- The Washington Times - Sunday, September 21, 2003

GENEVA — As AIDS runs rampant in Africa and threatens calamity for India, China and Russia, epidemiologists say even the promise of billions in rescue money cannot curb the disease as long as social and political barriers hamper the fight.

“Coping mechanisms are collapsing,” Richard Feachem, head of the Global Fund set up by leaders of the industrialized democracies, said in an interview. After two decades, he said, the pandemic is spinning further out of control.

Peter Piot, director of UNAIDS, the U.N. agency fighting the disease, agreed that denial and lack of urgency on the part of some governments have blunted international action.



“In Asia and Eastern Europe the political leadership isn’t there,” he said. At recent meetings in India, Mr. Piot said, “I heard great speeches, but as for action, zero.”

The U.N. General Assembly gathers for a special one-day session on AIDS today, brightened by the prospect of infusions of money, primarily President Bush’s promised $15 billion aid package. But the consensus among dozens of specialists interviewed in Europe and America is that the money won’t help much unless countries come out of denial and work together.

They say China and India have millions more HIV-positive cases than officials acknowledge. Russia largely is a mystery because many infected drug users and prostitutes have not been tested. Officials in Moscow say 250,000 people are registered as HIV-positive, but public-health doctors are convinced the real figure exceeds a million.

About 65 million people are known to have contracted human immunodeficiency virus, which causes AIDS, in the past 20 years, and 25 million of them have died, according to U.N. estimates. Last year, 3.1 million died, and 5 million more were known to be infected.

The experts praise Mr. Bush for giving new priority to the crisis, but they say the money promised over five years for 14 countries is a fraction of what is needed, and that overlapping programs with conflicting policies could muffle its effect.

A hard challenge made harder

Stigma and social taboos still thwart effective action, and AIDS money is lost to duplication, corruption and mismanagement.

“I don’t think there is malevolence here but rather a genuine confusion, a sort of land scramble,” says David Miller, an expert with the World Health Organization (WHO). “Everyone is competing for the same small amount of funding.”

“You’ve got every country learning their own lessons,” he said. “Nothing is clear. It’s like gazing at a plate of spaghetti.”

AIDS, say the specialists, must be seen as not just a medical problem but as a scourge that could affect the world economy by depleting work forces, disrupting farming cycles, and killing civil servants and business executives.

In sub-Saharan Africa, a third of adults are infected. A single highway linking Kenya, Uganda and Rwanda is seen as one of the major routes along which drivers and prostitutes carried the disease to crisis levels. In Zambia, the air force once had to be grounded because so many pilots fell sick.

Epidemiologists fear a similar effect on Asia and Eastern Europe unless sweeping measures are taken quickly to raise awareness, dispel stigmas and encourage people to get tested for HIV.

“We are still way, way short. We need a massive upgrade of care, with access to counseling and testing,” said Michel Lavollay, a respected French AIDS specialist. “Now, 95 percent of infected people don’t know they are infected.”

Effective research has produced drugs to slow AIDS, and these can be supplied at $300 a year per patient, said the Global Fund’s Mr. Feachem, but many governments lack either the funds or the will to supply them.

“On an effectively large scale, we have done nothing,” he said. “We haven’t achieved any of the changes that would have made a difference.”

Speaking in epidemiological terms, he put it starkly: “If in 1982 when we became aware of the virus we had decided to do nothing in order to observe its course without intervention, the world would be roughly where it is today.”

Mr. Piot, the UNAIDS chief, said he disagrees, arguing that there has been substantial progress. But, he said, “We should have invested far more in development, security and political issues.”

But he worries that too much focus on drugs will again allow governments to neglect such other essential components of the anti-AIDS fight as counseling, prevention and overall treatment.

Richard C. Holbrooke, former U.S. ambassador to the United Nations who now champions the fight against AIDS, said by telephone from New York that private business has done 5 percent of what it should have done.

“We’ve only scratched the surface on prevention and treatment,” he said, adding that productivity and growth are at risk in much of the world.

By supplying infected employees with drugs and other care, businesses can protect their work forces and, thereby, bolster the economies on which they depend, he said.

Mr. Holbrooke cited Thailand as a rare success story. Government officials helped AIDS workers deliver the message, through cartoons for children to a publicity blitz for safe sex and community care.

Rival bureaucracies

Several specialists fault turf wars for many of the problems today.

Mr. Feachem, a British epidemiologist with the University of California at San Francisco, runs the Global Fund, set up in Geneva after a Group of Eight summit in 2001 to raise money independent of the United Nations and individual governments.

But the worldwide campaign is coordinated elsewhere in Geneva by UNAIDS, a newer version of the Global Program on AIDS, or GPA, pioneered by American virologist Jonathan Mann in the 1980s.

Mr. Mann and his high-profile team made some headway in prevention, treatment and counseling, mobilizing families and communities to increase AIDS awareness and chipping away at prejudices that caused embittered victims to seek revenge by infecting others.

But Mr. Mann quit, accusing his superior, WHO Director General Hiroshi Nakajima, of thwarting programs by caving in to pressure from national health ministers who elected him. Mr. Mann died in a plane crash in 1998.

Mr. Nakajima was replaced, and the GPA was reshaped into UNAIDS, run by Mr. Piot, an eminent Dutch specialist.

But its staff of 250 operates on a yearly budget of $95 million, while the Global Fund has $4.7 billion to spend over the next five years fighting AIDS, tuberculosis and malaria and seeks an annual “cruising speed” budget of $7 billion.

Officials at UNAIDS as well as the Global Fund say cooperation has been limited.

“You’ve got the money in one agency and the operational people in another,” says Mr. Lavollay, part of Mr. Mann’s original team and now with the U.N. International Labor Organization. “It’s a five-minute drive away, but it’s an unbridgeable gap.”

“We are still not collectively capable of seeing the kind of world AIDS is going to create,” he said.

Money, politics, reality

Mr. Feachem said even the new billions pledged amount to “peanuts” compared with what is needed. But the real challenge, he said, is to persuade national leaders to confront reality.

“How can it be that in country after country, people well informed about what has happened elsewhere cling to denial?” he asked. “And then, after denial, they turn to minimalization.”

Kathleen Cravero, Mr. Piot’s deputy, said the Global Fund has lost time by creating parallel mechanisms. Nonetheless, she characterized Global Fund and UNAIDS’ efforts as effective, if less than perfect.

“We can’t afford to be sulking in the corner,” she said. “We have an epidemic on our hands; deal with it.”

She welcomed Mr. Bush’s AIDS initiative, though uncertain where it would go under the direction of former Eli Lilly chief Randy Tobias, whom she described as “completely new on the scene.”

“We’ll have to make a major effort to win him over — beg to get in the door, and we’ll do it,” she said. “It’s important. Our responsibility is to bring Mr. Tobias into the big picture.”

Noerine Kaleeba, who founded the successful Ugandan self-help group TASO, now organizes community-action programs at UNAIDS. Mrs. Kaleeba, who lost her husband and dozens of relatives to AIDS, briefed Mr. Bush during his trip to Uganda in July.

She said she was encouraged by Mr. Bush’s interest, but she agrees with the others that lessons of the 1980s have yet to sink in.

“People still say Africans can’t use drugs because they don’t have watches — we have roosters,” she said. Though few Africans have access to the drugs, of those who do, 85 percent take them regularly, she said, compared with 70 percent in the developed world.

“I’m still an optimist,” Mrs. Kaleeba said, adding that past mistakes and inaction were no reason to despair. “It is never too late to take action. But the question is, how much has this already cost us?”

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