An Unequal Calculus of Life and Death

In 1993, the talks ended.

Looking back, industry representatives say the failure resulted from the hostility the companies perceived at the WHO. Many executives saw Nakajima in league with France to dump responsibility on American and British companies. Geneva, Merck's Jeffrey L. Sturchio said recently, "seemed to be a huge, faceless bureaucracy that wasn't interested in working with the private sector."

Widdus, a member of the WHO bargaining team who still works on drug access from a small basement office, said the explanation is more concrete. Bringing treatment to Africa, he said, would have required resources "never heretofore dreamed of."

"No one forked over the money," Widdus said. "They literally decided that there was no more that they could do. Industry didn't have its back up against the wall as they do now."

'Paid for in Human Lives'

As drug companies balked at pleas for discounts, their scientists were racing to introduce powerful medicines that would transform the ethical landscape of AIDS. Jonathan Mann, then director of the WHO global AIDS program, put it this way in the last speech before his ouster in March 1990: "Global AIDS prevention and care will fail if only the rich have access to drugs and an eventual vaccine."

Mann asked his WHO staff to commission a study: What would it take to bring the new treatments to the poor?

Until then, the pressure building on industry centered mostly on domestic needs. The AIDS Coalition to Unleash Power, or ACT UP, was formed to protest the launch price that Burroughs Wellcome announced in March 1987 for zidovudine, or AZT, the first AIDS drug to reach the market. It cost $ 10,000 for each patient, each year.

"I can't get AIDS medicine in the Bronx! Don't tell me about people in Africa," David Barr, of Gay Mens Health Crisis, told Eric Sawyer, an ACT UP pioneer, in 1993. "It was self-interest," Sawyer recalled.

In any case, price was not the only barrier to antiretroviral drugs in Africa. In many rural precincts, people did not have basic antibiotics. Many lived their whole lives without seeing a doctor. Absent the infrastructure of a health care system, many drugs could not be used effectively. A Roche distributor told the All Africa News Agency in August, for example, that "huge quantities" of medicine donated to Zimbabwe reached expiration and had to be destroyed.

But most public health authorities rejected the implication that treatment of AIDS would have to await solutions to all of Africa's problems of poverty, war and indifferent or corrupt governments. AIDS drugs could not be compared with simpler treatments for such ills as pneumonia, but the disease had the advantage of political attention. If the drugs became affordable, many experts believed, there would be powerful incentives to build the means of delivering them.

One of the first to consider the practical issues was Sally Jody Heymann, then 30 years old and fresh from dual Harvard degrees in medicine and public policy. She took on Mann's assignment, and reported back on Dec. 28, 1990.