Mr. Speaker, the International AIDS Society meeting in Toronto last month focused the world's attention on ways to deal with the ongoing AIDS pandemic. Global health experts and advocates came together to discuss effective tactics and…
Mr. Speaker, the International AIDS Society meeting in Toronto last month focused the world's attention on ways to deal with the ongoing AIDS pandemic. Global health experts and advocates came together to discuss effective tactics and comprehensive strategies for improved prevention and therapies and, ultimately, a cure. I am particularly glad that the meeting highlighted the need for microbicides development, treatments that will allow vulnerable women to protect themselves and their families from infection.
As we consider the recommendations made in Toronto, I want to draw my colleagues' attention to a recent article, ``AIDS in 2006--Moving toward One World, One Hope?,'' published in the August 17 edition of The New England Journal of Medicine. Written by Dr. Paul Farmer and Dr. Jim Yong Kim, leading medical experts with years of front-line experience through their work at Partners in Health, they offer us important lessons that will help translate the optimism expressed in Toronto into the reality of improved global health.
As they point out, an effective approach to the global AIDS epidemic (and to the global TB and malaria epidemics as well) will require strategies that address the global epidemic of poverty and the inequitable distribution of health care resources. Affordable drugs, viable public health systems, access to trained health care personnel, and the provision of nutrition and other ``wrap-around'' services that make the difference between life and death are all essential components for success. As Partners in Health has proven in Haiti and Rwanda, this comprehensive approach is not a pie-in-the-sky notion. It is completely achievable given a commitment to make and sustain the necessary investments.
The work of nongovernmental organizations like Partners in Health, the Bill and Melinda Gates Foundation and the Clinton Foundations HIV/ AIDS Initiative has allowed us to make incredible strides, but they cannot solve these problems alone. As Dr. Farmer and Dr. Kim caution us, ``Only the public sector, not nongovernmental organizations, can offer health care as a right.'' The U.S. government can and must take the lead in expanding our commitment to defeating the twin dangers of global pandemics and global poverty. By doing so, we will not only make the world healthier, we will make it safer.
[From the New England Journal of Medicine, Aug. 17, 2006]
AIDS in 2006--Moving Toward One World, One Hope?
(By Jim Yong Kim and Paul Farmer)
For the past two decades, AIDS experts--clinicians,
epidemiologists, policymakers, activists, and scientists--
have gathered every two years to confer about what is now the
world's leading infectious cause of death among young adults.
This year, the International AIDS Society is hosting the
meeting in Toronto from August 13 through 18. The last time
the conference was held in Canada, in 1996, its theme was
``One World, One Hope.'' But it was evident to conferees from
the poorer reaches of the world that the price tag of the
era's great hope--combination antiretroviral therapy--
rendered it out of their reach. Indeed, some African
participants that year made a banner reading ``One World, No
Hope.''
Today, the global picture is quite different. The claims
that have been made for the efficacy of antiretroviral
therapy have proved to be well founded: in the United States,
such therapy has prolonged life by an estimated 13 years--a
success rate that would compare favorably with that of almost
any treatment for cancer or complications of coronary artery
disease. In addition, a number of lessons, with implications
for policy and action, have emerged from efforts that are
well under way in the developing world. During the past
decade, we have gleaned these lessons from our work in
setting global AIDS policies at the World Health Organization
in Geneva and in implementing integrated programs for AIDS
prevention and care in places such as rural Haiti and Rwanda.
As vastly different as these places may be, they are part of
one world, and we believe that ambitious policy goals,
adequate funding, and knowledge about implementation can move
us toward the elusive goal of shared hope.
The first lesson is that charging for AIDS prevention and
care will pose insurmountable problems for people living in
poverty, since there will always be those unable to pay even
modest amounts for services or medications, whether generic
or branded. Like efforts to battle airborne tuberculosis,
such services should be seen as a public good for public
health. Policymakers and public health officials, especially
in heavily burdened regions, should adopt universal-access
plans and waive fees for HIV care. Initially, this approach
will require sustained donor contributions, but many African
countries have recently set targets for increased national
investments in health, a pledge that could render ambitious
programs sustainable in the long run.
As local investments increase, the price of AIDS care is
decreasing. The development of generic medications means that
antiretroviral therapy can now cost less than 50 cents per
day, and costs continue to decrease to affordable levels for
public health officials in developing countries. All
antiretroviral medications--first-line, second-line, and
third-line--must be made available at such prices.
Manufacturers of generic drugs in China, India, and other
developing countries stand ready to provide the full range of
drugs. Whether through negotiated agreements or use of the
full flexibilities of the Agreement on Trade-Related Aspects
of Intellectual Property Rights, full access to all
available antiretroviral drugs must quickly become the
standard in all countries.
Second, the effective scale-up of pilot projects will
require the strengthening and even rebuilding of health care
systems, including those charged with delivering primary
care. In the past, the lack of a health care infrastructure
has been a barrier to antiretroviral therapy; we must now
marshal AIDS resources, which are at last considerable, to
rebuild public health systems in sub-Saharan Africa and other
HIV-burdened regions. These efforts will not weaken efforts
to address other problems--malaria and other diseases of
poverty, maternal mortality, and insufficient vaccination
coverage--if they are planned deliberately with the public
sector in mind. Only the public sector, not nongovernmental
organizations, can offer health care as a right.
Third, a lack of trained health care personnel, most
notably doctors, is invoked as a reason for the failure to
treat AIDS in poor
countries. The lack is real, and the brain drain continues.
But one reason doctors flee Africa is that they lack the
tools of their trade. AIDS funding offers us a chance not
only to recruit physicians and nurses to underserved regions,
but also to train community health care workers to supervise
care, for AIDS and many other diseases, within their home
villages and neighborhoods. Such training should be
undertaken even in places where physicians are abundant,
since community-based, closely supervised care represents the
highest standard of care for chronic disease, whether in the
First World or the Third. And community health care workers
must be compensated for their labor if these programs are to
be sustainable.
Fourth, extreme poverty makes it difficult for many
patients to comply with antiretroviral therapy. Indeed,
poverty is far and away the greatest barrier to the scale-up
of treatment and prevention programs. Our experience in Haiti
and Rwanda has shown us that it is possible to remove many of
the social and economic barriers to adherence but only with
what are sometimes termed ``wrap-around services'': food
supplements for the hungry, help with transportation to
clinics, child care, and housing. In many rural regions of
Africa, hunger is the major coexisting condition in patients
with AIDS or tuberculosis, and these consumptive diseases
cannot be treated effectively without food supplementation.
Coordination among initiatives such as the President's
Emergency Plan for AIDS Relief, the Global Fund to Fight
AIDS, Tuberculosis, and Malaria, and the World Food Program
of the United Nations can help in the short term; fair-trade
agreements and support of African farmers will help in the
long run.
Fifth, investments in efforts to combat the global
epidemics of AIDS and tuberculosis are much more generous
than they were five years ago, but funding must be increased
and sustained if we are to slow these increasingly complex
epidemics. One of the most ominous recent developments is the
advent of highly drug-resistant strains of both causative
pathogens. ``Extensively drug-resistant tuberculosis'' has
been reported in the United States, Eastern Europe, Asia,
South Africa, and elsewhere; in each of these settings, the
copresence of HIV has amplified local epidemics of these
almost untreatable strains. Drug-resistant malaria is now
common worldwide, extensively drug-resistant HIV disease will
surely follow, and massive efforts to diagnose and treat
these diseases ethically and effectively will be needed.
We have already learned a great deal about how best to
expand access to second-line antituberculous drugs while
increasing control over their use; these lessons must be
applied in the struggles against AIDS, malaria, and other
infectious pathogens.
Finally, there is a need for a renewed basic-science
commitment to vaccine development, more reliable diagnostics
(the 100-year-old tests widely used to diagnose tuberculosis
are neither specific nor sensitive), and new classes of
therapeutics. The research-based pharmaceutical industry has
a critical role to play in drug development, even if the
overall goal is a segmented market, with higher prices in
developed countries and generic production with affordable
prices in developing countries.
There has been a heartening increase in basic-science
investments for tuberculosis and malaria; funding for HIV
research at the National Institutes of Health remains robust.
Yet the fruits of such research will not arrive in time for
those now living with, and dying from, AIDS and tuberculosis.
New tools to prevent, diagnose, and treat the diseases of
poverty will be added to the stockpile of other potentially
lifesaving products that do not reach the poorest people,
unless we develop an equity plan to provide them. Right now,
our focus must be on improving access to the therapies that
are available in high-income countries. The past few years
have shown us that we can make these services available to
millions, even in the poorest reaches of the world.
The unglamorous and difficult process of increasing access
to prevention and care needs to be our primary focus if we
are to move toward the lofty goal of equitably distributed
medical services in a world riven by inequality. Without such
goals, the slogan ``One World, One Hope'' will remain nothing
more than a dream.