Chicago Tribune - November 22, 2005
David Greising, dgreising@tribune.com, Chief business correspondent

The pills start their journey in Italy, where Abbott Laboratories of North Chicago, Ill., makes the active ingredient. Abbott presses the drug into capsules in Florida, labels and packages them in Britain, then flies them via a Netherlands logistics center to Dar es Salaam, Tanzania's biggest city.

From there refrigerated trucks bound over pitted roads, dodging potholes the size of donkey carts, on their way to regional medical centers such as the one in Muheza town, which serves Maramba and dozens of other villages. Hospital workers hustle the medicine into refrigerated storage. The African heat would turn the pills into useless dust.

Drugs did not arrive in time to save Juraji's mother. She died of AIDS. But they are saving his life.

"Now that there is availability of drugs, he should be OK," said Zuwena Ibrahim, 24, who adopted her nephew after her sister's death.

Difficult as it is, getting pills to Maramba is one of the simpler parts of attacking AIDS in Tanzania.

For five years now, Abbott has worked with Tanzania's government to alleviate the impact of AIDS. The experience has taught the company that the biggest obstacles are less obvious, and less readily overcome, than getting drugs to the villages.

Hospital laboratories are archaic. Treatment wards are overrun with patients. There is little capacity to treat AIDS-related illnesses such as tuberculosis and malaria.

Tanzania cannot adequately care for the orphans of AIDS victims. A social stigma against AIDS victims persists, which deters people from getting tested and treated for the disease.

"People who simplify this into just drop-shipping gobs of drugs into remote areas of Africa, they're nuts," said Miles White, Abbott's chief executive, during a trip to Tanzania last month to review the progress of Abbott's work. "It's a lot more complicated than that."

UN issues new report on AIDS

Indeed, a report released by the United Nations on Monday indicates that efforts by big drug companies to fight AIDS face steep challenges.

The number of people infected globally with HIV, the virus that causes AIDS, doubled over the past decade, to 40 million. The UNAIDS report noted decreased infection rates in Zimbabwe, Kenya and Burkina Faso, and improvements in affecting behavior, but the disease continues to outrun efforts to stop its growth.

In Tanzania, at least, the fight is at least partly about making the best use of the $35 million Abbott has pledged to help Tanzania's government fix mundane problems in the country's health system that enable AIDS to remain a monstrous threat.

The Tanzania program is part of a $100 million Abbott commitment to alleviating the impact of AIDS in Tanzania, Burkina Faso, Romania and India.

Pitfalls for donors in Africa

Dealing effectively in Africa also means avoiding pitfalls that have hit other donors.

The United Nations-supported Global Fund to Fight AIDS, Tuberculosis and Malaria early this year cut off support for five programs in Uganda, citing widespread mismanagement. In Kenya, skepticism over the government's ability to deliver drugs has led church-backed organizations to form a private distribution company.

Merck & Co. teamed with the Bill & Melinda Gates Foundation five years ago to launch a groundbreaking $100 million program to aid Botswana, where 37 percent of the adult male population has AIDS. But the donors have found it difficult to distribute money, in part because of bottlenecks and logistical difficulties.

Tanzania has as many people with HIV/AIDS, 1.6 million, as Botswana has people. The official infection rate is 7 percent of Tanzania's 36.7 million people, though the actual rate probably is twice that, health experts say.

Five years into its commitment, Abbott still fights to find new ways to address the complexity of the AIDS challenge. Abbott is focusing almost exclusively on infrastructure and on the orphans and children victimized by AIDS. The government sets the agenda, then Abbott designs, funds and runs the programs accordingly.

When an Abbott program works, the government rolls it out more broadly.

Tanzania's health minister, Anna Abdallah, would not have it any other way.

"We expect them to do what the government wants them to do," Abdallah said of Abbott and other donors. "They can't do whatever they want in Tanzania, because it's our program. It's a national program."

Few donors are willing to concede so much control.

"Most international players haven't quite realized that they have to be cooperative with players on the ground," said Josh Ruxin, director of the program to expand delivery of health services in developing countries at the Center for Global Health and Economic Development at Columbia University.

Better cooperation makes donors and politicians more effective. When Abbott-funded programs work, politicians can use the results to build political support for their ideas, or to explain why some regions get help and others do not.

"There are domestic funds to do what needs to be done," Ruxin said. "It becomes a question of political will."

Abdallah has political skills honed in a decades-long career in Tanzania's government. Called "Mama Abdallah" by politicians and voters, she is determined to use Abbott's money and expertise to help reverse the hopelessness people have felt in the face of the AIDS epidemic.

"People were afraid to get tested before. They were afraid to know even the result, because what would happen next?" Abdallah said. "The question even haunted us as the government. What could we do for them after they were tested?"

Abdallah had no ready answers at first. But at a world AIDS conference in Barcelona, Spain, in 2002, she heard case studies that convinced her Tanzania had a chance. Returning home, she helped push through a governmentwide AIDS policy. One tangible goal: Get 44,000 Tanzanians on anti-retroviral treatment by the end of this year, up from 21,000 in August.

Abdallah is relying on Abbott to help reach the goal. White, who recently joined the board of Tribune Co., owner of the Chicago Tribune, ramped up Abbott's work in Tanzania after he first visited the country in 2002. Abbott had committed in 2001 to sell AIDS drugs at no profit in Africa. After the trip, White promised to sell Abbott's AIDS drugs in Africa at a loss.

During White's first visit, Abdallah laid out a set of distinctly unflashy needs: Better hospitals, better delivery of drugs, more testing of at-risk people, better prevention of mother-to-child infection. Caring for orphans and fighting the anti-AIDS stigma might be part of the equation too, Abdallah said.

Abbott has not turned itself entirely over to Tanzania's government, though. To increase its political savvy, Abbott has hired Axios International, a corporation that helps donors devise programs to fight AIDS in developing countries. Axios has helped Abbott shape Abdallah's agenda. One example: Abbott introduced a program to address the legal needs of AIDS orphans, helping them qualify for government assistance or protect the assets their parents leave behind.

Treatment alone not enough

"Treatment alone is not that useful. You can't have effective treatment without care and support for others affected by the disease," said Joseph Saba, a former official with the Joint United Nation Program on HIV/AIDS who is chief executive of Axios. After Abdallah saw the test program during a visit to Maramba, she laid plans to expand it elsewhere.

In the end, though, White believes it is important to follow Abdallah's lead. "It's her country," White said after a dinner on one of the three days she spent traveling with him in October. "Who are we to tell her what her country needs?"

Abdallah knew one priority from the start: Fixing Tanzania's largest hospital, Muhimbili National Hospital, by introducing a state-of-the-art laboratory for diagnostic tests, rebuilding its outpatient clinic to better accommodate the needs of AIDS patients, and introducing modern management systems that would help the hospital track patients' health. (See related story.)

But AIDS is a national problem, so Abbott has spent the bulk of the $35 million spent so far on improving facilities at 82 regional health centers and training 1,300 health-care workers to test, counsel and treat AIDS patients.

The Abbott money also has helped five regional hospitals qualify as national HIV treatment centers. It has provided test kits for nearly 60,000 people. About 20 percent of them were diagnosed as AIDS victims.

During White's four-day visit, he saw orphans fed and clothed thanks to Abbott money. Abbott is funding a day-care center in Bantu village, where half the children have parents who have died or are suffering from AIDS. He visited with an AIDS victims' support group that seeks to destigmatize the disease by talking openly about the illness. Loans of as little as $10 to some members have helped them start small businesses selling corn or crafts.

Some experts critical

Some outside experts believe Abbott is spreading its money too widely. There is debate about whether day-care centers, schools and support groups effectively address the AIDS problem.

Others believe Abbott and the Tanzania government should focus more on prevention--the distribution of condoms and counseling to avoid the disease. Abbott pays to train counselors, but not for condoms, an approach that aligns with the controversial stance of President Bush's AIDS fighting program.

"AIDS will be a problem as long as prevention is not working," said William Easterly, an economics professor at New York University and former World Bank economist who specializes in assessing assistance programs. "But it's more politically compelling both for corporate purposes and for political purposes to say they're helping sick people."

White knows outsiders will second-guess what Abbott does. Nuns from the Interfaith Responsibility Research Center regularly attend Abbott's annual meetings and complain Abbott is not doing enough. Shareholders write or call to complain that the company is spending too much.

"The debate is, 'What's enough?' And there's no good answer to that," White said.

Still, White acknowledges that Abbott must hold up its end of a social compact.

"Companies exist largely because society allows us to. They fund us by buying our products. Their governments regulate us," White said. "This is part of the return we have to give back because businesses like us are the only ones who can do what we do."

In Maramba, as Zuwena Ibrahim sits in front of her two-room house and cuddles her sleeping, adopted son, such debates seem beside the point.

Juraji was diagnosed through a testing program funded by Abbott. An Abbott-backed program covers Ibrahim's bus fare to the Diana treatment center where Juraji sees the doctor. She can get counseling from an Abbott-supported psychologist.

A national computerized system tracks her son's progress. Legal assistance is available to help Juraji qualify for government aid and to protect his rights should the child's family try to take his home away, a common problem. Anti-stigma programs may benefit him one day.

"Within the family, he is OK," Ibrahim said. "Outside the family, there might be problems."

Africa may always have an AIDS problem. But funding from Abbott, Merck and other companies helps the epidemic be slightly less acute.

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