Wall Street Journal - January 25, 2005
Mali Fleming at mali.fleming@wsj.com

For many people infected with HIV/AIDS, tuberculosis and malaria living in developing countries, there are often no drugs and no viable health systems to treat their illnesses. As a result, about six million people world-wide die of these three diseases a year.

The diseases are stunting economies and destabilizing communities around the globe. Per-capita growth in some sub-Saharan African nations is estimated to drop by 0.5% to 1.2% each year as a direct result of AIDS, and TB and malaria are expected to cost the poorest countries billions in income and lost gross domestic product.

The World Health Organization's mission is to attain the highest possible level of health for people around the globe. Its "3 by 5" initiative aims to get three million people with HIV/AIDS in developing and middle-income nations on antiretroviral treatment by the end of 2005, up from 440,000 people in these nations as of June 2004. WHO will give a "3 by 5" progress report at the annual World Economic Forum, which runs Jan. 26-30 in Davos, Switzerland. (See a map of antiretroviral use.)

Jack Chow, the WHO's assistant director-general for HIV/AIDS, TB and malaria, helps coordinate the United Nations health agency's efforts to combat these scourges. In an interview, Dr. Chow discussed the global campaign to fight AIDS, TB and malaria, their impact on poor nations, WHO's goals and why Western nations should continue to extend aid to those in need.

WSJ.com: About six million people die every year of HIV/AIDS, TB and malaria, with the brunt of the epidemics felt especially hard in developing countries. What can these nations do to halt the spread of these diseases?

Dr. Chow: We believe that no one country, no one institution ought to confront HIV/AIDS alone. We need to knit together coalitions to effectively raise awareness, promote prevention and provide treatment. What I would describe is a four-cornerstone approach. One is advanced effective public-health strategies that include prevention, treatment, care, training of the health work force, building of clinics and hospitals and doing research and development. The second cornerstone is mobilizing civil society, combining expertise in a way that takes advantage of core strengths. One can envision combinations that have labor unions working with business managers or faith-based organizations working with secular organizations.

The third cornerstone would be leadership ... at both the national and community levels. It's also important to have an assertive citizenry ... who bear witness to the benefits of that investment so that governments and other funders can sustain the effort in the long run, particularly since AIDS treatment is currently a lifelong therapy. The fourth cornerstone is resource mobilization, both within the country and globally.

And that is why there is now a new Global Fund to Fight AIDS, Tuberculosis and Malaria [an international partnership of governments and private donors that gathers and distributes funds globally] or the American Emergency Plan for AIDS Relief [President Bush's pledge of $15 billion for AIDS efforts].

Q: Does the WHO fear that its campaign against AIDS, TB and malaria will lose funding because of the massive global outpouring of donations to the tsunami victims in Asia?

A: We hope not. First we're very heartened with the response to the tsunami-stricken zones. It proves that the world does care and can rally and mobilize resources on short notice. WHO is working to address the direct health impact of the tsunami, and our teams are working to provide medical assistance. But we are also looking for ways to help the countries rebuild their health systems and replenish resources so that the long-term health of the people living in the tsunami-stricken zones can be bolstered.

Q: How do AIDS, TB and malaria impact the developing world in the short and long term?

A: The acute impact we are seeing is in the form of higher rates of mortality, broken families, generations of AIDS orphans, a direct impact on the national economies in the form of higher government expenditures for health care, higher government expenditures for social services. The indirect cost to countries is in terms of lost productivity and potential disruption of the economics -- when you have a country that's lost a major portion of its work force in terms of the global economy. In the long term, there will be a psycho-social impact on children growing up without their parents, insufficient funds to take care, educate and nurture these children into adulthood. You have companies that lost their work force, are less competitive and must devote more time and energy to fill the ranks of those people dying. And the long-term impact is higher risk of social instability and economic disadvantage.

Q: How do these diseases impact wealthier nations and why should richer countries care about them?

A: Well, first there's the humanitarian imperative. Combined, these three diseases are having a compounding effect. These three diseases are killing six million people a year -- three million from AIDS, two million from TB and one million from malaria. It promotes social instability and there's a real concrete economic cost. It weakens trading partners. Think in terms of the economics: African countries affected by these diseases are experiencing huge economic losses due to debilitated economies and work force. By 2020, there might be 20 million AIDS orphans, which will further contribute to destabilize societies and economies.

Q: Where are the hot spots for these three diseases?

A: The "hot spots" for the three diseases are sub-Saharan Africa, south Asia, India. There is a hot spot in the Caribbean -- Haiti and the Dominican Republic on the island of Hispaniola, on which reside 65% to 70% of the AIDS burden in the Caribbean. Areas of concern or areas where the three epidemics are smoldering include the central Asian republics, China and other parts of the Caribbean. There is a direct link between poverty and social inequities intensification of these epidemics. We need institutional resources and stronger health systems to prevent disease and care for the sick.

Q: In many Western countries, drugs and health care are available to treat these diseases. How can the West help poorer countries in dealing with HIV/AIDS, TB and malaria?

A: Since 2001 to 2004, the international spending on AIDS programs has about tripled from $2 billion to $6 billion. So that's a heartening start, but we feel that there are many people who desperately need to benefit from these medicines. That's why WHO embraced the "3 by 5" campaign to help countries put three million people on antiretroviral treatment by the end of this year. The three million target represents approximately half of those who could benefit from the antiretroviral treatment. So it's building a chain of concerted action -- a chain with three links. The first link is the financing -- that's the money in global funds, donations by governments like the U.S., the World Bank and aid foundations. That is connected to the middle link of expertise -- those that provide a blueprint for action. That is what WHO is doing. It's an agency that provides technical assistance to countries. It helps experts write up guidelines for treatment, guidelines for prevention, generating a roadmap to use resources efficiently and effectively. The third link is implementing programs that work in the countries at the community level to provide health services, to provide the antiretroviral medicines and proper care. So what the West aspires to do -- and it is doing -- is building this chain of concerted action to ensure that funds are well spent.

Q: What is the WHO's view on providing generic vs. patented drugs to poor nations?

A: We believe that there is value in both patented and generic medicines. The AIDS virus is a very powerful mutator and can become resistant to antiretroviral medicines. Therefore, we need fresh generations of antiretrovirals. The investment made by research at major pharmaceuticals is essential for innovation for antiretrovirals with fewer side effects. Quality generic medicines are valuable because they can be provided at low cost and can be distributed widely. So it's not an either/or. It's finding a strategy to provide AIDS medicines at an economical price with as low a transaction cost as possible.

Q: The WHO warned late last year that there would be a supply shortage of a key malaria drug from Novartis. How has that affected your fight against malaria?

A: There's a new generation of medicines, based on the Chinese silkwood plant. It is called Artemisia based combination therapy, or ACT. In many countries malaria has become resistant to conventional treatments such as chloroquine. ACTs are currently the most effective medicines available to treat falciparum malaria -- the deadliest form of the disease. WHO is helping countries to switch to new treatment policies and to purchase ACT drugs. Since 2001, WHO has recommended that countries where malaria is resistant to conventional treatments should use ACTs. Forty countries, 20 of them in Africa, have officially adopted these medicines for the treatment of malaria. Novartis makes the brand named called Coartem. The Chinese government, WHO and Novartis as well as some other partners are striving to increase the supply of the raw material from this plant.

So there has been high demand for this medicine because it's very effective. And the challenge on the production side is getting more of the plant to companies like Novartis and Sanofi and other producers to provide more of this medicine.

Q: Please explain how HIV/AIDS and TB are combining to have a deadly effect on some victims.

A: There is a deadly synergy between AIDS and tuberculosis. AIDS weakens over time people's immune systems, thereby making them susceptible to a wide range of illnesses and infections. One-third of the world's population already has tuberculosis bacilli germ in their lungs. Fortunately only a small fraction -- about nine million people -- develops active TB every year. But for those who have AIDS, the possibility of contracting tuberculosis is manifold.

Q: How can Africa, the worst-affected region by HIV/AIDS, recover from this epidemic?

A: It is working in partnerships with a concerned global community. Africa has actually pioneered innovative programs with assertive leadership. Uganda brought down its HIV rate from about 18-19% in the early 1990s to about 5% through comprehensive HIV programs and mobilization. In Senegal, the prevalence rate is lower than 1% for HIV/AIDS. The leaders there chose to comprehensively mobilize and educate.

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