AFRO-NETS> "We all have AIDS": case for reducing the cost of HIV drugs to zero

[Cecilia Snyder <csnyder@ccmc.org>]

"We all have AIDS": case for reducing the cost of HIV drugs to zero
-------------------------------------------------------------------

Dear Afro-Nets:

The article below appears in the latest issue of BMJ.com:
http://bmj.com/

Other articles in this issue include:
"Commentary: The reality of treating HIV and AIDS in poor countries"
http://bmj.com/cgi/content/full/324/7331/214?eaf#resp1

"Commentary: Most South Africans cannot afford anti-HIV drugs"
http://bmj.com/cgi/content/full/324/7331/214?eaf#resp2

"What did you do in the war against AIDS, granddad?"
http://bmj.com/cgi/content/full/324/7331/0/I

"The Focus on Women Kampala Declaration: Ugandan women call for ac-
tion on HIV/AIDS" 
http://bmj.com/cgi/content/full/324/7331/247

"AIDS and global justice" 
http://bmj.com/cgi/content/full/324/7331/181

--
Best wishes, 
Cecilia Snyder 
mailto:csnyder@ccmc.org


--
"We all have AIDS": case for reducing the cost of HIV drugs to zero

Donald Berwick, president and chief executive officer
Institute for Healthcare Improvement
375 Longwood Avenue
Boston, MA 02215, USA
mailto:dberwick@ihi.org

Last year I wrote a guest editorial for the Washington Post (NB: see 
bottom for the editorial)[1] in which I challenged the world's phar-
maceutical companies to cut the cost of HIV drugs to zero in poor 
countries. Here I explain why I wrote it and describe some of the re-
sponses it provoked. 

The prologue

People living in poverty being denied access to modern health care is 
a form of violent, systematic social deprivation that we, as a civi-
lised global community, ought not to accept. Even the poorest people 
in the poorest settings can, if they are allowed and assisted, be in-
volved in improving their health and can benefit from the most ad-
vanced drugs. 

This philosophy of social justice drives the international health 
programme Partners in Health, which was founded by Paul Farmer and 
Jim Yong Kim. Partners in Health is tackling a seemingly impossible 
problem: the treatment of multiresistant tuberculosis in a poor 
shanty town area called Carabayllo on the outskirts of Lima, Peru, 
and in rural Haiti.[2] The organisation has trained local residents 
as healthcare "promoters" able to give complex regimens of drugs to 
patients during directly observed treatment, while providing the pa-
tients and their families with a lot of psychosocial support. Success 
rates have been phenomenal over 80% of patients have apparently been 
cured of a disease that only five years ago was thought of in these 
areas as a death sentence. 

Kim's and Farmer's work is changing minds. Until recently, the World 
Health Organization advised most developing nations not to spend 
their resources on the diagnostic tools and complex drug regimens 
used to treat multiresistant tuberculosis in rich nations.[3] But 
now, thanks in part to advocacy from Partners in Health and other or-
ganisations, the WHO has at last placed many of the drugs needed to 
treat multiresistant tuberculosis on its list of essential drugs. 
Many pharmaceutical manufacturers have reduced the prices of antitu-
berculosis drugs by more than one order of magnitude.[4] 

In the international struggle against multiresistant tuberculosis, 
the sudden and dramatic decrease in the costs of antituberculosis 
medications was an important catalyst to action. When high costs 
meant that drugs were far out of reach, it seemed futile for poor 
countries to try to build infrastructures capable of managing pa-
tients with tuberculosis. When drugs became affordable, building a 
proper healthcare system was a task worth tackling. Peru has begun to 
broaden the Carabayllo programme to a national scale, and the Bill 
and Melinda Gates Foundation supports plans to broaden the impact of 
Partners in Health with multimillion dollar investment. 

It takes little imagination to carry one's mind from one scourge mul-
tiresistant tuberculosis to another AIDS.[5] The challenges are simi-
lar, and despair is just as seductive. AIDS is not yet curable, but 
modern medicine has chipped away at the pace and burden of the dis-
ease's progression. Sophisticated drug regimens can increase the 
healthy portion of the lives of people with HIV by years, even dec-
ades. Worldwide, the stakes are as high as our species has ever 
known. Without widely available care and effective prevention, AIDS 
is creating a pandemic without precedent on our planet.[6] With 
proper care and active prevention, we could save millions and mil-
lions of years of healthy life. [7][8] 

The work of Partners in Health led me, one sleepless night, to write 
an article about AIDS for an American national newspaper. I wrote a 
challenge as a guest editorial in the Washington Post.[1] Reduce the 
costs of anti-HIV drugs to zero, or nearly so, I proposed. I directed 
this challenge at the few people who, with a stroke of their pens, 
could make it happen the next morning the executives and boards of 
the world's pharmaceutical companies. 

The online debate

The Washington Post hosts question and answer sessions on line on the 
day that guest editorials are published. I spent two hours answering 
selected questions from readers. It was an opportunity an author 
rarely gets to hear first hand how the reader feels at the moment of 
reading. 

The questions I received provided a cross section of public opinions 
some encouraging, some shocking on our possible role as developed na-
tions in solving the world's AIDS crisis. 

Several of the questions debated serious points of fact and evidence. 
Would "attitude, cultural traditions, and gender discrimination" in 
poor countries "have an adverse effect on the battles against AIDS," 
even if medications were free? (I replied that removing the barriers 
of drug costs would, in fact, confront us with the need to tackle 
such obstacles. High drug costs are an excuse for avoiding other is-
sues.) 

Do "infrastructures" exist to distribute medications and manage 
treatment? (I cited the success of Partners in Health in developing 
and sustaining effective infrastructures.) Some questions raised con-
cerns about the implications for the pharmaceutical industry if it 
took my suggestion of making AIDS drugs free. 

"Where does the r[esearch] and d[evelopment] money come from? Current 
profits. If you take away the profits, then the companies will have 
no incentive to do . . . research." (I replied that drug companies 
today get no profits, anyway, from countries that cannot afford their 
products, and that the international goodwill that could come from 
bold generosity could put the companies in a much better position to 
make the case for support for their research agendas.) Some readers 
questioned whether AIDS care deserves such priority. 

"If drug companies ought to provide free AIDS drugs, by the same 
moral principle they ought to provide free antibiotics and . . . 
every lifesaving drug." (This "Pandora's box" argument is a formula 
for paralysis. "Let's start somewhere, instead of nowhere," I re-
plied. "And why not with at least one of the greatest scourges we 
face in the world today?") Questions about where responsibility for 
dealing with AIDS ought to lie were disturbing to me, because of what 
they suggested about the potential will for global action. 

"AIDS in most parts of the world is associated with behaviour . . . 
something over which people have some control." (So, should we there-
fore also not treat other "behaviour induced diseases," such as heart 
disease, cancer, stroke, and sports injuries?) 

"So who will ultimately end up paying for these drugs? . . . [I]t 
will be just another thing for the taxpayers to eat? . . . How is 
this [free drugs] supposed to help people help themselves?" ("This is 
why we have communities," I replied, "including a global community.") 

One email correspondent asked why he should care about AIDS in Af-
rica. "What does this have to do with me?" he asked. "I deeply be-
lieve we are one world," I responded, "and all humankind are con-
nected." He replied instantly with a further question, which haunts 
me still. "Where did you get that idea?" he asked. 

Conclusion

Seven months after the editorial appeared, one drug company executive 
has replied to me. He described and celebrated in a letter important 
steps his firm has taken to reduce the financial barriers to AIDS 
care and to support treatment and prevention programmes, steps that I 
knew about before I wrote the editorial, and that I applaud. 

But that is not enough, and it is not what I am asking for. These 
initial acts of generosity only set the stage for what the world 
really needs: a dramatic, unprecedented, and unequivocal decision by 
the boards and executives of several important pharmaceutical compa-
nies to make their anti-HIV drugs free. Not half a loaf a whole loaf. 
If they did that, these leaders would change the face of the world. 

References 

[1] Berwick DM. We all have AIDS. Washington: Washington Post, Jun
    26 2001:A17. 
[2] Farmer P, Kim JY. Community based approaches to the control of
    multidrug resistant tuberculosis: introducing "DOTS-plus." BMJ
    1998; 317: 671-674[Full Text]. 
[3] World Health Organization. Guidelines for the management of drug-
    resistant tuberculosis. Geneva: WHO, 1997. 
[4] Gupta R, Kim JY, Espinal MA, Caudron J-M, Pecoul B, Farmer PE, et
    al. Responding to market failures in tuberculosis control. Sci-
    ence 2001; 293: 1049-1051[Full Text]. 
[5] Farmer P, Léandre F, Mukherjee JS, Claude MS, Nevil P, Smith-
    Fawzi MC, et al. Community-based approaches to HIV treatment in
    resource-poor settings. Lancet 2001; 358: 404-409[Medline]. 
[6] Joint United Nations programme on HIV/AIDS (UNAIDS). AIDS epi-
    demic update: December 2000. Geneva: UNAIDS, 2000. 
[7] Mocroft A, Vella S, Benfield TL, Chiesi A, Miller V, Gargalianos
    P, et al. Changing patterns of mortality across Europe in pa-
    tients with human immunodeficiency virus infection. Lancet 1998;
    352: 1725-1730[Medline]. 
[8] Palella Jr FJ, Delaney KM, Moorman AC, Loveless MO, Fuhrer J,
    Satten GA, et al. Declining morbidity and mortality among pa-
    tients with advanced human immunodeficiency virus infection. N 
    Engl J Med 1998; 338: 853-860[Abstract/Full Text]. 


--
The Washington Post editorial: We all have AIDS 

In many occupied nations during World War II, the Nazis ordered Jews 
to wear a yellow star, as prelude to their destruction. But not in 
Denmark. According to legend, the Danish king, Christian X, threat-
ened that, if Danish Jews were to wear the star, he would, too. The 
story is almost certainly a myth, but its meaning is not. Despite the 
Nazi occupation, Denmark rescued the overwhelming majority of its 
Jews. "If some Danes are under siege," the story means to say, "then 
all Danes are under siege. So, for now, we are all Jews." Now we all 
have AIDS. No other construction is any longer reasonable. The earth 
has AIDS; 36.1 million people at the end of the year 2000. In Bot-
swana, 36 percent of adults are infected with HIV; in South Africa 20 
percent. Three million humans died of AIDS in the year 2000, 2.4 mil-
lion of them in sub-Saharan Africa. That is a Holocaust every two 
years; the entire population of Oregon, Iowa, Connecticut or Ireland 
dead last year, and next year, and next. More deaths since the AIDS 
epidemic began than in the Black Death of the Middle Ages. It is the 
most lethal epidemic in recorded history. Prevention will be the most 
important way to attack AIDS everywhere, but treatment matters, too. 
We can treat AIDS effectively. We cannot cure its victims, but we can 
extend their healthy lives by years with luck, by decades. We can re-
duce its transmission from infected mother to unborn child by two-
thirds or more. We are seeing the effects of advancing science plus 
enlightened public health policies in the United States, where the 
toll of AIDS began to fall in 1997. Successful, life-prolonging man-
agement of HIV infection is not simple. Important dimensions include 
education, social support and life-style interventions that are ex-
tremely difficult to achieve in the developed nations, and many times 
more so in impoverished nations. 

But it is a mistake to ignore the role of medications. In New York, 
San Francisco or Nairobi, no matter how different the cultural chal-
lenges, the correct mainstay of lifesaving care for the unborn child 
or the infected adult is medicine, given in a timely, scientifically 
accurate and reliable way. Most people on earth with HIV and AIDS do 
not get those medicines. The barriers are partly social and logisti-
cal, but the overwhelming barrier is cost. At current prices, one 
year of triple drug therapy for an HIV-positive person costs $15,000. 
Recent, welcome changes by a few progressive pharmaceutical compa-
nies, like Merck & Co., promise to reduce that cost by thousands of 
dollars per year. But keep in mind that no legend claims King Chris-
tian talked of putting on only half a yellow star. Here is what the 
world needs: free anti-AIDS medicines. The devastated nations of the 
world need AIDS medicines at no cost at all, or, at a bare minimum, 
medicines available at exactly their marginal costs of manufacture, 
not loaded at all with indirect costs or amortized costs of develop-
ment. No hand-waving or accounting maneuvers for all practical pur-
poses, free. Here is how it could happen: the board chairs and execu-
tives of the world's leading drug companies decide to do it, period. 

To the anxious corporate lawyers, the incredulous stockholders, the 
cynical regulators and the suspicious public, they say, together, the 
same thing: "The earth has AIDS, and therefore we all, for now, have 
AIDS. Therefore, we are taking one simple action that will save mil-
lions and millions of lives. We choose to do it, together, and we 
will use the intelligence of our own forces to figure out how to make 
it possible, while preserving the futures of our companies." No one 
could stop them; none would dare try. For the small profit they would 
lose, they would gain the trust and gratitude of the entire world. 
They would have created a story to be told for a millennium, and 
those who depend on the prudence of these leaders on their "fiduciary 
responsibility" might chose then not to blame them but to join them 
in celebration, as fiduciaries of humankind. The names of the people 
who can say this, together, include these: Raymond Gilmartin, (chair-
man and CEO of Merck & Co.); Sir Richard Sykes and Jean-Pierre Gar-
nier (respectively chairman and CEO of GlaxoSmithKline); Charles A 
Heimbold, Jr, and Peter Dolan (respectively chairman/CEO and presi-
dent of Bristol-Myers Squibb); Dr Franz B Humer (chairman and CEO of 
Roche). There are others; they know who they are. These few souls, 
with this act, would ultimately save the lives of more human beings 
than died in the Holocaust perhaps two or three times over. If a No-
bel Prize followed, it would be redundant. The memory of the deed 
would likely outlive even the story of the Danish king who joined his 
people in their need. [C A Heimbold Jr has since retired from Bris-
tol-Myers Squibb.]

© BMJ 2000.
BMJ 2002;324:214-218 (26 January) 

ARTICLE FOUND AT: 
http://bmj.com/cgi/content/full/324/7331/214?eaf 

WRITTEN BY: 
Donald Berwick, president and chief executive officer
Institute for Healthcare Improvement
375 Longwood Avenue
Boston, MA 02215, USA  
mailto:dberwick@ihi.org 

--
Cecilia Snyder
Senior Project Associate - CCMC
Communications Consortium Media Center
http://www.PLANetWIRE.org 

1200 New York Ave NW Suite 300
Washington DC 20005-1754, USA
Tel: +1-202-326-8711
Fax: +1-202-682-2154
mailto:csnyder@ccmc.org
http://www.ccmc.org

--
To send a message to AFRO-NETS, write to: afro-nets@usa.healthnet.org
To subscribe or unsubscribe, write to: majordomo@usa.healthnet.org
in the body of the message type: subscribe afro-nets OR unsubscribe afro-nets
To contact a person, send a message to: owner-afro-nets@usa.healthnet.org
Information and archives: http://www.afronets.org