Newsday - July 18, 2000
Laurie Garrett, Staff Correspondent

"We have changed the face of how societies deal with illness," Hong Kong AIDS activist Loretta Wong told the 12,000 conference delegates at the meeting's close. "The scientist has become activist. And the community has become scientists."

"The '60s are back," said Dr. Peter Piot, director of the United Nations AIDS Programme, in a reference to an era of populist activism.

In essence, this was a meeting that witnessed a shift from looking at AIDS as a science and health issue to seeing it as a problem that belongs to all sectors of society. It marked a shift as well from the dominance of wealthy nations of the Northern Hemisphere to the needs of poor nations in the South.

New York City AIDS activist and MacArthur Genius grant recipient Mark Harrington labeled the Durban gathering "the most politically active meeting since AIDS activists took over the Montreal [conference] in 1989." There, activists stormed the stage when Prime Minister Brian Mulroney was speaking, demanding an overhaul of the U.S. National Institutes of Health's AIDS research agenda. Their efforts ultimately had an impact.

Harrington went on to say that the scope of the epidemic "is so massive that there is going to be pressure from everywhere on all governments to fight AIDS."

Few Americans were among the 12,000 researchers, clinicians, activists and health workers here who experienced the paradigm change. Only 2,500 to 3,000 delegates were from the United States, as political controversy and travel cost combined to keep many away.

"I'm still pretty angry about that," Italian scientist Stefano Vella, president of the International AIDS Societies, said in an interview. "They have missed the most important gathering in the history of the epidemic."

It was more than just the first time the global AIDS community convened in Africa-or in any developing country. The Durban gathering witnessed an unprecedented meeting of minds, as delegates embraced issues as far-ranging as CD-4 T-cell counts in HIV-exposed newborns to International Monetary Fund debt-forgiveness policies and the policies of the government of South Africa.

In the weeks leading up to the conference, one trade union press release vowed to "turn Durban into Seattle"-a reference to the demonstrations last year at the World Trade Organization meeting in that city. Yet many of the "globalization" issues raised during those protests became central themes in Durban.

Whether scientists-such as the molecular biologists and virologists who toil daily in their laboratories searching for ways to fight the human immunodeficiency virus-will be comfortable within this new environment is an open question. American scientists, in particular, had already complained for years that the biennial world conference is a political circus. They prefer smaller, science-only meetings in which politics is restricted to back-biting over academic positions and grants from the National Institutes of Health.

But HIV isn't just a virus. It's the culprit for what former South African President Nelson Mandela told the conference was "one of the greatest threats humankind has faced, and certainly the greatest after the end of the great wars of the previous century."

Or, as Oxford University epidemiologist Roy Anderson put it, AIDS "is the biggest infectious disease crisis humanity has ever faced."

Some numbers are pertinent. According to a report released at the conference by UNICEF, more than 10 percent of children aged 15 to 24 years in 13 African countries are already infected with HIV. In five of those nations-Botswana, Lesotho, South Africa, Zimbabwe and Namibia-the child infection rate exceeds 20 percent. And in Botswana, it's a staggering 34 percent. The report went on to say 10 million to 12 million youngsters have lost one or both of their parents to AIDS.

"How is it that, after 15 years of such painful acquaintance with AIDS," the report asked, "we have bequeathed such a deadly legacy to 10.3 million of our young?"

Mandela was adamant:

"In the face of the grave threat posed by HIV/AIDS, we have to rise above our differences and combine our efforts to save our people. History will judge us harshly if we fail to do so now, and right now.

"Let us not equivocate: A tragedy of unprecedented proportions is unfolding in Africa. AIDS today in Africa is claiming more lives than the sum total of all wars, famines and floods, and the ravages of such deadly diseases as malaria. It is devastating families and communities; overwhelming and depleting health care services; and robbing schools of both students and teachers.

"AIDS is clearly a disaster, effectively wiping out the development gains of the past decades and sabotaging the future."

UN AIDS' Piot told the conference that it was time to stop thinking of AIDS as a scientific and health issue. It is bigger than that now, he insisted, a plague that is devastating every sector of society, from banking to farming, churches to schools. And as such, it must be addressed by both government and the private sector.

That puts science, which has historically been in the driver's seat in this microbial war, on a bus filled with other players. Now diplomats, presidents, world bankers, sociologists, religious figures, community planners-everybody is on the bus, and science is no longer the driver.

Science's primacy was directly challenged in the spring when South African President Thabo Mbeki convened a panel to question whether or not HIV causes AIDS. Stunned to have a politician question a fundamental tenet of contemporary science, researchers all over the world mounted a counter-attack, culminating in the "Durban Declaration," a document stating that HIV was irrefutably the cause of humanity's plague. More than 500 top AIDS researchers signed it, and that angered Mbeki.

But while the Mbeki-vs.-Science clash caused tension, a more fundamental erosion of science's primacy in the AIDS fight emerged. It was, ironically, the result of science's successes-of the role of protease inhibitors and the drug combinations that stifle HIV in patients in North America and Europe, giving them longer, AIDS-free lives.

The poor world can't afford the fruits of those scientific success stories, but now is demanding a share.

Ethicist Ron Bayer of Columbia University told the conference: "What is necessary at this point is to make clear that, from a moral point of view ...the gulf that separates the experience of the United States and other economically advanced nations and the nations where the HIV epidemic continues to surge is unacceptable.

"It constitutes an outrage against the most basic conceptions of international justice, of human dignity, against the very idea of human solidarity." That gulf "only serves to underline how fundamentally we need to change our ways of thinking, of acting and of organizing the global economy."

The drug companies at this meeting, the World Health Organization and UN AIDS found themselves in a maelstrom as activists and national leaders demanded cheaper drugs, elimination of patent barriers to generic product production, new trade agreements and lower pharmaceutical profits.

"People want drugs for all. But people should be realistic," Dr. Peter Lamptey, the Ghanaian director of Family Health International in the United States, said in an interview. "We need to improve prevention. We don't have even $300 million worth of donor money for prevention. Yes, we need to improve access [to drugs], but it needs to be realistic. Will it stay on the agenda? Yes, it must."

Seth Berkeley, president of the International AIDS Vaccine Initiative, agreed, saying that "a new dialogue is under way. What's doable? And not doable? I think drug access is clearly on the agenda and will stay on the agenda."

Boston University's Richard Laing said the global pharmaceutical market is now worth $406 billion and growing at a rate of 7.8 percent annually. More than a quarter of that market is in the United States- and just more than 1 percent is in Africa. Last year the industry earned $1.1 billion off just three of the dozens of AIDS drugs now on the market, Laing said. And industry profits among companies making leading AIDS drugs range from 11 to 33 percent annually.

Laing showed that Brazil, which manufactures its own generic versions of these drugs, is able to sell them at markedly lower prices. For example, AZT costs $304.20 a month in the United States vs. $32 a month in Brazil. The protease inhibitor ritonavir costs $1.86 per pill in the United States, but just 88 cents in Brazil.

Activists and the health officials of poor nations are confronting a drug industry that's on the defensive. At the conference, several drug companies unveiled programs to give free drugs to poor countries.

"We want to work with governments to assess what their needs are," said Jeffrey Sturghio of Merck & Co. "This is a complex problem and we're all trying to do something to address it."

Durban conference chairman Dr. Hoosen Coovadia insisted that the Pandora's boxes opened at this meeting will remain open. AIDS is politics. AIDS is economics. AIDS will never again, he said, be "just health and science."

"Something amazing, something profound and unforgettable has happened this week," he said at the closing ceremony. "And you know it. And I know it. All of us have generated a colossal energy here in Durban. And the mood - it's bordering on exhilaration."

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