Newsday - October 14, 2003
Laurie Garrett, Staff Writer

Sadly, there is nothing unusual about the Zulu family in modern Zambia, a nation besieged by HIV and its companion, tuberculosis. Winstone, now 39, was crippled by a childhood bout with polio. In 1990 he contracted the HIV infection. Seven years later, he nearly died of TB.

And he is the lucky one -- alive, married and father of two children. One brother died in childhood. In 1990, two brothers, already infected with HIV, contracted tuberculosis; they couldn't get appropriate medicine and both died during the same December week. Tuberculosis later claimed two other brothers.

A sister, Rebecca, died of an AIDS-related cancer.

Recently, a younger brother developed TB and died because a key antibiotic was in short supply. Winstone is the only surviving son -- and the family's only TB survivor. He lived because Zambian army friends smuggled antibiotics from South Africa for him. In New York last week, Zulu talked of the family's loss. "We are accepting this as normal in Zambia," he said. "I am losing all of my brothers. If I was to talk about my cousins -- wow, it's every other week, another funeral.

"And we see it now in Zambia as if it's normal, and that frightens me." He decried the shortage of antibiotics, which he said cost only $10 for a course of treatment: "You just say, 'Hey, all of this could have been avoided.'"

Zambia is a poor country, ranking 163rd out of 175 nations in per capita economy.

Last year Zambia spent just $11 per person on health, according to the World Bank. AIDS has infected nearly a quarter of the adult population. And the TB rate is the third highest in the world, behind Cambodia and Swaziland, the World Health Organization reports.

TB is the main killer of people infected with HIV in Africa. It takes advantage of body systems ravaged by HIV infection, lurking inside lungs until the immune system can no longer fight it off. Though TB can be treated with antibiotics taken daily for six months, the $10 price -- and the medical-support system necessary to deliver them -- is generally out of reach to most Africans with the disease.

Three years ago the WHO and a host of government and private groups mounted a global campaign, the Stop TB Partnership, a key element of which is the Global Drug Facility, which purchases antibiotics in bulk and distributes them to needy countries.

A staff in Geneva negotiates rock-bottom prices for the antibiotics that are mostly made in India and are shipped directly to each country. The staff also helps countries set up TB treatment programs and insist that governments ensure patients take medicines properly to thwart development of drug-resistant strains of the disease.

The program goes beyond "the parachuting of drugs into a country," Dr. Mario Raviglione, head of WHO's tuberculosis program, said in an interview. "It's making the whole system work."

Since March 2001, 2 million people have been cured as the Global Drug Facility has sent $20 million worth of drugs to 46 nations, manager Gini Arnold said in an interview. But a funding shortfall means the program intended to treat 739,200 TB patients in Zambia can supply drugs for only 683,200.

The Zulu family and the Global Drug Facility itself appear to be unlikely victims of public health successes. The Geneva-based health body's approach has proven so successful that WHO director-general Lee Jong-wook recently announced plans to use it as a model for supplying more costly and complicated anti-HIV medicines to poor countries.

Two years ago the Global Fund to Fight AIDS, Malaria and Tuberculosis was created. As the Global Fund grew with hundreds of millions of dollars in donations, the much smaller Global Drug Facility saw its donations fall. In interviews, WHO officials said that donors are overwhelmed by requests for funds. They also said that most of the political pressure for funding is on behalf of the Global Fund.

"We cannot afford to have a GDF that collapses simply because of competing elements in the atmosphere," Raviglione said.

Without an infusion of $25 million to $30 million, the organization is doomed to disappear in six months.

So Zulu is rolling his wheelchair through cities here in an effort to draw attention to the organization. He is being supported by a Washington, D.C.-based health charity called Results.

"In Zambia the big talk is, 'Let's put 10,000 people on antiretrovirals," the anti-HIV drugs, he said. "But ... first things first. I got treated for the TB first, then I got on the antiretrovirals. If I didn't have the tuberculosis treated, what good would the antiretrovirals do me?"

The U.S. Congress sent $3 million to the Global Drug Facility this year, 90 percent earmarked for drug purchasing. Funding for next year is likely to be reduced to $2 million, according to Results' legislative liaison Joanne Carter. Even as Congress debates its contribution to the Global Fund, the very existence of the Global Drug Facility seems to be off the politicians' radar screens, Raviglione said.

"When you have activists pushing for AIDS drugs, people forget there are other things: tuberculosis and malaria," he said. "It's a paradox." Global Drug Facility officials said its relationship with the Global Fund appears problematic.

"The Fund does not want to give priority to GDF as the procurer of drugs," Global Drug Facility spokesman Michael Luhan said.

The Global Drug Facility leadership insists the Global Fund should tell poor countries to get their TB drugs free -- from the Global Drug Facility -- rather than buying them from local manufacturers or on the open market.

But Global Fund spokesman John Leiden, reached in Geneva, said: "We don't give preferential treatment to GDF because that undermines our credibility and our principles. We don't tell countries where they ought to get their drugs."

The Global Fund's position is aimed at encouraging commercial competition, ultimately driving down the prices of antibiotics, Leiden said.

But Luhan said the situation is at an impasse. "The GDF is now out of money," he said.

Zulu said the drug shortage likely will result in families sharing the medicines. The result -- inadequate doses for all concerned -- would promote development of drug-resistant strains of tuberculosis.

The scenario leaves him desperate about the future. "How do we put the urgency back?" he asked. "We should be on a war footing."
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