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Nov. 20, 2000The African Studies Association this year organized a special plenary session on Combating HIV/AIDS in Africa. My remarks on the panel are below. -- Salih
Combating HIV/AIDS in Africa: 21st Century Strategies
African Studies Association Annual Meeting
[This presentation followed those of two senior U.S. officials: David Gordon, U.S. National Intelligence Council; and, Valerie Dixon-Horton, USAID. The Moderator was Pascal James Imperato, SUNY-Health Science at Brooklyn.] There is a useful quotation that says, 'One can accomplish a great deal in Washington; so long as you don't seek credit for it.' The source is, appropriately, anonymous. Valerie Dixon Horton has committed her career to African development and the belief that the US should play an important role, and she has accomplished a great deal. David Gordon has quietly and effectively pushed the intelligence and security establishment to accept that a public health crisis is a national security matter. This is unprecedented as was, I believe, the government's decision to go public with it. When the National Intelligence Estimate (NIE) declaring HIV/AIDS a threat to US national security was publicly released, Senator Trent Lott, the Senate Republican Leader, laughed on television when asked what he thought of it. He called it pandering to blacks! HIV/AIDS is the Shame of our time! As we explore the question of "Strategies for the 21st century" we know it is not just a question of what to do, but of whether we -- especially the United States, this richest country of all time -- are committed to do all that is necessary to defeat the AIDS pandemic in Africa. There are many issues of importance in U.S. relations with Africa, but there is no issue of greater immediate importance than AIDS. AIDS is more than a disease. AIDS is more than a public health crisis. AIDS is a global health crisis. AIDS is a national security threat as declared by the Clinton administration and AIDS is a global security threat. But much more than this, AIDS is a manifestation and consequence of the global apartheid that we face as we enter the 21st Century. I use the term 'global apartheid' because it offers a most useful framework for describing the gross inequality in access to basic human rights that pervades the current world order, including access to healthcare. Fighting global apartheid is also a useful framework for building alliances to promote a more just global order. The obvious allusion to racial apartheid also brings into focus a key determinant of this inequality and a key obstacle to global solidarity. The AIDS pandemic in Africa provides a dramatic and a sadly needed reminder. It is not only that global inequality is increasing. The distribution of the suffering, as in the past five centuries, is clearly linked to both place and race. According to the latest World Health Report, released in June 2000, forty-four of the fifty-two countries with life expectancies less than 50 years are in Africa. The glacial pace of the international response to AIDS exposes an entrenched double standard. As Dr. Peter Piot of the UN AIDS program remarked just before the World Aids conference in South Africa, 'If this would have happened in the Balkans, or in Eastern Europe, or in Mexico, with white people, the reaction would have been different.' AIDS is the black plague! Its epicenter is Africa, the region with the next highest infection rate is the Caribbean, and here in the U.S. (the region ranked third) HIV/AIDS infection rates are increasing mainly among young women of color. So while AIDS is a global threat that knows no borders and does not discriminate by race, at present it is mainly killing black people. And that is the cruel truth about why the world has failed to respond with dispatch! The question is how much inequality are we prepared to accept in the world? The question is do we believe that Africa is part of our common humanity? To see how much inequality the US government is prepared to accept globally, one only has to look at how much inequality it accepts at home. The impact of this pandemic is staggering. The previous speakers have provided ample statistics to describe the terrible devastation caused by AIDS in Africa and the alarming spread of the disease. AIDS is increasingly visible in many African countries, and beyond the deaths and suffering there are development reversals, a decline in life expectancy, decreased child survival rates, economic decline, less capacity for healthcare and education, threats to food security, political instability, war and displacement; this is how Africa is affected. And Africa will be affected in this manner for at least the next 30 years even if everything needed to defeat this pandemic falls into place. All these figures and the many more available are numbing. They are also often imperfect, inaccurate, estimates, taken out of context, distorted for nefarious reasons..etc., but there should be no denying the devastation Africa is facing because of this disease and the co-factor of poverty that sustains it, and spreads it. The numbers are indeed numbing but one statistic provides compelling context: Right now there are 6 to 7 thousand funerals a day in Africa due to AIDS. It is not just the deceased who has been affected by AIDS, but everyone at the funeral. The AIDS crisis in Africa is a stark reminder of the racial double standard which has marginalized African lives for the past five hundred years. This double standard divides the world between rich and poor, white and black. The past five centuries have brought much progress, but also much suffering and Africa has suffered disproportionately and still does. The consequences of slavery, colonialism and imperialism have been to keep Africa underdeveloped and poor, and African leaders are certainly not blameless. Apologies from the rich countries that took so much from Africa are insufficient. Now AIDS threatens Africa's very survival. Unless rich countries accept their responsibilities and obligations to fight AIDS and poverty simultaneously in Africa, this new century will witness only a deepening of the divide between the global haves and have-nots, and with devastating results for all humankind. Most African countries are deeply in debt to the international financial institutions and rich donor nations. The average African government spends more money per year to finance its foreign debts than on national health care, and many spend more on debt servicing than health and education combined. These are mostly illegitimate foreign debts and they beg the question: Who owes Whom? Early gains in healthcare in the sixties have been all but negated by the free market reforms imposed by international creditors beginning in the eighties. The AIDS pandemic finds African states unable to cope. Nevertheless African governments and even more so African societies are fighting AIDS: (1) Through public education programs intended to reduce the spread of the disease; (2) By trying to ameliorate the damage done to families and economies. Though these social welfare and other programs barely scratch the surface. And (3) The care and treatment of people living with AIDS. Medicines that might enable them to live relatively normal lives. But that has not been widely tried in Africa. The cost of such drugs is prohibitive. But for Africa, the question of how the poor can get cheaper, safer and effective medicines is vital. The recent US proposal to lend Africa $1 billion a year at commercial rates for the purchase of anti-retroviral AIDS drugs is a cruel hoax at best and a vivid example of government-subsidized corporate greed at worst. The plan aims to protect American pharmaceutical companies threatened by African rights under the World Trade Organization's rules to pursue parallel imports and compulsory licensing of anti-AIDS drugs. In other words, the US government is prepared to push Africa further into debt in order to prevent Africans from getting cheaper drugs from Brazil or India or from licensing local firms to produce generic versions at home. The move by African governments to ignore patents and acquire cheaper drugs through parallel imports and compulsory licensing has finally frightened rich countries and pharmaceutical companies into negotiating lower drug prices. These wealthy actors are embarrassed by the cruel logic of the market -- that he who cannot pay, dies. But even still they are pursuing legal actions in South Africa and Ghana, for example, to prevent those countries from having access to cheaper generic drugs. But even if prices are brought down by a proposed 85%, such treatments will not be effective without major health infrastructure rebuilding. Africa needs, and deserves, the cooperation of the rich countries to strengthen its healthcare systems. International debts must be canceled. Public investments in healthcare must be increased, and the drugs must become hundreds, if not thousands, times cheaper! The International AIDS Conference held in Durban this year generated tremendous news coverage as a sort of rediscovery of the AIDS pandemic and convinced the Clinton administration that they needed to something beyond yet another meager request for slight additional funding for AIDS programs. Setting up a debt financing program through the Export-Import Bank requires no funding from Congress and offers dramatic headlines because of the price tag. But the news out of Durban was not new. This was the 13th annual event, and no government can claim that it never saw the AIDS plague coming. Mind-boggling estimates of the spread of HIV/AIDS were available more than a decade ago. But because Africa has become the epicenter of the pandemic, the world is not yet willing to act. Africa is facing a deadly plague while prosperous Western countries spend huge amounts of money on finding cures for baldness and obesity. And even in the well-intended, if limited, international efforts that do exist, there are serious problems. For example, it is misguided to approach AIDS from a policy perspective narrowly focused only on the disease and on individual behavior, as opposed to everything else that AIDS represents, and this by and large is what's happening. Yet, the spread of any disease is related to social factors such as poverty and the repression of women. The spread of disease is also always related to the structural inequalities in a society, and in a global society it is no different. The focus on individual prevention, behavior and drug treatment is misguided. There is a scientific relationship between health and economic status that is irrefutable, but the "AIDS community" quickly agrees and says that they can't answer the larger socio-economic issues, that this is for others to address. However, interventions which ignore Africans' broader development objectives and pursue only a disease-centered agenda are misled. And by ignoring and even weakening the rest of the healthcare system in any country, such an approach will only reinforce internal and global inequities, and the poor will continue to pay the price. We believe that US policy to combat the HIV/AIDS pandemic in Africa must focus on the overall rebuilding of public health care systems and on structural inequalities (especially the economic and social exclusion of the poor) and on poverty itself! The US should support an integrated approach to treatment and care. And Washington should focus greater attention on lowering the price of antiretroviral drugs. Generally, the production costs of such drugs constitute only 1% of the price! Moreover the research and development costs are frequently subsidized or funded outright by public resources. The US also needs to cooperate more closely with African governments and scientists when determining issues of research priorities and ethical guidelines. If funding is increased - as it should be - there will remain questions regarding priorities: what to spend money on and which programs to fund. Similarly, there needs to be greater debate regarding the effectiveness of different vehicles for delivering support. In other words should we spend more on USAID, the World Health Organization, UNAIDS, or national Ministries of Health in Africa? To start, we need to learn what percentage of current AIDS resources is actually spent in Africa? We know that most of the world's people living with AIDS are in Africa, but most of the resources for AIDS-related activities are spent among the rich countries. Finally, I return to the question of 'how much inequality is tolerable'? In this election year, HIV/AIDS hardly figured in the campaigns or the debates. Elected officials should now begin to seriously consider dedicating a modest 5 percent of the budget surplus - approximately $9.5 billion this year - to a global health emergency fund. This would still fall short of what is needed, but it would be a leap above the paltry $325 million the US is providing for AIDS efforts worldwide. And it would send a signal that US politicians share a sense of global responsibility rather than regarding globalization only as an opportunity for corporate profit. We believe that the HIV/AIDS pandemic is absolutely intolerable and that it must be defeated by any means necessary. We believe that US policy should be built upon the following fundamental points.
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