Bridging the Digital Divide
October 2000
Banner photo: ©SEKAI BUNKA PHOTO
The Price of Life
Countless families in Africa face a bleak future with no hope of affordable treatment [N. Oshima/Seikyo Shimbun]
In its demographics HIV has altered from an epidemic whose primary toll seemed to be amongst gay white men of North America and Western Europe, to one that, overwhelmingly, burdens the heterosexual populations of Africa and the developing world. The data are so dismaying that reciting the statistics of HIV prevalence and of AIDS morbidity and mortality--the infection rates, the anticipated deaths, the numbers of orphans, the health-care costs, the economic impact--threatens to drive off, rather than engage, our sympathetic imagination. Our imagination shrinks from the thought that these figures can represent real lives, real people and real suffering.
But amidst the welter of disheartening data, two facts stand out very clearly:
- nine-tenths of all people living with HIV/AIDS are in poor countries; and
- two-thirds of the total are in sub-Saharan Africa.
But the demography of HIV has been overlain by a shift even more momentous, and one that in its nature is optimistic. It is the fact that over the last half-decade, various aggregations of drug types have been shown to quell the replication of the virus within the body. The result has been exciting, life-altering and near-revolutionary. For most of those with access to the new drug combinations, immune decline has not only halted but been reversed.
In most of Europe, in North America and in Australasia, illness and death from AIDS have dropped dramatically. Hundreds of thousands of people who a few years ago faced imminent and painful death have been restored to living, and the suffering, pain and bereavement from AIDS have been greatly reduced.
Beneficent social effects have come with the medical breakthrough. AIDS can now be compared with other chronic conditions which, with appropriate treatment and care, can be subjected to successful medical management.
The new combination drug treatments are not a miracle. But in their physiological and social effects they come very close to being miraculous.
But this near-miracle has not touched the lives of most of those who most desperately need it. For Africans and others in resource-poor countries with AIDS and HIV, that near-miracle is out of reach. For them, the implications of the epidemic remain as fearsome as ever.
This is not because the drugs are prohibitively expensive to produce. They are not. Recent experience in India, Thailand and Brazil has shown that most of the critical drugs can be produced at costs that put them realistically within reach of the resource-poor world. The primary reason why the drugs are out of reach to the developing world is twofold.
On the one hand, drug-pricing structures imposed by the manufacturers make the drugs unaffordably expensive.
On the other, the international patent and trade regime at present seeks to choke off any large-scale attempt to produce and market the drugs at affordable levels.
Of all the walls dividing people in the AIDS epidemic, the gap between the rich and the poor is most pervasive and pernicious. It is this divide that threatens to swallow up 25 million people in Africa.
I speak of the gap not as an observer or as a commentator, but with intimate personal knowledge. I am an African, proudly an African. I am living with AIDS. I therefore count as one amongst the forbidding statistics of AIDS in Africa, including the fact that nearly five million South Africans have the virus.
I speak also of the dread effects of AIDS not as an onlooker. Nearly three years ago, more than 12 years after I had become seropositive, I fell severely ill with the symptomatic effects of HIV. Fortunately for me, I had access to good medical care. With relatively minor adjustments, I have been privileged to lead a vigorous, healthy and productive life. I am able to do so because, twice a day, I take two tablets--one containing a combination of AZT (zidovudine) and 3TC, and the other Nevirapine (Viramune). I can take these tablets because, on the salary of a judge, I am able to afford them.
If, without combination therapy, the mean survival time for a well-tended male in his mid-40s after onset of full AIDS is 30-36 months, I should be dead by approximately now. Instead, I am more healthy, more vigorous, more energetic and more full of purposeful joy than at any stage in my life.
In this I exist as a living embodiment of the iniquity of drug availability and access in Africa. This is not because, in an epidemic in which the heaviest burdens of infection and disease are borne by women, I am male; nor because, on a continent in which the virus transmission has been heterosexual, I am proudly gay; nor even because, in a history fraught with racial injustice, I was born white. My presence here embodies the injustices of AIDS in Africa because, on a continent in which 290 million Africans survive on less than US$1 a day, I can afford monthly medication costs of approximately US$400 per month.
Amidst the poverty of Africa, I stand before you because I am able to purchase health and vigor. I am here because I can pay for life itself.
To me this seems a shocking and monstrous iniquity of very considerable proportions--that, simply because of relative affluence, I should be living when others have died; that I should remain fit and healthy when illness and death beset millions of others.
Surely our most urgent challenge must be to find constructive ways of bringing these life-saving drugs to the millions of people whose lives and well-being can be spared by them.
Instead of continuing to accept that AIDS is of necessity a disease of debility and death, our overriding and immediate commitment should be to find ways to make accessible for the poor what is within reach of the affluent.
Yet, in recent years, international agencies, national governments, and especially those who have primary power to remedy the iniquity--the international drug companies--have failed us in the quest for accessible treatment.
At the launch of the International Partnership Against AIDS in Africa in December 1999, UN Secretary-General Kofi Annan acknowledged that the scale of the crisis required "a comprehensive and coordinated strategy" between governments, intergovernmental bodies, community groups, science and private corporations.
Since then, in South Africa alone, every day 1,700 people have become newly infected with HIV.
In that time, to its credit, the World Bank has made the search for an AIDS vaccine one of its priorities; President Clinton has issued an executive order that somewhat loosens the patent and trade strangleholds around the necks of African governments; and UNAIDS has begun what it describes as "a new dialogue" with five of the biggest pharmaceutical companies, "to find ways to broaden access to care and treatment."
All these efforts are indisputably commendable. But they fail to command the urgency and sense of purpose appropriate to an emergency room where a patient is dying. The analogy is understated--for the patients who are dying number in their tens of millions. For each of them, and for all their families and loved ones, the emergency is dire and immediate. What is more, the treatment that can save them exists. What is needed is only that it be made accessible to them.
Poverty excludes millions from access to appropriate treatment
Amidst all these initiatives, the critical question remains drug pricing. No one denies that drug prices are only one among many obstacles to access in poor countries. But there are many, many persons in the resource-poor world for whom prices on their own are, right now, the sole impediment to health and well-being. A significant number of Africans with access to health care could pay modest amounts for the drugs now. Lowering drug prices immediately should therefore be an urgent and overriding priority.
In America, brave activists changed the course of presidential politics by challenging Vice President Gore's stand on drug pricing and trade protection. Their actions paved the way for subsequent revisions of President Clinton's approach to the drug-pricing issue.
In my own country, a small and under-resourced group of activists in the Treatment Action Campaign has emerged. In the face of isolation and hostility, they have succeeded in re-ordering our national debate about AIDS. And they have focused national attention on the imperative issues of poverty, collective action and drug access.
In the last years of his life, Jonathan Mann began speaking with increasing passion about the moral imperatives to action that challenge us all. He called for people to place themselves "squarely on the side of those who intervene in the present, because they believe that the future can be different."
That is our true challenge: to make the future different. By our action and resolutions and collective will, we can make the future different for many millions of people with AIDS and HIV for whom the present offers only illness and death.
We must demand of the drug companies urgent and immediate price reductions for resource-poor countries. We must also challenge them to permit without delay parallel imports and the manufacture under license of drugs for which they hold the patents.
Collectively and individually we can address the governments and intergovernmental organizations of the world, demanding a plan of crisis intervention that will see treatments provided under managed conditions to those who most need them.
Moral dilemmas are all too easy to analyze in retrospect. Many books have been written about how ordinary Germans could have tolerated the moral iniquity that was Nazism; or how white South Africans could have countenanced the evils that apartheid inflicted, to their benefit, on the majority of their fellows.
Yet the position of people living with AIDS or HIV in Africa and other resource-poor countries poses a comparable moral dilemma for the developed world today.
Those of us who live affluent lives, well attended by medical care and treatment, should not ask how Germans or white South Africans could tolerate living in proximity to moral evil. We do so ourselves today, in proximity to the impending illness and death of many millions of people with AIDS. This will happen unless we change the present government ineptitude and corporate blocking. Available treatments are denied to those who need them for the sake of aggregating corporate wealth for shareholders who by African standards are already unimaginably affluent. This cannot be right, and it cannot be allowed to continue.
The world has become a single sphere, in which communication, finance, trade and travel occur within a single entity. How we live our lives affects how others live theirs. We cannot wall off the plight of those whose lives are so close to our own.
Justice Edwin Cameron is a judge of the High Court of South Africa, Johannesburg. This is an edited version of the first Jonathan Mann Memorial Lecture, given by Justice Cameron at the 13th International AIDS Conference, Durban, South Africa, on July 10, 2000.
