New York Times-July 6, 2000
By LAWRENCE GOLDYN
SAN FRANCISCO -- President Thabo Mbeki of South Africa has
so exasperated AIDS researchers that some have decided not to
attend the international AIDS conference next week in his country. First
he said AZT, which has safely helped prolong the lives of hundreds of
thousands of people with H.I.V., might be too toxic for his people. Then
he announced that he was willing to entertain the ridiculous views of the
marginalized scientists who say H.I.V. does not cause AIDS.
But when Mr. Mbeki spoke to an audience in San Francisco a few
months ago, his iconoclasm began to make sense. He focused on a stark
reality: the pharmaceutical-based model of H.I.V. care in the West is not
applicable to South Africa. He may be arriving at this conclusion by a
route involving some indefensible detours, but the conclusion itself is
The stakes are high. South Africa has one of the fastest-growing H.I.V.
epidemics in the world, though with 20 percent of the adult population
infected, it is in better shape than many of its neighbors in southern
Africa, where 25 percent to 35 percent of adults have H.I.V. Most of the
infected South Africans will die of AIDS, leaving behind hundreds of
thousands of orphans with fewer resources and adult caretakers than if
AIDS had been kept at bay. The economy is likely to weaken as people
in their working years fall ill. The world held its breath as South Africa
moved essentially bloodlessly from apartheid to a stable democratic
government. Will H.I.V. unravel its stability?
Cost is the obvious barrier to drug therapy. A cocktail of drugs for an
H.I.V. patient costs between $10,000 and $15,000 a year --
unaffordable at a tenth of the price for the South African government,
which spends about $40 a year per person on health care. But Mr.
Mbeki stressed something else: the lack of social, economic and medical
structures to support drug treatment. Even in the West, where we have
an array of social agencies to help, patients do not always comply with
complicated regimens of H.I.V. treatment. If cheaper drugs arrived in
South Africa by the shipload, how would one get people to take them?
The history of another disease, tuberculosis, is sadly instructive. For
years some southern African nations have had large-scale TB programs
with cheap, easy-to-take drugs, but have not made a dent in infection
rates. Meanwhile, on black markets, TB drugs have different value
depending on whether they are "wet" or "dry." A wet pill is one that a
patient puts under his or her tongue in the presence of a health care
worker and then spits out later to sell. If South Africans had easy access
to H.I.V. drugs, imagine their black market value in the rest of
sub-Saharan Africa, where there are virtually no medications.
A more immediately compelling issue is transmission of H.I.V. from
mother to child.
In the United States, AZT for mothers-to-be, combined with Caesarean
section and other medical care, has practically eliminated transmission
during birth, and when Mr. Mbeki dismissed AZT, he angered many
physicians. But in a way his stance is perfectly rational.
With no medical intervention, about one-third of children born to an
infected mother will contract H.I.V.; AZT treatment alone could cut this
rate in half. But the United Nations estimates that 15 percent of H.I.V.
positive mothers infect their children through breast-feeding. So even if
mother-to-child infection were lowered at birth to 15 percent, six months
later it would still be around 30 percent.
One might legitimately ask if an AZT program is worth the effort and cost
if you still end up with a 30 percent infection rate among infants.
There is no alternative to breast-feeding for most women in South Africa.
There is little infant formula, and even if there were more, many rural
women would not have clean water to mix it with. Moreover, H.I.V.
carries such a social stigma that infected women have been driven from
their homes and villages. Few would want to signal infection by
What Africa most needs is an H.I.V. vaccine. Although there is an
international research effort, pharmaceutical companies, motivated by
profit, have not put their formidable resources into a vaccine, since the
nations that need it would not be able to pay much for it. Controlling
H.I.V. in South Africa now would require an international effort on the
scale of the Marshall Plan: creating incentives to produce and distribute
medicines and providing clean water, sanitation, clinics, health education,
refuge for women and care for children. This is not on the horizon.
That leaves South Africa little choice but to aim for less and hope for an
affordable vaccine. The best policy would probably be to provide
inexpensive antibiotics to fight the principal opportunistic infections of
AIDS and the sexually transmitted diseases that increase H.I.V. infection
rates, and to finance preventive education and efforts to destigmatize
H.I.V. infection. As Mr. Mbeki says, the Western model of fighting
AIDS is of little use to Africa now.
Lawrence Goldyn, a doctor who formerly taught political science at
Parsons School of Design, treats H.I.V.-positive patients.