An Unequal Calculus of Life and Death
Wednesday, December 27, 2000
ACORNHOEK, SOUTH AFRICA -- A River. Sounds of drowning. Struggling men, women and children, more every hour, engulfed.
This is the image of AIDS that pulled Paul Pronyk to Africa, 8,000 miles from a clinical practice near Boston. There, he fought the virus patient by patient. Here, he does little more than study it. In three years of local epidemiology, Pronyk has joined the helpless consensus on AIDS in Africa: that prevention may contain history's worst pandemic, but the millions swept up in it already are beyond hope.
"We've got to look farther upstream, to stop all the new people from falling in," Pronyk said in an interview outside the Elite Funeral Parlor ("Open 24 Hours--Day & Night"), the only thriving business in view of his hospital office. "Otherwise, the people drowning now are going to be endlessly replaced."
That kind of triage never applied in the United States and other wealthy countries, where new classes of drugs known as antiretrovirals have stripped AIDS of its uniformly fatal prognosis. But in Africa, where 25 million people are infected, fewer than 25,000--one-tenth of 1 percent--receive the therapy that could avert their deaths. At current levels of intervention, the number of Africans dead of AIDS in 10 years will probably surpass the population of France.
The starkness of the global divide between the drowning and the saved, and its growing political repercussions, galvanized the pharmaceutical industry and governments this year to pledge help. But scores of interviews in Europe, Africa and the United States, along with thousands of pages of records examined by The Washington Post, suggest that nothing fundamental has changed in the calculus of access to AIDS treatment.
Behind this year's call to action is more than a decade of confidential discussions within the pharmaceutical industry and governments. Corporate boards and regional operating companies weighed the costs and benefits of pricing AIDS medicines within reach of most of the dying. With the tacit and sometimes explicit assent of public authorities, the companies decided the costs were too great.
"The brutal fact," health economist William McGreevey told an invitation-only World Bank audience on May 22, 1998, was that "those who could pay" for Africa's AIDS therapy--the pharmaceutical industry, by way of price cuts, and "rich-country taxpayers," by way of foreign aid--"are very unlikely to be persuaded to do so."
Despite appearances, that assessment is yet to be disproved.
A five-company initiative announced in May led to front-page reports that Merck, Hoffmann-La Roche, Bristol-Myers Squibb, Glaxo Wellcome and Boehringer Ingelheim would make AIDS medicines widely available in the poorest countries at deep discounts. But only one of the companies has disclosed actual price cuts. Internal company projections call for increases in drug production to cover thousands of new patients in Africa, not millions. A World Bank economist, Hans P. Binswanger, describes the programs as "expensive boutiques . . . available to a lucky few."
A parallel gesture by Pfizer, made two months earlier, amounts to less. Under pressure over the $ 6,500 annual price for Diflucan, a powerful anti-fungal agent that nearly one in 10 African AIDS patients require for survival, Pfizer proposed in March to donate the drug to those in need. Pfizer limited the offer to South Africa, host of July's international AIDS conference. Nine months later, Pfizer has signed an agreement to do what it announced it would do, but shipment has not begun.
New sources of funding for AIDS treatment this year have also proved illusory. The Clinton administration's high-profile offer of $ 1 billion turned out to be Export-Import Bank loans, at commercial interest rates, to buy American drugs at market price. There were no takers. The World Bank ended a decade of resistance to writing loans for recurring health care costs, and announced a $ 500 million AIDS funding pool. But the bank still regards antiretroviral drugs as "cost-ineffective" in the Third World, and discourages borrowers from buying them.
"Like most things in the world, it comes down to money, and nobody has been willing to commit money to this," said Harvard economist Jeffrey Sachs, who chairs a World Health Organization (WHO) advisory commission on macroeconomics and health. "To me, it's as though the Black Death were going on in Europe in the 14th century, and China were sitting on a cure and saying, 'Why should we help?' We would consider it the crime of the millennium if that had happened, and yet we seem to be able to accommodate this without much trouble."