Bangkok theatrics miss the big picture -- Richard Tren, Business Day - South Africa, 2004-07-19
Bangkok theatrics miss big picture
AIDS ACTIVISM/Richard Tren
THE histrionics of the AIDS activists at the UNAIDS conference in Bangkok matched events in Barcelona two years ago. Among other stunts, activists besieged GlaxoSmithKline's stand and also poured blood (or rather fake blood we are assured) over pictures of US President George Bush and British Prime Minister Tony Blair.
The real worry is that the activists may feel, and the public may think, that the activists are actually doing some good with these theatrics. They are not. The activists have entirely missed the real drama of health care in poor countries.
So busy have the activists been that they probably missed the tragicomic reports on AIDS and health care to come out of Zimbabwe. President Robert Mugabe has banned the colour red from the country's television broadcaster.
Red is the colour of the opposition political party, the Movement for Democratic Change the party that would be in power had Mugabe not violently fixed the election in his favour. Thus, bizarrely, panellists discussing AIDS on a recent programme were requested to remove their red AIDS ribbons as wearing those ribbons might be construed as somehow supporting Mugabe's political foes.
Recently Mugabe announced HIV/ AIDS was one of the most serious challenges facing his country and, unlike many other African leaders, admitted that some of his extended family members have been affected by HIV/AIDS. Admittedly this is an improvement from when Zimbabwe's illegitimate leader blamed AIDS on homosexuals, whom he considers to be "un-African".
Yet Mugabe's new-found hatred of the colour red and views on sexuality are not the only things harming the fight versus AIDS and attempts to improve general health care in the country.
Because Zimbabwe cannot afford to run electric or diesel engines, its railways have recently had to bring back their old steam trains. This can only hamper whatever trade exists in Zimbabwe and will surely make it more difficult to get necessary drugs and medical resources to the areas that need them.
Yet it does not end there. In rural areas the government has replaced ambulances that rely on that modern marvel, the internal combustion engine, with, wait for it, carts drawn by oxen.
In 2002, in a move about efficient as the country's new oxen technology, Mugabe's government announced that it had declared a six-month state of emergency and would authorise the importation of generic AIDS drugs. That particular stunt made no difference to people living with HIV/AIDS as it did not address the fundamental problem of a rapidly deteriorating health system.
Also, only half of the available AIDS medicines are patented in Zimbabwe anyway, and those that are patented have either been offered free or at discounts of about 90%.
Yet western activists including, in what can only be considered a serious lack of judgment, the Nobel Prize- winning organisation Doctors Without Borders praised and lauded Mugabe's "bold" move. If the activists had bothered to listen to Zimbabweans, they would have been far more circumspect. At the time of the declaration, Zimbabwean AIDS activist Jefter Mxotshwa questioned whether the six-month emergency would result in wider access to drugs and urged the government to concentrate on improving health infrastructure.
Yet only last month, western activists had an opportunity to f≖te another Mugabe-style AIDS victory. The Harare- based generic drugs company, Varichem, announced that it would begin manufacturing knock-off versions of nine different antiretroviral therapies.
Building a plant and acquiring the machinery to produce drugs requires significant investment and expertise. Even the most optimistic commentator would have to admit this plan is fanciful.
The Romans transported their ill more efficiently than Mugabe's government; yet it claims it can produce costly, complex therapies, and cheaper than importing them from India or the US.
Zimbabwe's Standard newspaper, however, reveals a possible reason for the government's enthusiasm for this project. The Standard reports that the largest shareholder of Varichem is none other than the Zimbabwean government.
Now that Bangkok is over, the activists will continue their theatrics. The global media will continue to lap it up, blaming drug companies for the lack of treatment while Africa's many vicious and corrupt leaders will still remain the real problem.
Is it the stuff of fantasy to think the world's attention will finally turn to the real barriers to drug access?
For the sake of millions of unfortunate Zimbabweans, I hope so.
Tren is a director of the health advocacy group Africa Fighting Malaria. He recently co-authored with Dr Roger Bate a study on the real barriers to AIDS treatment for the American Enterprise Institute.
The British Lysenko? -- Dr Roger Bate, TechCentralStation, 2004-07-19
Slow and Steady Wins the Race -- Roger Bate & Richard Tren, TechCentralStation, 2004-07-14
Slow and Steady Wins the Race
By Roger Bate and Richard Tren Published 07/14/2004
Drug therapy and US policy jumped to the top of the agenda of this week's UN conference on HIV/AIDS in Bangkok, Thailand. A key talking point has been whether countries should be switching from existing therapies of brand-name drugs to formulations made from knockoff drugs that are simpler for patients to take.
Complex mixing of different drugs into a single pill holds the potential to make life easier for patients and is, in principle, a great idea. But it's a political hot potato because one of the few single pills on the market, and the one most promoted in Africa, is made by an Indian generics firm called Cipla and is made from copies of drugs developed by western companies. Furthermore, there are concerns that the drug has not been sufficiently tested, causing false hope and potentially leading to drug resistance. Cipla has taken producers in the right direction but its lack of quality control is worrying, especially to the patients taking it.
Cipla saw the single pill drug combination niche in the HIV drug market and went for it. It was a bold move, and its triple drug therapy, Triomune, is being widely used by thousands of patients in Africa. In the July 6th issue of the Lancet medical journal, several medical experts analyzed its efficacy in a small trial in Cameroon. Even though it was not a clinical trial and there was no control group, the Lancet authors were encouraged by what they found and are endorsing its use.
Cipla stole the march on the western companies who are now more belatedly developing combination therapies, usually called FDCs (fixed-dose combinations). Part of the reason for the inertia is that it is costly to test the drug combinations properly for bioequivalence.
"Combining different drugs leads to unexpected and often unknowable effects," says Dr John Martin, CEO of Gilead, a pharmaceutical company with two FDA approved HIV medicines. It's essential that the tests are done to ensure that the single dose pill acts in the same way for the patient as the pills do taken individually. Without such action there is a very real likelihood that inappropriate (usually sub-optimal) absorption of the drugs by the patient will lead to drug failure. This could be potentially fatal for the patient and very damaging to society by encouraging drug resistance.
Another reason for inertia is that the drugs one needs to combine to develop a single pill to combat HIV are patented by different companies. Cipla's Triomune uses drugs developed and patented by Boehringer Ingelheim, GlaxoSmithKline and Bristol Myers Squibb. But since Cipla can ignore patents in India (and most African markets), it just uses whatever drugs it wants without paying a royalty or negotiating with the patent-holder.
The research-based industry has been criticized by some doctors and health experts in Africa for not moving fast enough, in their view, to actively develop and market FDCs. African doctors require as much simplicity in treatment as possible, given the lack of both infrastructure and medical support staff. A more complex treatment regime often means the difference between life and death, since compliance is lower with complex treatments.
Gilead's John Martin is a fan of FDCs, and his company's two approved HIV drugs, Emtriva and Viread, are being combined as an FDC. It is expected to be approved before Sept. 12th, the date the FDA has set as its own deadline for a decision. Dr. Martin explained to us that his drug combinations have gone through extensive bioequivalence tests monitored by the FDA, which is why the FDC is not on the market yet.
Furthermore, when producing FDCs it's vital (and it's always important in single-drug formulations) that good manufacturing practice is followed. FDA officials descend randomly on Gilead's factories and all production facilities in the US to check that standards are maintained.
It is extremely unlikely that the Indian equivalent of the FDA randomly drops in on Cipla's facilities to check on performance. Very little is known about the reliability of supply of Cipla's HIV products. As such, the Triomune study discussed in the Lancet could be replicable to tens of thousands of patients; or it might have been just a lucky, well-produced batch that led to encouraging results. We don't know.
But even if the Indian officials did test facilities in the same manner as the FDA, the bioequivalence testing undertaken for Triomune would not conform to FDA standards. The World Health Organization pre-qualified some drugs for use, including lamivudine and lamivudine + zidovudine produced by Cipla. Since 2001, these drugs have been components of combination therapies, but WHO had to withdraw that prequalification (after thousands of patients have been taking the drug) in May this year because the drugs are not bioequivalent. Apart from anything else, this episode should be setting off alarm bells when it comes to the value of WHO's approval process.
The serious concerns regarding the quality of Triomune aside, FDCs will be part of the future of HIV/AIDS treatment. Indeed, following the slower, but safer, US procedures, Gilead, Merck and BMS are working together to produce a complete triple-drug FDC. It incorporates Gilead's two drugs and Efavirenz (patented by BMS and Merck). Testing is ongoing and the combined treatment, when approved, should only require patients to take one pill once a day, compared with Triomune's one pill twice a day, which should further help with treatment compliance.
While the Cipla hare was first to market extensively, the research-based, FDA-backed, tortoise will probably win eventually since Cipla is playing fast and loose with quality. Presidential nominee Kerry is currently backing Cipla, but he may have to change his mind after the election if he wins. Whoever wins out, the progress towards developing sound and effective FDCs should leave patients in poor countries better off.
Dr. Roger Bate is a visiting fellow of the American Enterprise Institute and Richard Tren is Director of Africa Fighting Malaria.
Obstacle Course -- Roger Bate & Richard Tren, TechCentralStation, 2004-07-12
By Roger Bate & Richard Tren Published 07/12/2004
One of numerous complaints against the war in Iraq is that it has diverted attention away from global health problems, such as HIV/AIDS, TB and malaria. But attacking US policy in general undermines the broadly correct US AIDS policy. This has the unfortunate and ironic effect of diverting attention away from the real barriers to good healthcare. Instead of picketing outside US embassies around the world, activists would achieve more for people living with disease if they targeted African governments instead. But when the world's AIDS experts meet in Bangkok Thailand this week for the global AIDS conference, more attacks on US policy can be expected.
Last week we published a paper that explored some of the more important barriers to effective AIDS treatment in poor countries. While the popular view is that large multinational drug companies, supported by US trade missions, ensure that poor Africans die because their governments enforce drug patents, the reality is somewhat different. Very few AIDS drugs are patented in poor countries, and indeed the WHO's list of essential medicines (which include AIDS medicines) are patented only 1.4% of the time in 65 poor or developing countries.
The simple and intuitive argument that drug patents lead to high prices and thus block access to drugs has been popular with the world's media. But this popularity has probably done significant damage by masking the real barriers and frustrating attempts to deal with these more fundamental problems.
Chief among the real barriers is poverty. When many Africans live on less than $2 a day and some of their governments can only afford to spend around $10 per person per year on healthcare, it is not surprising that even the most basic and affordable treatments are unavailable, to say little of complex treatments such as antiretroviral drugs.
The lack of African medical infrastructure is caused by poverty driven by failed socialist economic policies that many African governments pursued (and continue to pursue). Furthermore, some African governments choose to spend more money on their military than on doctors and nurses. Africa's ill and infirm are now paying for the policy decisions of corrupt politicians in the past. South Africa is losing many of its qualified medical staff to wealthier countries that can offer them better pay and working conditions. Yet instead of increasing the pay of its doctors, the South African government has chosen to spend almost US$6 billion on armaments, even though the country is not at war and has few enemies.
Over 22% of Namibia's population is reported to be living with HIV/AIDS, the country has only 29 physicians per 100,000 population (10 times lower than the US) and more than half the population lives on less than US$2 per day. Yet the country's president, Sam Nujoma recently lavished a $50million mansion on himself at taxpayer expense. One would have thought that this flagrant misuse of funds in a poor country would be far more worthy of activist ire than US foreign policy.
Apart from the lack of political will to spend taxpayer money sensibly, there is also a lack of will to be open and honest about HIV/AIDS. With the notable exceptions of Botswana and Uganda, most African governments have failed their citizens by either denying or ignoring HIV/AIDS. Before he was distracted with his efforts to abuse, torture, murder and rape his political opposition, Zimbabwe's Robert Mugabe blamed HIV/AIDS on homosexuals who he considers to be un-African. South Africa's effort to fight AIDS was harmed by President Mbeki and his minister of health's denials that HIV caused AIDS.
The various drug medicine regulators in Africa frequently hold up new registrations of drugs in lengthy and outrageously inefficient procedures. Drugs that have been registered for use in the US, EU and Japan can wait for over 2 years before South Africa's Medicines Control Council (MCC) will authorise their use in that country. All of this means that the expense of registering and selling drugs in Africa increases and inevitably it is the patient that suffers.
Removing taxes, such as South Africa's 14% value added tax on all medicines, or the Congo's 30% import tax, should be an important first step towards ensuring more affordable and available medicines. Yet it seems few African governments are willing to do the right thing and stop their bureaucracies from feeding off the limited budgets of Africa's sick and dying.
A far more difficult, yet no less important, task is to try to tackle the stigma of HIV/AIDS. Recently an AIDS treatment facility was opened in the South African town of Welkom in the Free State Province. The Province is home to an estimated 400,000 HIV positive people, and yet only 1 woman, Sigongile Sambo, was open about her HIV status and came for treatment.
One can only hope that at the conference in Thailand, drug companies, activists and governments will find some common ground and start tackling some of the real barriers instead of grabbing headlines with popular, but misguided arguments about healthcare in poor countries.
Roger Bate is a visiting fellow of the American Enterprise Institute and Richard Tren is the Director of health advocacy group Africa Fighting Malaria
 http://www.aei.org/publications/pubID.20841,filter.all/pub_detail.asp, The Real Obstacles to Sound Treat of AIDS in Poor Countries, Roger Bate and Richard Tren, American Enterprise Institute Health Policy Outlook paper.
A Bloody Mess -- Dr Roger Bate, TechCentralStation, 2004-07-09
A Bloody Mess
By Roger Bate Published 07/09/2004
Persistent remarks from AIDS activists and experts about sexual practices, especially anal sex in Africa, as the only major cause of the spread of AIDS are unhelpful. And recent statements from the Catholic Church are fanning the flames, too. By focusing solely on sex, we ignore the problems of infected blood, poor needle policy and other iatrogenic causes of the disease.
Pope John Paul II's Lenten message earlier this year focused on violence against children -- sexual abuse, human trafficking and the use of child soldiers. These are proper and noble aims for church activities. Brave, too, since child sex abuse is an in-house problem. But any hope that such discussions would raise awareness of the suffering of children was partially deflected by unguarded comments made by an over-zealous Jesuit missionary about AIDS, drugs and condoms.
Monsignor Paul Cordes, President of the Pontifical Council of the Vatican's charity arm, Cor Unum delivered the message, highlighting that the high cost of anti-retroviral therapy was preventing children receiving treatment. He said the Vatican was making ongoing efforts (through the WTO and UN General Assembly) to make treatment affordable.
During questions, the Monsignor declined to answer one about condom policy, but US Jesuit doctor, Father Angelo D'Agostino (who believes that it is Africans' culture of polygamy which causes the spread of AIDS) took the opportunity to weigh in with a sideswipe at the research-based pharmaceutical industry -- accusing it of "genocidal action" by "refusing" to make drugs affordable in Africa, even after making large profits.
Father D'Agostino was sharing the platform to publicize the Vatican's new fundraising postage stamp issue, which aims at raising $620,000 for organizations, such as the Children of God Relief Institute in Nairobi, that look after and educate AIDS orphans. I don't suppose that his outburst did much of a service to the campaign, nor that he will be invited back.
Aside from his indiscipline, Father D'Agostini is wrong and he's not alone. Firstly, it is fatuous to accuse the only providers of effectual AIDS treatment of genocide. Drug companies do not cause HIV infection. It's also worth noting that, for all its high cost and side effects, AZT has been around since 1987. Drug companies were not slow to throw R&D; at AIDS, and continue to do so, especially through recently-developed public-private partnerships. The fact is that drug development is expensive and only businesses which make a profit can afford to do it.
It is commonly supposed that most HIV transmission in Africa is caused by heterosexual intercourse; but properly controlled studies conclude that the rate of heterosexual transmission in Africa is no different than anywhere else in the world. What is worthy of note is that adult HIV sufferers also have high rates of TB and sexually-transmitted diseases and so are generally immuno-compromised.
As a transmitter of HIV, each act of (unprotected) heterosexual intercourse has an efficiency of one per cent or less, that is, a one-in-a-hundred chance of causing infection. On the other hand, HIV transmission by blood transfusion is almost 100 per cent effective in each case. Of all routes of HIV infection, transfusion of infected blood is at the same time the most efficient and the most amenable to prevention by known technologies and systems, such as testing of donors and screening of blood.
These startling facts have long been known. Despite this, a sizeable amount of HIV infection in Africa had been iatrogenic -- that is, caused by doctors or medical intervention. How could this be?
Hypodermic syringes are still routinely re-used without sterilization; injections are routinely overused, for example, for giving vitamins. Moreover, voluntary blood donation is rare outside western countries. So if a patient needs blood urgently, his family may be able to help and the patient will be receive a direct transfusion. However, where this is not possible, touts who work the hospital entrances contact "professional" blood donors, whom the family must pay, but about whom nothing much is known. The family will only do this when desperate since no tests are performed on the donor or his blood. Alas, there is no shortage of desperation in Africa and other les developed regions of the globe.
An under-appreciated fact is that children and women of childbearing age carry most of the burden of HIV infection. This is no coincidence -- the main recipients of transfused blood are children (more than 50%) who become anemic due to repeated bouts of malaria (anemia itself is a significant cause of death) and pregnant women, who often become anemic due to frequent pregnancies, hemorrhaging and abortion.
This isn't just a problem for Africa. Two doctors, writing to the British Medical Journal two years ago, said:
"In China we believe that iatrogenic infection, acquired through paid blood donation and receiving blood products, is a major contributor to the HIV epidemic."
The Chinese Vice Minister of Health himself admitted at a Press Conference in late 2001 that "30,000 - 50,000 paid blood donors have become infected," but this is widely believed to be an underestimate. A rough estimate of the impact can be made: many of those who are known to be infected were plasma donors who gave blood over 100 times. But even if they gave blood just 10 times following seroconversion this would mean that 500,000 people could have acquired HIV from these blood products alone.
The infected blood problem was recognized in the early 80s as a key culprit in the growing AIDS epidemic, but has since been eclipsed by the unnatural sex/condom story. The condom policy has the added (perhaps overriding) attraction to those who hold the underlying belief that there are just too many people in the world. The tragedy is that cleaning up blood supply is relatively easy, while changing supposed sexual attitudes is an infinite task.
The cause of HIV infection has become disturbingly politicized among the health establishment. Many of its members are aware that, should the infected blood story become more widely known, they must carry responsibility for more than half of HIV spread in the last ten years. As such, the health establishment is unlikely to shine a light on this aspect of the HIV/AIDS epidemic. It would be good if a non-medical organization would proselytize it. The Catholic Church has enormous clout in the developing world. Instead of issuing irresponsible accusations of genocide, it would be better for Church officials involved in the AIDS fight to focus its efforts on some of the real causes of the spread of HIV.
Dr Roger Bate is a director of health advocacy group Africa Fighting Malaria and a visiting fellow of the American Enterprise Institute.
Between sin and common sense -- Dr Roger Bate, Business Day, 2004-07-09
Between sin and common sense
HIV/AIDS AND THE VATICAN/Roger Bate
THE global HIV/AIDS debate is heating up as discussions concerning sexual practices will be highlighted during the Joint United Nations Programme on HIV/AIDS (UNAIDS) conference held in Bangkok next week.
Recent statements from the Catholic Church are fanning the flames too. By focusing solely on sex, we ignore the problems of infected blood, poor needle policies and infection caused inadvertently by medical intervention.
Pope John Paul\'s Lenten message earlier this year focused on violence against children sexual abuse, human trafficking and the use of child soldiers. These are proper and noble aims for church activities. Brave, too, since child sex abuse is an in-house problem.
Yet any hope that these discussions would raise awareness of the suffering of children was deflected by comments made by an overzealous Jesuit missionary about AIDS, drugs and condoms.
During questions after a message delivered by the Vatican\'s charity arm on the high cost of antiretroviral therapy, US Jesuit doctor, Father Angelo D\'Agostino (who believes Africans\' culture of polygamy causes the spread of AIDS) took a swipe at the research-based drug industry. He accused it of \"genocidal action\" by \"refusing\" to make drugs affordable in Africa, even after making a hefty profit.
D\'Agostino is wrong and he is not alone. First, it is fatuous to accuse the only providers of effectual AIDS treatment of genocide. Drug companies do not cause HIV infection. It is also worth noting that, for all its high cost and side effects, AZT has been around since 1987.
Drug firms were not slow to throw research and development at AIDS, and continue to do so, especially via recentlydeveloped public-private partnerships. Drug development is expensive and only profitable businesses can do it.
It is commonly supposed that most HIV transmission in Africa is caused by heterosexual intercourse, but properly controlled studies conclude the rate of heterosexual transmission in Africa is no different from anywhere else in the world.
As a transmitter of HIV, each act of (unprotected) heterosexual intercourse has an efficiency of 1% or less that is, a one-in-100 chance of causing infection. HIV transmission by blood transfusion is almost 100% effective in each case. Of all routes of HIV infection, transfusion of infected blood is the most efficient, but also the most amenable to prevention by known technologies and systems, such as testing of donors and blood screening.
These startling facts have long been known. Remarkably, many experts in Africa have maintained a sizeable amount of HIV infection in Africa had been iatrogenic that is, caused by doctors or medical intervention.
Hypodermic syringes are still routinely reused without sterilisation; injections are routinely overused, for example, for giving vitamins. Voluntary blood donation is rare outside western countries. If a patient needs blood urgently, his family may be able to help and will be transfused directly. However, where this is not possible, touts who work the hospital entrances contact professional blood donors, whom the family must pay, but about whom nothing much is known. No tests are done on the donor or his blood.
Children and women of childbearing age carry most of the burden of HIV infection. This is no coincidence the main recipients of transfused blood are children (more than 50%), who become anaemic due to repeated bouts of malaria, and pregnant women, who often become anaemic due to frequent pregnancies, haemorrhaging and abortion.
This is not just a problem for Africa. Two doctors wrote to the British Medical Journal two years ago: \"In China we believe iatrogenic infection, acquired through paid blood donation and receiving blood products, is a major contributor to the HIV epidemic.\"
The Chinese health vice-minister admitted at a press briefing in late 2001 that \"30000-50000 paid blood donors have become infected\", but this is widely believed to be an underestimate.
The infected blood problem was recognised in the early 1980s as a key culprit, but has since been eclipsed by the sex-condom story. The condom policy has an added attraction to those who hold the underlying belief that there are just too many people in the world.
The tragedy is, cleaning blood supply is relatively easy but changing supposed sexual attitudes is an infinite task.
The cause of HIV infection has become so politicised among the health establishment that if the blood story gains mainstream acceptance they must carry responsibility for more than half of HIV spread in the past 10 years at least.
Since they are unlikely to promote this story, it would be good if a nonmedical organisation would propagate it.
The Catholic Church has enormous clout in the developing world. It would be a shame if the condom controversy should undermine its credibility.
Bate is a director of Africa Fighting Malaria and a visiting fellow of the American Enterprise Institute.
Jul 09 2004 08:29:29:000AM Business Day 2nd Edition
US Military preventing return of Baghdad Boil -- Dr Roger Bate, The Hill, 2004-07-07
U.S. military preventing return of Baghdad Boil
By Roger Bate
It\'s hot in the Southern Iraqi desert and sand flies are returning. They bring with them \"Baghdad Boil,\" a nasty disease, more properly known as cutaneous leishmaniasis.
Sand flies are less weighty than your eyelash but they go about their ghastly business of extracting a blood meal and laying eggs in human skin. In 2003 to 2004 there were more than 650 cases of the disease. The reason was poor planning, imprudent regulations and military incompetence. It was unfortunate that young men, fighting for their country and being shot at on a daily basis, were contracting a largely preventable disease. But at least this summer the military gives the signs of taking the problem seriously.
Arcane rules about drug protocols and lack of Food and Drug Administration approval for the best drugs means all cases have to be hospitalized back in the United States, where treatment can last a month. As such, the cost is exorbitant and unnecessarily adds to a burgeoning war bill. Each case costs the U.S. taxpayer more than $20,000 in terms of flights, medical testing and other interventions, medical staff time, drugs and opportunity cost of soldiers incapacitated. As one Iraq-based medical entomologist put it: \"We were better off during the Second World War since doctors in the field had experience of the disease and could use drugs and insecticides in situ as required.\"
The vast majority of U.S. soldiers sent to Iraq were not issued with proper bed nets and mosquito repellent. This is an odd oversight: In Operation Desert Storm in 1991 there were 34 cases of the disease and so the military was fully aware of what to expect this time around.
\"It is understandable that these items are not top of any soldier\'s equipment lis, but [the current] failure rate is ridiculously high,\" says a senior U.S. military medic. One reason for the lack of supply is that the military units have to buy these items from small internal budgets that were unable to cover supplies -- a false economy given the costs of treatment. Furthermore, not all the bed nets deployed by U.S. and other allied forces are adequate. Bed nets must have a very fine mesh, at least 18 holes per square inch; otherwise the tiny sand fly can penetrate them.
Failure of management and command has also led to inappropriate requisitioning. Deltamethrin is the insecticide that has been most widely used by soldiers, even though it is known to break down in sunlight and sand storms. The choice was made partly to appease contentious environmental concerns about impacts on wildlife (not sand flies, presumably). The military should impregnate all equipment with the best insecticides, including DDT, which is better and cheaper than deltamethrin. Indeed, the Iraq-based entomologist I spoke with would love to use DDT but he cannot since it\'s not available due to the U.S. government ban. Taxpayers could save several million dollars if DDT was used instead of Deltamethrin (and the soldiers would benefit, too, from fewer sand flies).
Although the inability to use DDT is annoying, the entomologists\' largest frustration is that in some instances requests for insecticides last summer went unanswered for many months. The results were immediate. \"We started seeing soldiers basically eaten alive, 1,000 bites a night in a handful of cases,\" said one military medic. It is incredibly hot in the desert in the summer and most soldiers sleep in shorts and nothing else, with their tent flaps wide open to keep the air flowing.
One solution is mobile air-conditioning units, which keep the troops cool enough so they can shut the flaps on the tents and sleep in more than just shorts. Where these tents have been used, biting rates and infections fell massively. A-C tents should be deployed mmediately in some locations, such as Nasiriya, because 10-15 percent of troops in some units were infected -- compromising their military potency.
More broadly, a massive spray program using the best insecticides should be undertaken of the areas where the sand flies are most likely to carry the Leishmaniasis parasite.
The good news is that short of using DDT, the U.S. military has done some of this and looks set to expand on the current program before the end of the summer. This will lower the incidence of bites and hence disease, not just of the military but of the children of Iraq, who are most likely to die from the nastier form of the disease (visceral leishmaniasis).
For the soldiers returning home, carrying visceral leishmaniasis -- which the CDC describes as when \"leishmanial parasites replicate in the reticuloendothelial system (e.g., spleen, liver, and bone marrow)\" -- remains a possibility. In Desert Storm, more than a third of the 34 cases were visceral, with organ damage occurring in a few cases. So far none of the 650 cases in Operation Iraqi Freedom has been visceral; this might be because in Desert Storm (in 1991) most of the troops were stationed in Saudi Arabia, where visceral leishmaniasis is more common, but it may also be that the soldiers\' immune systems are fighting off the disease at the moment. But immunity may not last long; some soldiers may have the disease and currently be asymptomatic. Recently two visceral cases were reported in Afghanistan; we may yet see cases in Iraq.
Since the parasite can survive in the body for years, it could start damaging the organs of soldiers years from now. Vigilance is required for returning troops, they deserve better than waiting and hoping they do not develop a potentially fatal disease.
Two-thousand three was a bad year for the U.S. military, medically speaking; 2004 has started better because the medical experts have been heard -- we have to hope that effort continues. The men and women stationed in the Middle East deserve the best we can prvide.
Dr. Roger Bate is a visiting fellow of the American Enterprise Institute and director of the health advocacy group Africa Fighting Malaria.
Away from the "New Conservatism" -- Richard Tren, TechCentralStation, 2004-06-28
A Barrel of Brutality -- Roger Bate, National Review, 2004-06-24
June 24, 2004, 9:27 a.m.
A Barrel of Brutality
Should Shell be in Nigeria?
By Roger Bate
Should we boycott or engage with brutal dictatorships? This has always been a serious question, but it's one made even more vital by the threat of terrorism. Businesses, especially oil companies, are routinely criticized for "profiteering" in these countries, but is disengagement the wisest choice?
Nine years ago I visited Ogoniland, in the Niger Delta of Nigeria, to see the allegedly notorious oil-exploration activities of the Shell Oil Corporation. Activist Ken Saro-Wiwa had just been executed by the government of the day, led by the despotic General Abacha. The world's media were beginning to wake up to the troubles Nigeria faced on a daily basis, after having previously ignored the human-rights violations that had become commonplace there. Before his death, Saro-Wiwa had shown skill in turning a human-rights disaster, government-backed assaults, and nascent ethnic cleansing against certain tribal groups into an environmental issue: Shell's despoliation of the Niger Delta. As a green story, his death was eagerly reported in the West.
Shell was in a difficult place; its operations in Nigeria began in 1958, two years before British rule ended. Nigerian production now accounts for 10 percent of Shell's worldwide output, and Shell runs about half (2 million barrels a day) of Nigeria's oil output. When Shell was forced to downgrade 3.9 billion barrels of its proven oil reserves earlier this year, about a third was in Nigeria. Shell needs Nigeria's excellent-quality oil, and it puts up with a lot to get it. In 2001, there were 45 reported hostage-taking incidents, a number that remained high — 24 incidents in 2002 — after considerable effort to improve security. Stories circulating in 1995 that Shell provided the police with guns were true, but the company did so at the demand of the Nigerian government.
Furthermore, environmental damage continues to occur around broken pipelines. Not that that is entirely Shell's fault — such ruptures are mostly deliberate acts of sabotage, not the result of poor maintenance. Saro-Wiwa's followers spiked pipelines to create a news story back in 1994-1995, and outright oil theft, with its inevitable despoliation, continues unabated.
Today, Shell faces increased security threats. Organized, criminal siphoning from the pipelines remains rampant. At least $1 billion and possibly as much as $4 billion of oil revenue is stolen every year, which has been used by community militias to buy ex-Soviet weaponry, including rockets and even possibly surface-to-air missiles. Not only does this open a door to terrorists with wider aims, it threatens to destabilize the region.
At a domestic level, the effectiveness of Shell's social programs has been disputed. Shell claims to have spent nearly $70 million in social programs in 2002, but Christian Aid says the money has not helped the nonfunctioning water systems and health centers. On balance, there seems little doubt that Nigeria, and most Nigerians, benefit from Shell's continued presence. The current Nigerian government, led by Olusegun Obasanjo, is far from perfect, but it is relatively democratic — and so it seems Shell should stay. Whether they should have pulled out in the Abacha days is more to the point: Perhaps they should have opposed the dictator more, and boycotted the country, but they are still there now, and there they should stay. Whether they will be able to remain if more of their staff die in conflicts is another matter.
While Shell continues to stay the course in Nigeria, another Western oil company — Canada's Talisman Energy Inc. — is approaching the second anniversary of its divestment from war-torn Sudan. Since oil was discovered in Sudan in 1983, the lure of potentially gigantic profits has proven tantalizing. Oil companies, undeterred by both criticism from human-rights groups and the enormous risks incumbent upon foreign companies operating in what has effectively been, for the last two decades, a war zone, continue to operate there. That war, pitting the Islamist government in Khartoum against Southern black African factions dominated by the Sudanese People's Liberation Movement (SPLM), has been fueled in no small part by the existence of oil fields. While the Khartoum government — which has been accused of just about every atrocity within the power of a government to inflict — uses oil revenues to purchase arms, the southern rebels claim the fields as their own. The first Western foray into the Sudanese oil business ended abruptly in 1985, when Chevron left the country after a rebel attack on a company facility left three employees dead.
In acquiring a 25-percent interest in the Greater Nile Oil Project during the fall of 1998, Talisman calculated that the profits to be made in Sudan outweighed both the material risk to company assets and the public-relations risk associated with doing business with a militaristic government ostracized by the international community. With its ample injection of capital and technical know-how, Talisman jumpstarted Sudan's oil industry, making the country a net exporter for the first time in 1999. But while business was good, Talisman's self-avowed dedication to building health and educational infrastructure, as well as promoting peace, was not enough to dampen criticism from Western governments, church groups, human-rights agencies, and others. In October of 2002, after amplified pressure from institutional shareholders to divest — and with a lawsuit for complicity in genocide looming — Talisman sold its shares in Sudan to an Indian oil company. From the time of its entry in 1998, to its exit four years later, Sudanese crude-oil production had increased from almost nothing to nearly 250,000 barrels per day.
Unlike Shell, whose roots in Sudan extend back to colonial rule, Talisman entered Sudan with full knowledge of the human-rights ramifications of its investment. Though it certainly made an effort to enact benevolent reforms, like building clinics and schools, its crucial role in creating oil-generating capacity could not realistically hope to promote peace in any way. As The Economist stated in a fall 2000 report, "The dirty bottom line is that Talisman is helping the Sudan government finance its war."
Though difficult to imagine a few years ago, the situation in Sudan has gone from bad to inconceivably worse. Despite a tentative peace accord between the government and the SPLM, violence in the Western province of Darfur — blamed on government-backed militias — looks increasingly like ethnic cleansing of the most brutal kind. Ironically, this begs the question, "Should Talisman have left?"
Certainly, it was the right move for Talisman's shareholders. The 2002 sale turned a profit, new investments in the North Sea have increased profits and production, and after a recent 3-to-1 stock split, the company's outlook has never been brighter. But after spearheading the development of Sudan's oil-exporting infrastructure (along with Chinese and Malaysian partners), and starting a few humanitarian projects, Talisman effectively abandoned the Sudanese people to an Indian firm practically immune to human-rights pressures. In other words, Talisman not only entered into a situation where its actions effectively supported a repressive government, but also exacerbated the conflict by ensuring that oil revenues will continue to flow to Khartoum long after its exit. Perverting an old saying, we get: "Steal a man a fish, he eats for a day; teach a man to steal, he eats for a lifetime."
What does Talisman's example mean for Shell? Well, like Talisman and the Khartoum government, Shell supported, tacitly at least, the oppressive Nigerian regime of General Abacha, a decision for which it was rightly criticized. However, now that the company has seen Nigeria begin to turn the corner towards a more democratic government, it should remain.
As Africa's most populous nation, the way in which Nigeria faces the challenges of ethnic and religious strife has important implications for the continent. Certainly, the level of responsibility with which its oil wealth is managed will play a big role in meeting that challenge. Now that Shell has done its damage with the Abacha government, its time for it to step up and deliver on its promise to help the Nigerian people.
— Roger Bate is a visiting fellow of the American Enterprise Institute.
State must not let SA become huge clinical trial -- Richard Tren, Business Day - South Africa, 2004-06-23
State must not let SA become huge clinical trial
GENERICS MESS/Richard Tren
LAST week the World Health Organisation (WHO) issued a statement on its website that two generic versions of antiretroviral treatments for AIDS patients were to be removed from its prequalified drugs list.
According to the WHO, the prequalification process includes a rigorous assessment of data, yet the two drugs in question Cipla's lamivudine and lamivudine plus zidovudine have been found not to be bioequivalent.
This means the drugs don't work in the way they are supposed to and are not equivalent to the original drugs.
The withdrawal may compromise the WHO plan to treat 3-million people by next year and raises a number of very pressing questions for African countries.
To say HIV/AIDS is a problem is the grossest of understatements. UNAIDS, the joint United Nations programme on HIV/AIDS, estimates 3-million people lost their lives to AIDS last year, and a further 5-million were infected with HIV.
Antiretroviral treatment can greatly extend the lives of people living with HIV/AIDS; it can also give hope to many and can encourage them to be tested and be open about their status.
To provide treatment, cheap generic versions of patented drugs are essential. Generic versions are sometimes, but not always, cheaper than patented drugs and generic competition is seen as essential in driving down the cost of treatment.
A basic prerequisite is that the generic does the same job as the original. So the WHO's finding that these generic AIDS drugs are not bioequivalent should be setting off alarm bells.
The two researchers who found HIV, Robert Gallo and Luc Montagnier, are recently reported as having said: "If compliance and careful follow-up of patients is not achieved, we will see a dramatic increase in multidrug-resistant HIV mutants whose further spread will only aggravate the epidemic." Treating AIDS patients is vital, but treating them with substandard drugs that may drive through drug resistance would be disastrous.
The WHO has fully supported the use of generic treatments for HIV/AIDS, but has been less than enthusiastic about publicising the withdrawal of these two generic drugs.
The WHO issued the statement on its website and the story was picked up by the New York Times, but apart from that it has not been widely reported. It is not clear why the WHO issued its statement on these drugs on June 17 when its essential drugs and medicines department's policy prequalification project removed the drugs from its list on May 27.
However, there are some more important questions. Who, for example, is going to inform health workers throughout Africa that the drugs they might be using are not bioequivalent? Who, in turn, will tell the patients using those drugs that they do not work as they are meant to?
These developments may considerably harm the faith that ordinary people have in HIV/AIDS treatment.
It is also not clear who has the responsibility of withdrawing these failed drugs from the health systems. Should the WHO be held liable for prequalifying the drugs that do not work in the first place?
Some health professionals providing treatment in parts of Africa may already be one step ahead of the WHO.
Last year I spoke to a pharmacist in Lusaka who told me she preferred to dispense brand-name antiretrovirals at first and then consider moving patients to generic versions.
She was sceptical of the quality of the generics and thought it essential that the brand-name drugs be available to revert to if the generics were not working.
SA's government has been courting the Indian generics companies for some time. On one level this makes sense as government has been attempting to reduce the price of medicines to South African consumers. However, it appears government's interest in Indian generic companies has come at the expense of the research-based industry which has been slowly reducing its manufacturing and expertise in SA.
Given the WHO's withdrawal of these two antiretrovirals, it may be opportune to query the wisdom of government's approach. Generics have to be safe and effective otherwise poor countries are simply being used as a giant clinical trial by Indian generics companies. We deserve better than that.
Tren is a director of the health advocacy group Africa Fighting Malaria.
Tales of Horror and Hope -- Dr Roger Bate, Wall Street Journal Europe, 2004-06-18
Tales of Horror and Hope
By ROGER BATE
June 18, 2004
Rarely does an author combine experience, common sense and humor when writing about Africa -- especially African politics. It's even rarer when the analysis is as hard-hitting as in the writing of Robert Guest, recent Africa editor for the Economist and author of "The Shackled Continent: Africa's Past, Present and Future" (Macmillan, 288 pages, £20, $37).
Mr. Guest's five years in his job took him to most of Sub-Saharan Africa. His personal stories of extortion in the Ivory Coast, disease in Zambia, despotism in Zimbabwe and corruption nearly everywhere, are woven with the down-to-earth free market theory espoused by the Economist. His admiration for the Peruvian economist and this year's Milton Friedman prize winner Hernando De Soto is obvious in his analysis of the harm caused by the lack of property rights in most African countries.
His sense of humor isn't easily captured as it doesn't come in the form of clever one-liners but stems from portraying the absurdity of African life, juxtaposing the terrible hardship many Africans must endure with the sometimes ludicrously optimistic statements of their leaders.
His account of the appalling recent history of Robert Mugabe's totalitarianism is exceptionally depressing. Mugabe's suppression of media freedom and hostility to any political opposition is vividly portrayed by authoritative anecdotes, notably about the disappearance of dissidents. Mr. Guest shows how Mugabe's economic mismanagement has led to rampant inflation, which, coupled with his disregard for property rights, undermines any future investment and drives the economy down the tubes. He sums up Mugabe's approach this way: "Rather than signing laws and letting Zimbabweans live freely under them, he issued orders and expected them to be obeyed. This is a sensible way of running an army, but not a modern economy."
But Mugabe's excesses have been well documented elsewhere. One of the great strengths of this book is that Mr. Guest spends a good deal of time on those countries most reporters never visit, let alone write about. It is from these countries that he brings back some of the most horrid recollections. The worst describes Liberian soldiers betting on the "sex of a baby" and then opening the living mother up to find out. He concisely explains how tribal conflicts and disputes over mineral rights led to the death of hundreds of thousands, and displacement of millions, in Angola, Rwanda/Burundi, Congo and Sierra Leone.
The most personal story is that of Nestor Nebigira, who had to flee his country simply because he fell in love with the wrong woman. In Burundi, something as innocent as a Hutu marrying a Tutsi might be enough to seal one's death sentence. "He was terrified that Tutsi soldiers might kill him, or that angry Hutus kill his wife, or that zealots of either hue might kill the whole family for not being bigoted enough," explains Mr. Guest. The author gulps as he is told that the family fled to the Congo, a desperate move for anyone given how war-torn and poverty-stricken that country is. And indeed, two years later, war forced the family to move again. At least Nestor and his family were alive when Mr. Guest talked to him in the refugee camp in Tanzania. Once a successful businessman, Nestor was now selling combs from a tiny shack with a mud floor. Given that most of his clients were also refugees, business was slow and he was worried whether he would be able to feed his family in the weeks to come. Nestor would love to return home, but doubted this would ever happen. He knows his children will always be in danger since they are outcasts having mixed tribal parents. As he recounts there is a local saying "the son of a snake is a snake."
Mr. Guest contrasts these sad tales with stories of great hope: AIDS has become the continent's scourge but where leaders act responsibly, as in Uganda, the disease can be beaten back; economic growth and political stability can reign where property rights and the rule of law are respected and trade is fairly free, as is the case in Botswana and South Africa.
He is cautiously optimistic that South Africa will not go the way of Zimbabwe, even though their histories have similarities, especially the white rule and poor treatment of blacks. For years, some South African politicians have been lobbying hard for a land reform Zimbabwean-style. But the differences are probably more important: free elections and a powerful white business class in South Africa provide a stable basis for growth that have kept a lid on radical demands.
But given this is a book about Africa, it's the depressing stories one will remember most from Mr. Guest's writing. Traveling on the beer run with a truck driver for Guinness provided the most instructive example of the petty problems that keep the continent so poor. What should be an 18-hour journey of 360 miles turns into a four day, sweat-inducing nightmare. Occasionally extorted and continually delayed by 47 road blocks, the truck finally arrives at the destination with only two thirds of the original cargo. One tedious delay of 10 hours was over a bribe of only $12. Remarkably, Guinness still manages to make a small profit in Cameroon and remain in business -- for now. But with roads wasting away and rarely repaired, the outlook is not good.
Nevertheless, Mr. Guest is largely positive about the future of the continent. But he does identify one persistent and pernicious problem -- the role of external do-gooders. The more money is given to undemocratic and corrupt countries (even for AIDS), the slower Africa's advance will be. Aid just props up failing and despotic regimes. As the few African success stories show, only by enforcing property rights, the rule of law and free trade will Africa be able to join the ranks of the globalized and more prosperous world.
Mr. Bate is a visiting fellow of the American Enterprise Institute and a director of health advocacy group Africa Fighting Malaria.
The Cost of a Cure -- Roger Bate & Richard Tren, National Review Online, 2004-06-15
June 15, 2004, 8:51 a.m.
The Cost of a Cure
Anti-patent AIDS activists are hurting AIDS sufferers.
By Roger Bate & Richard Tren
As India overtakes South Africa as the country with probably the most HIV patients (estimates put it at over five million), clamorous calls for treating more of those patients with anti-retroviral drugs are taking hold. Seven months ago, the Clinton Foundation announced that the drugs could be purchased for $140 per person per year. But as a recent study by the Hudson Institute has pointed out, the actual figure ranges from about $285 to $450.
Why the disparity? The reason is that drugs in Africa are often sold at the higher price, and that is because much AIDS treatment is a business, not a charitable endeavor. Artificially low pricing is harmful because it encourages anti-patent activists to demand the impossible, which hurts AIDS victims and the drug companies alike.
These activists attack the Bush administration for its AIDS policy even though, unlike the Clinton administration and European governments, Bush has committed two billion dollars of new money per year to combat the disease. People may be annoyed at the slow appropriations process, but Bush has made the commitment and he will not backslide on it, especially in an election year.
A key demand from activists is that Bush must buy generic drugs. They insist that increased competition from generic-drug companies will lower the price of drugs in poor countries, so producing a net benefit for AIDS patients. If generic companies can sell patented AIDS medicines, the price of existing drugs will fall, but what they forget is that this will be a long-term disincentive for the companies that invent new drugs to engage in future research.
Of course, many activists focus on current AIDS sufferers. Understandably, then, they want drugs immediately available for these people and don't consider the cost of undermining future research. They could, however, at least correctly acknowledge how much patients pay for generic drugs.
Pharmacies in Zambia, for instance, sell various drug combinations at considerably higher prices than those quoted by the media. In a small sample of pharmacies in the capital, we found the prices of Cipla's cocktail range from $588 to $840 a year, a 60 percent to 140 percent increase over the quoted price. Incidentally, patented drugs from GSK (the Combivir cocktail) sell for between $1,740 and $2,250 a year.
At one of the best pharmacies we visited, Link Pharmacy in Lusaka's Manda Hill shopping center, Ann Zulu, the pharmacist, said she encourages people to buy the patented version of GSK's drug first, and then perhaps the generic alternative. Why? Because GSK drugs are better and of more reliable quality, and it is more likely that the GSK drugs are genuine, rather than the increasingly prevalent counterfeit copies. If a patient starts on the GSK drug and then switches to a generic, the pharmacist can note whether the generic is effective. If it's not, the patient can switch back to GSK's drug.
When the drugs became more readily available in 2001, many of the pharmacies assumed they would sell lots of drugs and stockpiled them. However, the drugs didn't sell, and most of them expired. So now pharmacies don't stockpile. Instead, they order from distributors on demand when a prescription comes in. Most pharmacies sell a couple of courses a month; the most we encountered was 30 per month.
We estimate that on average the Zambian wholesalers sell generic drugs at a significant premium to the announced prices from Cipla and Ranbaxy, another Indian generics company. Patients pay about 50 percent more than the frequently quoted price.
Malaria is still Zambia's biggest killer, but about 20 percent of Zambia's adult population has HIV/AIDS. Out of Lukasa's estimated two million people perhaps 400,000 have AIDS. Of that perhaps 15-20 percent — 60,000 to 80,000 people — require treatment. But its few pharmacies were not selling many courses and most clinics have few drugs. The drugs in the clinics tend to come free from companies like GSK and Merck, and not from the generic manufacturers. It is likely that fewer than 1,400 Zambians receive treatment through clinics.
The price of drugs, therefore, is a minor factor in the failure of Zambians to receive treatment. But at least the situation is better in Zambia than in Burundi or Zimbabwe. Nationals from these countries must cross the border, prescriptions in hand, to buy significant amounts of drugs from Zambian pharmacies.
In 2002, activist Richard Stern noted that the price of a course of generic drugs in Latin America was about $1,400 a year, even higher than in Zambia. Given that Latin America is relatively richer than Southern Africa, this higher price is not surprising. In Africa, too, a pattern is emerging as pharmacies in Mozambique, South Africa, and elsewhere sell generics at Zambian prices or higher.
This is to be expected. Drug manufacturers, wholesalers, and retailers need to make money to stay in business. But the media, portraying generics firms almost as charitable do-gooders, creates the myth that AIDS drugs delivery is not a business. The research-based industry perversely supports this myth by delivering its drugs for free, making it appear that since the people are so poor, one should make no money in Africa.
However, making Africa a no-profit zone is folly that will keep the continent in poverty. Until AIDS-drugs distribution is seen by politicians and the media as a business, we will continue to see Africa languish, drug companies reducing their research and their considerable local logistical support, and more people will die.
— Roger Bate is a visiting fellow of the American Enterprise Institute and Richard Tren is a director of Johannesburg-based health-advocacy group, Africa Fighting Malaria.
Le paludisme demain -- Richard Tren, Jeune Afrique, 2004-06-13