AN EPIDEMIC OF INACTION
The Washington Post
Last of two parts
RIVALS RESENTED a scientist's early push to fight AIDS. Testing for HIV in the developing world, some authorities said, would create a demand for futile treatment. And agencies and governments failed the `30 million white people test' in their response to Africa's crisis.
Early in 1986, the World Health Organization in Geneva still regarded AIDS as an ailment of the promiscuous few.
WHO director Halfdan Mahler enraged Peter Piot, who had been researching AIDS since 1983, with a casual suggestion that other diseases were far more important than AIDS.
Fakhry Assaad, Mahler's chief of infectious diseases, was beginning to disagree. He knew Jonathan Mann's research on AIDS at the U.S. Centers for Disease Control (CDC) and in November, brought Mann to Geneva.
In a two-hour conversation, the charismatic American upended Mahler's view of the world.
AIDS was not merely another infectious disease, Mann argued. It seemed to flourish in - and reinforce - conditions of poverty, oppression, urban migration and social violence. It therefore could not be solved as a biomedical problem. Women who feared a beating would not ask their husbands to use condoms. Street children and widows without rights of inheritance could not reduce the number of their sexual partners, because they depended on sex for subsistence.
In a September 1998 interview before his death in the crash of Swissair Flight 111, Mann said discrimination "isn't just an effect, it's actually a root cause of the epidemic itself."
Ambitious start, then failure
Mahler said he was transformed by his 1986 meeting with Mann. He put Mann in charge of a special program on AIDS that bypassed WHO's chain of command. Mann's operation grew headlong from a single room to one of the organization's biggest programs.
But resentments in the WHO secretariat began to surface after Mahler retired in 1988. His replacement, Hiroshi Nakajima, shared general displeasure at Mann's privileged status and unorthodox style.
Nakajima reportedly considered malaria to be a greater killer. And for a time, it was. But AIDS was growing exponentially; malaria was not.
Institutional rivals of the AIDS program told Nakajima that Mann's program was excessive, said WHO senior manager Marjory Dam. Nakajima set out to cut its resources.
After run-ins with Nakajima, Mann found himself excluded from meetings. The legal authority to spend his budget sat unsigned on Nakajima's desk. His travel requests were denied, anonymously and without explanation, or granted too late to matter.
On March 16, 1990, Mann told his staff he was quitting.
Nakajima, now retired, did not return telephone calls seeking an interview for this article.
Protecting their resources
By 1990, the sense of urgency about AIDS in wealthy nations had also started to dissipate. "In the '90s it became clear we were not going to have a major heterosexual epidemic in the States," said Michael Merson, who would succeed Mann at the WHO program.
The WHO was not the only agency trying to protect its resources from the demands of AIDS. Most major contributors to global health and development followed the pattern.
Throughout the early and mid-1990s, the Clinton administration debated the merits of paying for AIDS testing and counseling of vulnerable populations overseas. Among gay men in the United States, such programs had been credited with causing substantial change in risky behavior - increasing condom use and marginalizing the culture of promiscuous "bathhouse" sex.
The CDC and U.S. Agency for International Development (USAID) held out for years against paying for AIDS tests overseas.
"The argument was that testing was too expensive, and it led to things that were more expensive," said Gregory Pappas, a physician and Health and Human Services official who took part in the debate.
"The philosophy in development circles was, don't create demand," Pappas said. "The implications of a lot of people knowing that they have HIV, instead of just dying of it, is (that) it creates demands on the development assistance agencies. It's a calculation that they're trying to postpone paying for interventions that they don't think they can afford."
Beaten down by years of congressional attacks on foreign assistance - and on family planning especially - USAID did not propose budget increases to contend with AIDS.
Duff Gillespie, who oversaw AIDS assistance as director of USAID's programs on population, health and nutrition, explained the AIDS-funding problems: When decision makers divided their available funds for foreign aid, he wrote, the AIDS pandemic had many disadvantages. There was no tool available that "directly and invariably" prevents transmission. There was no cure. Costs of AIDS programs were high, and the afflicted populations often lacked "an inherently sympathetic `victim.' "
Nor, in the view of Gillespie and many other foreign-aid professionals in the 1990s, were AIDS interventions cost-effective. To save the life of a dehydrating child with diarrheal disease required little more than a foil packet of salts. Antibiotics cured an otherwise fatal case of tuberculosis.
What USAID and other agencies craved were programs that would demonstrate efficacy in congressional audits.
What's a life in Africa worth?
By the middle 1990s, two new trends took shape. In wealthy nations, effective drug therapies against AIDS became available - AZT as early as 1987, then combinations of antiretroviral agents in 1996.
The drugs gave authorities their first plausible lifeline to AIDS victims overseas. But they also led the developed world to believe that it would escape the pandemic without grave effects.
Now the wealthy nations had to decide what they thought a life saved in Africa was worth.
Policymakers did not contemplate attempts to bring the expensive new drug cocktails to Africa, in part because of the pharmaceutical cost and in part because most of the continent lacked the health-care apparatus to dispense them.
"Transplantation of Northern interventions to the South," Gillespie wrote, would "siphon off resources" with "limited or no impact on the course of the pandemic."
`Syndrome of abdication'
Meanwhile, Mann's departure from the WHO had not halted the AIDS program's slide. Mike Merson was as frustrated as his predecessor.
In Geneva, epic struggles were under way to control the bureaucratic turf around AIDS. The U.N. Development Program, in particular, attacked Merson's program as hopelessly focused on biomedical needs, ignoring the roots of AIDS in underdevelopment.
In 1994, donor governments began pushing for creation of a joint U.N. AIDS program. After two years of further acrimony over control, UNAIDS was established. Its ostensible partners cut back sharply on resources and personnel they devoted to AIDS. World Bank loans dropped from $50 million to less than $10 million, WHO spending dropped from $130 million to $20 million, UNICEF from $45 million to $10 million, and so on.
Inside UNAIDS, advisers to Peter Piot - the Belgian virologist, who had become its first director - were speaking of a "syndrome of abdication."
Summer 1998 brought a new director to WHO, former Norwegian prime minister Gro Harlem Brundtland. In speeches and reports, she emphasized tobacco and tuberculosis and seldom mentioned AIDS.
Last year, HIV/AIDS reached a long-expected milestone in the WHO's surveillance of disease and death: It surpassed all other causes of death in Africa. That fact was mentioned nowhere in Brundtland's 1999 World Health Report.
Today, in a secretariat of 2,000, the WHO has nine professionals who work full time on AIDS.
`30 million white people test'
In the wealthy nations, many AIDS authorities suspect, the place of Africa at the center of the pandemic accentuated skepticism or muffled the response. In and out of Africa, it is seldom possible to discuss the matter without touching the question of race.
James Love, an authority on global drug markets, imagines a "30 million white people test" by which to measure the urgency of the wealthy nations. "You'd move," he said, "kind of like it was an emergency."
UNAIDS chief Piot said he has no doubt that "if this would have happened . . . with white people, the reaction would have been different."
A belated awakening
In January, the CIA updated its AIDS projections. This report resulted from, and intensified, a sudden urgency in the Clinton administration to act. No import ant feature of the epidemic had been discovered in a decade. What mobilized the government, after seven years of modest effort, has been difficult for its policymakers to identify.
Global AIDS has reached a moment of unaccustomed prominence. Heads of state speak its name, and Piot - once unable to publish his study of the early epidemic in Kinshasa, Zaire, in professional journals - is now the subject of admiring notice in Vanity Fair. Pharmaceutical companies are deep in talks with African governments over discounts they may offer for HIV drugs.
The Clinton administration, which added $200 million to global AIDS prevention last year, is preparing proposals to add an additional $250 million, according to knowledgeable officials. Half a dozen proposals in Congress, representing Republicans and Democrats both, contemplate still higher spending.
Will the belated awakening bring real change? The answer, said many AIDS experts, depends in part on abandonment of the quest for what Merson - now dean of public health at Yale - calls "a magic bullet."
Governments in Africa and elsewhere repeatedly have pinned their hopes on a technical fix for AIDS - a vaccine, or a natural plateau in infections, or an effective pharmaceutical cure - that would enable them to sidestep more painful measures.
But among experts, there is a near-consensus that combating the disease requires governments to deal with controversies of sex, injected drugs and other taboos. It also requires costly change in economies and national cultures.
"We know what works," said Piot, who has spelled out the program in increasing detail since taking his UNAIDS post in 1996. "We know what to do."
What to do
Malegapuru Makgoba, president of South Africa's Medical Research Council, says Africans must take first responsibility. "I am tired of hearing that the international community is slow when governments on this continent are irresponsible," he said. Even so, nearly every authority believes those governments need outside help.
A multibillion-dollar prevention program in sub-Saharan Africa, according to plans now under preparation by the White House, World Bank, USAID and UNAIDS, would include hundreds of millions of dollars in youth-focused education, intensive counseling of sex workers, provision and "social marketing" of condoms and much more aggressive treatment of lesser venereal diseases, which speed transmission of AIDS.
Other programs would provide low-cost drugs to slow transmission of the virus in childbirth, blood testing and improvements in blood-bank quality controls.
Smallpox: cautionary example
A vaccine would, of course, make a difference. But many authorities still regard it as a mirage. Few countries in the developing world have the records, roads, facilities and trained personnel to locate, much less inoculate, all their citizens.
By way of analogy, Daniel Tarantola at the WHO cites a massive effort since the 1970s to inoculate every child against such common killers as measles. "Immunization efforts have been going on 20 years, and you still have countries with 40 or 50 percent coverage."
The world's great vaccination triumph is smallpox. Edward Jenner, the 18th-century Gloucestershire physician, demonstrated in 1796 that a weakened strain of the virus extracted from cows would build immunity in humans.
In time, the smallpox vaccine came into wide use, and a mass killer was expunged from humankind. It was 1979 when the world reached that milestone, 183 years after Jenner solved the problem in his lab.
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