Aids: A moral issue for as long as it is defined by inequalities Sanjay Basu The World Health Organization (WHO) recently released the first set of comprehensive data comparing the prevalence of HIV/AIDS in poor countries with the rates of antiretroviral (anti-HIV) drug access in those nations. The data are striking and disheartening, yet have received little press coverage. Indeed, at the time of their release, some American newspapers ran editorials indicating that antiretroviral access has received "too much attention". Two problems are implicit in such a contention. The first is political. AIDS is very much a symptom - albeit the most extreme symptom - of the large diseases of inequality and poverty that result not only in HIV, but also in hunger, hemorrhagic fever and housing problems. The same credit and political obstacles that have led to gender discrimination in housing and employment have led women into prostitution and relationships based on sexual dominance [1, 2]. The same structural adjustment programs and neoliberal economic policies that have crashed farming sectors and forced thousands into migration are the same policies that have led migrants to the barracks of minefields to live with depression, alcoholism and the subsequent solicitation of prostitutes [3-5]. And so to address AIDS appropriately would be to appreciate that it does not simply receive "too much attention", but that the attention it receives should be drawn towards its base - and this includes the inequalities in healthcare access that are symbolized by antiretroviral access disputes. The second problem with the new popular line of thought on antiretrovirals is a statistical problem. The recently-released WHO data are striking but perhaps not surprising. If "too much attention" has been focused on drug access, then why are only six-tenths of a percent of the 1.6 million infected people in Tanzania able to access antiretroviral medications? Why are only 1.5% of the 2.4 million in Mozambique and the Congo able to gain such access? In a country like Zimbabwe, where one of every four adults is infected, only one of every fifth can access an antiretroviral medication. As one scrolls through the WHO's data, the numbers of infected persons continue to be expressed in seven digits, while the percent of those gaining access to antiretrovirals continues into smaller and smaller decimal ranges. Some persons have stated that countries like those I have listed above lack the necessary infrastructure to deliver antiretroviral therapy [6]. The persons who make such claims do so in order to close conversations and prevent creative solutions from entering the public health community. But others who are determined to open new doors for patients have definitively responded to the "infrastructure line" - in Haiti, Paul Farmer's group has shown better treatment rates in the poorest sector of the Western Hemisphere than at Harvard's teaching hospitals [7, 8]; in the warring regions of the Congo, Doctors without Borders has seen better results than their colleagues at hospitals in France [www.msf.org]. The adherence of patients in poor settings to antiretroviral medications is often higher than that in the U.S. and other wealthy nations [9] - both because the groups that have worked in the poorest of places have incorporated community health workers into programs that are constructed with the advice of the poor (as opposed to employing a highly institutionalized and decentralized mode of care seen in the U.S., where a poor patient needs to travel to a dozen offices to complete welfare paperwork), and because generic medicine producers have combined the key antiretroviral medications into a single once-a-day pill [10]. Ah, but won't these generics undermine research and development (R&D)? That would be true, if the patent-based industry these generics compete against were to have done such R&D. But in reality, the top AIDS medicines were researched primarily through taxpayer funds distributed through the National Institutes of Health to government and university laboratories, then sold for tiny royalties to the American and European pharmaceutical industry [11, 12]. That industry has been the most profitable in the world for fourteen years - making profits as a percentage of revenue approximately three times the rate of the rest of the Fortune 500 [13, 14]. Eighty-five percent of the top therapeutic drugs on their market had their R&D conducted through taxpayer funding [14]. And the industry's own R&D is surprisingly unproductive, with over half of new drugs on the market being reformulations of old medicines, carrying little or no therapeutic value according to the Food and Drug Administration's rankings [14]. This should be unsurprising to those who view the industry's tax records, obtainable through the Securities & Exchange Commission. These records reveal that the patent-based industry spends, on average, 27% of its revenue on marketing and only 11% on R&D [12, 15, 16]. The effects of generic competition to help break this monopoly are striking in terms of improving medicine access [17], but what the WHO shows is that these generics have not reached far enough. In January of 2005, the provisions of the Trade-Related Aspects of Intellectual Property Rights (TRIPS) agreement passed by the World Trade Organization (WTO) will begin to kick-in, limiting the ability of key generic providers to supply poor markets, as described extensively elsewhere [18, 19]. Recent trade agreements written by the U.S. Trade Representative (USTR) have further restricted competition, ironically while claiming to be promoting "free trade" [20]. But what the WHO data reveal is that certain key institutions controlling antiretroviral expansion projects have been far more successful in this hostile context than others. The most transparent group - the Global Fund for AIDS, TB and Malaria - although not without its own problems, has enhanced access for the most number of people, including those in 63 countries. The group is notable for receiving public commentary and making its processes of change public and visible. Yet in comparison, groups that have worked with little public input and much secrecy - the Clinton Foundation and the World Bank group - have garnered press coverage while accomplishing comparatively little. The Clinton group, in spite of its fanfare, has reached only 18 countries with its drug deals; the World Bank has assisted 3 in procuring antiretrovirals, mostly for technical assistance purposes (the nature of which is unclear). And U.S. government based programs, in spite of their purported funding levels, have similarly poor coverage, with the President's AIDS Initiative reaching just 14 nations, excluding many with the highest burdens of disease. At every level, then, the issue of how effectively criticism from those most affected by this disease reaches those most in power ultimately reciprocates in terms of efficacy in treating the poor. From the perspectives of those who cannot leap to Geneva, such high-level bureaucracies may seem out of reach, and the problems therefore too out of control to effect. Yet a group of university students is assisting in changing that idea, demonstrating that multiple levels of action are necessary and can be effective in addressing this problem. On Saturday October 9th, a group of students called Universities Allied for Essential Medicines (UAEM) released an "Equitable Access License" (EAL) with provisions designed for universities to reshape the manner in which they sell (often taxpayer-funded) university research to pharmaceutical companies [www.essentialmedicines.org]. The provisions are based out of an earlier movement at Yale University, which resulted in a 40% decrease in the price of the key AIDS drug stavudine in South Africa. But recognizing, once again, that AIDS medicines are symbolic of a larger, systemic problem, the students have written the EAL to apply to all devices and medicines of public health importance. This is particularly crucial in the context of the USTR's recent trade agreements, which have not only included the types of provisions that lead to the spread of infectious disease, but also are likely to continue altering the food importation patterns of nations in such a manner that the recently-observed elevations in diabetes and cardiovascular disease in poor nations are likely to escalate [21]. The EAL may appear as a technical project - and it is - but its spirit has more to do with morality than with the details of intellectual property law. The word "morality" rarely appears in discussions of AIDS, since such conversations are usually clouded by questions about whether AIDS is a "development issue" (and I would suppose it is), whether AIDS is a "legal quandary" (I suppose everything can be made into one of these), and whether AIDS is a "national security issue" (what type of people need this kind of argument to address a pandemic?). At its core, these kinds of statements avoid the more basic, and perhaps more truthful, reality that AIDS will be a moral issue for as long as the politics of this Syndrome are defined by inequalities. In the face of such a truth, progress seems to be made by pushing at every level - from universities to global institutions - and observing what trends in the behaviour of the powerful can improve the livelihoods of the poor. *The WHO's data can be obtained at: http://omega.med.yale.edu/~sb493/files/IP/ARV%20coverage.xls Sanjay Basu is at the Yale University School of Medicine. http://omega.med.yale.edu/~sb493 References: 1. Farmer, P.E., M. Connors, and J. Simmons, eds. Women, Poverty and AIDS: Sex, Drugs, and Structural Violence. 1996, Common Courage Press: Monroe. 2. Bello, W., S. Cunningham, and L.K. Poh, A Siamese Tragedy: Development and Disintegration in Modern Thailand. 1998, London: Zed Books. 3. Campbell, C., Migrancy, Masculine Identities and AIDS: The Psychosocial Context of HIV Transmission on the South African Gold Mines. Social Science and Medicine, 1997. 45(2): p. 273-81. 4. 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