JIM KIM & PAUL FARMER
AIDS in 2006—Moving toward One World, One Hope?
355 New Engl J Med 645 (2006)
For the past two decades, AIDS experts—clinicians, epidemiologists, policymakers, activists, and scientists—have gathered every two years to confer about what is now the world’s leading infectious cause of death among young adults. This year, the International AIDS Society is hosting the meeting in Toronto from August 13 through 18. The last time the conference was held in Canada, in 1996, its theme was “One World, One Hope.” But it was evident to conferees from the poorer reaches of the world that the price tag of the era’s great hope—combination antiretroviral therapy—rendered it out of their reach. Indeed, some African participants that year made a banner reading, “One World, No Hope.”
Today, the global picture is quite different. The claims that have been made for the efficacy of antiretroviral therapy have proved to be well founded: in the United States, such therapy has prolonged life by an estimated 13 years—a success rate that would compare favorably with that of almost any treatment for cancer or complications of coronary artery disease. In addition, a number of lessons, with implications for policy and action, have emerged from efforts that are well under way in the developing world .During the past decade, we have gleaned these lessons from our work in setting global AIDS policies at the World Health Organization in Geneva and in implementing integrated programs for AIDS prevention and care in places such as rural Haiti and Rwanda. As vastly different as these places may be, they are part of one world, and we believe that ambitious policy goals, adequate funding, and knowledge about implementation can move us toward the elusive goal of shared hope.
The first lesson is that charging for AIDS prevention and care will pose insurmountable problems for people living in poverty, since there will always be those unable to pay even modest amounts for services or medications, whether generic or branded. Like efforts to battle airborne tuberculosis, such services should be seen as a public good for public health. Policymakers and public health officials, especially in heavily burdened regions, should adopt universal access plans and waive fees for HIV care. Initially, this approach will require sustained donor contributions, but many African countries have recently set targets for increased national investments in health, a pledge that could render ambitious programs sustainable in the long run.
As local investments increase, the price of AIDS care is decreasing. The development of generic medications means that antiretroviral therapy can now cost less than 50 cents per day, and costs continue to decrease to affordable levels for public health officials in developing countries. All antiretroviral medications—first-line, second-line, and third-line—must be made available at such prices. Manufacturers of generic drugs in China, India, and other developing countries stand ready to provide the full range of drugs. Whether through negotiated agreements or use of the Agreement on Trade-Related Aspects of Intellectual Property Rights, full access to all available antiretroviral drugs must quickly become the standard in all countries.
Second, the effective scale-up of pilot projects will require the strengthening and even rebuilding of health care systems, including those charged with delivering primary care. In the past, the lack of a health care infrastructure has been a barrier to antiretroviral therapy; we must now marshal AIDS resources, which are at last considerable, to rebuild public health systems in sub-Saharan Africa and other HIV-burdened regions….Only the public sector, not nongovernmental organizations, can offer health care as a right.
Third, a lack of trained health care personnel, most notably doctors, is invoked as a reason for the failure to treat AIDS in poor countries. The lack is real, and the brain drain continues. But one reason doctors flee Africa is that they lack the tools of their trade. AIDS funding offers us a chance not only to recruit physicians and nurses to underserved regions, but also to train community health care workers to supervise care, for AIDS and many other diseases within their home villages and neighborhoods….
Fourth, extreme poverty makes it difficult for many patients to comply with antiretroviral therapy. Indeed, poverty is far and away the greatest barrier to the scale-up of treatment and prevention programs. Our experience in Haiti and Rwanda has shown us that it is possible to remove many of the social and economic barriers to adherence but only with what are sometimes termed “wrap-around services”: food supplements for the hungry, help with transportation to clinics, child care and housing. In many rural regions of Africa, hunger is the major coexisting condition with AIDS or tuberculosis, and these consumptive diseases cannot be treated effectively without food supplementation….
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Fifth, investments in efforts to combat the global epidemics of AIDS and tuberculosis are much more generous than they were five years ago, but funding must be increased and sustained if we are to slow these increasingly complex epidemics. . .
The unglamorous and difficult process of increasing access to prevention and care needs to be our primary focus if we are to move toward the lofty goal of equitably distributed medical services in a world riven by inequality. Without such goals, the slogan “One World, One Hope” will remain nothing more than a dream.
Notes and Questions
Kim and Farmer approach the HIV/AIDS pandemic from the perspective they would describe as “social justice.” How does this perspective differ from a “health and human rights” perspective? Jonathan Mann, the founder of the health and human rights field, has observed that most of the problems of health are problems of poverty—nonetheless he also noted that framing them as poverty problems makes them seem insurmountable and intractable. Better, he thought, to focus on the basic human rights which most people support and whose recognition can dramatically improve health status.
Kim and Farmer (and the World Health Organization generally) have argued that we must make treatment available to all who are infected with HIV as soon as possible. This is a reasonable goal, but how can it be achieved? Most recently, for example, WHO failed in its attempt, labeled “3x5” to enroll 3 million new HIV patients in treatment programs by the end of 2005. It seems reasonable to note that in this same period of time more than 5 million new HIV infections occurred. The point needs to be emphasized: treatment is critical, but from a public health perspective, prevention is overwhelmingly vital. Consider how treatment and prevention go hand in hand. Assuming that not everyone can get access to treatment immediately, how should public health officials prioritize who should get access first? Do we need an explicit rationing scheme that puts parents, workers, children, or some other group at the top of the priority list? How should such a list be constructed and who should construct it? Would it be an inherent violation of the nondiscrimination basis of the human rights movement?
Of course, these same issues will be faced in the event of an epidemic or bioterrorist attack—who should be treated first with available drugs and vaccines? In this regard, the CDC has suggested priorities for flu vaccinations, both in the yearly flu (when supplies are short) and in the event of an avian pandemic, when vaccine will not be immediately available to anyone. Who should be at the top of the distribution list and why? See, e.g., Alfred I. Tauber, Medicine, Public Health, and the Ethics of Rationing, 45 Perspectives in Biology & Med. 16 (2002), and Ezekiel Emanuel & Alan Wertheimer, Who Should Get Influenza Vaccine When Not All Can?, 312 Science 854 (2006).
The editor of the Lancet, Richard Horton, was far less impressed by the August 2006 International AIDS meeting in Toronto than others. The meeting, for example, committed to a goal of “universal access to comprehensive prevention programs, treatment, care and support by 2010.”
Unfortunately, as Horton notes,
. . . the opportunity to produce a roadmap to reach the 2010
Target of universal access was squandered. Rarely has there
Been a meeting that felt so disengaged from a global
Predicament of such historic proportions. The agenda in
Toronto was unfocused, giving prime air time to celebrities,
Such as Bill Gates and Bill Clinton, while largely ignoring
Africa [even though] Africa bears the greatest burden of AIDS
Today—24.5 million of 38.6 million people with HIV.
Horton went on to raise ten specific questions that he believes need answers now, including: 1. Why do we refuse to admit that there is still no genuine global commitment to scale up our response to AIDS?; 2. Why are the wider health, economic, social and cultural contexts of AIDS still being ignored?; 6. Why do health agencies and programs still base their prevention messages on the outdated and scientifically corrupt idea of abstinence?, and 7. Why are civil society and NGOs still not being given the credit they deserve as vital levers in the global AIDS response?
The next International AIDS meeting will be in Mexico in 2008. In Horton’s view, “The litmus test for Mexico’s success will be the degree to which the conference can be transformed from a scientific meeting and global beacon for AIDS, to a coordinating mechanism to drive advances in prevention, treatment, and care at the country level. Talking is easy. Doing will demand a revolution.” Richard Horton, A Prescription for AIDS 2006-10, 368 Lancet 726-28 (2006). Horton’s essay echoes the much more generalized arguments of Laurie Garrett, Betrayal of Trust: The Collapse of Global Public Health (2000), a critical pre-9/11 look at global public health dedicated to Jonathan Mann.
As Horton notes, the stars of the 2006 AIDS meeting were Bill Gates and Bill Clinton, based largely on their recent work in donating and raising private funds for AIDS research and treatment. Their activities and status raise some disturbing questions for public health advocates. Why do governments fail to adequately fund public health programs? And what is the role of the private sector in public health? Are public-private partnerships the future of public health?
Of course, global public health problems demand global approaches. And even the Wall Street Journal has taken note that these issues have yet to be resolved, and that what decisions are made in late 2006 to fill the now vacant positions of Director-General of WHO, Executive Director of the Global Fund to Combat AIDS, Tuberculosis, and Malaria, and the Senior VP for Health Development of the World Bank “will help determine the world’s strategy for confronting health threats ranging from AIDS to pandemic flu for years to come.” Betsy McKay, Three Top Jobs in Global Health Face Vacancies, Wall St. J., September 5, 2006, A16.
Bill Gates has recently concluded that his foundation will put most of its resources into global health initiatives, especially HIV/AIDS, because he believes that this is the area in which you can get the most return on your investment in terms of lives saved. Warren Buffet, the second richest man in the US after Gates, has announced that he will leave most of his fortune to the Gates Foundation because he believes they have the right approach and his own foundation could not do it better. Private charity is to be admired and foundations funding is almost always welcome. But what does this say about public health to note that the Gates Foundation annually provides more funding for public health initiatives than the entire budget of the World Health Organization? Gates has said that he got most of his philanthropic investment ideas from reading a report by the World Bank, which is still well worth reading. World Bank, World Development Report 1993: Investing in Health (1993).
The Bill and Melinda Gates Foundation has so far been primarily interested in developing an AIDS vaccine, although the foundation has branched out more recently. Vaccines are, of course, the most basic of successful public health interventions, in that they can prevent disease in populations. Nonetheless, even the limited quest to provide already existing and effective vaccines to the world’s children has been consistently overwhelmed by politics. See, e.g., William Muraskin, The Politics of International Health: The Children’s Vaccine Initiative and the Struggle to Develop Vaccines for the Third World (1998).
5. One of the major legal issues involving world health of the past decade has been the debate around pharmaceutical patenting and profits. Although almost everyone now realizes that just providing drugs, without a public health infrastructure to deliver them and care for patients is not feasible, nonetheless the cost of drugs remains a critical issue to providing decent care, especially for HIV/AIDS, in many countries. An excellent introduction to this subject is contained in a symposium issue of the American Journal of Law and Medicine, vol. 32, numbers 2 and 3, 2006: Globalization of Pharmaceuticals: International Regulatory Issues. See also, Ellen ‘t Hoen, TRIPS, Pharmaceuticals Patents, and Access to Essential Medicines: A Long Way from Seattle to Doha, 3 Chicago J. International Law 27 (2002).
6. Norman Daniels has argued persuasively that bioethics should move to broaden its agenda from the doctor-patient relationship to broader public health and population problems, and should do so based on a social justice rather than a human rights perspective. The last three items he urges bioethicists to add to their agenda are to:
10) assess the implications of the obligation not to harm
for reducing health inequalities internationally;
11) develop an account of justice for the evolving international
institutions and rule-making bodies that have an impact on
international health inequalities; and
12) examine Promethean challenges from the perspective of
their impact on international health inequalities and obligations
of justice regarding them.
Norman Daniels, Equity and Population Health: Toward a Broader Bioethics Agenda, 36(4) Hastings Center Report 22, 33 (2006).
Other commentators prefer to keep bioethics at some distance from public health. Jonathan Mann, for example, has written that he believes bioethics is the correct language for medicine, but that human rights is the proper language for public health. See, e.g., Jonathan Mann, Medicine and Public Health, Ethics and Human Rights, 27(3) Hastings Center Report 6 (1997). Ron Bayer and Amy Fairchild would go much further, arguing that modern bioethics has no place in public health ethics. In their words, “Bioethics cannot serve as a basis for thinking about the balances required in the defense of the public’s health. As we commence the process of shaping an ethics of public health, it is clear that bioethics is the wrong place to start.” Ronald Bayer & Amy L. Fairchild, The Genesis of Public Health Ethics, 18 Bioethics 473, 492 (2004). Of course, the real answer may be that
when medicine and public health work together (usually the case) public health must take account of bioethics (sometimes called simply “medical ethics”), and that in real life there are no sharp borders between health law, bioethics, and human rights in public health practice. See, e.g., George J. Annas, American Bioethics: Crossing Human Rights and Health Law Boundaries(2005), British Medical Association, The Medical Profession and Human Rights: Handbook for a Changing Agenda (2001), and David J. Rothman & Shelia M. Rothman, Trust is Not Enough: Bringing Human Rights to Medicine (2006)