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GLOBAL HEALTHAnswering AIDSHarvard Faculty Shake Status Quo to Treat Poor In a turnaround last month, Senator Jesse Helms called for an additional $500 million in aid to poor countries to prevent transmission of HIV from mother to child. By this and many other indicators, global health is at a watershed, and initiatives of Harvard faculty are at the divide. Appealing to the collective conscience of wealthy nations, they and others are challenging the world to accept that good health is good economics, and that the world--enabled by agreements with multinational pharmaceutical companies to lower drug prices--can no longer allow poor people to die, untreated, of AIDS, TB, and other infectious diseases that account for 90 percent of mortality in the developing world. In areas hard hit by HIV/AIDS, the social and economic fabric is rending: factories in South Africa have instigated three-for-one job hiring to ensure replacements as workers die off; 20 percent of the country's nurses are HIV positive; traditional methods of agriculture are not being passed on to orphans (predicted to be a third of African children by 2010).
Jim Yong Kim (left) and economist Jeffrey Sachs are spearheading a global effort to treat tuberculosis, AIDS, and other infectious diseases in the developing world. Kim photo by Graham Ramsay. Sachs photo by Jon Chase, Harvard University News Office "The response to HIV in poor countries has been based on prevention alone, and it's just not working well enough," said Jim Yong Kim, an HMS assistant professor of medical anthropology and cofounder of Partners in Health; he oversees a multidrug-resistant tuberculosis (MDR-TB) treatment center in the shantytowns of Lima, Peru. Though there are many examples of successful prevention, such as the education programs among sex workers in areas of India and Thailand and the steep decline in new AIDS cases in Uganda, and there are many who advocate expanding prevention, current control methods have been unable to stop the runaway HIV/AIDS pandemic. In a recent symposium at HMS, Jeffrey Sachs, director of the Harvard Center for International Development, expressed dismay with the lack of antiretroviral therapy from official donor-supported programs. He said the world's response to the HIV pandemic, already affecting 60 million people, has been to "distribute condoms and put up billboards." Efforts have backfired in parts of sub-Saharan Africa, where many patients have become hostile to humanitarian organizations offering only these services. Kim, who recently became chief of the division of social medicine and health inequality at Brigham and Women's, and Partners in Health cofounder Paul Farmer, HMS professor in the Department of Social Medicine, have had a different experience. In Peru and rural Haiti, where the organization delivers antiretroviral treatment to AIDS patients, they find that treatment is an important tool for enhancing prevention. With a skeleton staff of medical personnel and local residents trained as health care promoters, they oversee complex drug regimens with directly observed treatment. After three years in Haiti, they saw viral suppression in 84 percent of their patients. And the number of people who came forward for testing and counseling "skyrocketed." "Throughout the world, communities like ours are desperately seeking medications," said Kim in testimony to the U.S. Senate. "All that remains is marshaling the political will and funding." Affordable DrugsUntil recently, the debate to treat or not to treat was moot, sometimes even in the health care community. The high price of antiretrovirals and "second-line" antibiotics against MDR-TB, each totaling $10 to 15 thousand per year per person, coupled with a dearth of funds, prohibited distribution in all but a handful of privately run programs. In the early 1990s, the WHO established its essential drugs program to stimulate production of quality generic drugs. During the 1980s and '90s, the price of first-line TB drugs fell precipitously, and under the leadership of the WHO, high-quality TB control programs expanded rapidly. Yet, citing limited resources, the WHO did not respond at first to the emergence of MDR-TB. The successes of the programs in Peru and Haiti, however, compelled a reevaluation. In 1999, working with Médecins Sans Frontières, Partners in Health, and others, the WHO arranged to have second-line TB drugs added to the essential drugs list and established the Green Light Committee to oversee dispensation. As principal buyer for developing nations, the committee guaranteed the generic pharmaceutical industry a market, causing second-line drug prices to fall by as much as 95 percent. An inexpensive antiretroviral drug market also seems assured. "That's almost a done deal," said Kim. Indeed, the WHO just released its first list of safe AIDS drugs, including several produced by generic manufacturers. Now that cheaper drugs are available, there have been renewed appeals to treat the poor who are suffering from AIDS and other infectious diseases in the developing world. Recent economic reckoning adds weight to their arguments. A report to the U.N. by the Commission for Macroeconomics and Health, chaired by Sachs, who is also the Galen L. Stone professor of international trade at Harvard, goes through a detailed cost analysis and puts an annual price tag of $8 billion to fight AIDS, TB, and malaria globally. The report provides data linking poor health to poverty and cites evidence gathered by the CIA showing a strong association between infant mortality and political unrest. As a whole, the report stands as an economic handbook for reform. Kim concludes that withholding money while medicines are available is not only morally repugnant, but it contributes to a downward spiral of poverty, violence, and chaos. The Health Sector's Fair ShareIn contrast to the $8 billion-a-year estimate to combat the world's deadliest infectious diseases, agricultural subsidies cost wealthy nations about $1 billion a day. Meanwhile, with current funding, international health organizations struggle to allocate limited resources. When the Bill and Melinda Gates Foundation entered the global health arena (including support for HSPH and HMS), it caused a sensation. "They gave $750 million for vaccines back in 1999, and the health care community was elated," said Kim. "Then Sachs said, 'Why are you guys so amazed? That's nothing compared to what the rich world could give.'" In Monterrey, Mexico, last month, at the International Conference on Financing for Development, President Bush pledged to boost foreign aid to $15 billion by 2006, an increase of 50 percent. This nudges the fraction of GNP going to foreign aid up to 0.13 percent, still far below the 0.7 percent U.N. target and not enough to raise the U.S. from what Sachs calls the "benchmark at the bottom of the world's donors." The administration is taking a "wait and see" approach. Treasury Secretary Paul O'Neill provoked an outcry by insisting that development organizations have "precious little" to show for a decades-long trillion-dollar spending spree. "It sounds terrible," Kim said, "but he has a point." Recipient government mismanagement and graft, sometimes carried out by leaders supported by first-world governments, coupled with conflicted goals of donors such as the International Monetary Fund and the World Bank, have led to poor outcomes despite huge expenditures. With the recent establishment of the United Nations Global Fund to Fight AIDS, TB and Malaria (GFATM), the possibility for dramatically expanded funding for health in developing countries is more real than ever before. Yet, unless GFATM recipients use the funds effectively for prevention and treatment, donors will lose interest, and the fund will be short-lived. Strict oversight by U.N. agencies and the GFATM of specific target programs will ensure that good health for the poor is the top priority. According to Kim, it's a matter of political will to make sure recipient governments cooperate: "We've leveraged entire countries to elect the president we want. We can do the same for health." --Anne Mahon |
