Treatment Action Campaign News, 17 July 2000. * The Treatment Action Campaign has announced the following actions following the Global March for Access to Treatment: - Legal action will be taken against the Minister of Health to ensure that the health ministry commences a phased implementation of a country-wide mother-to-child transmission prevention program. - TAC intends to start a defiance campaign to bring generic medicines, especially fluconazole, into South Africa. * A report on the Global March for Access to Treatment, by Richard Pithouse. (see body of email) * The text of the Jonathan Mann Memorial Lecture delivered by Edwin Cameron (text version -- MS Word or RTF version with footnotes, available on request). (see body of email) * The text of the memorandum handed over to various dignitaries at the end of the march. (see body of email -- also available at www.durban2000march.org) * A rebuke of a defamatory article written by Ranjeni Munusamy and that appeared in the Sunday Times on July 9, 2000. (see body of email) * AIDS 2000 and Sarafina III. Comment on the unnecessary opulence and poor taste of the opening of the 13th International AIDS Conference. (see body of email) * The Treatment Action Campaign requests donations in order to carry out our campaigns. Details are available on our website, www.tac.org.za. We do not accept money from the South African government or pharmaceutical companies. ------------------- March Report by Richard Pithouse In May 1998 Ms Gugu Dlamini was stoned to death in Durban for revealing that she was HIV positive. A few days ago 5000 people, many wearing "HIV Positive" T-shirts gathered at the Durban city hall to demand equitable access to HIV/AIDS treatment. The excited group of nuns, drag queens, sangomas, doctors, communists, teenage punks on skate boards, Pan-Africanists, gay activists, unionists, students and nurses had come from all over Durban, South Africa and the world to join the Global March for Access to HIV/AIDS treatment. The official posters castigated the drug companies for making huge profits from the AIDS crisis while the homemade posters said things like "AIDS is as real as cANCer" and "Mbeki, forget your R3 million jet and buy us medicine." The march was organised by the Treatment Action Campaign (TAC) - a rapidly growing organisation which strong support in the trade union movement. It was lead by people of the stature of leading Muslim theologian Dr. Farid Essack, Anglican Archbishop Njongonkulu Ndungane and Catholic Archbishop Denis Hurley. The streets of Durban were full of singing, dancing, laughter, warm solidarity and hope. Gugu Dlamini had been vindicated and the demand for equitable access to HIV/AIDS treatment had been turned into the single biggest issue confronting the 13th International AIDS Conference. Previous conferences had focused on prevention but now treatment, and equitable access to treatment, were topping the agenda. But there was another major issue: Mbeki's reluctance to make AIDS drugs available and his perceived support for the right wing American AIDS 'dissidents'. Before the conference he had been 'trashed' on the influential US news programme 60 Minutes and the leading intellectual Dr. Mamphele Ramphele had accused him of "irresponsibility bordering on criminality." Mbeki's credibility was compromised further by his government's casual dismissal of the Durban Declaration, the international outrage at his conference speech and the viciousness of his government's response to criticism. Professor Thomas Croates of the University of California went so far as to call the government's stance "genocidal". There was a danger that Mbeki, rather than the AIDS pandemic, would be the big news story coming out of the conference. But the extent of the crisis was certainly made apparent. No one had to tell South Africans that they were spending their weekends at funerals. But they learnt that there will be 44 million African orphans by 2010, that South Africa has the highest number of HIV infections in the world, that 5000 HIV positive babies are born in South Africa each month, that 4.2 million South Africans are living with HIV/AIDS and that by 2010 life expectancy in South Africa will drop to 36. Moreover the government's claim that AIDS drugs are ineffective and toxic was conclusively refuted. South Africans learned that the drugs do work and that those who can afford them can live a long and healthy life with HIV. Scientists presented rigorous research showing that women who were given AZT and 3TC after being raped by HIV positive men were not infected with HIV. And although the South African government had repeatedly claimed that Nevirapine is ineffective and toxic research showed that the worst side effect of Nevirapine is that a few patients develop a mild rash on the day after treatment and that Nevirapine does prevent mother to child transmission. "The position," Jerry Coovadia insisted, " is now absolutely clear." The Executive Director of UNAids, Peter Pilot concluded that: "This conference has made it irreversible - prevention and care are combined." But, according to Time Magaine, only 20 000 of the millions of Africans living with AIDS are receiving treatment. The rest will probably be dead within two to three years. High Court Judge Edwin Cameron made the point with headline grabbing eloquence: "My presence here embodies the injustices of Aids in Africa. Amidst the poverty of Africa, I stand before you because I am able to purchase health and vigour. I am here because I can afford to pay for life itself." Influential American economist Professor Jeffery Sachs agreed that "Talking about prevention without treatment has been ended decisively at this meeting" and added that "It (treatment) can be afforded." Jerry Coovadia insisted that "it is too expensive not to intervene" and experts estimate that the cost of non-intervention will be a 17% decline in the GDP by 2010. The South African Department of Health estimates that it would cost $6 billion a year at current prices to provide anti-retroviral therapy to all people living with HIV. That would be less than 3% of the national budget, less than a fifth of the $32 billion which the government recently spent on arms, and less than a sixth of the $40 billion which is spent on paying off the apartheid debt each year. But South Africans are still drinking bleach in a desperate attempt to self medicate and wandering from hospital to hospital in a fruitless search from help from the state. Nevirapine, which costs R24 a dose, could prevent 5000 babies a month from being infected with HIV but there is no treatment for the 1 in 4 15-24 year old South African women who are HIV positive. Nevirapine has been approved for use in Uganda and Senegal but the Medicines Control Council has still not approved the use of Nevirapine in South Africa. The attack on the drug companies, which was begun at the march, was taken forward by Edwin Cameron's widely reported comment that: "The drug companies and African governments seem to have become involved in a kind of collusive paralysis." And with the World Health Organisation (WHO) and the highly respected Nobel prize winning organisation Médécins sans Frontiérs (MSF) joining the attack the drug companies were forced in to a defensive position. It was clear that there is a critical mass of people who simply refuse to accept that the Brazilian government can treat a thousand people with dual therapy for the same price that the Ugandan government can treat 228 people or that 100 mg of AZT costs $200 in South Africa and $0.30 in Thailand. In response to the pressure a group of 5 drug companies offered to cut prices by 85% but the MSF likened the gesture to "an elephant giving birth to a mouse." MSF believes that the answer does not lie with donations or price cuts from drug companies but rather with the Brazilian approach of mass-producing quality generics. Countries which can't afford high prices can either manufacture their own generics or import them from producing countries. This could result in the cost of a year's anti-retroviral treatment being cut from the $2 250 which it would cost with the 85% discount to a mere $200 a year. This is not a pipe dream. The polio vaccine is sold for several dollars in the US and just a few cents in the developing world. Pfizer manufacture the fluconazole which is used to treat the opportunist fungal infections suffered by people with HIV. Pfizer, who made a profit of 800 million US Dollars last year from fluconazole alone (their total income was $3, 351 Million US Dollars), offered to provide free fluconazole to HIV patients with cryptococcal meningitis. But only about 14% of South Africans with HIV develop cryptococcal meningitis. Pfizer are not making fluconazole available to people with candida - the most common opportunistic infection plaguing people with HIV. Candida leads to severe discomfort but one or two fluconazole pills a day can restore quality of life, dignity and hope. So unless they are prepared to smuggle a fluconazole generic in from Thailand where it costs R3,72 a pill or India where it costs R7,81 a pill South Africans with candida will only be able to access fluconazole if they can pay R86 per pill - that's over R 60 00 a year. Pfizer's offer expires at the end of 2002, six months after their patent expires, and many people, including an expert from the World Health Organisation, suspect that the offer has been designed prevent the South African government from buying generics for those 6 months. It was no surprise to see that left leaning newspapers like England's Guardian and Australia's Green Left Weekly came out against the drug companies and the governments which support them. But it was highly unusual and noteworthy to see conservative newspapers like The Washington Post and The New York Times making similar arguments. The Washington Post said that the fact that effective treatment is available but priced beyond the means of the poor "constitutes an outrage against the most basic conceptions of international justice, of human dignity, against the very idea of human solidarity." This would have slotted in perfectly to Winnie Madikizela-Mandela's rousing speech at the TAC march and it seems that the enormity of the AIDS crisis has mounted a serious challenge to the orthodox view that the market's thirst for profit must be put before the needs of people. It has been widely recognised, even in conservative circles, that there is simply no way that the AIDS pandemic can be countered until governments insist that people's need be put before the profits of the multinationals. The demand to make the market serve the needs of people has passionate and growing global support. What's more the TAC is prepared to take the South African government and the drug companies to court if there is no immediate progress and they'll have the support of people around the world - including many those for whom the autonomy of the market was previously non-negotiable. But what about Mbeki? Will he continue to equivocate in the face of the avalanche of international condemnation which has even united Winnie and Nelson Mandela and the DP and the PAC in their criticism of the President? Coovadia has acknowledged that "There is strong disapproval of the government" and expressed his concern that the gap between the government and its critics is widening." This raises important questions of strategy for the AIDS activists. Should they challenge the government directly or should they rather give Mbeki the space to back down gracefully? The charismatic chairperson of the TAC, Zachie Achmat, has taken a principled decision not to take any anti-retroviral drugs until the government makes the medication available to all people living with HIV. He describes himself as "an ANC member in good standing - I attend all my branch meetings!" Moreoever the bulk of the rapidly growing TAC membership come from ANC aligned unions and are probably ANC supporters. Achmat explains that "Our approach is to take a firm, principled stand on the issues. But if it becomes clear that they won't compromise then we will issue a challenge." He confirmed that if the Minister of Health fails to provide Nevirapine to pregnant women by Friday the TAC will launch an urgent High Court application demanding the constitutional right to treatment. TAC has also served notice that it will take legal action against Pfizer to seek a compulsory license to allow South African companies to produce cheaper copies of fluconazole. TAC have also committed themselves to a defiance campaign. They will import fluconazole and distribute the drug through a number of doctors and nurses who have already indicated their support for the project. Achmat explained that: "We are taking this action because we've been in negotiations with government for two years. They promised to act as soon as they got the S.A.I.N.T. report on the Nevirapine trial. They got it two weeks before the conference but there has been no announcement." Mbeki's likely response to this action is still a matter of conjecture. But it is clear that the TAC and other AIDS activists have major support in South Africa and around the world. If Mbeki treats AIDS activists rather than AIDS as the enemy he runs a serious risk of losing all credibility. Indeed, it seems clear that if Mbeki fails this test a significant sector of his own electorate will judge him to be unfit to govern. ----------------------- XIIIth INTERNATIONAL AIDS CONFERENCE DURBAN 9 - 14 JULY 2000 FIRST JONATHAN MANN MEMORIAL LECTURE: "THE DEAFENING SILENCE OF AIDS" PLENARY PRESENTATION MONDAY 10 JULY 2000 BY MR JUSTICE EDWIN CAMERON HIGH COURT OF SOUTH AFRICA, JOHANNESBURG 1 It is a great honour to be asked to deliver the first Jonathan Mann Memorial Lecture. It is fitting that this remembrance should have been created to honour Mann's memory and legacy. He more than any other individual must be credited with first conceiving and constructing a global response to the AIDS epidemic. This he did not only as founding director of the World Health Organisation's Global Programme on AIDS between 1986 and 1990, but also after he left the WHO, in his theoretical and advocacy work within the discipline of public health. 2 It is particularly fitting that the lecture should be initiated at the start of the first international conference on AIDS to take place on African soil. Jonathan Mann's earliest experience with the epidemic was in Africa, where from March 1984 to June 1986 he was director of the Zaire AIDS Research Programme. It was here that Mann first confronted the social complexities and the dire implications of the disease. 3 Mann's work in Central Africa included epidemiological, clinical and laboratory components. In retrospect it is clear that it was on this continent that the motive forces impelling his insights into the epidemic were formed. He published early research indicating that HIV transmission occurs only rarely in the home or healthcare setting. His work in Zaire subjected him to an arduous schooling in all aspects of HIV: surveillance and epidemiology, issues of testing in a developing country, case definition, condom usage, and exposure amongst commercial sex workers. It alerted him from the outset to the fearful twinned menace of HIV and tuberculosis. His time in Africa also attuned him to questions involving children and pediatric AIDS, and he published pioneering work on what has perhaps become the epidemic's most poignant issue in Africa - transmission of the virus from mother to child. 4 But it was not in only the details of the epidemiology and management of HIV that Mann's years in Africa yielded insights that later proved critical. His work amongst Africa's at-risk communities, with Africans living with HIV and with those dying from AIDS, with the healthcare personnel, mothers, sex workers and government bureaucrats in Africa formed the basis of an insight he later termed a "very intense, emotional, and personal" discovery. This was his realisation during the 1980's that there are empirical and theoretical links between human rights abuses and vulnerability to HIV/AIDS. In each society, Mann later wrote, "those people who were marginalised, stigmatized and discriminated against - before HIV/AIDS arrive - have become over time those at highest risk of HIV infection". 5 Mann's statement cannot be accepted without nuance, since in some African countries it is precisely mobility and relative affluence that have placed people at risk of exposure to HIV. But Mann's analysis here had led him to a more fundamental and general insight - one that formed the focus of his future work and advocacy. This was his realisation that health and human rights are not opposing, but are complementary, approaches to what he called "the central problem of defining and advancing human well-being". 6 In relation to AIDS, Justice Michael Kirby of the High Court of Australia - one of the world's most eloquent voices for truth and fairness - has termed this "the HIV paradox": the insight that sound reasons rooted not only in respect for human dignity, but in effective public health planning, necessitate a just and non-discriminatory response to AIDS; that recognition of and respect for individual human rights does not impede prevention and containment of HIV, but actually enhances it. 7 In this perception Jonathan Mann located the core of his remaining life-work. And his commitment to advancing its practical realisation constitutes his most profound contribution to securing a humane world-wide response to the AIDS epidemic. Amidst the grievous facts of the epidemic, the one gleam of redemption is the fact that nowhere have the doctrines of public health overtly countenanced repression and stigma, discrimination and isolation, as legitimate governmental responses to AIDS. 8 That there has been discrimination and stigma against persons with AIDS and HIV, on an enormous and debilitating scale, is beyond question. The death by stabbing and stoning of Gugu Dhlamini, not twenty kilometres from here, in December 1998, provides a brutal testament of such hatred and ignorance. But these practices have not been supported - at least officially, or in any large measure - by the institutional power of the world's public health systems. That public policy at national and international level have weighed against them, constitutes a significant portion of the legacy of Jonathan Mann. 9 But this by no means exhausts the significance of his work. In the fourteen years since Mann left Zaire for Geneva in 1986, the epidemic has manifested momentous changes. The two most considerable are these: ¨ demographics of its spread; and ¨ the medical-scientific resources available to counter it. 10 In its demographics HIV has altered from an epidemic whose primary toll seemed to be within the gay communities of North America and Western Europe, to one that, overwhelmingly, burdens the heterosexual populations of Africa and the developing world. The data are so dismaying that reciting the statistics of HIV prevalence and of AIDS morbidity and mortality - the infection rates, the anticipated deaths, the numbers of orphans, the healthcare costs, the economic impact - threatens to drive off, rather than encourage, sympathetic engagement. Our imagination shrinks from the thought that these figures can represent real lives, real people, and real suffering. 11 Bud amidst the welter of disheartening data, two facts, well-recited though they are, obtrude with overwhelming force: ? nine-tenths of all people living with HIV/AIDS are in poor countries; and ? two-thirds of the total are in sub-Saharan Africa. 12 But the demography of HIV has been overlain by a shift even more momentous. It is the fact that over the last half-decade, various aggregations of drug types, some old and some new, have been shown, when taken in combination, to quell the replication of the virus within the body. The result has been exciting, life altering and near revolutionary. For most of those with access to the new drug combinations, immune decline has not only halted, but been reversed. 13 In most of Europe, in North America and in Australasia, illness and death from AIDS have dropped dramatically. In these regions, hundred of thousands of people who a few years ago faced imminent and painful death have been restored to living. Opportunistic infections have receded, and suffering, pain and bereavement from AIDS have greatly diminished. 14 Beneficent social effects have come with the medical break-through. The social meaning of the new drugs is that the equation between AIDS and disease and death is no longer inevitable. AIDS can now be compared with other chronic conditions which on appropriate treatment, and with proper care, can in the long term be subjected to successful medical management. Amongst the public at large, the result has been that fear, prejudice and stigma associated with AIDS have lessened. And persons living with HIV/AIDS have suffered less within themselves and in their working and social environments. 15 In short, the new combination drug treatments are not a miracle. But in their physiological and social consequences they come very close to being miraculous. 16 But this near-miracle has not touched the lives of most of those who most desperately need it. For Africans and others in resource-poor countries with AIDS and HIV, these drugs are out of reach. For them, the implications of the epidemic remain as fearsome as ever. In their lives, the prospect of debility and death, and the effects of discrimination and societal prejudice, loom as huge as they did for the gay men of North America and Western Europe a decade and a half ago. 17 This is not because the drugs are prohibitively expensive to produce. They are not. Recent experience in India, Thailand and Brazil has shown that most of the critical drugs can be produced at a cost that puts them realistically within reach of the resource-poor world. The primary reason why the drugs are inaccessible to the developing world is two-fold. · On the one hand, drug-pricing structures imposed by the manufacturers make the drugs unaffordably expensive. · On the other, the international patent and trade regime at present seeks to choke off any large-scale attempt to produce and market the drugs at affordable levels. 18 With characteristic prescience, Mann in his address at the XIth International AIDS Conference in Vancouver in 1996 foresaw the significance of the treatment issue. He said that of all the walls dividing people in the AIDS epidemic, "the gap between the rich and the poor is most pervasive and pernicious". 19 It is this divide that, fourteen years after Mann left Africa, threatens to swallow up 25 million lives in Africa. 20 I speak of the gap not as an observer or as a commentator, but with intimate personal knowledge. I am an African. I am living with AIDS. I therefore count as one amongst the forbidding statistics of AIDS in Africa. I form part of nearly five million South Africans who have the virus. 21 I speak also of the dread effects of AIDS not as an onlooker. Nearly three years ago, more than twelve years after I became infected, I fell severely ill with the symptomatic effects of HIV. Fortunately for me, I had access to good medical care. My doctor first treated the opportunistic infections that were making me feel sick unto death. Then he started me on combination therapy. Since then, with relatively minor adjustments, I have been privileged to lead a vigorous, healthy, and productive life. I am able to do so because, twice a day, I take two tablets - one containing a combination of AZT [zidovudine] and 3TC, and the other Nevirapine [Viramune]. I can take these tablets because, on the salary of a judge, I am able to afford their cost. 22 If, without combination therapy, the mean survival time for a healthy male in his mid-forties after onset of full AIDS is 30 - 36 months, I should be dead by about now. Instead, I am more healthy, more vigorous, more energetic, and more full of purposeful joy than at any time in my life. 23 In this I exist as a living embodiment of the iniquity of drug availability and access in Africa. This is not because, in an epidemic in which the heaviest burden of infection and disease are borne by women, I am male; nor because, on a continent in which the vectors of infection have overwhelmingly been heterosexual, I am proudly gay; nor even because, in a history fraught with racial injustice, I was born white. My presence here embodies the injustices of AIDS in Africa because, on a continent in which 290 million Africans survive on less than one US dollar a day, I can afford monthly medication costs of about US$400 per month. 24 Amidst the poverty of Africa, I stand before you because I am able to purchase health and vigour. I am here because I can afford to pay for life itself. 25 To me this seems an iniquity of very considerable proportions - that, simply because of relative affluence, I should be living when others have died; that I should remain fit and healthy when illness and death beset millions of others. 26 Given the epidemic's two most signal changes, in demographics and in medical science, it must surely be that the most urgent challenge it offers us is to find constructive ways of bringing these life-saving drugs to the millions of people whose lives and well-being can be secured by them. 27 Instead of continuing to accept what has become a palpable untruth (that AIDS is of necessity a disease of debility and death), our overriding and immediate commitment should be to find ways to make accessible for the poor what is within reach of the affluent. 28 If this is the imperative that our circumstances impose upon us, one would have expected the four years since Mann spoke at Vancouver to have been filled with actions directed to its attainment by those with power to change the course and the force of the epidemic. 29 Instead, from every side, those millions living with AIDS in resource-poor countries have been disappointed. International agencies, national governments, and especially those who have primary power to remedy the iniquity - the international drug companies - have failed us in the quest for accessible treatment. 30 In my own country, a government that in its commitment to human rights and democracy has been a shining example to Africa and the world has at almost every conceivable turn mismanaged the epidemic. So grievous has governmental ineptitude been that South Africa has since 1998 had the fastest-growing HIV epidemic in the world. It currently has one of the world 's highest prevalences. Nor has there been silence about AIDS from our government, as the title of my lecture suggests. Indeed, there has been a cacophony of task groups, workshops, committees, councils, policies, drafts, proposals, statements, and pledges. But all have thus far signified piteously little. 31 A basic and affordable measure would be a national programme to limit mother-to-child transmission of HIV through administration of short courses of anti-retroviral medication. Research has shown this will be cost-effective in South Africa. Such a programme, if implemented, would have signaled our government's appreciation of the larger problem, and its resolve to address it. To the millions of South Africans living with HIV, it would have created a ray of light. It would have promised the possibility of increasingly constructive interventions for all with HIV, including enhanced access to drug therapies. 32 To our shame, our country has not yet come so far as even to commit itself to implementing such a programme. The result, every month, is that 5 000 babies are born, unnecessarily and avoidably, with HIV. Their lives involve preventable infections, preventable suffering, and preventable deaths. And if none of that is persuasive, then from the point of view of the nation's economic self-interest, their HIV infections entail preventable expense. Yet we have done nothing. 33 In our national struggle to come to grips with the epidemic, perhaps the most intractably puzzling episode has been our President's flirtation with those who in the face of all reason and evidence have sought to dispute the aetiology of AIDS. This has shaken almost everyone responsible for engaging the epidemic. It has created an air of unbelief amongst scientists, confusion among those at risk of HIV, and consternation amongst AIDS workers. 34 One of the continent's foremost intellectuals, Dr Mamphela Rampele, has described the official sanction given to scepticism about the cause of AIDS as "irresponsibility that borders on criminality". If this aberrant and distressing interlude has delayed the implementation of life-saving measures to halt the spread of HIV and to curtail its effects, then history will not judge this comment excessive. 35 At the international level also, there have been largely frustration and disappointment. At the launch of the International Partnership Against AIDS in Africa in December 1999, UN Secretary General Kofi Annan made an important acknowledgement. He stated: "Our response so far has failed Africa". The scale of the crisis, he said, required "a comprehensive and coordinated strategy" between governments, inter-governmental bodies, community groups, science and private corporations. 36 That was seven long months ago. In seven months, there are more than 200 days: days in which people have fallen sick and others have died; days on each of which, in South Africa, approximately 1 700 people have become newly infected with HIV. 37 In that time, the World Bank, to its credit, has made the search for an AIDS vaccine one of its priorities. President Clinton, to his credit, in an effort "to promote access to essential medicines", has issued an executive order that commits the United States to existing international agreements, thereby loosening the patent and trade throttles around the necks of African governments. And UNAIDS, to its credit, "has begun" what it describes as "a new dialogue" with five of the biggest pharmaceutical companies. The purpose is "to find ways to broaden access to care and treatment, while ensuring rational, affordable, safe and effective use of drugs for HIV/AIDS-related illnesses". 38 All these efforts are indisputably commendable. But, whether taken individually or together, they fail to command the urgency and sense of purpose appropriate to an emergency room where a patient is dying. The analogy is under-stated - for the patients who are dying in their tens of millions. For each of them, and for all their families and loved ones, the emergency is dire and immediate. What is more, the treatment that can save them exists. What is needed is only that it be made accessible to them. 39 Amidst all these initiatives, the critical question remains drug pricing. No one denies that drug prices are "only one among many obstacles to access" in poor countries. But there are many, many persons in the resource-poor world for whom prices on their own are, right now, the sole impediment to health and well-being. A significant number of Africans have access to healthcare and could pay modest amounts for the drugs now. On any scenario, therefore, lowering drug prices immediately is necessary. It should therefore be an immediate and overriding priority. 40 In fact, lower drug prices are an indispensable precondition to creating just and practicable access to care and treatment. This is so for a number of reasons. First, the debate about drug pricing diverts attention and energy from the other vital issues, such as creating the institutional infrastructure for delivery and monitoring in poor countries. Second, and more crucially, it has sadly provided some governments with a make-weight for delaying implementation of programmes to prevent mother-to-child transmission of the virus. It has delayed also consideration of more ambitious alternatives in anti-retroviral therapy. 41 Amidst all of this, it is hard to avoid the impression that the drug companies are shadow-boxing with the issues. There is some evidence that they, in turn, are using lack of governmental commitment on drug provision as a pretext for not lowering drug prices immediately. There certainly has been no immediate follow-through to the announcement eight weeks ago that five of the largest drug companies had undertaken to "explore" ways to reduce their prices. This has devastated the hopes of many poor people who need lower prices, now, to stay alive and healthy. 42 It is in this context that it is also hard to avoid the conclusion that UNAIDS - whose programme leader, Dr Peter Piot, is a perceptive man of principle who worked with Jonathan Mann in Africa - has failed to muster its institutional power with sufficient resourcefulness, sufficient creativity and sufficient force. 43 Amidst this disappointment, it is quite wrong to speak, as the title of my lecture does, of "the deafening silence of AIDS". There has not been a silence. Gugu Dhlamini was not silent. She paid with her life for speaking out about her HIV status. But she was not silent. And her death has not silenced many other South Africans living with AIDS, black and white, male and female - most who are less protected by privilege than I - who have spoken out for dignity and justice in the epidemic. 44 In the supposed silence, there has also sounded the trumpet of principled activism. In America, brave activists changed the course of presidential politics by challenging Vice-President Gore's stand on drug pricing and trade protection. Their actions paved the way for subsequent revisions of President Clinton's approach to the drug pricing issue. 45 In my own country, a small and under-resourced group of activists in the Treatment Action Campaign, under the leadership of Zackie Achmat, has emerged. In the face of considerable isolation and hostility, they have succeeded in re-ordering our national debate about AIDS. And they have focussed national attention on the imperative issues of poverty, collective action and drug access. In doing so they have energised a dispirited PWA movement with the dignity of self-assertion, and renewed within it the faith that by action we can secure justice. 46 Jonathan Mann in the last years of his life began speaking with increasing passion about the moral imperatives to action that challenge us all. He well understood that this involves confronting vested interests: "Preventing preventable illness, disability and premature death, like preventing human rights abuses and genocide, to the extent that it involves protecting the vulnerable, must be understood as a challenge to the political and societal status quo." He also understood, in his last writing, the fundamental significance of human dignity in the debate about health and human rights. His work foreshadowed the transition of health and human rights and the "HIV paradox" to a full human entitlement to health care, where the means for it are available. 47 Ten months before his death, in November 1997, he called on an audience to place themselves "squarely on the side of those who intervene in the present, because they believe that the future can be different". 48 That is the true challenge to this Conference: to make the future different. Drugs are available to make AIDS, for most people with the virus, a chronically manageable disease. But for most people with the virus, unless we intervene in the present, that will not happen. 49 We gather here in Durban as an international grouping of influential and knowledgeable people concerned about alleviating the effects of this epidemic. By our mere presence here, we identify ourselves as the 11 000 best-resourced and most powerful people in the epidemic. By our action and resolutions and collective will, we can make the future different for many millions of people with AIDS and HIV for whom the present offers only illness and death. 50 This gathering can address the drug companies. It can demand urgent and immediate price reductions for resource-poor countries. It can challenge the companies to permit without delay parallel imports and the manufacture under license of drugs for which they hold the patents. 51 Corporately and individually we can address the governments and inter-governmental organisations of the world, demanding a plan of crisis intervention that will see treatments provided under managed conditions to those who need them. 52 Vancouver four years ago was a turning point in the announcement of the existence of successful drug therapies. This Conference can be a turning point in the creation of an international impetus to secure equitable access to these drugs for all persons with AIDS in the world. 53 Moral dilemmas are all too easy to analyse in retrospect. It is often a source of puzzled reflection how ordinary Germans could have tolerated the moral iniquity that was Nazism; or how white South Africans could have countenanced the evils that apartheid inflicted, to their benefit, on the majority of their fellows. 54 Yet the position of persons living with AIDS or HIV in Africa and other resource-poor countries poses a comparable moral dilemma for the developed world today. The inequities of drug access, pricing and distribution mirror the inequities of a world trade system that weighs the poor with debt while privileging the wealthy with inexpensive raw materials and labour. 55 Those of us who live affluent lives, well-attended by medical care and treatment, should not ask how Germans or white South Africans could tolerate living in proximity to moral evil. We do so ourselves today, in proximity to the impending illness and death of many millions of people with AIDS. This will happen, unless we change the present. It will happen because available treatments are denied to those who need them for the sake of aggregating corporate wealth for shareholders who by African standards are already unimaginably affluent. 56 That cannot be right, and it cannot be allowed to happen. No more than Germans in the Nazi era, nor more than white South Africans during apartheid, can we at this Conference say that we bear no responsibility for more than 30 million people in resource-poor countries who face death from AIDS unless medical care and treatment is made accessible and available to them. 57 The world has become a single sphere, in which communication, finance, trade and travel occur within a single entity. How we live our lives affects how others live theirs. We cannot wall off the plight of those whose lives are proximate to our own. 58 That is Mann's legacy to the world of AIDS policy; and it is the challenge of his memory to this Conference today. -------------------------- MEMORANDUM Global Manifesto to Save 34 Million Lives: Measures Needed to Rapidly Expand Access to Essential Treatments for HIV/AIDS Health before profits! Sunday July 9th 2000 To: The Honourable Deputy President of South Africa and Chairperson of the South African National AIDS Council, Mr. Jacob Zuma The Honourable South African Minister of Health, Dr. Manto Tshabalala-Msimang The Honourable South African Minister of Foreign Affairs, Dr Nkosazana Dlamini-Zuma Ms. Sandra Thurman, Coordinator, Director of the United States Office of National AIDS Policy on behalf of United States President, Mr. Bill Clinton Mr. Michael Laidler, Ambassador of the European Union in South Africa Dr. Harvey Bale, Director General of the International Federation of Pharmaceutical Manufacturers Associations Dr. Peter Piot, Executive Director of UNAIDS Prof. Jerry Coovadia, Chairperson of the International AIDS Conference Dr. Stefano Vella, President elect of the International AIDS Society The Treatment Action Campaign and Health Global Access Project Coalition (Health GAP) have mobilized the largest coalition of concerned citizens ever assembled to insist on the right to health care and access to life-sustaining medicines. Our march today demanding access to treatment is the most broad-based in the twenty-year history of the HIV epidemic. We bring before you thousands of people from many different countries and perspectives. On our march today are thousands of people living with HIV and AIDS, our friends and families, as well as trade unionists, representatives of political parties, and a wide range of non-governmental organizations. We represent organizations and movements in over 34 countries, many of which cannot be physically present with us today. We are all united with a single purpose, to ensure that everyone - including people with HIV and AIDS -- has access to their fundamental right to health. Underpinning our demands are several issues, which we ask you to recognize publicly: AIDS has become a catastrophe that threatens the very future of this planet. Terribly high levels of HIV infection and death due to AIDS are now a reality (rather than merely a projection) in poor communities worldwide. More than half off all these infections occur among women. AIDS is causing widespread devastation in Africa and Asia especially. This was avoidable. It is the consequence of negligence, particularly on the part of 'First World' governments whose resources could have been mobilized to come to the practical assistance of poor nations many years ago. Scientific research has blessed us with breakthroughs in treatment and care. These advances have resulted in a major drop in AIDS-related mortality in rich countries, and have turned HIV infection from a certain death sentence into a chronic disease. With few exceptions, these benefits have not been extended to developing countries, despite the fact that more than 95% of all people with HIV live in these nations. These breakthroughs could be brought very quickly to benefit many millions of lives - if only the drive for profit by pharmaceutical companies could be tempered. Profiteering from essential goods contributes to what Gro Harlem Brundtland, Director General of the World Health Organization, recently described as the "scandalous inequity" in access to health care. In this regard, we note that in 1999 the combined profits of the 12 largest pharmaceutical companies was US$27.3 billion. This amounts to a horrendous exploitation of the needs of the poor, the sick and the vulnerable. Access to medical treatment is essential to effective HIV prevention. People with HIV have the right to expect access to the best treatment. To expect anything less is to surrender. Recognizing these truths has implications for governments of the North and South, pharmaceutical companies, UNAIDS, and civil society. We will ensure that history measures your response from this day onward. We would like to address specific proposals to each of the parties we have called here today: 1.TO THE SOUTH AFRICAN GOVERNMENT The South African Government has a unique potential to right the wrongs and inequalities that exist around AIDS. Not only is South Africa the worst affected country in the world, but you have the moral legitimacy that has accrued to a nation that has risen peacefully from apartheid, under the leadership of former President Nelson Mandela. In your own words, AIDS is a "new struggle". In the words of the Organisation of African Unity's recently signed Ouagadougou Commitment (May 2000) "health constitutes a right and a foundation for socio-economic development," whereas the AIDS epidemic is a major "public health, development and security problem for Africa." We call on the SA Government to: Immediately implement a country-wide program to reduce the risk of mother-to-child transmission of HIV using AZT or neviripine. Immediately accept and implement currently offered drug donation programs provided there are no strings attached. Immediately issue a compulsory license for fluconazole. This drug could be immediately imported from the lowest-priced producers to extend the lives and improve the quality of life of people with HIV. Call on other developing countries to do likewise. Demonstrate leadership and integrity in the governance of its HIV/AIDS programs as a model for developing countries. Campaign for the appropriate and transparent use of public funds for public need, and especially for the development of health infrastructure. 1.TO THE GOVERNMENTS OF THE USA AND EUROPEAN UNION People from poor countries cannot help but believe that whilst your governments will draw massively from public funds when your own security is threatened, the lives of poor and black people in the emerging 'global village' are considered dispensable and unworthy of protection. The policies of trade liberalization that you endorse and have pursued through bodies such as the World Bank, IMF and World Trade Organization have had a devastating impact on social services, and particularly health services. We demand that you: Immediately and publicly renounce all trade sanctions or other punitive measures against governments exercising their right to protect the health and well-being of their populations through mechanisms such as compulsory licensing and parallel importing. Renounce all threats of bilateral trade sanctions against any country and adhere to the multilateral procedures for dispute resolution to which you are committed by treaty and international law. Least-developed countries should not be pressured to develop intellectual property laws until the established deadline of 2006. Immediately offer financing to developing countries, to improve and expand the health infrastructure, both human and capital, needed to treat HIV, AIDS and many other causes of illness and disease. This will benefit all people, not just those affected by HIV/AIDS We call on the US government to extend the scope of the recently issued US Executive Order acknowledging countries' rights to employ compulsory licensing and parallel importing to protect public health to all developing countries, not just Africa. We call on the European Union to adopt similar measures. All these measures should be represented not as charitable "exceptions," but as recognition of countries' legitimate rights under international law. We also demand that you provide substantial public funding for independent scientific research to develop new therapies and find a cure. This research should be freed from the grip of pharmaceutical companies who will exploit it for private interest. Resulting products should remain a public trust, and be made available to the international community. In addition to relevant vaccine research, we consider particularly important the urgent development of effective spermicidal and non-spermicidal microbicides. These will reduce gender inequality and increase women's ability to protect themselves. In addition we call for anti-retroviral therapies that are easier to use by children and adults in countries where there is a shortage of food, water and electricity. Immediately grant licenses to international agencies to produce all HIV medications for which governments maintain licensing rights, and provide funding to produce these medications in quantity for developing nations. 1.TO THE INTERNATIONAL FEDERATION OF PHARMACEUTICAL MANUFACTURERS' ASSOCIATION (IFPMA) The pricing policy defended by the IFPMA, where patent monopolies allow your members to place essential drugs beyond the influence of market competition, has become the cause of an unprecedented burden of illness and death. We do not dispute your need to recover investments in research and development, or to profit from these investments. But, in your hands, the profit motive has led to the development of new medicines that are far out of reach of the people who need them. We call on all members of the IFPMA to: Immediately reduce the price of essential anti-HIV/AIDS medications to a level affordable to the populations of developing countries. Publish on a drug-by-drug basis the actual costs of research and development, active ingredients, manufacturing costs, and all other relevant information necessary for an objective evaluation of the pricing structure for all essential HIV/AIDS medications. Direct the South African Pharmaceutical Manufacturers' Association to withdraw its Court action against the South African Government aimed at preventing health service transformation. Cease all actions, whether through litigation or through pressure exerted by other governments, aimed at preventing states from exercising their rights to use compulsory licensing and parallel importing to protect the health of their populations. Negotiate with governments of developing countries in good faith, toward serious action aimed at addressing a global health-care crisis-not with the media, in public statements aimed at confusing cosmetic gestures with real solutions. We specifically demand that Pfizer, Inc.: Reduce the price of fluconazole internationally to the lowest currently available price per 200 mg tablet by 1 October 2000, e.g. US $0.29. Eliminate all conditions from your drug donations. Donations should apply to all developing countries and to all relevant medical conditions, without restriction; should be implemented without delay; and should entail no arbitrary time limitations. Not require any conditions that would adversely affect governments' efforts to employ compulsory licensing, parallel importing, or other legal mechanisms to protect public health. We specifically demand that Boehringer Ingelheim, Inc.: Expand your proposed donation of nevirapine for pregnant women to all developing countries and relevant medical conditions; implement the program without delay without arbitrary time limitations. All Boehringer Ingelheim's available resources should be devoted to making this donation a meaningful act, not a publicity stunt. Not require any conditions that would adversely affect governments' efforts to employ compulsory licensing, parallel importing, or other legal mechanisms to protect public health. Include countries manufacturing generic versions of nevirapine in this offer. Reduce the price of nevirapine for users other than pregnant women. 1.TO UNAIDS We salute the efforts made by UNAIDS and its predecessor the Global Programme on AIDS (GPA). But they have been insufficient. In your own words "18.8 million people around the world have died of AIDS, 3.8 million of them children." But we reject the manner in which you already appear to have given up on the lives of those who today live with HIV. You say, "34.3 million are now living with HIV, the virus that causes AIDS. Barring a miracle, most of these will die over the next decade or so." We do not need a miracle. We need political leadership, resolve and action on the recognition that health is a human right. UNAIDS is vested with this responsibility. We therefore call on UNAIDS to: Support national governments by beginning international procurement of AIDS drugs, and by December 1, 2000 put out tenders to the proprietary and generic industry for mass procurement of opportunistic infection and HIV medicines. Consider previous vaccine and contraception procurement projects as a guide. In all negotiations with drug companies, consult with and ensure the participation of states, particularly developing countries, most affected by the AIDS pandemic. All "partnerships" should be accountable to the populations whose lives are at stake. With the World Bank, ensure that countries have sufficient financing (offered without restrictive or repressive conditions) to develop a health infrastructure appropriate to administering AIDS therapies. 1.TO THE INTERNATIONAL AIDS SOCIETY (IAS) , CLINICIANS AND RESEARCHERS We salute your commitment to understanding HIV and to research into treatments and vaccines. We call on you to Step up this research. Also, we request that you make your voices heard side-by-side with us in demanding additional public funding and the best use of medicines for the greatest number of people. Silence equals complicity when institutions that use your intellectual ability to produce medicines that are then withheld from the people who most need them. Publicly quantify and demand the funds you consider necessary for urgent and relevant vaccine research, effective microbicides and anti-retroviral therapies that are easier to use by children and adults in countries where there is a shortage of food, water and electricity. We will actively campaign for the necessary funding if you announce the sums needed. Initiate and coordinate an international scientific collaboration on a plan and timeframe for research. The alliance you have constructed behind the Durban Declaration, which we welcome without reservation, must now be turned to research. In conclusion we request: An initial response from each of the parties we have addressed at the close of the International AIDS Conference on July 14th 2000. A detailed response to the proposals made in this Memorandum by August 8th, 2000. Failure to satisfy us on these proposals will result in an international day of action on December 10th, International Human Rights Day. We conclude with the words of the Gro Harlem Brundtland, Director General of the World Health Organization, who stated in an address to the Parliament of Brazil earlier this year, "investing in health is a measurable, results-oriented and effective way to reduce poverty ... access for all to essential drugs and vaccines is also a short cut to lower mortality and better health for the entire population. Improving such access is among the most effective health interventions any country can make. Health is not a peripheral issue that only more affluent economies can afford to spend money on. It is a central element of development. And access to drugs is an essential element of any health policy." The millions of people who stand behind our call are awaiting a meaningful response to these demands. We will not go away. Promise Mthembu On behalf of the TAC Mark Heywood On behalf of the TAC Julie Davids On behalf of Health GAP Eric Sawyer On behalf of Health GAP --------------------------- Defamatory Article in Sunday Times ---------------------------------- The 9 July issue of the Sunday Times contains an article on page 2 written by Ranjeni Munusamy. The article contains the following libelous paragraph. 'Another spokesman for the Treatment Action Campaign, Mazibuko Jara, warned that Mbeki would "spark anger and violent reactions" if he spoke in support of the AIDS dissidents at tonight's ceremony.' Mazibuko Jara, a spokesperson for TAC and former chairperson, has never made this statement. Falsely attributing a statement calling for violence to Jara damages both his good name and the good name of the Treatment Action Campaign. Months before the march, TAC released a joint press statement with the March organisers stressing that the march would be a non-violent, legal event. Interestingly, almost the entire media chose to ignore this press release. The absurdity of the Sunday Times article comes from hindsight. Arguably, the president did side with the dissidents and there was not even a hint of violence during or after the global march, despite the immense disappointment clearly felt by most of the crowd at the end of Mbeki's speech. Actually, TAC has a perfect record when it comes to organising peaceful events. Jara was interviewed by Munusamy for the article, but he points out that there is no correlation between what he said and what Munusamy reported. Strangely, Munusamy attempted to push Jara into proposing a violent stance, but Jara clearly insisted that the TAC does not advocate violence. Munusamy poor reporting skills are not unknown to TAC. The previous week she authored an article in the Sunday Times Metro (Durban edition) which devoted much space a pharmaceutical company allegation (made by Glaxo-Wellcome) that implied that TAC would not be able to prevent violence at its march. She failed to solicit comment from TAC on the matter. In a telephone conversation, I pointed out to Munusamy that she should have asked TAC for comment on the matter. Munusamy replied that she was under no obligation to quote us. Correct, I replied, but she is under an ethical obligation to pursue objective reporting. Since she chose to make allegations against us, she should have had the decency to get our opinion on the matter. Munusamy was left speechless at this retort. That she failed to solicit TAC's opinion in her article in the Sunday Times Metro can be assigned to inexperience. That she misquoted a TAC spokesperson in her article on 9 July is an indication of her gross incompetence. Two defamatory articles in two weeks has led some to speculate that Munusamy might be in the pocket of the pharmaceutical industry. However, it seems to me that is a much simpler but sadder (for Munusamy) possibility: Munusamy might simply be an incurably poor journalist. The Sunday Times would do well to print a retraction and to pursue disciplinary hearings against the offending journalists. by Nathan Geffen --------------------------------- AIDS 2000 and Sarafina III -------------------------- Over 30 million people worldwide are infected with HIV and it is arguable that we are in the midst of a holocaust, albeit a preventable one. Common sense would therefore indicate that events dealing with HIV should be marked by modesty and humility. Unfortunately, the opening ceremony of the 13th International AIDS Conference, organised by AIDS 2000, reminded one of the Sarafina II scandal, a R12 million debacle funded with public money and rightly criticised at the time by some of the organisers involved in AIDS 2000. The ceremony was marked by an elaborate song and dance program, followed by a fireworks display -- fitting for the opening to the Olympic Games, but hardly for an event dealing with a health catastrophe. The misallocation of funds in the health-care industry was made starkly clear to many members of TAC over the last two weeks. One of our volunteers fell sick with cryptococcal meningitis, an AIDS defining disease. He was admitted to King Edward Hospital in Durban, a short drive from where the opening of the conference took place. One of our volunteers visited him in hospital and found the walls smeared in vomit and the floors damp with urine. Strange priorities: there was sufficient funding for a fireworks display at the opening of the International AIDS Conference, but not enough to clean the wards of the people most affected by the virus at a hospital which was recently described in the press as "world-class". The conference itself offered a wealth of trinkets, fridge magnets, CDs, glossy advertisements and high-paid executives from pharmaceutical companies, governments, the UN and NGOs -- vital signs of a fabulously successful industry which has become known as the AIDS beaurocracy. by Nathan Geffen ------------------------------