International Socialist Review, September–October 2002

Elizabeth Terzakis

The global AIDS crisis

From International Socialist Review, Issue 25, September–October 2002.
Downloaded with thanks from the ISR Archive.
Marked up by Einde O’Callaghan for the ETOL.

A SIMPLE truth came to light at the Fourteenth International AIDS Conference, held July 2002 in Barcelona, Spain: The main impediment to the fight against the global AIDS crisis is a lack of funds–more precisely, a lack of willingness to provide them. When United Nations (UN) Secretary General Kofi Anan launched the Global Fund to Fight AIDS, Tuberculosis, and Malaria in 2001, he called on world governments to ante up $10 billion. To date, the fund holds less than $2 billion.1 As one might expect, AIDS activists covered the Barcelona conference site with bright orange stickers demanding, “Where is the $10 billion?” They also shut down United States Health and Human Services Secretary Tommy Thompson when he tried to defend the Bush administration’s meager contribution to the fund.2

But the $10 billion question was being asked from the front of the room as well. In the opening plenary session of the conference, Dr. Bernhard Schwartländer, Director of HIV/AIDS at the World Health Organization (WHO), noted that there will be another 45 million people living with HIV/AIDS by 2010 unless world governments deliver on financial commitments made to the UN. “However, if countries, rich and poor, live up to the commitments they made 29 million of these infections or more than 60 percent could be averted. Delaying this response by just one year is going to cost another 5 million lives.”3

State of the crisis

Schwartländer did not pull this figure out of a hat: Five million is the number of people newly infected with HIV in 2001, bringing the total number of those infected to over 40 million people. More than 95 percent of new infections occur in developing countries, and 28.5 million of those infected live in sub-Saharan Africa.4 Sixteen sub-Saharan African countries have infection rates of over 10 percent, and seven of those countries have adult infection rates of over 20 percent.5

The Joint United Nations Program on HIV/AIDS (UNAIDS) has stopped keeping statistics for cumulative AIDS deaths, due to the impossibility of ensuring accuracy. The agency does report that three million people died of AIDS in 2001, and estimates that more than 20 million people have died of AIDS worldwide since the start of the epidemic. Around 13 million of these deaths occurred in sub-Saharan Africa, where they have had a ripple effect of suffering and destruction, creating 11 million orphans (out of a world total of 14 million AIDS orphans), and cutting life expectancy drastically. In Botswana, life expectancy hovers just above 35 years, down from a high of 62 in 1985.6 AIDS, like war, kills people at the prime of life, leaving behind only the very old and the very young. As a result, whole societies and cultures are being destroyed.

Though Africa has been the hardest hit, AIDS has been permitted to ravage other areas of the world as well. In the Asia-Pacific region as a whole, more than 6 million people are infected with HIV, with one million new infections in 2001 alone.7 Earlier this year, the Chinese government released a report estimating that there are 850,000 HIV-positive individuals in China, a 40 percent increase from their 2001 estimate.8 Elsewhere in Asia, the numbers are similarly devastating: In India, 3.97 million people are living with HIV/AIDS.9 In Thailand, AIDS is the leading cause of death, with an estimated one million of Thailand’s 60 million people infected with HIV.10

In Latin America and the Caribbean, 1.9 million people are infected, with prevalence rates in Haiti and the Bahamas the highest outside of sub-Saharan Africa, at 6 and 4 percent respectively. High rates of poverty and unemployment are driving the epidemic’s growth in Central America. In Mexico, while the overall adult prevalence rate is still quite low (under 1 percent), socially marginalized groups like intravenous drug users and gay men experience much higher rates–6 percent for injecting drug users and 15 percent for gay men.11

Europe is not immune to the crisis: HIV cases have been doubling annually in Russia since 1998, and HIV incidence is rising faster in Eastern Europe than anywhere else in the world. In Western Europe, an estimated 6,800 people died of the disease in 2001 and another 560,000 became infected.12

Here in the United States, AIDS is the fifth leading cause of death among people aged 25 to 44, the third leading cause of death for 25-to-44-year-old Black women, and the leading cause of death for Black men in this age group. Currently, there are 950,000 people in the U.S. living with AIDS, with 40,000 new cases reported each year. As many as 25 percent of those carrying HIV do not know that they are infected.13

“Where is the $10 billion?”

Though the numbers are staggering in and of themselves, they present only a pale shadow of the lived impact of the epidemic. In And the Band Played On, Randy Shilts chronicles the suffering and death of Ken Horne, the first AIDS patient reported to the Center for Disease Control (CDC) in Atlanta in 1981: “His once-toned dancer’s body had shrunk to 122 pounds, and his fever constantly ran at 102 degrees. He was blind now, too, from the CMV [cytomegalovirus] herpes infections that had wasted his nervous system. His mind also seemed to be going, like that of an old person suffering from dementia.”14

Twenty years later, a woman dies a similarly agonizing death in Zimbabwe:

Beneath a translucent scalp, the plates of Gertrude Dhlamini’s cranium etch a geography of pain. Her illness is obvious in the thin, stretched skin under which veins throb with the shingles that have blinded her left eye and scarred that side of her face. At 39, she looks 70. The agonizing thrush, a kind of fungus, that paralyzed her throat has ebbed enough to enable her to swallow a spoon or two of warm gruel, but most of the nourishment flows away in constant diarrhea.15

If the main obstacle to halting this catastrophe is money, why hasn’t it come?

One way to approach this question is by asking another: Where is the money supposed to come from? While WHO Director Schwartl”nder called on all countries at the Barcelona AIDS conference to pay up, former President Bill Clinton, addressing the final plenary, pointed a finger straight at rich nations like the United States: “Developing nations should figure out what they can pay and send the rest of us the bill for the difference.”16

Clinton’s record on fighting AIDS while president belies his current commitment.17 His last budget as president allocated only $789 million to fighting AIDS.18 In 2000, Clinton’s contribution was an offer of $1 billion import-export loans to 24 African countries at 7 percent interest rates. African governments rejected the loans, rightly suspecting that they would “enrich American and Western drug manufacturers while creating an extra debt burden for African nations.”19 This year, President George W. Bush followed Clinton’s lead by playing shell games with AIDS allocations, redirecting $200 million out of the global fund, making sure that Washington’s contribution to the fund remains at about a tenth of the $2.5 billion that it should be.20

The UN initially requested that the U.S. give $1 billion yearly to the fund; so far this year $450 million has been pledged, of which only $250 million is for 2002. To put this number in perspective, sub-Saharan Africa pays $200 million a week to its creditors. To put it into another kind of perspective, the $1 billion per year that the UN requested is equivalent to U.S. military spending for one day. The U.S. could float the entire fund–$7 billion–from a week’s worth of what it now spends to rain terror and death down on countries like Afghanistan and Iraq.21

And despite its history of paltry contributions, the United States is the world leader when it comes to giving money to fight AIDS. How can this be? Why isn’t more being done?

The answer is simple but runs very deep: The AIDS crisis reveals in the most striking way possible the failure of the world capitalist system to provide for human need. It shows how uninterested capitalism is in preserving, prolonging, or improving human life. The accelerated rate of HIV infection in the developing world and beyond is inextricably tied to the policies of the IMF, the World Bank, and the efforts of the U.S. and other governments to maximize profits. Moreover, the massive increase in inequality that has occurred over the last 20 years as the result of these policies has insured that the impact of AIDS–the level of suffering and death that it causes–is enormously greater than it had to be. The pandemic is one of the most compelling examples ever of why the profit system needs to be abolished.

From the beginning

When AIDS first broke out in the U.S., bigotry and budget cuts ensured that the disease would not get the kind of attention it deserved. The first reports of AIDS among gay men in New York and San Francisco coincided with the introduction of Ronald Reagan’s “family values” agenda, which associated AIDS with deviance and sin. As Reverend Jerry Falwell put it in a 1983 sermon: “AIDS is God’s punishment. The Scripture is clear: We do reap it in our flesh when we violate the laws of God.”22

One practical expression of this homophobia was a willful ignorance on the part of health care agencies and medical journals. Evidence of AIDS outside of the gay community in the United States was ignored, despite the fact that even in the earliest days of the epidemic–before the disease had a name–doctors in poor neighborhoods from Newark, New Jersey to San Francisco’s Tenderloin were treating children with symptoms of immune deficiency.23 Doctors who attempted to demonstrate links between sick children and dying gay men were dismissed and their papers went unpublished by medical journals such as the New England Journal of Medicine. The official line had a distinct impact on diagnoses: Intravenous drug users presenting similar symptoms who died before their sexual preferences could be ascertained “would somehow turn out to be gay in the end,” according to health officials.24

Consequently, bigotry delayed an early identification of the disease as the product of a blood borne agent, as medical officials searched for an “environmental” explanation within the gay subculture, such as a bad batch of poppers (nitrate inhalants) or Crisco (used as a lubricant).25 Racial bigotry also steered scientists away from the conclusion that AIDS could be heterosexually transmitted; when they finally accepted that the Haitian immigrants showing up at New York hospitals with a rare brain infection were not gay, it was offered instead that they had contracted the disease through voodoo.26

Budget cuts–due to the rigid limits placed on all nonmilitary spending by the Reagan administration–also played a part in preventing any kind of early, concerted strategy against the disease. Concerned physicians volunteered time and diverted resources to track the new disease with little or no support from the National Institutes of Health (NIH), one of the richer institutions of the United States medical research establishment. Even at the CDC, a case-control study of the new disease languished because of a lack of funds.27

Bigotry and budget concerns still determine the way the AIDS crisis is framed by most politicians and policy makers. Now that AIDS is ravaging whole populations, it is harder to portray the disease as a scourge on homosexuals; 48 percent of adults now living with AIDS are women, and 80 percent of all adult HIV infections resulted from heterosexual intercourse.28 However, the pundits still blame the victim whenever possible. Even though treatments now exist that reduce the transmissibility of the virus and allow the infected to live somewhat normal lives, the crisis is painted as the result of an incontrovertibly fatal virus combined with obstinate, backwards, or just plain careless people who refuse to refrain from “high risk” behaviors. The solution, according to the solemn pronouncements of people like President-select George W. Bush and his flunkies is simple: If people would just stop having sex and shooting up drugs, the crisis would disappear.

It is chilling to think that 20 years ago, when the number of AIDS cases was around 1,000, with a 50 percent fatality rate, politicians were saying the same things, and doing just as little.

The dying don’t matter

The current scale of the crisis did not come as a surprise to the U.S. ruling class. In the late 1980s, “national intelligence officer at large” Katherine Hall spent three years lobbying her superiors at the CIA for permission to study AIDS. Finally, in July of 1991, the CIA distributed Interagency Intelligence Memorandum 91-10005 through classified channels. The report was titled simply, “The Global AIDS Disaster,” and it projected 45 million fatal HIV infections by the year 2000, the great majority in Africa.29

James Sherry, director of program development for UNAIDS, described the response to the unfolding AIDS crisis as follows: “I can’t think of the coming of any event which was more heralded to less effectÖ. The bottom line is, the people who are dying from AIDS don’t matter in this world.” As a result of this admitted indifference, when the U.S. submitted its first budget after the memo, it allocated a mere $124.5 million to fighting AIDS overseas.30

Other agencies didn’t do much better. To open the ninth international conference on AIDS in Berlin in 1993, Michael Merson, head of the WHO AIDS program, announced that it would cost $2.5 billion a year to prevent half of the 20 million new infections projected by 2000. Like Schwartl”nder at this year’s conference, Merson didn’t see his request as unreasonable, noting “the world can find this kind of money when it wants to.”31

Apparently, the world didn’t want to. After a brief period of intense commitment to fighting the crisis between 1987 and 1988, the WHO turned its attention to more popular programs, that is, ones that cost less money and showed immediate results, operating under the principle of what one official called “demand management.” Demand management requires that costly problems be ignored lest they create a demand for a solution.

Demand management also governed the actions of the CDC and the U.S. Agency for International Development (USAID). For years, these agencies refused to pay for AIDS tests overseas. They were only willing to pay for tests to track the spread of the disease, and didn’t tell individuals who tested positive that they had AIDS. According to Health and Human Services official Gregory Pappas:

The argument was that testing was too expensive, and it led to things that were more expensive. The philosophy in development circles was, don’t create demand. The implications of a lot of people knowing that they have HIV, instead of just dying of it...creates demands on the development assistance agencies.32

It was also in 1988 that WHO head Hiroshi Nakajima started talking about the need for balance between the rights of AIDS patients and the interests of society at large, opening up the door for discrimination against people with AIDS, like bans on immigration and employment.

It wasn’t until 1996 that the United Nations recognized the inadequacy of international efforts to deal with the global AIDS crisis and established the Joint United Nations Program on HIV/AIDS (UNAIDS). The idea was that organizational differences were preventing the various international agencies from cooperating effectively to fight AIDS. If they could all be convinced to become partners in a new agency, specifically dedicated to fighting AIDS, priorities could be reset and differences could be overcome. However, as soon as UNAIDS was established, its partners cut back on the 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, and so on.33

Prevention versus treatment

Until recently, international efforts to deal with AIDS have focused their very limited funds exclusively on preventing the spread of the virus, rather than treating those already infected. Prevention programs promoting safe sex and condom use among high-risk groups like prostitutes and intravenous drug users have produced substantial reductions in prevalence rates in Thailand, where the infection rate dropped from a high of 140,000 in the early 1990s to 30,000 in 2001.34 Uganda and Senegal have made similar progress with programs that include counseling sex workers, providing condoms, educating youth, and treating venereal diseases that facilitate HIV infection.35

Despite their successes, safe-sex-oriented prevention programs are repeatedly threatened by right-wing efforts to regulate sexuality. The most recent example of this idiocy is President Bush’s refusal to sign a United Nations declaration on children’s rights unless sections encouraging condom use are dropped.36

But even well funded prevention programs have their limits. Sex workers cannot depend on condoms as protection from AIDS if their clients refuse to use them. Condoms are also of little use to women who wish to have children. In fact, according to a 1992 UN report, for most women, the major risk factor for HIV infection is not being a sex worker but being married.37

In addition, unprotected sex and intravenous drug use are not the only ways HIV is transmitted. In the Henan province of China, most HIV infections come from selling blood to collection centers that do not follow basic safety procedures.38 Because of a cultural stigma on giving blood, selling blood is something poor people do to make ends meet. Many sell blood several days a week just to get by. To keep them from collapsing, blood collection centers remove the platelets from the blood of several donors, combine the plasma, and then re-inject it into the donors. When they cannot give any more blood, these blood sellers are likely to become part of the “liudong renkou” the floating population of 100 million unemployed people who travel the country looking for work. In China, it is painfully clear that poverty and corporate carelessness, not individual irresponsibility, are optimizing conditions for the epidemic.39

The prevention-only approach became downright criminal in 1995 when the U.S. Food and Drug Administration approved the first of a new class of AIDS drugs which block an enzyme called protease that the virus needs in order to reproduce. It was found subsequently that “triple therapy,” involving two older drugs and a protease inhibitor, reduced the virus to undetectable levels, greatly improving both quality of life and life expectancy for those lucky enough to get the new drug cocktails. According to then-Health and Human Services Secretary Donna Shalala: “This is some of the most hopeful news in years for people living with AIDS.”40

Unfortunately, these benefits were not available to everyone. If the cost of the new combination therapy denied its benefits to millions of people in the U.S.–initially costing $18,000 a year, down to about $10,000 by 200141–they were completely out of reach for the vast majority of people living in poorer countries.

1995 also marked the creation of the World Trade Organization (WTO) and the elevation of intellectual property rights to sacrosanct status. Even before the WTO was created, the Clinton administration was working to extend patent protections globally, but when the WTO came into being these protections were formalized into a new agreement called Trade Related Aspects of Intellectual Property Rights, or TRIPS.42 Developing countries were not permitted to make or buy unlicensed generic copies of the new drugs. The WTO sought to insure that drug company profits would take precedence over saving lives. So the new drugs did not reach most of those who needed them. As a result, according to Charles Chidoti, a health worker who gives seminars on AIDS in Malawi: “[Health workers] suppress information. I find myself saying nothing about triple-therapy antiretrovirals because I look at the village and think it will be of no benefit to these people.”43

According to Swiss AIDS authority Bernard Hirschel the disparity between developing countries like Malawi and countries like Switzerland is simply outrageous: Antiretrovirals cut AIDS mortality in Switzerland by 84 percent: “Now contrast this with the fact that [most infected people lack] access to such treatment, and that you can produce these drugs and can produce them cheaply. You will then start to understand the urgency and indeed the rage behind the clamor for access.”44

Limited success, limited access

Fortunately, activists were able to turn that rage into victory. In 1997, after South Africa announced its intention to import or manufacture generic AIDS drugs, 39 drug companies sued the government for violating their “intellectual property rights.”45 When the trial opened, AIDS activists responded with huge demonstrations in cities all over the world. In 1999, when then-presidential candidate Al Gore expressed support for trade sanctions against South Africa, AIDS activists in the U.S. dogged him on the campaign trail. Mobilizations in South Africa itself and outraged protests around the world forced the Clinton administration to back down, and the drug companies dropped their suit in 2001.46

As a result, when the WTO met in Qatar in November of that year, it issued a statement that patents would not stand in the way of public health.47 Recently, Zimbabwe took advantage of this rule change and declared a national emergency so that it too can begin manufacturing or buying generic AIDS drugs.48

While turning back the WTO was a big victory, it is important to note that it only goes so far. It does not solve the problem of poverty. By declaring a national emergency, Zimbabwe risks losing international investment–which it will need both to produce the drugs and to distribute them. And the World Bank still regards antiretroviral drugs as not “cost-effective” in the developing world, and discourages borrowers from buying them.49

What’s more, it is important to remember that the generic drug industry is not a charity. It is a for-profit industry. Companies like Cipla in India, which offer to provide antiretrovirals for $350 per person per year,50 claim to be acting on humanitarian impulses. Yusuf Hamied, chief executive of Cipla, told a hearing of European Union representatives and multinational pharmaceutical companies, “I represent the needs and aspirations of the Third World. It is up to you, the international community, to grasp this opportunityÖto alleviate the suffering of millions of our fellow men who are afflicted with HIV and AIDS.”51

In fact, Hamied represents the needs and aspirations of the Third World ruling class. Third World drug manufacturers are investing in generics because they hope to break into the market, make some money, and have funds to sink into research and development. That way they can get their own patents and cash in on the profit margins the big pharmaceutical companies enjoy–an 18.5 percent return on revenues, six times higher than the median return for Fortune 500 companies, according to Families USA.52

Discounts for the rich

Meanwhile, there have been many announcements about discounts and giveaways on the part of the five major pharmaceutical conglomerates–Merck, Hoffmann-La Roche, Bristol-Myers Squibb, Glaxo Wellcome and Boehringer Ingelheim. Sector Director of Rural Development and Environment in Africa for the World Bank, Hans Binswanger, described the programs as “expensive boutiques...available to a lucky few.”53 Thousands of doses are provided when millions are needed, and even drastic discounts are not much help to people living on a dollar a day. In sub-Saharan Africa, where 28.5 million people are infected, fewer than 30,000–roughly one-tenth of 1 percent–receive the therapy that could avert their deaths. This unnecessary suffering is not isolated to Africa; in Eastern Europe, only 1,000 of the 1 million people infected with HIV are receiving antiretroviral drugs. In high-income countries like the U.S., there are 1.5 million people living with AIDS/HIV and only 500,000 receiving treatment.54 Among the “low and middle income countries” only Brazil can hold up its head; 110,000 of the 230,000 of low and middle-income AIDS sufferers receiving antiretroviral treatment live in Brazil.55 Glaxo Wellc ome offered Senegal discounted drugs that cost from $1,000 to $1,800 a year per person; this will increase the number of people who can receive the drug by eightfold. But that would still be less than 1 percent of the 79,000 Senegalese with AIDS.56

Anything less than giving millions of doses of drugs away for free is an inadequate response to the problem, but the pharmaceutical companies are, according to health economist William McGreevey, “very unlikely to be persuaded to do so.”57 This is not because they can’t afford it. Pharmaceutical companies make such enormous profits in the developed countries that they do not need to do business in the developing world to make a return on their research investment. Africa accounts for only 1 percent of all pharmaceutical revenue; 80 percent of revenues and an even higher proportion of profits come from North America, Europe, and Japan. But cheaper drugs in Africa could undermine prices in the developed world, either through “the re-export of cheaper medicines from poor to rich countries, or from a political backlash if the discounts drew attention to the high profit margins in developed countries.”58

Discounting drugs to save lives in developing countries is a threat to the profit system. If cheap, mass-produced drugs are distributed at cost or for free to save AIDS victims, what will come next? Free food for the starving? Free homes for the homeless? Where is the profit in that?

The impact of neoliberalism

The most commonly used cover for the greed of the pharmaceutical industry is “lack of health care infrastructure.” According to this excuse, pharmaceutical companies would gladly distribute antiretrovirals at cost if developing countries didn’t lack the infrastructure to administer the drugs. A little history is helpful in understanding this claim. The spread of AIDS coincided with and was exacerbated by the adoption of neoliberal policies–also known as Structural Adjustment Programs (SAPs)–as the primary way of dealing with developing countries’ problems with debt and poverty.59

In the 1980s, for example, African nations experienced a debt crisis and became increasingly dependent on the World Bank and the International Monetary Fund (IMF) for loans. The conditions attached to these loans required African countries to enact economic changes that favored “free markets,” including cutbacks in government spending and the privatization of government industries and services. While these “adjustments” were purportedly intended to make African economies stronger and more competitive, they in fact made them weaker and more dependent on foreign loans. They also undermined Africa’s health care system.

In the 1960s and 1970s, most post-independence African governments increased spending on health care, attempting to develop public health systems that would make up for the inequalities of the colonial era. They increased the numbers of health professionals working in the public sector, improved health care infrastructure, and extended care to formerly unserved areas. As a result, infant mortality rates went down and life expectancy went up. World Bank and IMF loan conditions threw this progress into reverse by forcing governments to make drastic cuts to health care spending. According to a report by the Inter-Church Coalition on Africa, spending on health care fell by 50 percent in the 42 poorest African nations during the 1980s.60

This pattern was repeated later in Asia after the economic crisis of the late 1990s; for example, Thailand, lauded for its effective prevention programs of the early 1990s, saw government spending on AIDS prevention cut in half in the late 1990s.61

The lack of health care infrastructure in developing nations was mandated by the IMF and the World Bank,62 something to keep in mind when politicians and pharmaceutical companies claim that antiretrovirals are not “appropriate technology”63 for fighting AIDS in developing countries.

Myth: Patient noncompliance

Another excuse given for not providing antiretrovirals to people with AIDS in developing countries or poor people with AIDS in rich countries like the U.S. is the fear of “patient noncompliance.” Andrew Natsios, head of USAID under Bush, expressed this fear when he told a House subcommittee that giving AIDS drugs to Africans wouldn’t work because “[t]hey don’t use Western means to tell time. They use the sun. These drugs have to be taken in certain sequences. You say, take it at 10 o’clock, they say, what do you mean, 10 o’clock?”64

According to this idea, AIDS patients in developing countries would not be able to handle the complicated drug regimens that would make treating their disease possible. The same holds true for poor people of color in the United States. They “live in the present” too much to be trusted with the best AIDS drugs. Dr. Doug Dietrich, who helped write AIDS reimbursement guidelines for Blue Cross Blue Shield, sums it up neatly: “If you give protease inhibitors to people who are not compliant they’re really wasted. It’s tantamount to flushing them down the toilet.”65

Not only will they not get better, these presumed noncompliant patients would contribute to the development of drug-resistant strains of HIV. This is racist nonsense and blatant hypocrisy. “When Brazil decided to provide [drugs] free to all its AIDS victims,66 it disproved the argument that poor countries couldn’t master the complex regime of AIDS pills,” admitted one Time magazine article. “The government set up effective clinics, and reports indicate that Brazilian AIDS patients take their medicine as meticulously as American AIDS sufferers do.”67

In fact, the main reason for “patient noncompliance” is when access to AIDS drugs is abruptly cut off. In 1997, poor AIDS patients in Mississippi were told that their drug cocktails would be cut off in 30 days because the state government was uninterested in matching funds available through the federal drug program. But the state of Mississippi was not accused of encouraging drug-resistant strains of HIV.68

Fears of noncompliance also disappear when the patient has money. “Living in the present” is only a problem when poor people do it. Wall Street Journal editor and AIDS patient David Sanford was an avowed live-in-the-present kind of guy: “I had blown my mother’s estate, about $180,000, on living for the moment, eating in the best restaurants and taking three or four foreign vacations a year.” Describing AZT as “a drug for lepers” he “took the pills for five days and quit.” Somehow, none of this was held against him and he was allowed to partake in newer and more effective drug regimens when they were developed without bearing the stigma of noncompliance.69

But the overriding reason that most AIDS patients are denied treatment is cost. According to a CDC official: “Our experience...is that treatment always drives out prevention. We were afraid that if we opened the door on treatment at all, then all of our money would be drawn away. You get into paying for commodities that have to be supplied, supplied, supplied, to the end of time.”70

The case of South Africa

Despite overwhelming evidence that the governments of developed countries have been scandalously indifferent to the AIDS crisis, the bodies that have received the most criticism for their lack of action around AIDS–besides the actual infected bodies of people with AIDS–are the governments of the developing countries.

For example, South African President Thabo Mbeki’s refusal to deal with AIDS has generated a great deal of press. Mbeki has never really repudiated his willingness to entertain the idea that HIV does not cause AIDS. His contention that antiretroviral drugs do more harm than good caused him to squander the 2001 victory of international AIDS activists who forced pharmaceutical companies to drop their lawsuit against South Africa for its intention to produce its own generic AIDS drugs.

Although Mbeki formally reversed his position on antiretrovirals in April of 2002, his administration had to be sued by AIDS activists in the Treatment Action Campaign (TAC) and ordered by the South African Supreme Court to distribute antiretrovirals to infected pregnant women–a decision the government appealed (and lost) in July. In a country where 100,000 babies are born each year HIV-positive, such a program could drastically reduce the number of new AIDS cases. Dr. Costa Gazi, Secretary of Health for the Pan Africanist Congress of Azania, has accused the government of preferring to use funds to build up the military and repay Apartheid-era debts.71 The TAC was forced to threaten legal action again when Manto Tshabalala-Msimang, Mbeki’s minister for health, blocked a grant from the Global Fund to Fight AIDS, Tuberculosis and Malaria to an independent project in KwaZulu-Natal that distributes antiretroviral drugs.72

Such actions on the part of the Mbeki government are particularly appalling because the South African AIDS crisis is particularly acute. More people are infected with HIV in South Africa than in any other country–about 4.7 million people. In the early 90s, infection rates in Thailand and South Africa were both less than 1 percent. Now the infection rate for adults is just over 2 percent in Thailand, while in South Africa it is just over 20 percent.73

However, criticisms in the Western press that focus on a South African “culture of denial”74 distort the issue and let the governments of developed countries like the U.S.–and their proxies in the IMF and World Bank–off the hook. While Mbeki’s policies have rightly earned the outrage of AIDS patients and activists, his statement at the Durban AIDS conference in 2000–that alleviating poverty and social inequalities will play a pivotal role in conquering the African AIDS crisis–is simply a statement of fact. Poverty is a key determinant for both HIV infection and the acquisition of AIDS; at the time of the Durban conference, South Africa was struggling to pay off a $24 billion dollar debt to the World Bank.75

It is important to understand the role that the legacy of apartheid played in creating conditions of extreme poverty, poor housing and sanitation that contributed to the spread of AIDS. As Paul Farmer points out, historical explanations “in which poverty and inequality, the end result of a long process of impoverishment, are reduced to a form of cultural difference” are common but inadequate.76 Equally significant is the fact that what is called “denial” when it comes from the head of government of a developing country is called “demand management” when it is carried out by USAID and the CDC.

Yet this should not blind us to the fact that the African National Congress (ANC) has failed to live up to its most basic promises to the mass of Black workers and the poor in South Africa–promises that would have required a commitment to using the leverage of state power to drastically redistribute resources and services to apartheid’s millions of victims. Instead, the new regime embraced neoliberal capitalism, placating international and domestic capital rather than challenging them. As Patrick Bond has written in his book Elite Transition, “Not only were free enterprise and property rights enshrined in every major economic policy statement and the constitution itself, full-blown neoliberal compradorism became the dominant (if not universal) phenomenon within the ANC policy-making elite.”77

Throw money at the problem

By responding to the demands of activists rather than adhering to demand management, Brazil became a leader in Latin America and around the world for its success in AIDS treatment and prevention. In 1986, the government formed a national commission with ¸articipation of all the ministries involved in the issue, plus nongovernmental organizations (NGOs), universities, researchers, intellectuals, and social specialists. Bucking the international trend, the Brazilian program was organized around the idea that prevention and treatment are not mutually exclusive, and that respect for human rights is an essential component of fighting AIDS. By focusing on both prevention and treatment, Brazil has achieved a remarkable reduction in both transmission and mortality. The number of AIDS deaths in Brazil last year was half that predicted by the World Bank. Hospitalization is down by 75 percent, while infection rates in Brazil are lower than in the U.S.78

The most recent innovation to the Brazilian AIDS program is a campaign to redirect attention to the spread of the disease in the gay community, in which there has been a recent upsurge of infections. The campaign includes billboards and television ads. On one billboard, two young gay men embrace, one holding a condom and the other holding a tube of lubricant. In a television spot, a family discusses their gay son’s new boyfriend and convinces him that, eventually, he will find “someone who cares enough to use a condom.”

But by far the most significant innovation came in 1996, when the government took steps to make antiretroviral drugs available to all AIDS patients. In order to make this affordable, Brazil needed to produce its own antiretrovirals.79 Dissatisfied with Swiss pharmaceutical giant Hoffmann-La Roche’s offer to discount the drug Nelfinavir by 13 percent, Brazil threatened to make its own drugs on its own terms. The U.S. initially tried to have Brazil disciplined through the WTO, but then backed off because of pressure from activists, forcing Hoffman-La Roche to the negotiating table. Brazil now produces eight of its own antiretrovirals, and imports the rests at drastically reduced prices.80

What can be learned from the Brazilian success? For one thing, it completely disproves the adage that you can’t just throw money at a problem. Brazil spends $300 million annually on antiretrovirals alone. The Brazilian program shows what can be accomplished with good planning and a willingness to devote real resources to controlling the epidemic. It proves that AIDS is not unstoppable, that prevention and treatment can go hand in hand for the greater good. The problem with the Brazilian solution is that it is a national solution. It isn’t replicable in poor countries like Malawi, and it isn’t exportable. Because of agreements with the drug companies, Brazil will not sell or give its generics to other countries. The only thing they are willing to export is advice.

According to Dr. Paulo Roberto Teixeira, Director of the Brazilian National Program on Sexually Transmitted Diseases and AIDS: “We can’t take the place of other countries’ governments. We can recommend, which we’ve done exhaustively.” Brazil’s global victories on access to AIDS drugs will be much more effective for Latin America “than Brazil taking on a commitment that isn’t ours and that we are unable to meet.”81

As a result, Brazil is the latest government to come under the fire of AIDS activists. In May of 2002, a Honduran woman died after Brazil’s denial of a last-minute plea to sell or donate drugs to save her life. Days later activists protested at Brazilian embassies across Latin America, asking for a commitment from Brazil to export or donate AIDS drugs in emergencies and to use its diplomatic clout in the world AIDS arena to pressure regional governments to urgently develop their own drug distribution programs. Teixeira responded by saying that Brazil is not responsible for providing drugs to other countries.

This attitude is not consistent with Brazil’s stated commitment to human rights. However, its actions taken as a whole are perfectly consistent with a desire to improve Brazil’s position in the hierarchy of global capitalism. Milton Seligman, president of the National Institute for Land Reform in Brasilia, sums this up neatly: “The social impact of free-market reform can be very negative at first. But...[w]e’re in the international dance hall now, and we have no choice but to dance. If we can confront the challenge, provide schools, land, health, Brazil can be a major international power within 15 years.”82

That is, the ruling class of Brazil has everything to gain from getting its AIDS crisis under control before it destroys the Brazilian economy the way it has done to some countries in Africa. Because it is a relatively rich country, it also has the means. But it has little to gain from undermining patents and a price structure that it expects will make it rich somewhere down the line, just to help the poor in other countries.

The role of activism

Given the unwillingness of governments, international agencies, and pharmaceutical companies to provide an effective, universal response to the AIDS crisis, the outlook for most people living with AIDS today is grim. And the end is not in sight; health officials assert that we are only at the beginning of the AIDS pandemic–not the middle, certainly not the end. With over 20 million dead, HIV/AIDS has only just begun to ravage the globe. It is difficult to imagine what this will mean to the people of the world in the coming years.

In its 2002 reports, UNAIDS stresses the important role that activism has played in prevention and treatment efforts thus far.83 More and broader activism is needed to demand adequate resources for fighting and treating AIDS, both in developing countries and in the United States.

In the U.S., the fact that the AIDS crisis is mainly impacting poor communities of color has changed both the composition of the movement against AIDS. When the AIDS Coalition to Unleash Power (ACT UP) was founded in the 1980s, meetings attracted mostly white, middle class gays and lesbians. They did great things–they shut down the New York Stock Exchange, sat in on pharmaceutical company board meetings, and pioneered many of the direct action tactics used by global justice activists today. Through the efforts of thousands of people, they succeeded in winning drugs, treatment, and respect for AIDS patients.84

In the late 1990s, antiretroviral drug cocktails extended the lives of those who could afford them. But the many who could not got busy and changed the face of ACT UP, which is still going strong in cities like Philadelphia. Driven, according to Philly ACT UP member Asia Russell by “death and neoliberalism,”85 ACT UP members, largely people of color and people from low-income communities, are raising class demands in their efforts to fight AIDS, demands for housing assistance, treatment in prisons, needle exchange and health care and medication.

These AIDS activists are working internationally, making links with groups like the Global Treatment Action Campaign in South Africa. Another Philly ACT UP member, Julie Davids, points out the organic connections between people with AIDS in the U.S. and those in the developing countries: “Our members feel passionate about these issues because they realize it’s the same life-threatening forms of racism and economic injustice that impact their lives in the U.S.”86

The effects of privatization and austerity are being felt everywhere. As the global justice movement in this country recovers from its disorientation post-9/11, AIDS is sure to come up as a central organizing issue. We know now, because of Brazil, that it is not medically or scientifically or practically impossible to wage a successful fight against AIDS, one that protects people’s dignity and prolongs and improves their lives.

The need for a socialist alternative

However, we must also recognize that activism is necessary because the system is failing. In the case of the AIDS crisis, the system’s failure is 20 million deaths deep. As long as we are living under capitalism, the efforts of all the best activists in the world will never be enough to prevent needless suffering and the loss of millions of lives. As long as the drive for profit governs what drugs are produced and who gets them, epidemics like the AIDS crisis will never be properly addressed. You only have to look at the return of deadly diseases like tuberculosis–which is prevalent in many developing countries and in some parts of the U.S.–to see that this is true.87

Corporations are beginning to wake up–not to the crisis, but to the idea that it might impact profits. According to BBC news, South African gold producer Anglogold has figured out that HIV and AIDS are raising gold production costs by up to $6 an ounce. Higher production costs mean lower profits and so Anglogold has developed “a comprehensive program to tackle AIDS which would ensure continued profitability.”88

Talk about too little too late: South Africa’s gold mines were built by migrant workers living in single-sex hostels far from their homes–an ideal breeding ground for sexually transmitted disease. What if Anglogold had instead provided them with decent housing in communities with hospitals and schools and hope? Such provision is simply not possible under capitalism. Nothing causes high production costs and low profits like providing workers with the means of a decent existence. Better to let a couple of million people die before risking any investment.

International agencies are also taking unprecedented steps. On April 22, 2002, the WHO added 12 antiretroviral drugs to its list of “essential medicines” and released new guidelines recommending triple-combination therapy as well as the simplest acceptable laboratory tests for possible AIDS patients. Adding the antiretroviral drugs to the list of essential medicines is meant to dispel any fears of their toxicity or inefficacy on the part of skeptical governments, to silence drug industry executives who have argued that triple therapy is too complex and dangerous for poor patients, and to encourage countries applying for grants from the Global Fund to Fight AIDS to include drug treatments in their budgets.89

Like so much of the “progress” that is made around battling the AIDS crisis, the WHO’s announcement packs more form than substance, as it comes with no money to back new programs.90 It merely broadens the range of options for which the scant resources of the Global Fund to Fight AIDS can be doled out. The guidelines do not call for the free distribution of antiretrovirals to those in need. At best, according to the WHO’s Jonathan Quick, the guidelines will encourage price competition between patent-based and generic companies.91

By remaining within the logic of the system, the WHO hopes that by 2005, if African and Asian health systems can stand the strain, up to three million people will be getting treatment. That’s three million out of some 50 million, and it’s not enough.

Meanwhile, President Bush’s main approach appears to be to manipulate the crisis for political gain. His most recent AIDS program–in addition to pulling money out of the Global Fund–is focused entirely on preventing “vertical transmission,” the passage of the disease from a pregnant mother to her child at birth or through breast-feeding. A simple regimen of antiretrovirals cuts the rate of mother-to-child transmission in half. However, no provision is made for the infected mother after breast-feeding is completed–or for her orphaned child when she inevitably succumbs to the disease, as she most certainly will without treatment. The program upholds the right-wing idea that the fetus is more worthy than the woman carrying it and that some lives are “innocent” and therefore worth saving, while others are not. It is also perfectly consistent with the administration’s attacks on abortion rights.92

The AIDS crisis is only the extreme edge of a crisis of human health around the world. It will not be stopped or significantly slowed as long as capitalist priorities prevail. A global health care system that is truly consistent with a commitment to human rights is one in which the same treatment is available to all–regardless of their race, nationality, gender, sexual orientation, or ability to pay. Moreover, no matter what measures are adopted to stop up one health crisis, the conditions which breed new crises–unemployment, poor sanitation, poor housing, lack of clean water, malnutrition–are continually being reproduced by capitalism. So long as the obscenity exists whereby a minority can pay for good medical care while others cannot even find clean water, talk of a real solution is impossible. The resources for a global health care system that puts human need first exist today. But they are under the control of forces that prioritize profits. That is why when we are fighting to get better AIDS treatment to more people, we also need to organize for socialism.

In a socialist society, production would be geared towards meeting human need and not towards making profit. The vast resources made possible by modern methods of production would be distributed on the basis of the needs of the many–for antiretrovirals, food, housing, etc.–not hoarded in the hands of a few money-hungry corporate heads and their servile politicians. It is important to recognize that the way that governments, international aid agencies, and pharmaceutical companies have dealt with the AIDS crisis from its inception is no accident; they are motivated by the drive for profit and fully aware of the impact of their actions and inaction. The situation is incredibly urgent, and we should waste no time in building a socialist alternative. Millions of lives are at stake.

* * *

Notes

1 “Global fund update 2002,” International Council of AIDS Service Organizations (ICASO), June 2002, p. 10. See also Office of the Spokesman for the Secretary General [of the United Nations], “Contributions pledged to the global fund to fight AIDS, tuberculosis, and malaria,” for a complete breakdown of contributions by country, organization, and corporation, at www.un.org/News/ossg/aids.htm.

2 Chris Hogg, “The 10 billion dollar question,” BBC News, July 13, 2002. According to an article in the Washington Post, the activists’ expression of disgust will not go unpunished: “The Department of Health and Human Services is reviewing the federal government’s financial support of more than a dozen prominent AIDS service organizations whose members joined in a noisy demonstration against Health and Human Services Secretary Tommy Thompson at last month’s international AIDS conference in Barcelona, Spain.” See also David Brown, “AIDS groups feel heat after demonstration Federal funding probe follows Barcelona protest against U.S. health secretary,” Washington Post, August 19, 2002.

3 Bernhard Schwartl”nder, “The HIV/AIDS epidemic: What is it doing? Where is it going?” Paper given at the Fourteenth International AIDS Conference, Barcelona, Spain, July 8, 2002.

4 “The report on the global HIV/AIDS epidemic,” UNAIDS at Barcelona, July 7–12, p. 8, available at www.unaids.org/barcelona/presskit/report.html. 5 Barton Gellman, “The belated global response to AIDS in Africa,” Washington Post, July 5, 2000.

6 “The report on the global HIV/AIDS epidemic,” pp. 22–23, 45.

7 “China AIDS victims ëexceed one million,’” BBC News, November 28, 2001.

8 Joe McDonald, “China announces jump in AIDS cases,” Associated Press, July 11, 2002.

9 “The report on the global HIV/AIDS epidemic,” p. 30.

10 “Thailand to launch dollar-a-day anti-AIDS cocktail,” Agence France-Presse, March 22, 2002.

11 “The report on the global HIV/AIDS epidemic,” pp. 35ñ36.

12 “AIDS races through Eastern Europe,” BBC News, 28 November 2001,

13 D.L. Hoyert et al., “Deaths: Final data for 1999.” National Vital Statistics Reports; vol. 49, no. 8. Hyattsville, Maryland: National Center for Health Statistics, 2001. See also the National Institute of Allergy and Infectious Diseases HIV/AIDS Worldwide Fact Sheet for August 2002 available at www.niaid.nih.gov/factsheets/aidsstat.htm.

14 Randy Shilts, And the Band Played On (New York: St. Martin’s Press, 1987), p. 100.

15 Johanna McGeary, “Death stalks a continent,” Time, February 12, 2001, p. 42.

16 Sabin Russell, “Time lost on AIDS, says Mandela; Clinton wants rich to buy drugs for poor,” San Francisco Chronicle, July 13, 2002, p. A2.

17 In an interview before the closing session, Clinton said that he, too, regretted not having done more about AIDS while in office. Lawrence K. Altman, “Former presidents urge leadership on AIDS,” New York Times, July 13, 2002.

18 Russell, “Time lost on AIDS.” Note: Budget allocations are often misleading, as they tend to be spread over a number of years–a detail that is often left out of headlines and press releases.

19 Lewis Machipisa, “Africans spurn U.S. loan offer for anti-AIDS drugs,” Third World Network, August 29, 2000, available at www.twnside.org.sg/title/spurn.htm. See also “Letter to President Clinton,” from the Advocacy Network for Africa (ADNA), August 21, 2000, available at www.woaafrica.org/AIDS3.htm.

20 “Retreat on fighting global AIDS,” editorial, New York Times, June 21, 2002. The United States currently contributes 0.1 percent of its gross national product to fighting AIDS, compared to the 0.7 percent given by smaller nations like Norway and Ireland. Helen Redmond and Eric Ruder, “U.S. gives pennies to global battle against AIDS,” Socialist Worker, July 6, 2001, p. 5.

21 Redmond and Ruder, p. 5.

22 Barton Gellman, “The belated global response to AIDS in Africa: World shunned signs of the coming plague” Washington Post, July 5, 2000. Available at www.washingtonpost.com/wp-dyn/world/issues/aidsinafrica/.

23 Shilts, pp. 103–104, 189, 299–300.

24 Shilts, pp. 106 and 124.

25 Shilts, pp. 86–87.

26 Paul Farmer, Infections and Inequalities (Berkeley: University of California Press, 1999), pp. 105ñ106.

27 Shilts, p. 106.

28 “The report on the global HIV/AIDS epidemic: December 2001, UNAIDS, available at www.unaids.org.

29 Gellman, “The Belated global response.”

30 Ibid.

31 Ibid.

32 Ibid.

33 Ibid.

34 “China’s AIDS victims ‘exceed one million,’” BBC News, 28 November 2001; “New AIDS fears in Thailand,” BBC News, 25 June 2001.

35 Gellman, “The belated global response.”

36 Gaby Hinsliff, “US undermines global declaration,” The Observer (UK), May 5, 2002.

37 Farmer, p. 51.

38 “The report on the global HIV/AIDS epidemic,” p. 29.

39 Bates Gill, Jennifer Chang, and Sarah Palmer,“China’s HIV crisis,” Foreign Affairs, March/April 2002.

40 Barton Gellman, “An unequal calculus of life and death: As millions perished in pandemic, firms debated access to drugs,” Washington Post, December 27, 2000. Available at www.washingtonpost.com/wp-dyn/world/issues/aidsinafrica.

41 Barton Gellman, “Drug discounts benefit few while protecting pharmaceutical companies’ profits,” Washington Post, December 28, 2000

42 Gellman, “An unequal calculus of life and death.”

43 David Finkel, “Few drugs for the neediest HIV patients in impoverished Malawi: One man faces the odds,” Washington Post, November 1, 2000.

44 Barton Gellman, “A turning point that left millions behind: Drug discounts benefit few while protecting pharmaceutical companies’ profits,” Washington Post, December 28, 2000.

45 Sharon Smith, “How drug companies let this horror happen, Socialist Worker, July 26, 2002, p. 7.

46 Redmond and Ruder, p. 5. See also Gellman, “A turning point that left millions behind,” for an account of ACT UP New York’s occupation of pharmaceutical giant Pfizer’s corporate offices, “demanding radical cuts in the price of Diflucan, a leading antifungal agent used in combating secondary infections in AIDS patients.”

47 Joseph Kahn, “Trade deal near for broad access to cut-rate drugs,” New York Times, November 12, 2001.

48 Henri E. Cauvin, “Zimbabwe declares emergency to obtain low-cost AIDS drugs,” New York Times, June 1, 2002.

49 Gellman, “An unequal calculus.” Gellman notes that the World Bank has conducted a number of studies on the cost-effectiveness of antiretroviral treatments and produced several “yardsticks” for determining the economic feasibility of treatment: “Dean Jamison of the World Bank introduced the concept of a “disability-adjusted life year,” or DALY, to measure the number of productive years lost to illness or death. By his calculus, for example, a country that spent $1,000 a year to save the life of someone earning $500 a year would suffer a net economic loss.”

50 Smith, p. 7.

51 Gellman, “A turning point.”

52 Smith, p. 7.

53 Gellman, “An unequal calculus.”

54 “The report on the global HIV/AIDS epidemic,” pp. 23, 32 and 39.

55 “Why is accelerating access so slow?” AIDS 2002 Conference News, Health & Development Networks/Key Correspondent Team, July 11, 2002. Available at www.hdnet.org.

56 Gellman, “Drug discounts benefit few.”

57 Gellman, “An unequal calculus.”

58 Gellman, “An unequal calculus.”

59 See Ann-Louise Colgan, “Hazardous to health: The World Bank and IMF in Africa,” Africa Action Position Paper, April 2002, available at www.africaaction.org/action/sap0204.htm and “Misunderstanding Mbeki,” an op-ed prepared by staff members at the Institute for Health and Social Justice at the Department of Social Medicine, Harvard Medical School, in response to a July 11, 2000 Boston Globe editorial, available at www.rethinking.org/aids/zmag/misunderstanding_mbeki.html.

60 “Beyond adjustment: Responding to the health crisis in Africa,” Inter-Church Coalition on Africa (Toronto, 1993) p. 17.

61 “Chinks in Thailand’s AIDS armor,” BBC News, December 1, 2000.

62 The World Bank’s early statements on the crisis show that this was not at all accidental. According to the World Bank’s 1992 report on population and human resources: “If the only effect of the AIDS epidemic were to reduce the population growth rate, it would increase the growth rate of per capita income in any plausible economic model.” The report helpfully points out that this is what happened in the 14th century with the bubonic plague. Cited in Gellman, “The belated global response.”

63 Paul Farmer defines “appropriate technology” as “good things for rich people and shit for the poor,” Infections and Inequalities, p. 28

64 Redmond and Ruder, p. 5.

65 Farmer, p. 269.

66 While antiretrovirals are certainly more affordable in Brazil than elsewhere, fewer than 10,000 of the 110,000 patients receiving such treatment in Brazil get the drugs at no cost. See John Donnelly, “WHO issues guidelines on AIDS care,” Boston Globe, April 23, 2002.

67 Johanna McGeary, “Paying for AIDS cocktails: Who should pick up the tab for the Third World?” Time, February 12, 2001, p. 54.

68 Farmer, pp. 271–72.

69 Farmer, pp. 269–70

70 Gellman, “An unequal calculus of life and death.”

71 Ling Wu Kong, AIDS: South Africa criticized in NGO session for inaction in the isssue of HIV/AIDS, The Earth Times, August 26, 2002, at www.earthtimes.org.

72 Chris McGreal, “Mbeki minister attacks UN fund’s Aids grant,” The Guardian (UK), July 22, 2002.

73 Jon Jeter, “South Africa’s advances jeopardized by AIDS,” Washington Post, July 6, 2000, p. A1. Available at www.washingtonpost.com/wp-dyn/world/issues/aidsinafrica/.

74 Editorial, Boston Globe, July 11, 2000.

75 “Misunderstanding Mbeki.”

76 Farmer, p. 7.

77 Patrick Bond, Elite Transition: From Apartheid to Neoliberalism in South Africa (London: Pluto Press, 2000), p. 16.

–8 Charo Quesada, “The fruits of foresight: An architect of Brazil’s AIDS program describes the ëcritical and innovative vision’ that led to success,” IDBAmerica (Magazine of the Inter-American Development Bank), February 2002. Available at www.iadb.org/idbamerica/English/FEB02E/feb02e1.html.

79 Charo Quesada, “Leadership, consensus, and technology: With broad support from society, Brazil is improving the quality of life of HIV carriers,” IDBAmerica (Magazine of the Inter-American Development Bank), February 2002. Available at www.iadb.org/idbamerica/English/FEB02E/feb05e1.html.

80 “Brazil to break Aids patent,” BBC News, 23 August 2001.

81 Katherine Baldwin, “Latin American AIDS activists turn on Brazil,” Reuters, May 25, 2002.

82 Roger Cohen, “Brazil pays to shield currency and the poor see the true cost,” New York Times, February 5, 1998, A1.

83 “The report on the global HIV/AIDS epidemic,” p. 11.

84 Redmond and Ruder, p. 5; Gellman, “An unequal calculus.”

85 Richard Kim, “ACT UP goes global,” The Nation, July 9, 2001, p. 17.

86 Kim, p. 17.

87 See Paul Farmer’s Infections and Inequalities for a detailed discussion of the links between AIDS and tuberculosis.

88 “Mbeki signals AIDS policy shift,” BBC News, 24 April 2002.

89 Donald G. McNeil, Jr., “World Health Organization moves to make AIDS drugs more accessible to poor worldwide,” New York Times, April 23, 2002.

90 Rachel Zimmerman, “WHO characterizes AIDS drugs as medically essential treatment,” Wall Street Journal, April 23, 2002.

91 John Donnelly, “WHO issues guidelines on AIDS care,” Boston Globe, April 23, 2002.

92 David Rogers, “Bush’s AIDS plan further exposes rivalries within administration,” Wall Street Journal, June 10, 2002.