Keeping Faith

Seventeen million Africans have died from AIDS, and each year, two million more Africans are added to the toll. Economist Jeffrey Sachs and his colleagues at the Center for International Development believe it doesn’t have to be this way.

by Sarah Abrams

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 an outline 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 advocacy being 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.”