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Treatment Access as a Human
Right
by Zackie Achmat
Editor’s Note: At
the XIV International AIDS Conference in Barcelona in July,
science was practically dead. Politics was in. It seemed the
doctors felt that research is useless if you can’t use it
to save lives. The movement that began in full force with
the last international conference two years ago in Durban,
South Africa, towards saving the countries that are dying,
continued to get stronger. In his plenary address to the Barcelona
conference, South African activist Zackie Achmat, of the Treatment
Action Campaign, brought us up to date on how much progress
has been made since Durban. Achmat delivered his talk by video
because of a bacterial lung infection that kept him from traveling.
He is a person living with AIDS who refuses to take antivirals
until they are widely available in his country. An edited
version of his speech follows.
But it is not only the
activists and the advocates acting as a force for change.
In his opening talk, Dr. Stefano Vella, the out-going president
of the International AIDS Society, which organizes the international
conference, talked about the growing advocacy role of medical
providers. “I never saw in other fields of medicine this growing
‘scientific activism’ and the inclusion of the [concept of]
universal access to health care in the scientific agenda of
the most relevant AIDS research institutions of the world.
Indeed, scientists progressively understood that they should
take the lead with the idea that the advancements of medicine
cannot be reserved to small numbers of people… If there is
anything that should be globalized, it is the right to a healthy
life.”
And in his talk at the
closing ceremony, incoming IAS president Dr. Joep Lange said,
“A specific issue close to my heart is access to decent HIV
care, including antiretroviral therapy, for the millions and
millions of infected people in developing countries who need
it. The world can simply not afford to let them die, from
a humanitarian perspective, from a developmental perspective
and from a security perspective. And it is possible to do
something about it—it is actually quite simple. It is going
to require enormous effort, yet it is simple. Do not be fooled:
People make simple things complex to condone their inertia,
and the inertia of those who are living off this epidemic.
Or maybe not inertia, but simple lack of imagination.
“We need to be creative.
For instance, you do not need a lot of infrastructure [clinics,
labs, etc.] to deliver HIV/AIDS care. You do not need complex
regimens. You do not need doctors and nurses to deliver the
care in every remote corner of Africa. If we can get cold
Coca-Cola and beer [delivered by truck] to every remote corner
of Africa, it should not be impossible to do the same with
drugs.
“Bad government
and lack of leadership has actually killed more people with
HIV than anything else.” As for the money, Lange said, “I
am actually convinced that the 10 billion dollars that is
often quoted is an underestimation of what is needed. But
even if it were 25 billion dollars per year, it would still
be peanuts. Do you know how much the England-Argentina World
Cup football match cost the UK [United Kingdom] economy? Two
billion dollars. It just takes five to 12 football matches
and a concerted global effort to really do something about
HIV/AIDS. What are we waiting for?”
The international conference
has spoken. As one report noted, “Discussions here have shifted
from the feasibility of antiretroviral therapy for individuals
in resource-poor countries to how quickly this can be accomplished.”
Leaders are demanding the world’s political will to combat
the epidemic.—Enid Vázquez
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When we last met in Durban
we had hope and we had arguments about HIV treatment. Today
we have facts. In Khayelitsha, outside Cape Town, Médicins
Sans Frontières (Doctors Without Borders) have illustrated
that people with HIV/AIDS, a majority with a non-existent
or serverely damaged immune systems, could recover life, health
and dignity with antiretroviral therapy.
Treatment Works
The majority of MSF’s patients
who started ARV [antivirals] at a primary health care level
had fewer than 48 CD4 cells and viral loads greater than 170,000
copies. Over six months, the majority achieved undetectable
viral loads, and more importantly were able to re-constitute
their immune systems. This follows on the success of Paul
Farmer, Partners in Health, and the people of Haiti. So today
when we speak to you of ARV therapy access in poor countries,
we speak not only with arguments, not only with hopes, not
only with desperation, but actually with facts and the lives
of the people themselves.
The Durban Effect
The global community decided
to campaign for affordable medicines and ARV access for poor
countries and communities in the wake of the Durban 2000 conference.
That campaign has given many of us the hope and the will to
survive. Our movement has achieved many successes and met
many challenges over the last few years. I want to highlight
some of these successes and challenges.
In the constitutional court
judgment on the issue of the mother to child HIV prevention,
the court quotes the South African government’s assessment
of HIV and AIDS as an “incomprehensible calamity.” Although
the facts and arguments I will use are rooted in South African
realities, in many instances the arguments elsewhere are similar,
or they can be used to illustrate the differences.
The Impact of HIV/AIDS
on Morbidity and Mortality
The Department of Health
stated last September that 24% of all public hospital admissions
were due to HIV/AIDS. This demand for hospitalization will
increase steadily every year in the absence of significant
alternative interventions. We would like to ask, what are
these interventions?
To us this is not only a
matter of the cost to the state, but the lives of mothers,
the lives of women, the lives of children and the lives of
men. Many of us in our productive years, many of us who have
not yet have reached the prime of our lives. Central to all
our work on HIV prevention and treatment are the issues of
life, dignity and access to health care.
HIV prevention and treatment
cannot be separated. Not to treat HIV effectively will destroy
the already weakened health care systems in poor countries.
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Combine Prevention and
Treatment
From a purely public health
care perspective, it is shortsighted not to treat HIV, to
say that we must focus on prevention and exclude treatment.
On the other hand, it is unconscionable, because what we are
speaking of are not cold statistics, but our lives. Our lives
matter, the five million people in South Africa with HIV matter
and the millions of people throughout the world already infected
with HIV, their lives matter. And so, it is not simply the
question of the cold statistics that we are putting to you,
but a question of valuing every person’s life equally. Just
because we are poor, just because we are black, just because
we live in environments and continents that are far from you,
does not mean that our lives should be valued any less.
It is critical that every
treatment activist also becomes a prevention activist. Active
prevention of mother and child transmission, assisting rape
survivors, all these issues and above all, the use of condoms
for everyone who is positive. Making clear to people with
HIV that they should use condoms—such a prevention message
is critical to all our treatment efforts. Therefore the dichotomy
between prevention and treatment is one that this conference
should lay to rest immediately. We need to stop this counter
productive debate.
Let us return to practical
concerns. What are the practical obstacles to getting the
vision of the World Health Organization that three million
people should be on treatment by the year 2005?
Voluntary Licenses for
Generic Production
The partial price reductions
and insufficient donations by drug companies will not assist
in the long term to deal with the epidemic in a sustainable
and an effective manner. What is required is generic competition
and therefore we appeal to all the drug companies with brand
name medicines to issue non-restrictive voluntary licenses
at between 3-4% royalty, to ensure that poor countries and
communities have access to ARV therapy. This will eliminate
the unnecessary conflict between the activist community, government
and drug companies.
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Health-care essential for
development
To be able to deliver drugs
to people, to be able to save the lives of the millions with
HIV and AIDS, we need effective public health care systems.
We can only start by endorsing both Amartya Sen and the World
Health Organization’s Commissions on macro-economics report
that regards health care as an essential public good. Not
only for dignity and life, but as a component of a sustainable
development strategy for most developing countries. We therefore
endorse the request for additional funding for health care
systems across the globe by the World Health Organization
to ensure that public health care systems are effective and
that they deal with HIV and AIDS, with TB, with malaria and
with all the diseases of poor people.
Support the Global Fund
A necessary element to enable
public health care systems to deliver ARV therapy in poor
countries is the funding of the Global Fund on AIDS, TB and
Malaria. It is unfortunate that the fund has not received
the necessary amount of between seven and 10 or 11 billion
dollars called for by the UN Secretary General, Kofi Annan.
We believe that the United States, Europe, Japan and countries
like South Africa and Brazil all have an important contribution
to make to that fund, to ensure that all poor people get access
to treatment with ARV. We appeal to you to step up the activism
in your countries to ensure that the Global Fund has the money
that it needs.
Political Will and Denialism
There is an additional element
essential for all of us to get access to life saving treatment
and that is political will. Many of you know the South African
government’s position on HIV and AIDS was not only scandalous,
did not only reduce many of us to despair, did not only take
away the hope of many thousands of people in our country,
but it also threw health care workers and our health system
into disarray. That position has now fortunately changed.
However, we still believe that we all have to be vigilant,
that we should encourage the South African government and
all its officials to maintain a position that HIV does in
fact cause AIDS. And more importantly, that HIV can be treated
as well as prevented.
Unfortunately, our government
has not yet committed formally to a national treatment plan,
in a country where nearly 300,000 people will die this year
of AIDS-related illnesses. However, it is not only our government
that is lagging behind.
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Private Sector Responsibility
Regrettably, the richest
corporation in our country, the Anglo-American Corporation,
cancelled its pilot ARV programs to treat gold miners and
miners who have suffered, who live in single sex hostels on
their mines far from their families and who have HIV. We appeal
to them to reinstate those programs and to treat those workers.
Those workers have sacrificed their bodies and their families,
allowing the company to make the enormous amounts of profit
it does on the world market for gold and other minerals. We
appeal to the entire private sector to make it possible for
people to be treated, including companies such as Coca Cola,
Ford Motors and Daimler Benz who have done a superb job. We
appeal to all of them to work together to ensure that people
across the globe have access to treatment, their workers in
particular.
Brazil
We have seen many successes.
A tremendous example to all of us has been the Brazilian program.
We commend the Brazilian government for an effective program.
As all of you will know, TAC supported MSF in importing generic
ARV into South Africa for the program in Khayelitsha. We will
continue to support that action because we are opposed to
patent abuse by the drug companies and we want to set an example
that can work. However, we appeal to the Brazilian government
to lead a political campaign to enable them to export its
drugs to other countries in Latin America and Central America.
There are many poor people in Ecuador, Nicaragua and other
countries of that region who need these medicines urgently.
This will sustain the Brazilian program in the long run because
of economies of scale and cost effectiveness. But most importantly,
it will give hope to the region itself.
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Botswana
On our doorstep in Botswana,
the government has committed itself to a comprehensive treatment
program for its people. However, its president, Festus Mogae,
mentioned that he is not sure how sustainable that program
will be. We appeal to the Gates Foundation, to the Merck Corporation
and to the government of the United States to ensure that
Botswana is able to use generic ARV to lower the prices and
to be able to make its program sustainable, so that more than
one third of its population who are already infected will
be able to have treatment in a sustainable and an effective
manner.
Treatment Literacy
A critical element to be
able to deliver treatment to people will be treatment literacy
programs. Everyday in our communities we are able to educate
people in workshops about nevirapine [Viramune], about AZT
[Retrovir] and about side effects. We are able to sing songs
about these drugs, we are able to educate people about fluconazole
and cotrimoxazole. These are medical terms and pharmacological
names that none of us knew when we were first diagnosed, or
even much later. But fighting for our lives has made it essential
and necessary for us to learn these things. Everyone can learn
them. In our communities we have done workshops with people
who have never opened a pharmacological textbook, but most
of our people can speak eloquently and articulately about
the medicines that they need to take, their side effects and
how to look after themselves.
We believe that by working
together—nurses, doctors, scientists, patients and government—all
of us—we can achieve the necessary required treatment literacy
that will make our adherence possible.
Over the last few years,
it has been the power of ordinary people that has held drug
companies accountable, made governments accountable and made
the global community accountable.
The TAC thanks the Health
GAP Coalition [Global Access Project, Philadelphia], MSF,
Gay Men’s Health Crisis [New York City], all of our African
comrades, our Brazilian comrades, Pela Vidda and people across
Asia and Europe—you have made our work much easier. We hope
our work at home will be of some assistance to you. In the
words of the labor movement, “an injury to one is an injury
to all.”
Born in 1962, Zackie Achmat
joined the anti-apartheid movement in South Africa during
the 1976 uprisings. He was detained and imprisoned on more
than five occasions as a youth activist. He also organized
for labor, health and community organizations. He was a founding
member of the National Coalition for Gay and Lesbian Equality,
which campaigned for the equality clause in the country’s
Constitution. He is still an active member of the African
National Congress. Achmat was also director of the AIDS Law
Project between 1994-97. He has researched, written, and directed
numerous television documentaries.
In December 1998, he launched
the Treatment Action Campaign (TAC). At the risk of arrest,
Achmat volunteered for TAC’s Defiance Campaign against Pfizer’s
patent to bring life-saving treatment for opportunistic infections
into South Africa. TAC also opposed the HIV denialist positions
in government and campaigned for access to antivirals for
pregnant women with HIV. Achmat is also completing a master
in philosophy of law at the University of Capetown.
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