Wall Street Journal - June 28, 2001
Mark Schoofs

NEW YORK -- Surprising AIDS doctors and activists in her own country, the South African health minister declared that her nation will not provide AIDS drugs in public hospitals unless it can provide exactly the same standard of care as offered in Western nations. Her stance goes against the grain of new research and treatment initiatives for developing countries, which seek to find low-cost but effective ways of delivering the so-called antiretroviral drugs.

The health minister, Manto Tshabalala-Msimang, made her comments in an extensive interview in New York, in which she and her top deputy, Director General for Health Ayanda Ntsaluba, explained why they believe AIDS drugs cannot be offered in state hospitals and clinics. They cited the lack of infrastructure, especially in the country's impoverished rural areas, and maintained that the drugs and associated costs of monitoring patients were simply unaffordable.

"Given the budget that I have, there is no way that we can have the widespread scale of administering antiretrovirals," said Dr. Tshabalala-Msimang. She stressed that her government is committed to providing medicine to treat tuberculosis, pneumonia and other opportunistic illnesses associated with AIDS. South Africa is estimated to have 4.7 million people infected with HIV -- the highest number of any nation -- and many experts agree that it is important to improve the health-care system before dispensing AIDS drugs.

But Dr. Tshabalala-Msimang also invoked a reason that several leading doctors and activists in South Africa said that they had not heard her say before. "We cannot apply substandards when it comes to our country," she said. Many doctors in South Africa "don't have the systems to do exactly the same things a doctor would do in Copenhagen," she said. "We must exactly apply the same standards in the developing countries" as are applied in Europe and the U.S.

As the price of AIDS drugs has fallen, the cost of monitoring treatment looms as one of the largest financial barriers to treating AIDS patients in poor countries. For example, in the U.S. it is standard practice to measure the amount of HIV in the blood with a "viral load" test. But because that test can cost $100, doctors in some poor countries, such as Uganda, are treating their patients without it. Asked about this type of effort, Dr. Tshabalala-Msimang said, "I would find it very unethical and morally very difficult for me to give a person medicine and then I'm not able to detect whether I am bringing down the viral load [or] whether I am increasing it."

But Peter Mugyenyi, a leading Ugandan physician who runs the Joint Clinical Research Centre in Kampala, says he is treating about 200 patients who can scrape together the money for the drugs but cannot afford the viral-load tests. "The response of such patients is excellent -- as good as those getting viral-load monitoring," said Dr. Mugyenyi. "It would be extremely unethical to wait for Western-style monitoring and let these patients die."

Several leading AIDS doctors and researchers in South Africa agreed. "Health care in South Africa is not the same as in the U.S.," said Salim Abdool Karim, a leading AIDS researcher at the government-funded Medical Research Council. "We shouldn't make an exception on AIDS." He and other medical authorities cited numerous examples of treatment for other diseases -- including kidney failure, stroke, tuberculosis and blood infections in newborns -- that are treated at a different, lower standard in South Africa than in the U.S. or Europe.

The minister's latest comments come amid controversy in South Africa over how to treat AIDS. President Thabo Mbeki has cast doubts on the most fundamental aspects of AIDS science, including whether HIV causes AIDS, and has questioned whether AIDS drugs are too toxic to use. In April, the president was asked on national television if he would take an HIV test, but refused. Many AIDS workers in South Africa believe President Mbeki is obstructing the use of AIDS drugs because of his beliefs, but the health minister denied that, pointing out that the government is not prohibiting the private sector from using the drugs and is establishing guidelines for their proper use.

But the Treatment Action Campaign, a South African AIDS activist group, is preparing to take the government to court to make it provide pregnant women with AIDS drugs that can prevent them from transmitting the virus to their babies during childbirth.

For treating adults, activists have proposed that the government could begin pilot programs in urban centers, where many South African hospitals have the infrastructure to provide sophisticated medical care. But that would be "the worst thing that we can do to the South African health system," said Dr. Ntsaluba. "You might as well forget about any other program running" in those hospitals, he said, adding that the lure of treatment could cause mass migration to urban areas, causing additional health problems.

Write to Mark Schoofs at mark.schoofs@wsj.com

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