Petrelis Files

Foreign Affairs: Mbeki Right on HIV Drug Costs?
Elizabeth Pisani's Reaction

(An excerpted page from Foreign Affair's article on HIV drugs for Africa, with a passage about Thabo Mbeki.)

[Update: Longtime AIDS and health writer Liz Highleyman offers keen insight into this debate in the comments section.]

The July/August issue of Foreign Affairs magazine ran a provocative article titled "No Good Deed Goes Unpunished," written by Princeton N. Lyman, former US Ambassador to Nigeria and South Africa, and Stephen B. Wittels, a research associate at the Council on Foreign Affairs.

The full piece, which is behind a pay-wall, looks at the American program PEPFAR, President's Emergency Plan for AIDS Relief, is summarized thus by the magazine:

The United States' commitment to helping treat HIV patients is limiting Washington's leverage over recipient countries and undermining other development goals.

I was interested in all of the points the authors make, but one passage especially stood out, because it called attention to one controversial theory made by the former head of South Africa:

During the early years of this century, then South African President Thabo Mbeki accused the West of focusing on the HIV/AIDS pandemic in order to hook patients in African countries on expensive drugs produced largely by Western pharmaceutical companies. The West would then shift this obligation to African governments, Mbeki argued, crippling their efforts to reduce poverty or meet other development needs. At the time, Mbeki's argument was dismissed as an expression of his deep-seated resistance to recognizing the seriousness of the epidemic. Soon, African governments may begin to wonder if he was right. [...]

Frankly, I was shocked this scholarly publication would have anything positive to say about a single thing to do with any of Mbeki's many controversial theories related to HIV/AIDS drug cocktails, but at the same time it pleased me to see the author include this single point, suggesting Mbeki may have been correct in his criticism of Big Pharma.

Looking for an expert view of the article, I contacted my friend Elizabeth Pisani, an English writer, epidemiologist and public health consultant, who wrote the controversial AIDS book "The Wisdom of Whores," which is also the name of her terrific blog. She sent a long and considered response to what Foreign Affairs published, and I've excerpted key points:

The article doesn’t use the term “AIDS exceptionalism”, but it clearly calls into question the wisdom of putting so many eggs into one basket, on focusing so much spending and attention on HIV, and in particular on treatment. The article frames this in very US-centric terms: the over-emphasis on AIDS treatment is bad for the US because it reduces our ability to use aid as a big stick, to wield when governments don’t act nicely with their people or otherwise do what we want. [...]

The article is concerned that the “bait and switch” dependency foreseen by Thabo Mbeki has come to pass. One cannot fault Mr. Mbeki’s accuracy in observing, at the time, that PEPFAR created a giant market for US-made pharmaceuticals (not for nothing did we all joke that the initials really stood for Purchasing Expensive Pharmaceuticals From American Retailers). [...]

And it was the activism of Africans (including the South African government) that broke PEPFARs initial compact with US-based Big Phama and forced PEPFAR to buy generics and drugs made more cheaply by non-US producers. [...]

What I don’t understand so well is why it is necessarily such a terrible thing if some of the responsibility for paying for drugs reverts to African governments. For one thing, PEPFAR (and external funding for HIV treatment in general) has had a huge displacement effect. It’s true that African governments don’t pick up much of the tab, but that’s not always because they can’t, it’s sometimes they don’t need to — PEPFAR’s already paying. [...]

What the piece does not say: the true dereliction of PEPFAR has been on prevention. Part of the reason we can’t treat everyone even now, let alone in the future, is that there are TOO MANY PEOPLE with HIV. That’s not a value judgement, it is a fact. [...]

The policies of PEPFAR’s first 6 years, in particular the obsession with abstinence-only prevention programmes and the prohibition on working constructively with sex workers are likely actively to have contributed to the further spread of HIV in sub-Saharan Africa, and thus the intractability of the treatment problem. In short, the treatment problem exists in part because PEPFAR’s approach to prevention has been so wrong-headed.

Right now, on the prevention front, we’re clutching at new straws, in particular the Quixoitc hope that more treatment will in itself act as effective prevention. While recent data from San Francisco are encouraging, the same cannot be said for any other site bar Sydney. Looking at the dynamics, it is my expectation that treatment roll-out will, in the absence of better prevention, lead to MORE new cases of HIV in most African settings, not fewer [...].

Elizabeth also said my query to her made have inspired her to write something up for her own blog, regarding the article. I hope she does that, and in the process, brings more international attention to the article, its many criticisms and suggestions.

We need all need to continue the debate about PEPFAR, the US's donations to global HIV programs, Big Pharma's greed and high cost of cocktails, the responsibilities of African governments, and lots more important issues. The Foreign Affair piece is a good jumping off point for that debate.

Please email me, if you need a PDF version of the full text of the article.