[Marxism] In AIDS Fight, Ambitious Goals Meet Hard Realities

Walter Lippmann walterlx at earthlink.net
Thu Jul 1 07:34:14 MDT 2004

(Cuba continues to have the lowest HIV-AIDS rate in
the entire world, a fact not mentioned here by the
Wall Street Journal, a publication which detests Cuba
and its Revolutionary goverment. In most news stories
on this topic we often read about how there aren't any
statistics with which to compare Cuba to the rest of
the Caribbean where AIDS is a raging epidemic and
so this is a particularly important broad survey of the
current international reality in the fight against AIDS.

(Keep this in mind as you contemplate the Bush regime
and its assault on the Latin American School of Medicine
with its scholarship program for US medical students.

("One reason the Global Fund needs so much money 
is that it's expensive to shore up health systems that 
are short of trained medical personnel. For example, 
thousands of South African nurses desperately needed 
at home to deal with a rising tide of AIDS patients have 
been wooed away by the higher pay in England. 
Mozambique is considering importing doctors from 
Brazil, India and Cuba.")

Walter Lippmann

July 1, 2004 
Viral Strain
In AIDS Fight,
Ambitious Goals
Meet Hard Realities

Millions of Ill in Poor Nations
Fail to Get Drugs as Funds,
Medical Systems Fall Short
Attention Shifts to Terror
July 1, 2004; Page A1

Four years ago, the United Nations, governments of wealthy countries and major foundations committed for the first time to bring drugs to the millions of AIDS sufferers in poor countries. No longer, it was declared, would the life-saving medications proven effective in the mid-1990s be restricted to rich nations that could afford to spend thousands of dollars a year per person.

Today, however, the major global programs are falling short -- either in getting funding, reaching treatment targets, or both. According to the World Health Organization, more than 93% of the six million AIDS patients in the developing world who urgently need drugs aren't getting them.

As many as 40 million more people world-wide have the virus that causes AIDS, a number that rose by an estimated five million last year. Controlling the epidemic will be the top issue at the International AIDS Conference in Bangkok starting July 11.

There are two major campaigns against AIDS. One is the Global Fund to Fight AIDS, Tuberculosis and Malaria, a brainchild of U.N. Secretary General Kofi Annan. He originally envisioned the fund as a $10 billion-a-year effort. But its executive director now says pledges look likely to peak at about $3 billion a year in 2008, of which a little more than half will be spent on AIDS. He says that's not enough to stem the tide of the disease.

In the U.S., meanwhile, President Bush pledged $15 billion over five years for AIDS and related programs overseas in his State of the Union address in 2003. So far, the U.S. is close to being on track to meet its funding commitment, but far from its goal of treating two million people by 2008. Mr. Bush's global AIDS coordinator, Randall Tobias, says 200,000 people will have received the drugs by next year under its programs. One reason for the slow progress, according to critics: The Bush administration is blocking access to cheaper versions of AIDS drugs and insisting on rules that favor big pharmaceutical companies. The administration says it's opening the door to cheaper drugs but wants to ensure their safety.

The U.S. isn't the only target of criticism. Many European governments are giving less to the AIDS cause than the U.S. relative to the size of their economies. Amid the fight against terrorism, AIDS has lost the status it held four years ago as the compelling global issue of the day.

The World Health Organization, which provides on-the-ground support for many AIDS programs, said last December that it hopes three million people will be receiving AIDS drugs in the developing world by the end of 2005. The current figure is less than one-sixth of that. "In my heart of hearts, I worry we won't make it," says Charles Gilks, a WHO official, noting the challenge of distributing drugs in remote places and training thousands of doctors and nurses.

To be sure, the programs now under way will vastly multiply the number of people in Africa and other poor regions getting drug treatment, and officials both in the U.S. and abroad say they hold out hope of reaching their targets. Mr. Tobias asserts that the U.S. plan is off to a "fast start" and adds: "I think we're building some momentum, and I'm very confident."

Although cocktails of AIDS drugs were shown to prolong life in 1996, at first there wasn't any major attempt to distribute the drugs in poor countries. In the absence of drug-company discount programs or generic drugs, it cost about $10,000 to treat a patient for one year -- far too much for governments or charities to pay. It was also widely believed that health-care systems in poor countries would have difficulty getting reliable supplies of the drugs and teaching people how to take them.

A turning point came in June 2000 at the World AIDS Conference in South Africa. Nelson Mandela declared that AIDS on his continent was "claiming more lives than the sum total of all wars, famines and floods." World leaders and the media began to take notice of AIDS's enormous toll.

A call by Mr. Annan, the U.N. secretary general, for $10 billion a year to fight AIDS, tuberculosis and malaria developed into the Global Fund. It was set up in January 2002.

Despite its origins, the fund isn't part of the U.N. It is financed largely by direct contributions from Western governments as well as private donors such as the Bill and Melinda Gates Foundation. Rather than directly giving sick people medicine, the fund receives proposals for grants from individual countries and awards money to them if a panel of experts thinks the proposals are workable.

In 2004, more than 80 countries sought a total of $2.8 billion from the Global Fund, of which $968 million was approved. Since donor countries committed $1.5 billion for 2004, there was more than enough money this year to pay for every proposal judged workable.

Some facts on AIDS as of the end of 2003:
People infected with AIDS virus: 34 million to 46 million
People newly infected in 2003: 4.2 million to 5.8 million
Deaths from AIDS in 2003: 2.5 million to 3.5 million
Worst-hit region: Sub-Saharan Africa, about 60% of total cases
Percentage of sub-Saharan Africans with HIV: 8%
Percentage of North Americans with HIV: 0.6%

Source: World Health Organization estimates
But next year looks tougher. The fund has long planned for a major ramp-up in 2005 and beyond, so that it can fund new programs while continuing to give drugs to AIDS patients who started treatment in earlier years. (The drugs must be taken for life.) Based on its analysis of likely grant proposals, it believes that it could put $3.3 billion to good use in 2005. But donors have made pledges so far of only $900 million.

To stem the AIDS epidemic, the Global Fund believes it needs to raise -- and pay out -- $7 billion to $8 billion a year from 2007 onward. But the fund's projections suggest that contributions at their peak will reach only $3 billion per year. The fund has made "extremely rapid progress in the right direction," says its executive director, Richard Feacham. "On the other hand, it's nothing like enough."

One reason for the shortfall is that many donor nations only commit funds year by year. Some, such as France, have agreed to give as much in 2005 as they did this year. But that leaves the fund far short of the goals set in 2000-01 when the world's attention was focused on the AIDS crisis.

Overall, many wealthy nations gave less to the global AIDS fight in 2003 than the U.S. when donations are considered relative to the size of each nation's economy, according to the Kaiser Family Foundation, a Menlo Park, Calif., health-care research group. By this measure, France committed half as much as the U.S. and Japan about a third, says the foundation.

Meeting fund-raising goals isn't the only problem for the Global Fund. Finding worthy recipients is a challenge too, since the fund can only give money to countries that write workable proposals -- a difficult task for poorer countries.

Kenya, home to 2.5 million patients infected with HIV and some 900,000 AIDS orphans, asked this year for $92 million from the Global Fund to pay for antiviral drugs. It was turned down because the "use of funds wasn't clearly stated," says a person familiar with the decision. The fund's technical experts found similar faults in proposals from some other hard-hit countries, including Nigeria, South Africa and Zimbabwe, and these proposals were also rejected.

Still, the fund encourages most of the rejectees to try again and advises them about the details needed for a successful proposal, such as who will distribute the drugs and how many doctors and nurses are available to prescribe them. Officials are confident that over time many countries will figure out how to devise proposals -- and programs -- that work. Countries hit hard by AIDS "are falling over themselves to get going and every day we lose is unnecessary," says Stephen Lewis, the U.N.'s special envoy for AIDS in Africa.

Evidence to date suggests that even very poor countries can use the Global Fund's money effectively to deliver drugs to AIDS patients. For example, Honduras has put 40% more patients on AIDS drugs than it originally targeted when it got a Global Fund grant in 2003, according to a fund-raising official for the fund. Haiti exceeded its goal of treating 1,200 patients by 67%, even though it was in the midst of a civil war. Audits of the fund's first 25 recipients showed that only five were failing so badly that they were at risk of losing their grants.

One reason the Global Fund needs so much money is that it's expensive to shore up health systems that are short of trained medical personnel. For example, thousands of South African nurses desperately needed at home to deal with a rising tide of AIDS patients have been wooed away by the higher pay in England. Mozambique is considering importing doctors from Brazil, India and Cuba.

South Africa's North West Province recently advertised for a doctor to run the HIV/AIDS program in Taung hospital, located about 125 miles from the provincial capital. But no one applied for the job because, says health department official Calvinia Sebekedi, "people wouldn't like to work in this remote area."

The Global Fund's struggles are playing out alongside the other big effort in global AIDS: the Bush administration's $15 billion, five-year commitment.

The Bush plan, which includes small amounts for tuberculosis and malaria programs, officially got started in the fiscal year that began in October 2003. Mr. Bush proposed spending $2 billion for the fiscal year and Congress raised the amount to $2.4 billion. While $547 million of that went to the Global Fund, most is going to America's own programs. For the fiscal year beginning this October, Mr. Bush has proposed spending $2.8 billion and Congress is expected to approve that amount.

In order to meet Mr. Bush's $15 billion pledge, the U.S. will have to boost spending to more than $3 billion a year for each of the plan's final three years. Mr. Tobias, the U.S. global AIDS coordinator, and a former Eli Lilly & Co. executive, says the acceleration in spending is exactly what was planned from the beginning. Starting with smaller amounts allows aid recipients to prepare facilities and staff, and lets U.S. officials identify the wisest investments, he says.

"Let's be sure we're going to use this money as efficiently and effectively as we possibly can," says Mr. Tobias, adding that he's confident the U.S. will make good on its full $15 billion pledge.

The bigger controversy is over how the money is being spent. Countries and charities that work with Global Fund money have slashed drug costs by using generic copies, even though the original brand-name drugs still enjoy patent protection. AIDS groups have been pushing Washington to let organizations receiving U.S. grants buy two Indian-made drugs that each combine three medications in a single pill. The pills cost as little as a quarter of the price of the three brand-name medicines they are replacing. And patients only have to take two pills a day instead of six.

The World Health Organization has judged the Indian drugs and some other copies as safe and effective under a program that "prequalifies" the drugs for purchase by poor countries and charitable groups. But Washington has prohibited groups that receive U.S. money from buying the copies, insisting that they stick to drugs that are approved by the Food and Drug Administration.

"We've never had any hesitation about buying copy drugs per se. The hesitation is about buying drugs for which there is no evidence of safety and effectiveness," Mr. Tobias says. "A lot of very, very well-intentioned people have taken a very simplistic view -- that we have got to get drugs out there fast without knowing whether they're safe and effective."

In June, Mr. Tobias points out, the WHO removed two copy anti-AIDS drugs from its prequalified list because their maker, Cipla Ltd. of India, hadn't proved they were equivalent to the original drugs. Cipla, which also makes one of the three-in-one pills, says it is redoing tests for the delisted drugs and will submit new documentation to the WHO. Defenders of the WHO say its action demonstrates the rigor of its quality-checking process.

In May, the U.S. said it would set up a fast-track program for makers of generic copies to get the FDA's seal of approval for their safety and quality. U.S. grant recipients for global AIDS programs could then buy drugs from these approved makers. Mr. Tobias says he expects that U.S.-funded groups will be able to buy copy drugs "fairly quickly," provided that manufacturers apply. Until that happens, though, grant recipients such as Catholic Relief Services and the Elizabeth Glaser Pediatric AIDS Foundation must buy brand-name drugs.

Write to Gautam Naik at gautam.naik at wsj.com3, Mark Schoofs at mark.schoofs at wsj.com4 and Sarah Lueck at sarah.lueck at wsj.com5 


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