of Mbeki's tired truisims, namely that immune systems in townships and villages are 'assaulted by a host of factors related to poverty and deprivation.' In spite of a recently-published ten-year government review aiming to show increased delivery of old-age pensions and child support grants, there is no disguising the role of the allegedly 'prudent macro-economic policies pursued by government' in creating poverty and inequality.

The conflict between neoliberalism and life was rarely as explicit as in the case of AIDS medicines, and was compounded by patriarchy, traditional and modern sexual practices such as multiple partners for men, and domestic violence against women. Rape continues at scandalous levels. The TAC leaders, some of whom (like the brilliant activist Zackie Achmat) learned politics in highly vulnerable Trotskyist cells within the ruling party, are more than capable of simultaneously fighting capitalism, racism and sexism together. But a few other political choices may also become more urgent.

One relates to their alliances within South African politics, which have been effective in attracting the most forward-looking trade unions, the SA Communist Party, churches, NGO activists and technical supporters (lawyers, healthworkers, academics, journalists). Yet these alliances have not strayed far from the African National Congress.

Does TAC have sufficient linkages to non-ANC communities (especially those devoted to building the new independent left)? Will the myriad of problems that cause AIDS opportunistic infections-especially dirty water and air (thanks to coal/wood/paraffin)-also be addressed? At a time that the South African government is disconnecting water and electricity at a lethal rate, alongside evictions for those who cannot afford expensive rental and mortgage payments, addressing links between AIDS and diseases of poverty/homelessness are crucial.

This leads to another problem: will TAC and its allies make the case that access to ARVs is a human right and that people should not pay user-fees or partial cost-recovery for the medicines? They do make this case, but only in the event that people are too poor to pay for medicines. Yet 'means-testing' of black South Africans with irregular informal incomes is notoriously difficult. TAC may need to consider a more explicit 'free lifeline' strategy, as the water and electricity campaigners have done, partially successfully. After all, I see TAC as integral to the overall politics of 'decommodification' and 'deglobalisation' that are so crucial to social progress across the world. To decommodify is to take that which is life-giving-our medicines and healthcare, water and a decent environment, clean energy, education and childcare, support for the elderly, even food and culture, as well as employment-and remove them from the market, as much as is required to ensure a lifeline access to all, on a universal basis.

Such socio-economic human rights can be won, in my view, only through deglobalisation, namely the delinking of countries and regions of the world from the bureaucratic straightjackets designed in Washington and Geneva-structural adjustment, TRIPs, etc-on behalf of corporate interests.

Nevertheless, whether or not TAC continues to tackle the three structural impediments to ARV access-neoliberal fiscal policy, pharmacorps and corporate control of health perks-the immediate victory will make a huge difference. For the half million South Africans who are symptomatic with AIDS or who have a CD4 blood count less than 200, there is now hope. Across the world, for three million people who died this year of AIDS, this breakthrough has come too late. But for 40 million others infected, the treatment activists and their international allies deserve a standing ovation. Those who help Washington-based Africa Action protest Bush health policies on December 1, World AIDS Day, will gather strength from the South African breakthrough, and they will be louder and prouder than ever.

The Dangerous Deradicalization of AIDS Discourse: Meanings and Implications for Representative Activism
Sanjay Basu

Earlier this week, the Clinton Foundation announced the dramatic reduction of AIDS drug prices after its negotiations with several "generic" pharmaceutical manufacturers; the result was a cutting in half of the price of antiretroviral treatment for AIDS patients in several poor countries. While the news was welcome to most persons working on the issue, and while indeed many groups eagerly await specific details that might reveal problems or wonders in this deal, there is an underlying question that will remain unaddressed by technical evaluations of the new drug price reduction: what does it mean when a foundation headed by a person who--years ago--placed trade sanctions on countries attempting to import low-cost medicines now helps to procure such drugs and enters the spotlight of praise in the "AIDS community"?

The issue is not merely one of hypocrisy or even of repentant revelation and progressive reform. At issue, more generally, is the question of what the meaning of AIDS has become as it has travelled through so many powerful institutions and been altered by so many professional "institutionalists", and what the implications of this are for those people genuinely concerned about human well-being. The answer might be found in the frequently-expressed bitter remark from young public health students who now say that AIDS is getting "too much attention." Those who disagree with this perspective will, quite rightly, point to the disease's devastating toll and suggest that such attention is certainly justified and perhaps not even provided in adequate magnitude or appropriate programs. But, perhaps just as importantly, a second rebuttal is needed: that criticisms about one disease becoming too mainstream or too attractive for the institutional crowd assume that public health advocates are not fighting for general well-being, but rather battling against each other to steal the most funds from one another, like slaves competing for maximum output at the mill. If there is one thing that the AIDS activist movement has taught us over the last several years, it is this: that rather than fighting amongst ourselves over a fixed pot of money, those of us who stop thinking through the "cost-effective" framework and think through politically strategic paradigms can make the overall pot of money significantly larger, and can make our set of available options much wider. The funding provision may involve chaining ourselves to things, but the campaigns do in fact work, and few who review the history of AIDS activism can argue otherwise. To expand our paradigms simultaneously has also meant addressing the plain fact that diseases are not isolated and singular entities, but agents with reciprocal effects--that HIV rates affect TB rates, which affect community well-being and family stability (and vice versa), which in turn affect vulnerability to other diseases and social stresses and nearly everything else that matters to living a decent life.

Years ago, the paradigms used to address AIDS were focused on identifying specific "risk groups" and "targeting" them for interventions. These interventions were almost exclusively constructed though a "rational choice" framework (or what I've called "public health behaviourism")--a framework that wrongly assumes that poor women in economically-dependent relationships can negotiate sex, or that assumes that depressed men in the all-male barracks of South African mines (with a 42% injury rate) will care more about a disease that can kill them 10 years down the line than about finding some minor satisfaction through alcohol or sex. The paradigm even promotes "models" like Uganda, failing to account for the fact that much of the data coming out of such countries indicates that "prevention-only" measures were working only among the wealthier sectors, while the poor continue to suffer the greatest burden of disease. I have compared the realities of poverty and the rhetoric of public health behaviourism elsewhere (1); my task here is to argue that something very strange is going on if this behaviouristic paradigm has finally shifted to a new paradigm that addresses the issue of resource (mal)distribution and inequality--in particular, "access to antiretrovirals"--but in the midst of this, the Clinton Foundation, of all groups, has emerged as a central hero.

What is odd about this event is captured by the very framework of the Clinton initiative. I am not, here, referring to the extensive patent law strengthening done under the Clinton administration, which now ironically undermines in some ways the Clinton Foundation's own initiative; this set of issues around hypocrisy is obvious enough. What I am referring to is that the deal made by the Foundation was narrowed to one about AIDS, and more specifically, antiretroviral drugs. This seems appropriate, but I will argue that while it may be technically competent, it is not politically so, and the press releases and narrowing of scope of the negotiations to just antiretroviral drugs avoided the core of the problem. Not only was the scope merely "narrowed", but it was done in a way to suggest that such price negotiations could not lead to questioning of intellectual property issues, and more importantly, could not be used for diseases besides AIDS. This was merely an "AIDS drug access agreement". And AIDS will supposedly be solved through existing behaviouristic prevention measures and a few of these new types of drug negotiations. In essence, the deal moves us back towards the days when AIDS was treated as a singular entity, a problem to be addressed without asking questions of why it has appeared the way it has, and why it continues to sustain itself in the way it does (that is, why it remains a disease of the poor).

The Foundation focused on the drug price reduction as an AIDS issue, and AIDS as now primarily an "access to antiretrovirals" issue. If there is any sure indication that "access to antiretrovirals" has become a mainstream concern, this is it. And yet, as someone who has advocated for such access for nearly 7 years, this is a frightening phenomenon.

My concern is that lack of access to antiretrovirals is an indicator of something much broader, and AIDS is also a symptom of much more nested problems. If AIDS is appearing so often in the context of trade agreements, where the crash of primary commodity prices leads farmers to migrate to industrial centres and break off their marriages, making "monogamy" a nonsensical idea (2); if inequalities in access to jobs and education force women into prostitution as the means to survive (3); if the terms of inequitable worker contracts mean that depression and drug abuse are the two primary options for workers in the lowest income sectors (4, 5), then AIDS is not just a "syndrome", but an end-stage "symptom" of a much larger disease.

What is problematic, then, is that as "access to antiretrovirals" has become part of the centre of AIDS discourse, two camps have appeared to negotiate the phrase's meaning. On one side we have the Clinton Foundation, who through technical interventions and isolated negotiations will attempt to disguise its past and avoid coming to terms with patenting and other structural problems as it "solves" the pandemic through the most elite forms of politics: closed-door negotiations. On the other hand, there are those that recognize that "access to antiretrovirals" is merely a group of code words that indicate, most broadly, "the right to resources needed for a decent life." The lack of antiretrovirals in poor countries is part of a broader problem of lack of medicines; this, in turn, is symptomatic of a broader problem of inappropriate resource distribution, which in turn indicates dramatic power inequalities. That form of thinking is precisely what the Clinton Foundation's press releases seem to try to hinder, arguing that this selective price reduction was AIDS-specific, and something that the elites can take care of.

The distinction is not minor, for it brings us to bear upon our role as self-described "activists"--a term that, all too often, carries with it the most extreme forms of self-promotion and self-righteousness, and often a vulnerability to injure those who we claim to advocate for. The problem with treating AIDS as just a disease, and not a symptom of broader inequalities, is that this prescription is more frequently coming from "activists" who have lost touch with the context of the statements they receive from those they claim to represent. In the letters and editorials of papers in neighbourhoods and cities most affected by AIDS, the disease is not merely a concern about drugs. Drugs are crucial; but talk about inequality in access to drugs are also representative--they are indicators, social markers (like conspiracy theories or public protest) that something much deeper is going wrong. And the hegemony exerted by activists who lose this sense is a hegemony that is indeed very dangerous, because it inflates a desire for personal heroism and self-promotion and neglects the structural inequalities few are willing to approach for fear of being left out of elite conversation. The new public health advocates struggle with the task of understanding medicine distribution technicalities and little else; they do not ask if there are other avenues to approach, or even if this is merely one recipe torn apart and read in isolation, because they have forgotten (or have never learned) that this recipe was part of a much larger cookbook. AIDS is reduced to an issue of "access to antiretrovirals", rather than having "access to antiretrovirals" be a representative AIDS issue that serves to hint at the direction of the fuel tanks supplying the biggest fire in human history.

All too often, the "structural problems" fuelling the fire are declared impossible for public campaigning; too difficult for effective activism, or--worse yet--the domain of lunatics and extremists. Once again, the common, day-to-day forces in AIDS activism prove such contentions wrong. At universities across the U.S., U.K., and Canada, students are engaging with activist groups in "the South" to alter university drug development policies in line with the community needs of those who have been excluded from research benefits (www.essentialmedicines.org); in other parts of the U.S., even as federal funds get shredded under neo-conservative fiscal policies, activists have kept pressure on local governments to preserve key social services by promoting ballot initiatives among the poor; elsewhere, labour policies are becoming central parts of AIDS activism movements, which are winning battles to improve housing and terms of contracts after involving mine workers and other affected persons more centrally in the campaigning process. The key, then, to maintaining a representative discourse on AIDS is to diffuse power in this manner and consistently expand the meaning of AIDS to its structural causes rather than its most visible and easily acceptable end-points; the commonality between all of these effective "structural interventions" is that they are operated with a sense of caution, and a fear of exerting dangerous hegemony that forces those involved to re-think what it at stake. Rather than taking a mainstream issue and carving out a field of power within it, these campaigns are directing themselves in the opposite direction: taking an issue that is already mainstream ("access to antiretrovirals") and asking what is unrepresentative about it, what is missing from its ranks ("access to general resources needed for decent life"). And who better to ask than those who are most affected; those who do not gain entrance into the drug price negotiations of the Clinton Foundation (but, importantly, have gained access to the core of South African AIDS activism, 6)?

This article may be written as a formulaic prescription, and the more educated groups will criticize my simplicity and extravagance even as I discuss hegemony and preach humility. Their criticisms may be warranted; but in spite of that, a healthy warning should remain: that the fear of hegemony, the fear of being unrepresentative, can drive us much farther towards improving each others' livelihoods than any attempt to force our issues to be arbitrated by the mainstream sources of power in isolation from the core of active suffering, or to force social space into our preconceived visions by selectively filtering the voices and livelihood realities of those we claim to defend.

References:

(1) AIDS, Empire and Public Health Behaviorism:
http://zmag.org/content/showarticle.cfm?SectionID=2&ItemID=3988

(2) Bello, W., S. Cunningham, et al. (1998). A Siamese Tragedy: Development
and Disintegration in Modern Thailand. London, Zed Books.

(3) Farmer, P. E., M. Connors, et al., Eds. (1996). Women, Poverty and
AIDS: Sex, Drugs, and Structural Violence. Monroe, Common Courage Press.

(4) Campbell, C. and B. Williams (1999). "Beyond the biomedical and
behavioural: towards an integrated approach to HIV prevention in the
Southern African mining industry." Social Science and Medicine 48: 1625-39.

(5) Connors, M. M. (1994). "Stories of Pain and the Problem of AIDS
Prevention: Injection Drug Withdrawal and Its Effect on Risk Behavior."
Medical Anthropology Quarterly 8(1): 47-68.

(6) www.tac.org.za

African leaders told: "stop playing hide and seek whilst people are dying"
Speech by Nomfundo Dubula on behalf of people living with HIV, closing ceremony, ICASA

My name is Nomfundo Dubula. I am a person living with HIV. I am from the Treatment Action Campaign in South Africa and I also represent the Pan African Treatment Access Movement.

I want to say that as communities and people living with HIV we are angry. Our people are dying unnecessarily.

African leaders, the ball is in your hands. You have to decide whether you want to lead a continent without people. So, stop playing hide and seek whilst people are dying.

The World Health Organisation has declared antiretroviral therapy a state of global emergency and our leaders are still in a state of denial.

The Doha and the UNGASS declarations have opened the way to decide about the future of Africa, so, when is your action? The Doha declaration on health is hope, and it must be implemented.

Two years ago, the Abuja declaration promised 15% of the budget on health but up to now that has not happened. How many people must die? Please, move from talks to real action.

Give women powers to decide and lead and they will overcome this epidemic.

African leaders, lead us. Don't divide people living with HIV, as we all want to assist in this fight.

We need CCM's in each country with positive attitudes towards treatment, especially ARV's, so that we have effective and unequivocal treatment plans.

We need you to speak out about nutrition and not confuse us with the debate about nutrition versus ARVs. Nutrition goes hand in hand with ARVs!

I also want to address the WHO. WHO has promised to give technical assistance in the procurement of drugs. Now we need your assistance in our countries to ensure that cheaper generic drugs reach every country, with or without manufacturing capacity.

You also have a key role in ensuring resources for poor countries. The 3 by 5 plan should also ensure that all treatment programmes include treatment literacy efforts. On our side, we commit ourselves in educating our people and ensureing adherence.

We need real leadership in the implementation of effective strategies to reach the 3 by 5 goal. We will assist you in this effort if you show commitment and independence in prioritising people's health over any other interest.

I want to refer to the drug companies, whose bags are full with profits. Stop squeezing poor Africans which only represent 1.3% of your global market.

Don't delay access by giving exclusive licenses that are only transferring the monopoly to local companies blocking competition.

Your diagnostics are still too expensive and inaccessible.

Provide low prices and allow our governments to bring us life-saving drugs and the necessary monitoring systems.

I want to say to the donors that they should donate more money to the Global Fund. We welcome the US initiative led by president Bush. But we want money that is free of hidden agendas. Put more money in the Global Fund and stop blocking our government's rights to import generic drugs.

The IMF and World Bank should cancel the debt, as Africa is fighting for its life. Don't even pinch the last drop of its blood.

And where was the Global Fund in this conference? How can you communicate with our brothers and sisters, and what is going on with their countries proposals? We need you to have a booth in the GNAP+ conference so that you can be visible, and we can ask questions.

The Pan African Treatment Access Movement - PATAM - is fighting for the lives of Africans. So, we will continue to mobilize our people as we did in the court case of the Pharmaceutical companies against the South African Government.

We will continue to mobilize our people as we South Africans did in the PMTCT court case against our government.

We will continue to mobilize our communities to ensure access to treatment and care.

We will continue giving treatment literacy workshops to ensure adherence, promote VCT, prevent new infections and promote openness.

We will be watchdogs in ensuring real implementation.

AMANDLA, AMANDLA POWER, TO THE PEOPLE.

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