When my comrades and I disrupted Minister of Health Manto Tshabalala-Msimang’s speech at the Health Systems Trust conference, a public health official taunted one of the Treatment Action Campaign (TAC) members by saying: “How did you get HIV anyway?” We also received an angry letter from a man who feels our demand for treatment is unfair. This article is written for them. It is also written for people like Western Cape African National Congress health spokesperson, Cameron Dugmore, who called us bullies for disrupting the minister.
First, I apologise unconditionally to the minister for referring to her personal appearance during our disruption. Any reference to the personal appearance of an opponent to discredit them is wrong. It’s also wrong because it undermines the dignity of the protest of thousands of TAC volunteers and allows people who need to curry favour with officials a cover for their lack of courage and morality. It is also no excuse to say that I was angry, because a few minutes before my own anger against indifference became uncontrollable I had told a comrade whose mother had been hospitalised with a CD4 count of 54 and raging tuberculosis that she should use her anger to demonstrate peacefully. But there are many things I do not apologise for. I do not apologise for holding Tshabalala-Msimang and Minister of Trade and Industry Alec Erwin responsible for thousands of HIV/Aids deaths. Second, neither the TAC nor I will make any apology for making the minister of health, any politician or bureaucrat feel uncomfortable through a disruption of any meeting, office or event where they may find themselves. Hundreds of premature, painful, awkward, silent and screaming deaths of children, men and women daily are caused by the failure of the government to implement a comprehensive treatment and prevention plan for HIV/Aids.
To Dugmore and the other detractors of our campaign who call us bullies, let me ask: were you at the many lawful marches to Parliament to give memoranda to the minister and the president begging for HIV treatment? Perhaps you did not see our march of about 15 000 people on the South African Parliament asking the government to sign a treatment and prevention plan on February 14? What about our early pickets of Parliament, drug companies and the United States government? Civil disobedience is action of last resort for us, because exhaustive efforts at engagement have not worked. Let me ask further: did you attend any of more than 10 submissions to various parliamentary portfolio committees begging, cajoling, charming and arguing for HIV treatment? Did you attend any of more than 30 interfaith services held by the TAC and our allies across the country appealing to the conscience of the health minister and the government? Do you know that we tried quietly to persuade Dr Ayanda Ntsaluba, Dr Nono Simelela, Dr Essop Jassat, Dr Ismail Cachalia, Dr Saadiq Kariem, Dr Kammy Chetty, Dr Abe Nkomo and other doctors who are members of the ANC to ensure that the government change its policies or to let their scientific training, their Hippocratic oaths and their consciences allow them to speak the truth? Maybe you also tried to persuade them that real loyalty to the ANC and the ideals of the Freedom Charter required open criticism after numerous private pleas? Have you reminded the ministers of health and trade and industry that they are undermining the ANC’s traditions of freedom, equality, solidarity and dignity?
Do you remember that the health minister and her supporters in Cabinet really represent the anti-democratic traditions of the former Stalinist states that supported them? Perhaps one should expect people who denied the existence of the Gulag or applauded the invasion of Czechoslovakia, Hungary, Poland and East Germany by Soviet troops and called the latest Zimbabwean election legitimate to deny the existence of HIV/Aids and the efficacy of antiretrovirals? Did you attend hundreds of community meetings addressed by TAC volunteers across the country to educate ourselves and our people about HIV, prevention and treatment? Did you help late into the night, in support of the government, to develop a court case against the drug companies to reduce the prices of all medicines including HIV/Aids medicines? Do you remember how the health minister spurned the TAC after the case? Do you know the anguish of the person who made the poster that said: “Thabo your ideas are toxic”? Were you at the funeral of Queenie Qiza (one of the first TAC volunteers) or did you hear Christopher Moraka choke to death after appealing to Parliament to reduce the prices of medicines? Maybe, like me, you avoided the funeral of my cousin Farieda because I cannot face the pain of death? Did you feel as encouraged as we were by the Cabinet statement of April 17 2002? Are you as disappointed a year later that so little has been done? Were you there when we illegally imported a good quality generic anti-fungal drug (Fluconazole) and shamed drug company Pfizer for profiteering?
Maybe you followed the TAC/Congress of South African Trade Unions’s treatment congress where unemployed people, nurses, scientists, cleaners and trade unionists invited the government to develop a treatment plan? Do you remember our meeting with Deputy President Jacob Zuma that led to a promise that a treatment and prevention plan would be developed by the end of February 2003? Did you miss the word-games played by the government over negotiations at the National Economic and Development Labour Council (Nedlac)? Are you one of the people who phone Nedlac regularly to hear when the government will return to the negotiating table? Or, are you one of the people too busy taking care of someone dying but who have a little pride in your heart when an activist says to the president: “Comrade, you are not listening to our cries. You are denying the cause of our illness. You are not helping us get medicines.” After countless attempts at talking, public pressure and even a court case to prevent HIV infection from mother-to-child, the government allows the deaths to continue while it plays the caring, right-minded diplomat in Africa and the Middle East. Politeness disguises the moral and legal culpability of these politicians and officials. We believe that the personal crises faced by many of our families, friends, nurses, doctors, colleagues and their children should be turned into discomfort and a crisis for the politicians and bureaucrats who continue to deny our people medicine.
The fact that the health minister is obstructing the departments of health, finance, labour and the deputy president’s office from signing and implementing a treatment and prevention plan costs our society more than 600 lives and many new HIV infections every day. The government uses Parliament, Cabinet, provincial governments and all its resources including the Government Communication and Information Service, in the person of comrade Joel Netshitenze, or health communications officer, Joanne Collinge, to justify its denial of life-saving medicines to people who need them. It uses these resources to protect the reputation of the minister of health. And you add your voices to their chorus? When will you join reason, passion and anger to win treatment for people living with HIV/Aids and a decent public health system for all?
The TAC will win in this campaign because its members act in good faith. And when we win, we will sit down on any day with the government for as long as it takes to tackle all the difficult problems of HIV/Aids and the health system. These wounds between ourselves and the government will not be healed easily. But they will heal easier than the pain of the millions who are denied life-saving treatment and those who have succumbed to that pain.
* Zackie Achmat is the Treatment Action Campaign’s chairperson
* See the Equity and Health General section of Equinet News for more news on this issue.
Editorial
We hereby demand that a police docket be opened to investigate the deaths of the many thousands of people who died from AIDS or AIDS related illnesses and whose deaths could have been prevented had they been given access to treatment. We further demand that the Accused be arrested and charged with the offence of Culpable Homicide for negligently causing the deaths of these people. The details of the charge and a summary of some of the facts which form the basis of the Charge are attached. We believe that many thousands of people can bear witness to this horrible crime.
ACCUSED NO. 1
NAME: MANTOMBAZANA EDMIE
SURNAME: TSHABALALA-MSIMANG
OCCUPATION: THE MINISTER OF HEALTH, SOUTH AFRICA
ACCUSED NO. 2
NAME: ALEXANDER
SURNAME: ERWIN
OCCUPATION: THE MINISTER OF TRADE AND INDUSTRY, SOUTH AFRICA
THE CHARGE
THE PEOPLE versus MANTOMBAZANA EDMIE TSHABALALA-MSIMANG alias "MANTO", MINISTER OF HEALTH (RSA) and ALEXANDER ERWIN alias "ALEC", MINISTER OF TRADE AND INDUSTRY (RSA). Hereinafter respectively referred to as Accused No. 1 and Accused No. 2.
Both accused are charged with the crime of culpable homicide in that during the period 21 March 2000 to 21 March 2003 in all health care districts of the Republic of South Africa, both accused unlawfully and negligently caused the death of men, women and children. They also breached their constitutional duty to respect, protect, promote and fulfill the right to life and dignity of these people.
1. Both accused Ministers knew that failure to provide adequate treatment including anti-retroviral therapy for people living with HIV/AIDS would lead to their premature, predictable and avoidable deaths.
2.In their capacities as Ministers in the government of South Africa, both accused had the legal duty and power to prevent 70% of AIDS-related deaths during this period through developing a treatment and prevention plan, providing medicines and using their legal powers to reduce the prices of essential medicines for HIV/AIDS including anti-retroviral therapy.
3. Both accused Ministers had in their possession scientific, medical, epidemiological, legal, social and economic evidence of the devastation of potential and actual AIDS deaths on individuals and communities. They not only ignored this evidence but suppressed it.
4. Both accused Ministers consciously ignored the efforts of scientists, doctors, nurses, trade unionists, people living with HIV/AIDS, international agencies, civil society organisations, communities and faith leaders to develop a treatment and prevention plan, to make anti-retroviral therapy available and to ensure that medicine prices in the public and private sector were reduced to save lives.
5. Both accused Ministers were under a legal duty, by virtue of their public office and the provisions of the Constitution of the Republic of South Africa, to provide access to health care services by reducing the price of essential medicines for HIV/AIDS including anti-retroviral therapy, and by providing them through the public health sector. They remain under this legal duty.
6. Both accused Ministers negligently failed to carry out their legal duties. Their conduct in failing to make these medicines available to people who need them does not meet the standards of a reasonable person, and in particular a reasonable person holding the position of Minister of Health or Minister of Trade and Industry.
7. During the period 21 March 2000 and 21 March 2003, this failure caused the death of between 250 and 600 people every day as a direct result of premature, avoidable and predictable AIDS-related illnesses.
THE PEOPLE versus MANTOMBAZANA TSHABALALA-MSIMANG (Minister of Health) (hereinafter referred to as The Minister of Health) and ALEXANDER ERWIN (Minister of Trade and Industry) (hereinafter referred to as The Minister of Trade and Industry)
CHARGE: Culpable Homicide (unlawfully and negligently causing the death of another human being)
SUMMARY OF SUBSTANTIAL FACTS
1. During the period 21 March 2000 to 21 March 2003, many people throughout the Republic of South Africa died from AIDS or diseases caused by AIDS.
a.) Information on the prevalence of HIV/AIDS and HIV/AIDS related deaths each year has been available to both Accused Ministers throughout their terms in office.
b.) It is estimated that at least 600 people in South Africa die from AIDS-related illnesses each day.
c.) In the past 12 years, the HIV sero-prevalence among first time antenatal clinic attenders, as indicated by the Minister of Health's own Department's Annual Antenatal Clinic surveys has risen from 0.76% in 1990 to 10.44% in 1995 to 28.4% in 2001. Based on these surveys, it is estimated that there are currently 5 million South Africans infected with HIV. The latest survey estimates that 15,4 percent of women under 20 years, 28,4 percent of women between 20 and 24 years and 31,4 per cent of women between 25 and 29 years are living with HIV/AIDS. The survey further notes that "high HIV prevalence rates have significant implications on the future burden of HIV-associated disease and the ability of the health system to cope with provision of adequate care and support facilities."
d.) In the Department of Health's Second Interim Report on Confidential Enquiries into Maternal Deaths in South Africa (1999), non-pregnancy related sepsis mainly caused by AIDS was recorded as the leading cause of maternal deaths. In the Report, 35.5 percent of women whose deaths were reported were tested for HIV and 68 percent of these were HIV positive. The Report noted that HIV is significantly under-diagnosed.
e.) A study by the Medical Research Council, estimated that about 40 percent of adult deaths aged 15-49 that occurred in 2000 were due to HIV/AIDS and that, if combined with the deaths in childhood, it was estimated that AIDS accounted for about 25 percent of all deaths in 2000 and was the single biggest cause of death. The Report continued that projections indicate that, without treatment to prevent AIDS, the number of AIDS deaths with grow within the next 10 years to double the number of deaths due to all other causes. The Report estimates that approximately 200 000 people died of an AIDS-related illness in 2001 alone. The Minister of Health was directly involved in attempts to suppress this report.
f.) A report issued by Statistics South Africa on 21 November 2002 entitled Causes of death in South Africa 1997-2001: Advance release of recorded causes of death, indicates that unnatural causes still remain the leading cause of death. However, the report states that HIV-related deaths are significantly under-reported. One reason advanced for the under-reporting is that such deaths are often recorded as TB or pneumonia-related. Of particular significance is the finding that patterns of mortality shifted dramatically over this period, primarily as a result of HIV, TB and pneumonia-related deaths. In 2001, for example, 8.2% of all recorded deaths were attributable to unspecified unnatural causes, down from 15.3%.
g.) In contrast, 34.6% of all recorded deaths in 2001 were attributed to HIV, TB, influenza/pneumonia and "ill-defined causes of death", up from 29.5% in 1997.
h.) The largest single impact of HIV/AIDS on the public health sector lies in the hospital sector. Research commissioned by the Department of Health (Abt Associates, 2000) indicates that, in the year 2000, an estimated 628 000 admissions to public hospitals were for AIDS related illnesses, which amounts to 24% of all public hospital admissions. As more people who are already HIV positive become sick each year, this demand for hospitalisation will increase steadily every year in the absence of significant alternative interventions. In financial terms, the cost of hospitalising AIDS patients in public facilities was estimated at the time to amount to at least 12.5% of the total public health budget.
2. Many of these people would not have died if they had access to anti-retrovirals
a.) HIV/AIDS is a progressive disease of the immune system that is caused by the Human Immunodeficiency Virus (HIV).
b.) When left untreated HIV profoundly depletes the immune system and may prove fatal because of the inability of the body to fight opportunistic infections such as tuberculosis, pneumonia and meningitis.
c.) The scientific evidence indicates that without effective treatment, the majority of people with HIV/AIDS die prematurely of illnesses that further destroy their immune systems, quality of life and dignity.
d.) Early diagnosis, clinical management, medical treatment of opportunistic infections and the appropriate use of anti-retroviral therapy prolongs and improves the quality of life of people living with HIV/AIDS.
e.) Anti-retroviral drugs are a class of drugs that suppress viral load activity and replication. When used effectively they reduce the volumes of HIV to undetectable levels in the blood. This leads to immune reconstitution. It also prevents and delays the destruction of a person's normal immune system.
f.) In its HIV/AIDS Policy Guideline, entitled Prevention and Treatment of Opportunistic and HIV-related diseases in Adults (August 2000), the Department of Health (which operates under the direction of The Minister of Health) has recognised the efficacy of anti-retroviral treatment, stating as follows: "Current research also strongly indicates that suppressing HIV viral activity and replication with anti-retroviral therapy or Highly Active Antiretroviral Therapy (HAART) combinations prolongs life and prevents opportunistic infections".
g.) The Medicines Control Council, has the statutory duty to investigate and determine whether medicines are suitable for the purpose for which they are intended, and whether their safety, quality and therapeutic efficacy is such that they should be made available in South Africa. They have registered various anti-retroviral drugs for treatment of people who have HIV/AIDS.
h.) The World Health Organisation (WHO) has included anti-retrovirals on the Core List of its Model List of Essential Drugs (12th edition, April 2002). The Minister of Health is aware of the inclusion of anti-retroviral medication in the World Health Organisation's Essential Drugs List.
i.) With access to anti-retrovirals people with HIV/AIDS are able to lead longer and healthier lives and it directly results in an improved quality of life and the restoration of dignity, allowing people with HIV/AIDS who were previously ill to resume ordinary everyday activities, such as work.
j.) A comprehensive plan to treat people living with HIV/AIDS as advocated by civil society organisations, faith based organisations, scientists, health care workers, trade unionists, activists and communities over the past four years, would have reduced the number of people dying of AIDS related illnesses and would have mitigated the horrendous impact of AIDS on people in South Africa.
3. Both Accused were aware of need to make anti-retrovirals available to prevent these deaths.
a.) The Minister of Health has had direct knowledge of the serious impact of HIV/AIDS and the need for care and treatment of people living with HIV/AIDS, before she took up her position as Health Minister. As early as 1994 The Minister of Health was a key drafter or the NACOSA National AIDS Plan for South Africa 1994 - 1995. (The Plan states that "The number of people becoming ill as a result of HIV infection is already high and will continue to increase dramatically over the next few years. The health care systems will have to cope with this increase and strengthen their ability to provide HIV/AIDS care in order to reduce the impact of HIV/AIDS on individuals, their families and communities"). In terms of this Plan, it is also clear that The Minister of Health was fully aware of the need to broaden access to treatment for people living with HIV/AIDS ("In dealing with HIV/AIDS, an essential drug list should be developed, based on the efficacy of the drugs in the clinical management of the disease, as well as on costs and availability? As research develops and knowledge about treatment expands, it may be necessary to add drugs to those which are routinely supplied. All drugs and medicines should be available as widely as possible").
b.) The Minister of Health and the Minister of Trade and Industry were aware of the Joint Statement issued by the then Minister of Health, Dr Nkosazana Dlamini-Zuma and Treatment Action Campaign, which confirmed that all treatment for HIV/AIDS and all related medical conditions is a basic human right (30 April 1999). At the time, the Minister of Health called on all sectors to pressurise companies to unconditionally lower the price of all HIV/AIDS medications to an affordable price for poor people and countries.
c.) The Minister of Health has herself confirmed that "access to affordable drugs is a matter of life and death in our region" (World AIDS Day speech, 1 December 2000). During this speech, The Minister of Health also emphasized that access to drugs should be improved and that "drugs at current prices remain unaffordable". The Minister of Health, in her capacity as Minister of health, and as a doctor, knew that action had to be taken to reduce the prices and that she could use her legal power to procure or produce generic anti-retrovirals and other essential HIV medications.
d.) In its Cabinet statement of 17 April 2002, Cabinet, and the Accused as members of the Cabinet, recognised that anti-retrovirals can improve the conditions of people with HIV "if administered at certain stages ... in the progression of the condition, in accordance with international standards."
e.) After taking up office, The Minister of Health and the Minister of Trade and Industry have consistently been reminded of the need to improve access to treatment for people living with HIV/AIDS since 1999 (e.g. Speech by Edwin Cameron at the 2nd National Conference for People Living with HIV/AIDS on 8 March 2000, in the presence of the Minister of Health; the Call for a Global March issued in March 2000; COSATU's Submission on HIV Treatment to Health Portfolio Committee on 10 May 2000; letter by TAC requesting meeting with President and Minister of Health on access to treatment dated 20 March 2000).
* To read the full indictment please click on the URL provided.
If you cross paths with Robert Zoellick's mother over the next few weeks, please remind her that applications to George Washington University's School of Public Health are due soon. Her son needs to hurry up and submit his paperwork. Mrs. Zoellick might be surprised at the suggestion that her son Robert, US Trade Representative, should go back to school. She might tell you that her dear Robbie already graduated magna cum laude from Harvard's Law School and received an MPP from the Kennedy School of Government. Mrs. Zoellick might say that her son's overqualified for his job. The only problem is that Robert Zoellick has been making a lot of decisions about public health lately - and in that realm, he is terribly uninformed.
Take, for instance, his actions last month at the WTO council. Trade representatives from the other 143 member countries of the WTO decided that the poorest of nations - those without any pharmaceutical manufacturing facilities - should be able to import cheap generic drugs, since they can't pay for the more expensive patented versions. But Mr. Zoellick became the only minister at the WTO to refuse to agree to the measure.
This isn't the first time that's happened. Back in December, Mr. Zoellick did the same thing just before Christmas. The issue was how to implement the WTO's "Doha Declaration" on public health, which the WTO (with Mr. Zoellick's vote) passed in November 2001. That agreement declared that the patent rights of drug companies should be secondary to public health concerns to "promote access to medicines for all." In the agreement, the WTO promised to determine how countries without manufacturing facilities were going to import generic drugs.
But Mr. Zoellick decided that he would "reinterpret" the Doha Declaration. He claimed that the Declaration was not really about promoting "access to medicines for all" (in spite of the wording in the Declaration itself) but it was really only intended to cover a short list of diseases. He came to the table with a list of 15 diseases he thought were suitable. The only problem was that major killers like cervical cancer and pneumonia were not included. Mr. Zoellick said those diseases not on the list were "lifestyle" disorders. So the three million kids who will die from pneumonia in Africa this year better whip themselves back into shape and learn to change their ways. Some of the other trade ministers thought this was a bit perverse, and refused to agree to that deal.
February was supposed to be a finalization of the delayed negotiation process, but Mr. Zoellick came to the table with a new set of rules, once again using his "alternative" theories of public health practice. This time, medicine access would not be restricted to just a short list of diseases, but countries would also be restricted to importing generics only after a "national emergency." So health ministers in Burkina Faso, which is currently in the beginning stages of a major meningitis epidemic, should sit tight and wait for a couple hundred thousand people to die - then they can begin the legislative process to get medicines. Other rules proposed by Mr. Zoellick would be extraordinarily cumbersome. Under the system proposed, if Pakistan wanted to get cheaper drugs from an Indian generic manufacturer, the Indian government would have to pass legislation for Pakistani citizens. How politically pragmatic!
No one mentions, of course, that the very measures Mr. Zoellick is pushing on the poorest of countries are far more stringent than those followed by the United States. Remember the anthrax scare? After only four deaths, Congress was threatening to import generics immediately if Bayer Corporation didn't produce its anti-anthrax drug quickly enough. But other countries, of course, aren't allowed to do the same when they have real public health crises.
I pity Mr. Zoellick's public relations officer, who will no doubt be working long hours to generate an entirely new system of logic justifying the nature of these deals. But, of course, there's plenty of support for Mr. Zoellick and his worker bees at the Washington trade office. It comes from the pharmaceutical industry, as was made explicit at the WTO council. Instead of negotiating with each other, the trade ministers declared they would just circumvent the whole process and start negotiating directly with Pfizer. Companies like Pfizer don't want a break in their global monopoly on prices. But if the most profitable industry in the world can't handle the fact that poor countries represent a tiny percentage of their pharmaceutical market, then our trade ministers need to be able to stand up to them and defend the Doha Declaration.
The industry, and the USTR, claims that generics would undermine their capacity to pay for research and development - that is, the research and development that American taxpayers actually foot most of the bill for. The industry doesn't bother to release it's own tax information, however, which reveals that Merck this year used 13% of its profits on marketing and only 5% on R&D, Pfizer spent 35% on marketing and only 15% on R&D, and the industry overall spent 27% on marketing and 11% on R&D according the Securities and Exchange Commission. That's not accounting for the fact that 52% of new drugs on the market aren't even the result of R&D, but are "me too" drugs that are simple reformulations of old products slapped with new stickers.
The industry still claims that generics will undermine its business, even as it continues to be ranked by Fortune Magazine as the world's most profitable industry for 11 years in a row (having profits as a percentage of revenue nearly three times the rest of the Fortune 500 industry). When confronted with the fact that Africa comprises only 1.3% of the industry's revenues (making its loss equivalent to "about three days fluctuation in exchange rates," according to an industry analyst quoted in The Washington Post), the industry claims that generic drugs will get diverted to the North to undermine its key markets, and cites GlaxoSmithKline's recent loss of AIDS drugs sent to Africa as a case in point. But a look at the GSK case shows that Glaxo failed to even track the shipments and only discovered after a year that its packages to Africa had been shipped improperly, allowing them to be smuggled to Europe. Tracking mechanisms, however, seem to be no trouble for neighbourhood flower shops. Indian generic manufacturers, meanwhile, have shipped medicines for over two decades without a single case of "diversion".
It's time for Mr. Zoellick to learn what it means when 24,000 people die a day from treatable diseases; otherwise, he should take a fraction of the $20 million in campaign contributions pharmaceutical companies donated last year and use it for his tuition at the School of Public Health.
* Read more about the WTO negotiations in the 'Equity and Health General' and 'WTO, Economic and Social Policy' sections of Equinet News.
Last month, I spent two weeks touring four countries in Southern Africa: Lesotho, Zimbabwe, Malawi and Zambia. The primary purpose was to view the link between hunger and AIDS. I want to look back at that visit, because little will have changed between then and now (except, perhaps, that things will have deteriorated further), and then look forward to the prospects for addressing the pandemic in 2003.
At the outset, however, let me express, yet again, the fundamental conviction I have every time I visit Africa: there is no question that the pandemic can be defeated. No matter how terrible the scourge of AIDS, no matter how limited the capacity to respond, no matter how devastating the human toll, it is absolutely certain that the pandemic can be turned around with a joint and Herculean effort between the African countries themselves and the international community.
I am weary to the point of exasperated impatience at the endless expressions of doubt about Africa’s resolve and Africa’s intentions and Africa’s capacities. The truth is that all over the continent, even in the most extreme of circumstances, such as those which prevail today in the four nations I visited, Africans are engaged in endless numbers of initiatives and projects and programmes and models which, if taken to scale, if generalized throughout the country, would halt the pandemic, and prolong and save millions of lives.
What is required is a combination of political will and resources. The political will is increasingly there; the money is not. A major newspaper in the United States, reflecting on the paucity of resources, used the startling phrase “murder by complacency”. I differ in only one particular: it’s mass murder by complacency.
You will forgive me for the strong language. But as we enter the year 2003, the time for polite, even agitated entreaties is over. This pandemic cannot be allowed to continue, and those who watch it unfold with a kind of pathological equanimity must be held to account. There may yet come a day when we have peacetime tribunals to deal with this particular version of crimes against humanity.
As bad as things are in Southern Africa - and they are terrible - every country I visited exhibited particular strengths and hopes.
The little country of Lesotho has a most impressive political leadership, but is absolutely impoverished. If it had some significant additional resources, with which to build capacity, it could begin to rescue countless lives. I vividly remember the Prime Minister of Lesotho saying to me: “We’re told repeatedly by donors that we don’t have capacity. I know we have no capacity; give us some help and we’ll build the capacity.” It’s worth remembering that Lesotho has a population greater than that of Namibia and Botswana, but it has nowhere near the same pockets of wealth. It has, however, one of the highest prevalence rates for HIV on the continent, higher than Namibia; almost as high as Botswana, and is fatally compromised in its response by the lack of resources.
Zimbabwe, whatever the levels of political turbulence, has created a sturdy municipal infrastructure for the purpose of dealing with AIDS. You will know that for the last couple of years, Zimbabwe has had a 3% surtax on corporate and personal income, devoted to work on AIDS. A good part of that money has been channelled down to district and village level, through a complex array of committees and structures which actually get the money to the grassroots. It’s visible in the work of youth peer educators, outreach workers and home care through community-based and faith-based organisations. In other words, for all the convulsions to which Zimbabwe is subject, there remains an elaborate capacity to implement programmes, if only there were more programmes to implement.
In Malawi, we may be about to see the most interesting of experiments in the provision of anti-retroviral treatment in the public sector. The Government of Malawi had originally intended to treat 25,000 people based on receipt of monies from the Global Fund. They then realized that the calculation of 25,000 was based on the purchase of patent drugs, but now that it is possible to purchase generic drugs, the numbers eligible for treatment could rise to 50,000. There has been, predictably, a great deal of skepticism in the donor and other communities. However, while we were in Malawi, the country was visited by a WHO team which carefully examined the capacity and delivery issues, and came to the conclusion that treating 50,000 people, phased in of course, was entirely possible. This is an exciting prospect: the treatments are meant to be free of charge, and delivered through the public health sector.
Zambia, whatever the difficulties - and they are overwhelming - is emerging from the bleak and dark ages of denial into the light of recognition. The bitter truth is that in the regime of the previous President, nothing was done. He spent his time disavowing the reality of AIDS, and hurling obstacles in the way of those who were desperate to confront the pandemic. I can recall personally attending an annual OAU Summit on behalf of UNICEF, and sitting down with the then President Chiluba, and asking him what he intended to do about AIDS, and he simply wouldn’t talk to me about it. Well there’s a new President in Zambia. And although he’s been in place for only one year, everyone agrees that there’s a dramatic change in the voice of political leadership around the subject of AIDS.
The fact is that in every country, even under the most appalling of human circumstance, there are signs of determination and hope. Whether they can be harnessed in the name of social change will be known in the year 2003. God knows, there are incredible hurdles to leap.
In August 2002 Gro Harlen Bruntland, Director General (DG) of WHO, announced that she would not seek a second term as DG. This issue of the EQUINET newsletter compiles some of the debates and papers that have been presented around her record at WHO, the candidates for the new DG and the selection process itself. The political moment created by the election of a new DG stimulates debate about WHO’s priorities and role in international and global health, as the leadership qualities sought in a new DG should reflect those roles.
Bruntland’s achievements at WHO are notable. She raised the profile of health in the global agenda, including within economic and political forums and is reported to have restored WHO’s credibility with donors. She launched a number of global health campaigns. During her period as DG, WHO has reasserted itself as an international standard-setting body around areas such as tobacco control, pre-qualification for procurement of antiretrovirals, food safety standards, and essential drugs. Bruntland had some success at negotiating partnerships with foundations and the private sector.
Yet the debate on WHO priorities and the realities of health from the perspective of a southern African network indicate that there are many unresolved issues. Whatever the changes that were achieved at global level, they have not been felt at country level. Poverty and unavoidable and unfair inequalities in opportunities for and access to health are pronounced and persistent. Despite this WHO is not perceived to have been a strong public advocate for health equity or for protecting public health in economic and trade policies. Neither is there a perception of the powerful advocacy of primary health care or of forms of health financing that enhance access to health care in poor communities, in women and other vulnerable groups. In contrast, in an environment of rapid and powerfully driven market reforms and privatization, there is some criticism of WHO unwillingness to confront commercial interests over patient interests in access to medicines under TRIPs, or protect national authority rights to regulate private health providers under the WTO GATS agreement.
Hence even while the Macroeconomic Commission on Health raised the profile of the US$27bn shortfall in global resources for health, and the Global Health Fund (GHF) created one vehicle for responding to this shortfall, the impact of these global shifts has been weak. Beyond the insufficient and poorly sustained funding of the GHF, WHO has not yet made clear or put its international policy weight behind the public policy measures needed nationally and globally to ensure that health services and systems spend more on those with greatest need. This has left a number of issues poorly addressed, such as for example the attrition and loss in health personnel from public to private sectors and from low to high income countries; the collapse of primary care level services in some countries; the shift in the burden of caring for HIV/AIDS to poor households and inability to secure treatment access in many low income countries, or the still weak link between public health and the wider systems of rights and procedural justice needed to manage the contestation over scarce resources for health.
The nature of the issues to be addressed, and their significance in Africa make the policies of the next DG a matter of some concern for Africans. The public policy shortfalls identified above do not simply call for business as usual with a bit more focus on Africa. In the same way as poor people’s health needs demand a wider review of public policy generally, so too does meeting the needs of health in Africa demand critical review of wider global, international and national health policies for where they generate vulnerability and impede public health authorities in Africa making coherent responses to ill health.
This editorial does not scrutinize the candidates – there are links to articles about the candidates at the end of this editorial. While effort has been made to make the process of selection of the DG more open to public debate through journal papers and email lists, in fact the process is still tightly controlled within the 32 health ministers in the Executive Board. It would however be important to make two comments. The first is to note the presence as a candidate of Pascal Mocumbi, a southern African who has championed health equity for many years, both working on ways of providing incentives for health equity and articulating equity oriented policies, including as at the 1997 Kasane meeting that launched EQUINET. The second is to note that while individual attributes, perspectives and experience are clearly important, the challenges to be addressed by the new DG call for wider alliances for health. Here perhaps WHO has untapped potential: A number of partnerships for service delivery have been built by WHO.
Bruntland has mobilized resources and raised the political profile of health. The challenge for a new DG is to bring in new strategic alliances and constituencies that advance WHOs role as global advocate for public health and that bridge global opportunity with national practice. Beyond the technical and political support that has been raised, this implies tapping into the massive social support that exists for health rights and values.
LINKS:
(Please note that links to articles from The Lancet require a short and easy registration process)
* AND THE NOMINEES FOR DG ARE …
http://www.thelancet.com/journal/vol360/iss9348/full/llan.360.9347.news.23403.1
* NINE CANDIDATES LINE UP FOR TOP POST
http://bmj.com/cgi/content/full/325/7375/1259?ijkey=l5xSvpnNpSrp6
* WHO’S NEXT DG – THE PERSON AND THE PROGRAMME
http://www.thelancet.com/journal/vol360/iss9348/full/llan.360.9348.editorial_and_review.23505.1
* HAVE THE LATEST REFORMS REVERSED THE WHO’S DECLINE
http://bmj.com/cgi/content/full/325/7372/1107?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=World+Health+Organisation+and+Bruntland&searchid=1040232817123_11702&stored_search=&FIRSTINDEX=0&fdate=12/1/1998&resourcetype=1,2,3,4,10
* ELECTION PROCEDURES LOW AND SECRETIVE
http://www.thelancet.com/journal/journal.isa
* LETTER TO THE LANCET ON ELECTION PROCEDURES
http://www.afronets.org/afronets-hma/afro-nets.200210/msg00057.php
A third of the world’s population still has no access to essential drugs. In the poorest countries of Africa and Asia this figure rises to half. With the global agreement on intellectual property rights (TRIPS) forcing countries to introduce new patent protection laws over the next decade, this situation could worsen, according to a new report from the London-based Panos Institute.
Developing countries have until 2005 or 2016 to implement TRIPS-compliant legislation on pharmaceuticals. So far many governments have drafted or enacted legislation that seems to prioritise patent rights over public health. Some countries are being pressurised into adopting policies that go further than TRIPS in protecting patents. Patents give big international pharmaceutical firms monopoly over production of new drugs, including, for example, those needed to treat HIV/AIDS.
There is concern they may push up prices, and the TRIPS rules could thus limit poor countries’ freedom to buy cheaper “generic” versions of patented drugs. For example, in January 2001, South African HIV/AIDS treatment activist Zackie Ahmat went to Thailand to buy 5,000 pills of the generic version of an anti-fungal drug patented by the US pharmaceutical giant Pfizer. He paid $0.21 a pill. The price of the patented version in South Africa was $13.
The Panos Report, 'Patents, Pills and Public Health: can TRIPS deliver?' warns that patent legislation is not being debated widely enough in most developing countries, and the process of introducing it needs to be more consultative and transparent. In Uganda, for example, American consultants were brought in to review the country’s patent laws and make proposals for reform. The result was the drafting of laws which, according to local campaigners, are skewed in favour of business interests rather than social or development needs. The principle of extending access to essential drugs in poor countries is widely supported, but the means of doing this is still hotly disputed, says the report.
According to the World Bank, middle-income countries may benefit from increased foreign investment, but if the cost of drugs rises as a result of patent systems spreading throughout the developing world, there is a real danger of restricting access to drugs, such as anti-AIDS drugs, where they are most needed. The World Health Organisation suggests that implementing patent protection where it did not already exist would result in the average price of drugs rising, with projected increases ranging from 12 to 200 percent.
The pharmaceutical industry argues that patent systems promote innovation and investment in research and development. Without patents, new ones would not be developed to tackle diseases such as tuberculosis and HIV/AIDS. They believe the real barriers to making drugs more available are poverty, weak political leadership, lack of trained health personnel and poor health infrastructures.
The report examines alternative approaches and gives examples where differential pricing (where poorer countries pay considerably less for a product than wealthier ones) and compulsory licensing (where a patent is overridden in return for a payment of a royalty) have potential, although they are not free of problems. Two countries highlighted in the report, show how differently patent protection can impact on the nation’s public health: Brazil is seen as a model for other countries of what can be achieved for public health by boosting local production of drugs such as the anti-AIDS drug AZT, lowering prices through competition and negotiating discounts on patented drugs. Between 1996 and 2001 around 358,000 AIDS hospitalisations were prevented, saving around $1.1 billion. On the other hand, Thailand’s capacity to provide essential drugs for its people has been severely limited in the last decade due to relentless pressure from the US to tighten up its patent laws which, they complained, meant the loss of $30 million a year in sales for the American pharmaceutical industry because it referred only to pharmaceutical processes and not products. The US went as far as imposing $165 millions’ worth of sanctions on eight Thai products exported to the US. The US continued to exert pressure until the patent laws were changed and made even more restrictive than the international TRIPS agreement requires.
“This report should be a wake-up call to developing countries to look carefully at how they go about complying with TRIPS legislation and make sure that access to essential drugs is kept as an overriding right for the entire population – not just a wealthy few” says Martin Foreman, author of the Panos report.
* The full report and additional country studies can be downloaded from this website http://www.panos.org.uk/
* The Panos Institute is an independent, non-profit organisation specialising in communication for development. It works to catalyse informed public debate, particularly in developing countries. It has 12 offices in Africa, Asia, Europe and the Caribbean.
A Speech to the HIV/AIDS and "Next Wave" Countries Conference, the Centre for Strategic and International Studies Washington, DC, October 4, 2002, on the US National Intelligence Council report, 'The Next Wave of HIV/AIDS: Nigeria, Ethiopia, Russia, India and China', published September 1 2002.*
For more than a decade now, those who have chronicled the sweep of the pandemic have warned about the excruciating consequences of societies falling apart. Now, more than ever, we have groups coming together to fashion scenarios of what will happen in the future. The Next Wave study repeats in several places, that: "The rise of HIV/AIDS in the next wave countries is likely to have significant economic, social, political and military implications". That seems to me to be unarguable.
But if the present teaches anything about the future, then just draw back and look at what is happening in Southern Africa. It has been established that 14.4 million people are at risk of starvation in six countries: Zimbabwe, Zambia, Lesotho, Swaziland, Malawi and Mozambique. Now allow me to be personal for a moment. Last week, I met with Mr. James Morris, head of the World Food Programme, who had just returned from a mission, as Special Envoy, to the six beleaguered countries. He was a man physically and emotionally reeling from what he'd seen. He had instantly recognized that food was only part of the problem; the heart of the problem was AIDS.
That should ring one of the most piercing alarm bells that we've yet heard during the course of the pandemic. If you read the Mission report, it's like a revelation: "What the mission team found was shocking. There is a dramatic and complex crisis unfolding in Southern Africa. Erratic rainfall and drought can be identified as contributing factors to acute vulnerability, but in many cases the causes of the crisis can be linked to other sources. Worst of all, Southern Africa is being devastated by the HIV/AIDS pandemic. HIV/AIDS is a fundamental, underlying cause of vulnerability in the region, and represents the single largest threat to its people and societies".
And then, over and over again, in country after country, the report chronicles the way in which AIDS exacerbates the crisis. The language is startling, allow me to quote one other section: "The relationship between the HIV/AIDS pandemic and the reduced capacity of the people and governments of Southern Africa to cope with the current crisis is striking. In every country of the region, HIV/AIDS is causing agricultural productivity to decline, forcing children to drop out of school, and placing an extraordinary burden on families and health systems".
I've read the report carefully. I've talked to numerous colleagues. I've discussed the matter with three people who were on the UN mission. I've consulted a notable academic who is the pre-eminent scholar on AIDS in Southern Africa. Let me tell you what I think - I obviously cannot prove - but what I think has happened. I think it is reasonable to argue that AIDS has caused the famine; that what we all feared one day would happen, is happening. So many people, particularly women, have died, or are desperately ill, or whose immune systems are like shrinking parchment, that there simply aren't enough farmers left to plant the seeds, till the soil, harvest the crops, provide the food. We may be witness to one of those appalling, traumatic societal upheavals where the world shifts on its axis.
We've been predicting that you can't ravage the 15 to 49 year-old productive age group forever, without reaping the whirlwind. The whirlwind is in Southern Africa. And surely that has huge implications for the next wave. If you watch while your educational systems are shattered, your health infrastructure is frayed, your agriculturalists are dying, your militaries and police have astronomic levels of infection, your private sector is atrophying, then it becomes impossible to escape the economic and social and political and military consequences. For the so-called next wave countries, there is no time left to contemplate. There is only time left to act. Southern Africa is the canary in the pandemic […]
I want to re-emphasize my conviction that this pandemic, in all its multivarious forms in the countries with which we're dealing, can be turned around. There is tremendous knowledge and selflessness at the grass-roots; it just has to be given a chance. We - and it's the royal, generic 'we' - know a great deal, if only we can apply it. We know how to go about Voluntary Counselling and Testing; we know ways in which to reduce, dramatically, vertical (mother-to-child) transmission; we know how to administer anti-retroviral treatment; we know of excellent preventive interventions; we know the world of care at community level, provided by the women, and rooted in faith-based and community-based organizations; we know the knowledge and expertise that can be brought to bear by People Living with AIDS. We know, as well, the huge challenges of mobilizing the political leadership, galvanizing the religious leadership, fighting the curse of stigma and strengthening advocacy on all fronts.
What we don't have is the means to do it with. We don't have the dollars. I've knocked this particular nail through the wall so many times that even I feel a certain ad nauseam quality merely to mention it; in fact, I feel like a minor clone of Jeffrey Sachs. But the truth is that what's literally killing the women and men and children of Africa is the lack of resources.
Just two weeks ago, I was meeting in Arusha, Tanzania, with a group of women living with AIDS. I asked them, as I always do, to tell me what they most needed and wanted, and as always the same replies came back: food, because everyone is hungry, especially the children; money for school fees, and some kind of guarantee to keep their kids in school, because when they die they want their children to be assured of an education. And drugs. Anti-retroviral drugs to prolong life ... so as not to leave their children so prematurely-orphaned. To be quite honest, I never know what to say in such a situation. I'm strangled by the double standard between developed and developing countries. I'm haunted by the monies available for the war on terrorism, and doubtless to be available for the war on Iraq, but somehow never available for the human imperative.
I believe that all the things those women asked for could be provided, or at least provided in large measure, if we had the money. Next weekend, the Global Fund will pronounce on its financial needs. There will then ensue a tenacious, indefatigable effort to round up the dollars. I have no idea what to expect.
I know only that if the Next Wave is to escape the wretched fate of the last wave, then the world and its governments will have to come to their senses.
* 'The Next Wave of HIV/AIDS: Nigeria, Ethiopia, Russia, India and China', prepared for the National Intelligence Council of the CIA, highlights the rising HIV/AIDS problem in five countries of strategic importance to the United States: Nigeria, Ethiopia, Russia, India and China. It is available as a pdf file at: <a href=http://www.cia.gov/nic/pubs/other_products/ICA%20HIV-AIDS%20unclassified%20092302POSTGERBER.pdf>http://www.cia.gov/nic/pubs/other_products/ICA%20HIV-AIDS%20unclassified%20092302POSTGERBER.pdf<a/>
We, the SADC Health Ministers gathered at Roodevallei, Pretoria, on 30 August 2002 deliberated over the severe famine facing the SADC region [...]
We, the SADC Health Ministers [...] recognize that the famine is super-imposed on an already severe HIV/AIDS pandemic in the region. Both the famine and HIV will lead to deeper impoverishment of the people of the region, and further compound the magnitude of premature death of vulnerable groups namely children and women, from diseases aggravated by poverty like HIV/AIDS and malnutrition, such as malaria, TB and diarrhoeal diseases.
Notwithstanding the effect of the famine on productivity, combined with the HIV/AIDS pandemic household food security through reduced productivity is further compromised and an additional burden placed on already overstretched health systems.
We, the Ministers, recognise the current severe shortfall in food production and food availability in the region, with a cereal deficit of 4,071,300 metric tonnes (MTs) in the region. We also recognise the complex causes of the famine but identify the high levels of poverty in the region as a key factor underlying the current disaster. In the countries affected by the famine, between 1996 and 2001, the number of people living below the poverty line has stayed the same or increased, with on average 68% of the population living below the poverty line in 2001. We further recognise that poor people are most vulnerable to any adverse events.
We note with great concern, the environmental and agricultural factors as a cause of the drought and famine in Africa, with an estimated 500 million hectares affected by soil degradation since 1950, including as much as 65% of agricultural land. A combination of inequitable distribution of land, poor farming methods and unfavourable land tenure and ownership systems have led to the decline in productivity of grazing land, falling crops and diminishing returns from water supplied. Nearly two- thirds of Africa is semi -arid, and Southern Africa is one of the sub regions that is most affected. This dryness makes the land vulnerable to degradation.
Economic factors contribute significantly to this situation. High debt burdens and unequal trade have undermined effective responses by Southern African countries. In particular, greatly increased subsidies to U.S. and European farmers threaten the viability of farming in the region [...]
The urgent need for medicines to save lives, families and the fabric of our communities today impels a group of applicants (which includes the Treatment Action Campaign, unions and doctors) to launch a complaint with the Competition Commission in South Africa against two major international drug companies, GlaxoSmithKline (GSK) and Boehringer Ingelheim (BI). The complaint charges these corporations with excessive pricing in respect of several key drugs for the treatment of AIDS. The drugs are: RetrovirAE (zidovudine or AZT), 3TCAE (lamivudine), CombivirAE (AZT/lamivudine) and ViramuneAE (nevirapine).
This is a novel step that engages South Africa's sophisticated competition regulatory system in an effort to secure justice and rationality in drug pricing in the AIDS epidemic. Tens of thousands of people in our country are dying every year because of excessive prices for these medicines and because of government's lack of determined action to reduce the prices.
People living with HIV/AIDS, our doctors and nurses, the Treatment Action Campaign (TAC), the Congress of South African Trade Unions (Cosatu) and the Chemical Energy Paper, Printing, Wood and Allied Workers Union (CEPPAWU) have decided to act jointly against continued, unjust and insupportable drug company profiteering. South Africa needs affordable medicines now.
According to the World Health Organisation, the most commonly recommended triple drug therapy for HIV/AIDS is the combination of CombivirAE AZT/lamivudine) and ViramuneAE (nevirapine). We are placing the following powerful evidence before the Competition Commission: a month's supply of this treatment regimen at retail prices costs R1176.00 from Glaxo and Boehringer. By contrasts, the best-priced generic internationally cost R276.00 per month. The stark fact is that for the cost of one treatment from the brand name companies four people with AIDS can be treated on generics. We have additional evidence of excessive pricing for individual drugs.
Excessive pricing or profiteering by GlaxoSmithKline and Boehringer Ingelheim is directly responsible for premature, predictable and avoidable deaths of people living with HIV/AIDS, both children and adults.
For nearly four years, TAC and our allies have campaigned globally for drug companies to issue unconditional voluntary licences, against a royalty payable to the corporations of 4-5%, to allow generic competition and the lowest prices. This is a rational, fair and life-saving proposal. The drug companies have ignored it. Now we are asking the Competition Commission to investigate the complaint and to refer it to the Competition Tribunal.
We seek the following relief:
An order that GlaxoSmithKline and Boehringer Ingelheim stop the excessive pricing practices; A declaration that the excessive pricing conduct is a prohibited practice for purposes of damages claims by all persons who can establish that they have suffered loss or damage as a result of the prohibitive practice concerned; and An administrative penalty against the companies.
We are taking this action to ensure that:
The right to life is placed before profiteering; People living with HIV/AIDS who work can afford to buy medicines to save their lives; Children living with HIV/AIDS will get access to antiretroviral medicines; Medical schemes can afford to treat people living with HIV/AIDS without going bankrupt; Employers can treat their workers on a sustainable basis; and that Government shakes off the denialist paralysis and develop a national treatment plan.
We call on all people in South Africa and across the world to support this action taken by people living with HIV/AIDS, health care professionals, TAC, Cosatu and Ceppawu. We urge everyone to call on all drug companies to immediately issue unconditional voluntary licences for antiretroviral medicines to save the lives of millions in our country and across the world.
* Note: Equinet jointly with Oxfam GB will shortly be putting out a call for applicants for a grant looking at equity issues in relation to HIV/AIDS and particularly treatment access.
Thumida Maistry will be leaving Equinet as at the end of October 2002. Equinet is grateful to Thumida for her energetic commitment to the network. She has been working for the past three months on background work for an advocacy plan for Equinet that will be more substantively taken up in 2003. Programme co-ordination will continue to managed through TARSC as always and communications should be directed to admin@equinetafrica.org.