| Summer
in academia often means hushed hallways, empty classrooms, and
less than fully staffed offices — a time when academics
finally have a chance to slow down and enjoy a more leisurely
pace. This past summer at the Center for International Development
(CID) — a Harvard-wide initiative established at the Kennedy
School just three years ago — however, such a downshift
in activity was hard to detect.
CID director Jeffrey Sachs and his colleagues
have been pressing hard to educate government and health officials
from wealthy nations about the havoc AIDS has wrought on poor
countries and the actions they can and must take to change
the scenario. In late June, a CID researcher attended the
World Economic Forum Conference in Durban, South Africa, and
a first-of-its-kind UN assembly on AIDS in New York. In July,
the center hosted its third AIDS-related conference in less
than nine months to help galvanize researchers around AIDS-specific
issues — this time on AIDS prevention. And a delegation
from Malawi, including its vice president, also stopped by
in July, to discuss the country’s newly developed AIDS
plan.
An internationally renowned macroeconomist,
Sachs is acutely aware of how health affects economic development.
In the last several years, Sachs has been collaborating with
public health researchers on a World Health Organization (WHO)
project analyzing the link between malaria and economic stability.
In January 2000, WHO Director General Gro Harlem Brundtland
named Sachs chair of the Commission on Macroeconomics and
Health, a group of economists and public health researchers
looking at health as a central factor in economic development.
A Modern-Day Black Plague
Despite this understanding that health and economics
are inextricably intertwined, says CID associate Amir Attaran,
a scientist and lawyer, who has been working closely with
Sachs for more than a year on the center’s international
health initiative, he and Sachs were “gob-smacked”
when they realized the full measure of AIDS devastation on
poor countries. “I knew something about AIDS and so did
Jeff, but six months into it, both of us woke up and said,
‘Oh man,’” Attaran says.
For now, Sachs and Attaran are focusing their
attention on Africa, where a disproportionate number of people
are HIV-infected. Of the 36 million HIV-infected people in
the world, 95 percent live in less developed countries. Each
week, 75,000 Africans are infected with the HIV virus, and
each year AIDS kills another 2 million Africans. In sub-Saharan
Africa, more than 25 million people are infected, and more
than 17 million have died.
In some African countries, the epidemic has
moved in with such ferocity that life expectancies have plummeted
30 years or more, undoing years of economic progress. In Botswana,
which has the highest infection rate in the world, 36.8 percent
of adults ages 15 to 49 are HIV-infected, and nearly 90 percent
of boys in their teens are forecasted to die of AIDS. Sadly,
for many Africans, attending funerals has become a routine
social event.
“We have to get people to understand that
this is the worst pandemic in 650 years, that we have more
deaths from this one disease than we’ve had from any
other since the Black Plague,” says Attaran, who is frustrated
by the indifference much of the developed world has shown
to a disease that has already killed more than 22 million
people worldwide.
A health crisis of this magnitude, they say,
permeates every segment of society. With one in five adults
HIV-infected in sub-Saharan Africa, experts project that as
many as 40 million children will be orphans by 2010. Already,
12 million African children are orphaned.
“It used to be the norm in African countries
that kids must attend school,” says Sara Sievers, CID’s
executive director. “Now when children are seen during
the day, it’s assumed they’re AIDS orphans. That’s
a society falling apart.”
And the repercussions may extend well beyond
national borders. When a generation of AIDS orphans is maturing
without the guidance of adult leadership, even peace is threatened,
Attaran says. AIDS has so devastated African countries, he
says, that it transcends being just a disease threat and is
a national security threat. “When you have a society
full of children with diamonds to fight over, what you have
is Sierra Leone and Angola all over again. And that’s
the scenario we’re going to face across southern Africa.”
Changing Course
When it comes to taking on tough problems, CID’s
director Sachs has never been shy. In the early 1990s, he
worked with Russian leaders as they made their first attempts
at setting up a free-market system. He is a frequent consultant
to fledgling democracies in Latin America and Eastern Europe
and, most recently, has been part of a crusade to relieve
struggling poor nations of their debts to wealthy countries.
His bold approach over the years has captured the attention
of the media, which took particular interest in his unlikely
friendship with Irish rock star Bono, another outspoken advocate
for debt relief. The two have traveled the globe together
speaking out on the subject. In June, Sachs was on the podium
at Harvard’s graduation when Bono delivered the commencement
address.
The high-profile, itinerant economist has taken
on a similar role when it comes to the AIDS crisis, calling
for much bolder action from wealthy countries in fighting
the disease. What Sachs saw when he turned his attention to
the AIDS crisis was a public health community that —
while making progress — had, in many ways, been thrashing
about. Public health officials were dong what they had always
done: working through traditional institutions such as the
World Health Organization, USAID, and UNAIDS. If things were
to change, Sachs figured, he needed to raise consciousness
outside these traditional health/development institutions.
Toward that end, in the last two years, Attaran
and Sachs have been “putting the numbers out there on
the finance side in a way that nobody else has done,”
Attaran says. In an article in the British journal Lancet
earlier this year, Sachs and Attaran detailed the resources
allocated for AIDS to poor countries and called for several
important changes. Support from wealthy countries, they wrote,
must increase by as much as $10 billion annually for the next
few years — in the form of grants, not loans. They also
recommended a “bottom-up” approach that is culturally
sensitive and allows the countries’ leaders to propose
the best ways to develop programs.
In dozens of interviews and op-eds during the
past 18 months, Sachs and Attaran have repeated this message:
Wealthy countries have the capacity to come up with the money
for AIDS treatment. The money requested from the United States
and Europe represents modest amounts, but for Africa, represents
millions of people per year in lives saved.
In an article that appeared in the journal Science,
published by the American Association for the Advancement
of Science, Sachs admitted that he was “not aware of
how incredibly impoverished the global public health system
was. I learned what other people knew, but…the numbers
mean something different to me as a macroeconomist than they
do to a public health official. Many times I had to shake
public health officials and say, ‘Millions are not enough.
This is a matter of billions of dollars at the minimum. And
don’t be shy of the billions, because that’s what
macroeconomic work is all about right now — and public
health is getting unbelievably short shrift compared to the
urgency of the issues.’”
The likely U.S. share would be about $3 billion
a year, or about $10 a year for every American, “the
cost of a movie ticket with popcorn,” said Sachs in a
Boston Globe interview earlier this year. A few billion
dollars, as he has repeatedly stated in the Globe interview
and other media, would enable poor countries to purchase drugs
at discount and get them safely and effectively to the people
who need them.
Attaran concurs that the resources to provide
such support are well within the means of the United States.
“The U.S. government spends in excess of $1 billion daily
against defense threats that are as yet inchoate,” Attaran
says. “We could easily spend a few days of that —
say a week’s worth — for AIDS. In 1998, the rich
world scraped together $70 million, as much as it costs to
build about three miles of highway in the United States,”
he says.
CID researchers have also been identifying needless
crusades that waste precious time and resources. According
to Attaran, the public health community has spent years on
the issue of drug patenting of AIDS drugs, arguing about the
importance of eliminating drug patenting for drugs to developing
countries. But patenting was really never an issue, Attaran
says. “There’s been an awful lot of talk about whether
patents are killing people, whether AIDS drugs are not available
in Africa because of patents, but patents have almost nothing
to do with it. When drugs cost several hundred dollars per
year, the problem is that Africans can’t afford it. It
has almost nothing to do with patents and everything to do
with money,” Attaran says.
A Blueprint for Change
But money was not the only hurdle in the fight
against AIDS in the developing world that the CID team encountered.
Deeply entrenched beliefs about what is possible in poor countries
also needed to be dealt with. For years, the international
AID agencies have largely written off HIV-infected Africans
as untreatable. Widely accepted objections to treatment —
such as lack of adequate medical infrastructure, inability
of people in poor countries to adhere to complicated medication
regimens, and lack of resources to afford the drugs —
have resulted in millions of Africans dying without any treatment
whatsoever.
Such neglect has occurred despite enormous advances
during the last decade in the treatment of AIDS. The development
in the mid-1990s of a highly active antiretroviral therapy
(HAART), a treatment cocktail of HIV-fighting drugs, has prolonged
the lives of millions of HIV-infected people in wealthy countries.
In the last five years, AIDS death rates in the United States
have dropped 70 percent (see graph on page 39). Yet, of the
25 million people infected with AIDS in Africa, perhaps about
25,000 — or 0.001 percent — currently get treatment.
In Malawi, just 30 persons out of 800,000 HIV-positive individuals
currently receive HAART.
In February, a group of 140 Harvard economists,
scientists, AIDS doctors, and policymakers laid out anoutline
for an antiretroviral treatment strategy in the poorest and
hardest-hit countries in the world. The Harvard faculty members
put forth a plan that would provide the broad availability
of HAART treatment to be phased in during the next three to
five years. The therapeutic regimen would be made available
through large-scale pilot programs that would oversee best
treatment strategies. As an initial effort, they proposed
targeting at least 1 million AIDS patients in Africa to be
in treatment within three years.
Describing the proposal as “powerful and
effective,” Sachs says he is gratified by the response
from the international community and by the way the university
worked together to develop the statement. “Working across
disciplines and standing together as collaborators is the
best thing a university can do,” he says.
Being Heard
Evidence suggests that the information and advocacybeing
put out by Harvard — along with many other international
researchers and scientists — are making a difference.
In May, the Bush administration pledged $200 million to the
global disease fund set up by UN Secretary General Kofi Annan,
and in June, at the UN assembly on AIDS, U.S. Secretary of
State Colin Powell pledged that additional money would be
forthcoming. Attaran expresses frustration by U.S. reluctance
to commit more: “If the United States is putting in $200
million, are we expecting the rest of the world to put in
the other $6.8 to $9.8 billion? That’s a bit nonsensical.
Two hundred million amounts to the grand total of 72 cents
per American to deal with the three leading infectious diseases.”
While Sachs also believes the United States
should do much more, he is encouraged by what progress has
occurred in the last several years. He has been working with
the Bush administration and finds a lot of resonance with
its members in stepping up support to fight AIDS. “Definitely,
things are moving,” says Sachs. “Even the current
U.S. commitment is four times what it was three years ago.
I don’t think what has happened yet is nearly sufficient,
but I am gratified that the administration is listening.”
All things considered, the CID researchers are
pleased with what they’ve achieved in less than two years.
Because of Sachs’s stature on the international stage
and his place on the commission, they are heard in “all
the right places,” Attaran says. “We have been one
of the first to show how AIDS treatments are possible in poor
countries and the very first to show how little the rich countries
are doing about it. And that’s good enough work for one
year.”
Sachs is also gratified at how well CID has
performed around such a complex issue as AIDS, proving, he
says, that “the multidisciplinary nature of the center
works.” More, however, needs to be done at the center
level, Sachs says. He wants the university to make a greater
commitment to health and development, an intersection that
should be at the center’s intellectual core. This core
must be sustained in a number of different ways, Sachs says.
He wants to see senior and junior faculty added and joint
programs with the MPA/ID program and public health established.
He would also like to get students working on the intersection
of health and development.
“This epidemic is not going to be solved
in the next year or two,” Sachs says. “It’s
going to take a lot of knowledge. We have to gird ourselves
not for the single breakthrough, but for the long haul.”
Attaran is encouraged with the number of AIDS-related
projects at the Kennedy School. This year, CID helped to support
the school’s annual Spring Exercise, an issue-focused,
two-week-long program for first-year MPP students, which this
time centered on AIDS. CID supplied much of the course content
and many of the expert speakers, such as Kofi Annan’s
personal advisor on AIDS, Stephen Lewis. Attaran wants the
center to continue to provide that kind of support to the
Kennedy School. “There is all this talent. We just have
to harvest it.”
Despite the enormous complexity of the AIDS
epidemic, the CID team is convinced that the capacity is there
to change the course of this epidemic. The world, says Sievers,
has the means to fight AIDS. “As a system and a world,
we’ve never really tried. If we do, we can do a spectacular
job.”
photo: AP photo/Obed Zilwa
|
