USING THE AIDS INDUSTRY: LESSONS FROM BANGKOK Sanjay Basu Using the AIDS Industry: Lessons from Bangkok Sanjay Basu Ongoing coverage of the International AIDS Conference in Bangkok is bewildering to those who are familiar with the current political battles in the HIV/AIDS arena, and no doubt disheartening or annoying to those reading from a distance. The AIDS industry is in full swing: government forces delivering glittering generalities; actors and ex-presidents discussing their "outrage" while eating five-course dinners in Bangkok hotel penthouses. Non-governmental organizations (NGOs) provide some context and much confusion. Some, like Doctors Without Borders or Partners In Health, push a consistent line that demonstrates their commitment and closeness to the poor who suffer from HIV and its related social pathologies [1, 2]. Others seem to care more about winning New York Times headlines than about the implication of what those newspaper stories will have for the poor. The American Foundation for AIDS Research in Manhattan, for example, produced a report that should have provided an evaluation of Thailand's generic production facilities within the context of technical suggestions and cross-border comparisons with other nations' production centers; instead the report was publicized in a manner divorced from its technical minutiae and left the impression that generic medicines from Thailand would kill millions [3]. This, in a context where the US AIDS Czar Randall Tobias is looking for any means to undermine generic manufacturing and return to an oligopoly system in the pharmaceutical industry [4]. The heavy focus on drug access at the conference does, however, serve as one piece of good news, in spite of the fact that many believe it is "distracting" from other matters (an issue I will deal with later in this article). The fact that the discussion is not about whether antiretrovirals can be used in poor countries, but about how to get them there, is a marked shift from previous years. But that is not to say that efforts like the WHO's "3-by-5" Initiative (three million people gaining access to antiretrovirals by 2005) are not being undermined [4]. The battles will continue over this and related initiatives, but what are the rest of us to do as we watch the actors and ex-presidents deliver glittering generalities? What positive outcomes can come for the poor when the wealthy of Manhattan produce statements of "outrage" while consuming pad thai in the security-fenced sector of Bangkok? Perhaps an answer can be found in a statement made earlier this week by the physician Paul Farmer, whose own success in providing both medical and socioeconomic assistance to patients in Haiti has finally produced too much positive data for the rest of the medical community to ignore. ''When you're in a clinic in rural Haiti and someone comes in with a broken arm or in obstructed labor, you can't say, 'Sorry, we only do AIDS prevention and care,''' said Farmer. ''The massive loss of life due to H.I.V. disease is only one symptom of a very sick world in which hundreds of millions are going without any modern medical care at all. Addressing AIDS properly offers a chance to set some of this right.'' [5] What Farmer refers to is the window of opportunity we have as persons who are watching so much attention focused on AIDS and yet ironically wondering what good may come of it. With so bright a spotlight on funding shortfalls and patenting and health worker "brain-drains", what can be done to help the HIV-infected poor, who have not been given tickets to the Bangkok conference? The answer: everything. Because AIDS is a symptom of a much larger disease, there is a way for us to manipulate the AIDS industry--to use the attention acquired by the rock stars and ex-presidents to show that AIDS is the end-stage of a very long pipeline. The focus on HIV treatment provides a case in point. While HIV medicines have been prohibitively expensive in the past due to patenting heavy focus on antiretroviral drug access has allowed several groups to ask broader questions about patenting and licensing for all medicines, not only those used to treat HIV [6]. This has allowed greater questioning of the WTO's TRIPS agreement and a number of newer bilateral and regional trade agreements with the United States [7]. HIV prevention services are another case in point. While education-based prevention initiatives have had mixed success, and all-too-many failures, a focus on "structural prevention" seems to be taking shape. Recognizing that education or ignorance among the poor is not the key barrier to better health and livelihoods when women are engaged in relationships based on economic dependency, or when depressed men work in dangerous mining-fields and live in all-male barracks far from their homes, AIDS activists in many countries have begun to link their efforts to unionization issues and concerns about labor rights and access to credit for the poor [8, 9]. Farmer's own initiative in Haiti, for example, now includes an effort to develop a poor person's bank. Indeed, while "lack of infrastructure" was once used as an excuse to prevent the poor from receiving antiretroviral medicines, the new focus on gaining drug access has allowed many persons to argue that AIDS provides a better time than ever before to start building infrastructure rather than waiting for some future epidemic and repeating the mistakes of the past. In India, this has meant not only building clinics, but also developing an independent pharmaceutical production structure. In South Africa, this has meant revising funding structures to emphasize comprehensive care, according to the stunning critiques of the Treatment Action Campaign [9]. In the United States and many Eastern European countries (but also in sectors of Bangkok not far from the conference itself), this has meant emphasizing harm reduction for injection drug users, helping to push against the barriers faced by those who are stigmatized and blamed with a rhetoric divorced from social context [10]. In every location, key sites where the poor are most marginalized--prison systems, red light districts, the barracks of migrant laborers--serve as the geographic locales that need most emphasis, and upon which we can shine the AIDS industry's spotlight to reveal numerous injustices and stare further up the pipeline that leads to HIV infection [11]. In every location, the issue is not whether AIDS or antiretroviral drug access is "competing" with other diseases and issues, but rather the issue of how problems of the poor--of which AIDS is just one horrific manifestation-- competes with the priorities of the wealthy [8]. And if indeed such a competition can be exposed, there may still be hope that the Bangkok rhetoric can be put to good use. * Sanjay Basu is at the Yale University School of Medicine. http://omega.med.yale.edu/~sb493 Recommended reading: http://www.pih.org/library/books/dying_for_growth.html http://www.zmag.org/content/showarticle.cfm?SectionID=2&ItemID=3988 References 1. http://www.accessmed-msf.org/ 2. http://www.pih.org/index.html 3. http://query.nytimes.com/gst/abstract.html? res=F30C1EFB3E5F0C7B8CDDAE0894DC404482 4. http://www.zmag.org/content/showarticle.cfm?ItemID=5181 5. http://www.nytimes.com/2004/07/14/health/14aids.html 6. http://www.maketradefair.com/en/index.php>?file=26032002105549.htm&cat=2&subcat=5&select=13 7. http://www.doctorswithoutborders.org/publications/reports/2004/ftaa_05>- 2004.pdf 8. http://www.zmag.org/content/showarticle.cfm?SectionID=2&ItemID=3988 9. http://www.tac.org.za/ 10. http://www.harmreduction.org/ 11. http://www.pih.org/library/books/dying_for_growth.html