Editorial: Whose priorities? A response to the issue of antiretrovirals in Africa
Article first published online: 21 DEC 2001
Tropical Medicine & International Health
Volume 6, Issue 8, pages 575–577, August 2001
How to Cite
Pronyk, P. M. , Kim, J. and Porter, J. D. H. (2001), Editorial: Whose priorities? A response to the issue of antiretrovirals in Africa. Tropical Medicine & International Health, 6: 575–577. doi: 10.1046/j.1365-3156.2001.0763a.x
- Issue published online: 21 DEC 2001
- Article first published online: 21 DEC 2001
The recent Harvard Consensus Statement on Antiretroviral Treatment for AIDS in poor countries makes some important advances in furthering the global response to the ‘modern world’s greatest pandemic.’ It calls for the infusion of $5 billion over the next 5 years to make available combination antiretroviral therapy and the concurrent infrastructure to support their use (Harvard University 2001).
To its merit, the statement draws attention to the devastating impact of the epidemic and marks the urgency of immediate action. The issue of drug access has now become a focal point for international solidarity. Witness the recent forfeit by the Pharmaceuticals Manufacturing Association of the suit brought against the South African government over proposed legislation to allow the import or production of less expensive antiretroviral medications (Beresford 2001). While activism around HIV has been occurring for decades in Europe and North America, only recently has the public outcry extended its scope to include the countries worst hit by the epidemic.
While reducing inequalities around access to life- prolonging treatment carries profound moral weight, equally challenging questions need to be posed regarding the potential dangers of adopting this approach. Are we simply looking for a ‘quick fix’ to a complex international problem that affects the health of us all? Is antiretroviral treatment a solution or merely a further complication for countries in sub-Saharan Africa and elsewhere? Should efforts not instead be focusing on developing systems that aim to establish equity more broadly, rather than on technical solutions to a disease whose transmission is being fuelled through the inequitable systems that currently predominate?
In South Africa, the evolution of the HIV epidemic is a telling case study in the failure of ‘systems’. While it was not until the early to mid-90s that the explosion in new infections took place (Department of Health 2000), the seeds for this had been sown much earlier. The system of apartheid was based on the systematic entrenchment of inequality through a process of separate and decidedly unequal development. It laid roots for the epidemic in the creation of the homeland system – a means of providing a cheap pool of migrant workers for white-owned business. The legacy of apartheid has meant that even today, more than half the value of the Johannesburg Stock Exchange lies in the gold, diamonds and platinum mined by labour migrants. An abundance of rural families remain economically dependant on income generated from young men who live away from home for more than 11 months of the year, in a labour system that helps to fuel the sexual transmission of HIV (Churchyard 1996; Lee & Zwi 1996). Further consequences of this ‘unhealthy system’ are that boys grow to be men without the influence of fathers, mentors, and male role-models, and women who choose to remain in relationships have little expectation of meaningful support from their partners. The system helps to further entrench gender-based inequalities and violence, and in such a context, negotiation for safer sex to prevent HIV transmission remains deeply constrained (Krieger & Margo 1991; Jewkes & Abrahams 2001).
The realities of South Africa are profoundly echoed in the experience of its sub-Saharan neighbours. With a per capita GDP of less than a year’s supply of AIDS drugs for one individual, even at the new prices, addressing HIV is one of a long list of health and social priorities – albeit one of devastating importance.
Historical lessons from the past two centuries would suggest that biomedical approaches to disease control in individuals, when acting in isolation, often fail to achieve sustainable health gains at the level of populations. ‘Quick fixes’ do not work. Instead, there is a need to understand and challenge the underlying systems that foster high rates of disease transmission. In the treatment of diarrhoeal disease, for example, antibiotics can be helpful in certain cases, but improving sanitation and water supply systems will lead to a sustainable decrease in infections (Gray 1993). Similarly, effective medications for the treatment of tuberculosis have been available for nearly five decades – yet, in the context of the inadequate, overcrowded living conditions which fuel its transmission, tuberculosis remains responsible for more deaths worldwide than any other infectious agent (McKeown et al. 1975; Kaye & Frieden 1996). And despite an effective array of anti-malarial drugs, bed nets and insecticides combined with widespread support from donor countries, we are witnessing the ongoing failure to contain malaria in many of those same countries currently worst hit by the AIDS epidemic. Yet we forget that malaria, a scourge in the US and Europe in the 1800s, disappeared long before it was ever known to be caused by a parasite or transmitted by the mosquito (Barber 1929). It was improved systems of housing, nutrition and agricultural irrigation, which were far more important in their long-term eradication (Cleaver 1977).
Activism to support the reduction in the price of AIDS drugs needs to be tempered with an understanding of the complexity of the problem within countries that have few resources and many other health priorities apart from HIV. We need to understand that governments also have the responsibility for developing appropriate systems for the delivery of health care. Successful international activism which leads to cheaper AIDS drugs will undoubtedly increase the stress on individuals working within already strained government structures. Once again, governments will be targeted to make rapid changes in response to international pressures.
Galvanizing support internationally for a certain disease (and a certain approach to its control) can lead to a distortion of national health priorities and a failure to assist country governments in the development of appropriate systems for deciding on how funds should be managed and spent. In many ways, there is the danger of distracting energy, activism and attention away from the need to confront and address far more fundamental failures.
Like any of history’s other major pandemics, HIV is not so much a disease as a symptom of the profound structural inequalities in which the world is immersed. It is no coincidence that more than 90% of new HIV infections occur in countries of the South (UNAIDS 2000). It is ironic to observe governments of the North taking the ‘moral high ground’ in the drama over the pharmaceutical industry, while the G8 renege on debt relief, structural adjustment policies continue to impoverish many low income countries, and the European Union scuttles an agreement for tariff-free access to their markets for the world’s 48 least developed countries (Denny 2001). Thus we are witnessing a situation where the attempts by governments in poorer countries to address some of the fundamental inequalities driving the AIDS epidemic are increasingly undermined by coalitions of those same countries who now extend the charity of cheaper medications. While the issue of drug availability is one that is easy to rally around, and something that governments in industrialized countries can ‘feel good’ about, it does not examine or challenge those broader systems which further entrench inequalities and fuel HIV transmission.
The international community needs to find ways of playing a meaningful role in this new climate of global activism while supporting the more difficult process of deeper change. It is a sensitive balance. Quick fixes are not a reality in the case of HIV, and its control will not come simply through the provision of antiretroviral therapy to infected individuals. Rather, a commitment to improving the ways international, national and local systems broadly articulate and interrelate, may well carry a far more substantial and lasting impact on this pandemic in the years to come.
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