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Bangkok Bust - failing AIDS policy, again

Roger Bate
July 29, 2004

The prostitutes in Bangkok are back at work - no doubt relieved that since the AIDS gravy train left town last week they are no longer receiving daily sermons about condom use. But while the oldest profession was the chief local talking point, the main discussion at the recently completed XV International AIDS Society's conference was of the failing policies of the United States. In addition to the usual stream of complaints that the Iraqi war has diverted attention away from HIV/AIDS, the chief concerns were that US policy was driven by drug company desires to protect patents and that the Bush administration was being stingy.

The July 13 edition of The Bangkok Post headlined "US blasted for 'doing too little.'" While Uncle Sam is donating $15 billion over five years, the Post noted, "It was not enough for the activists who even praised Thailand as having done more than the US in helping the fund. Thailand has decided to give $1 million for five years." As Newsday columnist James Pinkerton, assessed: 'Now let's see here: the US is giving $15 billion over five years, while Thailand is giving $5 million over five years. Even adjusting for population and GDP, the US is making 134 times the effort. And yet the activists "praised Thailand as having done more." Welcome to the bizarro world of AIDS conferences.

Ignoring the specific absurdity highlighted above by Pinkerton, attacking US policy in general undermines the broadly correct approach the Bush administration has taken. This has the unfortunate and ironic effect of diverting attention away from the real barriers to good healthcare. Instead of picketing outside US embassies around the world, or shouting down Pfizer's CEO in Bangkok, activists would achieve more for people living with disease if they targeted African governments instead.

Earlier in the month I co-authored a paper [1] that explored some of the more important barriers to effective AIDS treatment in poor countries. While the popular view is that large multinational drug companies, supported by US trade missions, ensure that poor Africans die because their governments enforce drug patents, the reality is somewhat different. Very few AIDS drugs are patented in poor countries, and indeed the WHO's list of essential medicines (which include AIDS medicines) are patented only 1.4% of the time in 65 poor or developing countries.

The simple and intuitive argument that drug patents lead to high prices and thus block access to drugs has been popular with the world's media. But this popularity has probably done significant damage by masking the real barriers and frustrating attempts to deal with more fundamental problems.

Chief among the real barriers is poverty. When many Africans live on less than $2 a day and some of their governments can only afford to spend around $10 per person per year on healthcare, it is not surprising that even the most basic and affordable treatments are unavailable, to say little of complex treatments such as antiretroviral drugs.

The lack of African medical infrastructure is caused by poverty driven by failed socialist economic policies that many African governments pursued (and continue to pursue). Furthermore, some African governments choose to spend more money on their military than on doctors and nurses. Africa's ill and infirm are now paying for the policy decisions of corrupt politicians in the past. South Africa is losing many of its qualified medical staff to wealthier countries that can offer them better pay and working conditions. Yet instead of increasing the pay of its doctors, the South African government has different priorities: The Health Minister claimed 18 months ago that the US might invade, as a reason to defend a 2002 allocation of $4 billion in one solitary arms deal.

Over 22% of Namibia's population is reported to be living with HIV/AIDS, the country has only 29 physicians per 100,000 population (10 times lower than the US) and more than half the population lives on less than US$2 per day. Yet the country's president, Sam Nujoma recently lavished a $50 million mansion on himself at taxpayer expense. One would have thought that this flagrant misuse of funds in a poor country would be far more worthy of activist ire than US foreign policy.

Apart from the lack of political will to spend taxpayer money sensibly, there is also a lack of will to be open and honest about HIV/AIDS. With the notable exceptions of Botswana and Uganda, most African governments have failed their citizens by either denying or ignoring HIV/AIDS. Before he was distracted with his efforts to abuse, torture, murder and rape his political opposition, Zimbabwe's Robert Mugabe blamed HIV/AIDS on homosexuals, who he considers to be un-African. South Africa's effort to fight AIDS was harmed by President Mbeki and his minister of health's denials that HIV caused AIDS.

The various drug medicine regulators in Africa frequently hold up new registrations of drugs in lengthy and outrageously inefficient procedures. Drugs that have been registered for use in the US, EU and Japan can wait for over 2 years before South Africa's Medicines Control Council (MCC) will authorise their use in that country. All of this means that the expense of registering and selling drugs in Africa increases and inevitably, it is the patient that suffers.

Removing taxes, such as South Africa's 14% value added tax on all medicines, or the Congo's 30% import tax, or Rwanda's 9.5% foreign exchange charge, should be an important first step towards ensuring more affordable and available medicines. Yet it seems few African governments are willing to do the right thing and stop their bureaucracies from feeding off the limited budgets of Africa's sick and dying.

But its not just African countries that are to blame in taxing drugs. Argentina (21 per cent), Bangladesh (15 per cent), the Dominican Republic (28 per cent), Greece (15 per cent) and Turkey (18 per cent) charge sales tax on life-saving drug imports. Brazil, considered to have the best HIV program in a developing country, charges an 11.7 per cent import duty on medicines. Perhaps worst of all is India, with probably five million HIV cases and only 17,000 people on treatment, which charges at least 25 per cent duty on medicines. These taxes are easy to remove, and activists should apply pressure here.

A far more difficult, yet no less important, task is to try to tackle the stigma of HIV/AIDS. Recently an AIDS treatment facility was opened in the South African town of Welkom in the Free State Province. The Province is home to an estimated 400,000 HIV-positive people, and yet only 1 woman, Sigongile Sambo, was open about her HIV status and came for treatment.

I hoped that at the conference in Thailand, drug companies, activists and governments would find some common ground and start tackling some of the real barriers instead of grabbing headlines with populist, but misguided arguments about healthcare in poor countries. Sadly my hopes were dashed by the usual US-bashing. The HIV patients in poor countries deserve better.

[1] The Real Obstacles to Sound Treat of AIDS in Poor Countries, Roger Bate and Richard Tren, American Enterprise Institute Health Policy Outlook paper.

Roger Bate is a visiting fellow of the American Enterprise Institute and a Director of health advocacy group, Africa Fighting Malaria

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