Devil’s Bargain


Alternative and mainstream media reported no breakthrough on AIDS funding at the Jo’burg summit on sustainable development. The mood among AIDS activists in South Africa seemed especially grim. That collective dark cloud has hung over them since a year ago last April, just after a consortium of pharmaceutical companies dropped its legal suit against the South African government over intellectual property rights to the patents for anti-retrovirals. The reason: South African officials announced no plans to distribute anti-AIDS drugs to the populace. This was a death sentence after a brief glimmer of hope.

Cries of dismay, disappointment and shock are still heard over the airwaves, in print and on the Web as the debate carries on after Johannesburg. Yet despite very recent victories in several skirmishes with the South African government, and despite de Beers announcing that it would distribute retroviral treatment to its workers, little real progress has been made at the level of national policy.

We really shouldn’t be surprised. Ayanda Ntsaluba, then director general of the South African health department, at the end of April 2001 urged those who need the drugs to go to the private sector, where anti-retrovirals cost at least twice as much. The BBC reported that he explained his recommendation with, among others, these words: “The issue of affordability is still with us.” This is now – and, until there is an AIDS vaccine, will continue to be – the defining issue in this debate. Read on to hear why..

When I returned to the United States from Africa, two of my nephews were very perplexed about my ‘juniah brudder’ from Ghana, Jehrawn. “How can he be your brother if he’s black?” they demanded. Well, for one thing among many, he saved my life off in the bush – deep in the bush; no clinics or antivenom anywhere near – when a green mamba was poised maybe four inches from my right boot. One of the unofficial survival guides circulating in West Africa reads: “If you are struck by the green mamba, sit down and light a cigarette. You will not have time to finish it.”

Some months later, I had the opportunity to reciprocate by helping to save Jehrawn’s life when he somehow contracted cerebrospinal meningitis during the annual outbreak — yes, annual. His brothers and one sister arrived at my digs around 10:45 one night, to ask, “Uncle Ned, Jehrawn ees very seek. Can you help?”

They handed me a prescription written by a doctor at the local hospital: 115,000 cedis – at the time, some $65 – for the CSM inoculation and related medicines. That sum was more than Jehrawn and the four wage earners in his family would make in two weeks. Certainly they did not have that amount to spare; all moneys went to school fees and food. So I conscripted a pickup truck, we piled in, then I climbed over the wall of the pharmacist’s compound to beat on his door at 11:00.

When Jehrawn’s family and I arrived at Otua Hospital in Odumasi, Eastern Region, just before midnight, the nurse grabbed the inoculation and other medicines and emptied them all into Jehrawn – through new syringes I had purchased. No way was he going to get jabbed with a dirty needle! He was stone cold to the touch, deep in a coma.

Early next morning I went back to call on the chief of medicine, a smiling young Ghanaian who had trained in England. Following the Ghanaian custom of hospitality, he immediately called for sodas for me, Vida, Jehrawn’s exquisite sister, and Ransford, Jehrawn’s brother. The doctor laughed and laughed because, he said, he was delighted to hear me refer to Jehrawn as “my brother.” That young Doctor is still a hero to me because he saved Jehrawn’s life and because he told me the truth.

I asked the Doctor, “What would happen to Jehrawn if I had not arrived with medicines last night?”

“He would be allowed to die.”

“But why?” I demanded.

The Doctor explained: “Your brother is a black man, so I will tell you. My friend, we are in Africa. Medicine is very expensive. We practice a type of financial triage. If you cannot pay, you will die. Your brother is very, very lucky.” He informed me that the single greatest cost – on top of a spinal tap, the hospital bed, ongoing care “if he survives” – would be medications. I agreed to pay.

Jehrawn recovered. He was in a coma for almost five days, during which the CSM fever burned twenty-five pounds off him. When he came to, his left leg was, he said, “dead,” and he had lost hearing in his left ear. He stumped around on a cane for a month or so. But just three months later he and I guided tourists on a traverse of Krobo Mountain, the sacred, ancestral home of the Krobo tribe and clans amongst whom I lived.

During that trek, from under a rock by the side of the trail, a green mamba streaked through his legs and over my left boot. My crew of sixteen men was working below us at the southernmost spur of Krobo Mt., building an ecotourism facility. They did backbreaking labor for 3,500 cedis — just under $2 — per day. Zeke Obu, my foreman, told me they were very glad to have steady employment at “proper” pay double the national average of $1 daily.

Over a year ago U.S. and European pharmaceutical companies volunteered to sell HIV treatments to African nations at radically discounted prices compared to the $10,000 to $15,000 per patient per year charged in the U.S. These gestures resulted when Cipla, an Indian manufacturer of pharmaceuticals, announced it has asked the South African government for permission to sell inexpensive, generic versions of eight of the 15 most common drugs used to make anti-HIV medications.

Cipla managers said they can provide generic cocktails for just $600 per year. Another Indian company, Hetero, joined in with a bid to supply a generic triple-drug cocktail for $350 per year. Cipla countered with an offer to sell a basic cocktail to NGOs for $350 per year. Merck is offering African nations two of the most widely used AIDS drugs for $600 per patient per year and $500 per patient per year.

The least expensive option from a U.S. or European group comes from GlaxoSmithKline, which offers a basic cocktail to African nations for “only” $2 per day. That drug includes only three of the eight or so most efficacious anti-HIV medications, and is considered only a partial regimen. Other manufacturers are offering drugs at one-tenth the U.S. purchase price, or some $1,000 to $1,500 per year.

Sounds good, but let’s do some basic arithmetic. “Only” $1,000 or $1,500 per patient per year is two to five times the average income of your average African. Even at $1 or $2 per day, Africans cannot afford the HIV medications. Two dollars is the most common maximum — repeat, maximum — daily African wage.

That $2 is the amount many Africans have to spend daily on food, clothing, shelter and medical care.  Many other Africans earn less than $2 per day. Thus, if they do not have money for medication, Africans who fall seriously ill very often are left to die. Wealthy Africans (at best, 10% of the population) will receive treatment for HIV; they can afford it. So, too, might those who work for expatriate or African firms where terms of employ include medical care. Botswana, rich in diamonds and the revenue they generate (and, importantly, unencumbered by IMF/World Bank strictures), recently announced it would distribute anti-retrovirals at no cost to all comers.

Yet for the vast majority of Africans — the 70%-plus who live on subsistence farms off in the bush, or eke out meager livings in towns — medical care is a dream. In terms of purchasing power, $1 to $2 a day is the absolute best that Africans, on average, can manage for essentials. That figures out at $365 to $730 per year.

In other words, the average daily wages earned are precisely the cost of even the least expensive HIV treatments. This is a Devil’s Bargain, no choice at all: The choice is, very simply, between absolute destitution and death. At the very least, the choice is between reduced rations for an entire family and pulling kids out of school, on one hand, and AIDS treatment for one person on the other. Bad juju lingers on either horn of this dilemma.

Ergo, the options tendered by the patent-holding pharmaceutical firms simply do not address the reality of African economies. Those options are not viable and will in no way mitigate the AIDS epidemic in Africa without massive financial assistance from the developed countries. Such assistance most likely will add to the debt burden of over $380 billion currently crushing sub-Saharan Africa, where more is spent on servicing debt than on public health and education combined.

Such assistance would be analogous to my loaning money at interest to Jehrawn’s family, so that they could pay me back for his medications and follow-along treatment, which amounted to some 3.5 million cedis, or about $2,050. This is more than two times the amount his entire extended family earns in a year – a crushing burden I could in now wise contemplate.

Add to these factors the costs associated with upgrading or creating the medical infrastructure requisite for distribution and monitoring of results, which aid groups have estimated will cost further tens of billions. (Not to mention costs related to venality, outright corruption and hoarding.) Total expenditures rocket out of sight.

Thus, even radically discounting prices for anti-retroviral drugs will not solve the problem of HIV/AIDS. As the pharmaceutical companies – in their infinite cynicism – have known for years, the central issue is affordability: Neither the vast majority of Africans nor their governments can afford to buy the drugs, even at cut-rate prices.

Just as the pharmaceutical companies practiced economic triage when they ignored – over years – the AIDS epidemic in the Third World (in favor of high-priced sales in the developed North and West), so, too, must African and other developing countries practice financial triage – but for very different reasons.

If the people do not have the money for medications, and governments do not have the money to treat HIV/AIDS sufferers, then those people will die. Even the cheapest drugs on the market will not help stop the pandemic. But the South African ministers will not admit this at the present time because they cannot afford to offend the pharmaceutical companies or donor countries.

Nonetheless, they are in a position common in Africa – they must resort to financial triage. Yet to avow this, after the pharmaceutical companies have capitulated on price, would be a tremendous blow to the cause of bringing anti-HIV/AIDS drugs to needy nations: If the cheapest drug prices are of little avail, what incentive will the pharmaceutical companies have in discounting?

Faced with this dilemma, it is not at all surprising that African and other Third World regimes are threatening to copy patented AIDS drugs. Brazil already does so. Given the options, who can blame them? For my part, I say ‘God speed, patents be damned': Payback to the pharmaceutical companies that made it impossible – through financial triage, through economic apartheid – for Africans to buy needed drugs.

In the meantime, don’t be surprised if African nations do not sign contracts for the huge amounts of drugs they need to truly fight the pandemic: The issue is – still – affordability. As they must, most African regimes will practice financial triage – and pass death sentences – for the foreseeable future.

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